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J Nurs Care Qual

Vol. 22, No. 1, pp. 2833
c 2007 Lippincott Williams & Wilkins, Inc.


Nurses Perceptions of Causes

of Medication Errors and
Barriers to Reporting
Virginia M. Ulanimo, MS, RN, CCRN;
Colleen OLeary-Kelley, PhD, RN, CCRN;
Phyllis M. Connolly, PhD, APRN-BC, CS
This study describes nurses perceptions about medication errors and the effects of physician order
entry and barcode medication administration on medication errors. A convenience sample of 61
medical-surgical nurses was surveyed. All nurses surveyed perceived that information technology
decreases medication errors. However, medication errors continue to occur despite the availability
of sophisticated information technology systems. Key words: information technology, medication administration, medication errors, patient safety

NE of the most important nursing functions is to administer medications safely.

The process of administering medications is
multidisciplinary, but the final check to ensuring patient safety lies with the nurse.13
Furthermore, the process of medication administration takes many steps, and in any of
them, the nurse may commit medication errors. Making a medication error, even if only
minor, can be psychologically devastating to
the nurse and harmful to the patient.1,4 Studies have revealed that only serious or ad-

From the VAPAHCS, Palo Alto, Calif (Ms Ulanimo),

and School of Nursing, San Jose State University (Drs
OLeary-Kelley and Connolly), San Jose, Calif.
The views expressed in this article are those of the authors and do not necessarily represent the views of the
Department of Veterans Affairs.
This research was supported by the Department of
Veterans Affairs, Veterans Health Administration, VA
Palo Alto Research Administration, Project No. 2718
(96295).
The authors thank Marilyn Douglas, DNSc, RN, FAAN,
Associate Chief for Nursing Research, for consulting on
this research.
Corresponding author: Virginia M. Ulanimo, MS, RN,
CCRN, VAPAHCS, Palo Alto, CA 94304 (e-mail: virginia.
ulanimo@.va.gov).
Accepted for publication: March 13, 2006

28

verse events resulting from medication errors are being reported while medication errors that have not harmed the patient go
unreported.1,4,5 A study by Mayo and Duncan1
found that negative reactions from the nurse
manager and peers were barriers to reporting
medication errors.
The purpose of this study was to describe
medical-surgical nurses perceptions of frequent causes of medication errors, of what
constitutes a medication error, and of what
are the barriers and empowerments to reporting. The study also explored nurses perceptions of the effect of physician order entry
(POE) and barcode medication administration
(BCMA) on medication errors.
LITERATURE REVIEW
Causes of medication errors
Causes of medication errors have been examined in previous studies in an attempt to
find commonalities among the causes and
offer solutions that may control potentially
lethal, psychologically damaging, and costly
errors.1,4,5 Benner et al2 analyzed 21 cases of
nurses medication errors from 9 state boards
of nursing and identified that lack of attentiveness, inappropriate judgment, and missed

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or mistaken physicians orders were the usual
causes of errors. Leape et al cited 13 proximal causes of medication errors: (1) lack of
knowledge of the drug, (2) lack of information
about the patient, (3) rule violations, (4) slips
and memory lapses, (5) transcription errors,
(6) faulty drug identity checking, (7) faulty interaction with other services, (8) faulty dose
checking, (9) infusion pump and parenteral
delivery problems, (10) inadequate monitoring, (11) drug stocking and delivery problems, (12) preparation errors, and (13) lack of
standardization.6
Medication errors are not necessarily
caused by one individual but are caused
by many factors involving many people.2,7
Medication errors may be the result of an
error made by the nurse (human error) by
bypassing safety measures or caused by a
system error that ultimately affects patient
safety. McGillis et al8 concluded that a higher
proportion of professional nurses in the
staff mix on medical and surgical units in
an Ontario teaching hospital was associated
with fewer medication errors occurring in
those units.
The observational study by Tissot and
colleagues9 suggested that nurse workload
and incomplete or illegible prescriptions
were factors associated with medication administration errors. Dean et al10 examined
prescribing errors in the United Kingdom. Of
the 36,200 medication orders written during
the 4-week study period, there were 543 prescribing errors.
Barriers to reporting
Barriers to reporting medication errors hinder quality improvement measures. The study
by Mayo and Duncan1 of 983 registered
nurses acknowledged that nurses know what
constitutes a medication error and that they
are more likely to inform the physician than
the nurse manager because of fear of reprisal
from the manager. The study of Osborne
et al4 on 57 medical-surgical nurses revealed
that nurses do not report medication errors
because of fear of disciplinary action.

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An interesting finding of how nurses adopt

practices to accomplish daily nursing tasks
in a hectic and complex work environment
was identified in a qualitative study conducted
by Baker.11 One of the findings was that
nurses use criteria to redefine or reclassify
medication errors. After reclassifying an error, the nurse may decide it was not an error and thus not require being reported, with
no guilty feelings attached. For example, if a
nurse found that a medication was omitted
and then administered it, this was no longer
considered a medication error because it was
corrected.
Technology
A variety of information technology (IT)
systems is now available to enhance safe
medication administration. The Institute of
Medicine report in 1999 strongly recommended that hospitals and other healthcare
organizations implement POE systems.12,13
The POE system not only generates legible
physician orders but also allows for physician orders to be entered electronically and
distributed to appropriate departments and
services.14,15
Barcode medication administration is another IT application that enhances patient
safety. Johnson et al16 found that at ColmeryONeil Veterans Affairs Medical Center, BCMA
drastically reduced medication errors. In addition, the computerized patient record system
(CPRS) increases caregivers communication
by creating fast access to electronic patient information for easier planning of patient care.
Information is readily available to providers at
point of care.17 With IT, many challenges to
improve patient safety can be overcome.18
Published articles on IT systems support
their contributions to safe medication administration. Even with the advancement of IT,
however, medication errors continue to occur. Studies have not examined nurses perceptions of frequent causes of medication
errors, barriers to reporting, and empowerments to reporting in settings with IT systems
in place.

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Research questions
The research questions for this study were
as follows:
1. What are nurses perceptions of the frequent causes of medication errors?
2. What is the estimated percentage of
medication errors reported to the nurse
manager as perceived by the nurses?
3. Which scenarios are perceived by nurses
as having had a medication error occur and whether or not that error needs
to be reported to the physician and/or
nurse manager?
4. What are nurses perceptions of barriers
and empowerments to reporting?
5. What are nurses perceptions of the effects of POE and BCMA on medication
errors?
METHODS
The study had a descriptive design. The
convenience sample included 61 registered
nurses and licensed vocational nurses at a
Veterans Affairs Medical Center in Northern
California who were working in medicalsurgical units and routinely administered
medications to patients. POE, BCMA, and
CPRS systems are used in these units. The
participants worked in 3 acute care inpatient
units: telemetry and medical, oncology
and hematology, and surgical. The nurseto-patient ratio was 1:4 to 1:5 on all units.
Nurse managers, clinical nurse specialists,
and nurse educators were excluded from the
study. The investigator received 27 return
questionnaires; 2 of these were not used
because they were incomplete or left blank,
resulting in a 44% return rate.
Instrument
A modified Gladstone questionnaire was
adapted with permission. Content validity
was determined by previous researchers.1,4
Reliability using the test-retest method was established at 0.78.1 The Modified Gladstone instrument has 5 parts. Part 1 asks the nurse
to rank a list of 10 possible causes of medica-

tion errors, with #1 being the most frequent

cause and #10 being the least cause of medication errors. Part 2 asks the nurses perception of what percentage of all medication errors are reported to the nurse manager by the
completion of an incident report. Responses
can range from 1% to 100%. Part 3 consists of
6 patient care scenarios, and in each scenario,
the nurse is asked to indicate (a) whether or
not a medication error occurred, (b) whether
or not the physician should be notified, and
(c) whether or not an incident report should
be completed, by answering Yes or No after each condition. Part 4 contains questions
that ask about the nurses views on reporting
medication errors, and Part 5 collects demographic and background information.
The adapted questionnaire used for this
study includes a section that asks the nurse to
list his or her views and comments about medication errors. Two questions about the effect
of POE and BCMA implementation on nursing
practice were also added to the questionnaire.
Procedures
The IRB approvals from the study hospital and from the affiliated university were obtained prior to the start of the study. At the
staff meeting, it was reinforced to the staff
that the survey was anonymous and confidentiality of nurses was protected. When the
primary investigator emphasized the importance of giving qualitative feedback about barriers and empowerments to reporting medication errors, nurses expressed concern that
information would be traceable to individual
nurses. The investigator reassured them of the
confidentiality of returned surveys.
FINDINGS AND DISCUSSION
Demographic and background
information
Ninety-six percent of the nurses were female, and 72% were Asian. Most of the nurses
(n = 13, 52%) were 40 to 49 years old.
The majority (n = 17, 68%) had a bachelor
of science in nursing degree. Many of the
participants (n = 10, 40%) had more than

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20 years of nursing experience. Eightyfour percent worked full-time. Forty percent
worked days, 40% evenings, and 20% night
shift.
Thirty-two percent (n = 8) remembered
making 1 to 2 medication errors, and 24%
(n = 6) remembered making no errors. Four
nurses remembered making 3 to 4 errors, and
3 remembered making more than 5 errors in
the course of their careers. Four nurses did
not answer this question.
Perceptions about medication errors
In response to the question What are the
nurses perceptions of the frequent causes
of medication errors? the number 1 cause
of medication errors identified in the study
was when the nurse failed to check the patients name band with the patients medication administration record (45.8%). The number 2 perceived cause of medication errors
was when a nurse was tired and exhausted
(33%) (Table 1).
These findings are similar to those of the
study conducted by Osborne et al.4 These reTable 1. Nurses perceptions of frequent
causes of medication errors

Causes
Nurse fails to check name band
with MAR
Nurse is tired and exhausted
Physician prescribes wrong dose
Nurse miscalculates dose
Confusion between 2 drugs with
similar names
Physicians writing is illegible
Nurse distracted by patients,
coworkers, and events in the
unit
Nurse confused by different types
and functions of infusion device
Medication labels/packaging is
poor quality/damaged
Nurse sets up/adjusts infusion
device incorrectly

% of
nurses
45.8
33.3
30.4
29.2
29.2
28.0
25.0

25.0
25.0
24.0

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searchers used a Modified Gladstone instrument for their study of medical-surgical nurses
and identified the 2 most frequent causes of
medication errors as failure to check the patients name band with the medication administration record and fatigue or exhaustion on
the part of the nurse.
In response to the research question, What
is the estimated percentage of medication errors reported to the nurse manager as perceived by the nurses?the nurses believed that
nearly one third (mean 28.9%) of medication
errors were reported to the nurse manager
by the completion of an incident report. In
Mayo and Duncans study,1 subjects perceived
that only 25% of all medication errors were reported to the nurse manager using an incident
report. Both study results are of concern for
quality and patient safety.
The research question, Which scenarios
are perceived by nurses as having a medication error occurred and whether or not the
error needs to be reported to the physician
and/or the nurse manager?resulted in a wide
range of nurse responses. Interpretation of
what constitutes a medication error and when
to notify a physician and the nurse manager
varied among the nurses. This result indicates
that nurses need to be educated and provided
with refresher in-services on what constitutes
a medication error and when to report one to
a physician and nurse manager as defined by
their institution.
Views about barriers and
empowerments to reporting
The nurses believed that some medication
errors were not reported because of fear of
the reaction they would receive from the
nurse manager (60%) and their peers (64%)
(Table 2). Yet, most of them (64%) indicated
that they report medication errors, even ones
that are not serious. Only a few nurses (16%)
failed to report a medication error because of
fear of disciplinary action or losing their jobs.
This finding is similar to that of Mayo and Duncans study.1 In their study,1 76.9% of nurses
do not report medication errors because of
the managers reactions and 61.4% because

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Table 2. Nurses views about reporting medication errors

Views
I am usually sure what
constitutes a medication
error.
I am usually sure when a
medication error should be
reported using an incident
report.
Some medication errors are
not reported because
nurses are afraid of the
reaction they will receive
from their coworkers.
Some medication errors are
not reported because
nurses are afraid of the
reaction they will receive
from their nurse manager.
Have you ever failed to report
a drug error because you
did not think the error was
serious to warrant
reporting?
Have you ever failed to report
a medication error because
you were afraid that you
might be subject to
disciplinary action or even
lose your job?

Yes (%
of nurses)
92

88

64

port; and (4) the nurses attitude, personality, and compliance as barriers to reporting
medication errors. Empowerments to reporting were listed by the nurses as (1) understanding and supportive physicians and supervisors, (2) active involvement of nurses and
clinical nurse specialists in determining medication errors and promptly reporting them to
the nurse manager, (3) having enough time to
report, and (4) having nurse managers who
consistently follow through on disciplinary
action when a nurse is making frequent
errors.
Effect of POE and BCMA

60

36

16

of coworkers reactions. In addition, 80.4% of

nurses were not afraid of losing their jobs.
Nurses appear comfortable with their job security, but nurse managers and their coworkers perceptions of them after making an error are strong barriers to reporting medication
errors.
The qualitative portion of the study asked
the nurses to list other barriers and empowerments to reporting that were not covered in
the quantitative portion of the questionnaire.
Nurses cited (1) lack of knowledge about policies, procedures, and unit routines; (2) busy
units and not enough time to report a medication error; (3) the nurses negligence to re-

Research question 5 asked What are

nurses perceptions of the effect of POE and
BCMA on medication errors? Eighty percent
of the nurses (n = 20) remembered making no
medication errors, and 12% (n = 3) remembered making only 1 error since the implementation of POE and BCMA in their units. All
(n = 25) of the nurses agreed that medication
errors have decreased since the implementation of POE in 1999 and BCMA in 2001.
Limitations
There are several limitations of this study.
The study was conducted in inpatient VA
medical-surgical units that use BCMA, POE,
and CPRS. Therefore, this study may not be
generalized to medical-surgical nurses who do
not use these 3 IT systems in their practice.
Although the survey return rate was adequate
(44%), the small sample size of 25 is a limitation. The convenience sample might not reflect the actual population. The primary investigator was previously the nurse manager
of the oncology and hematology unit, and the
qualitative portion of the study was not completed by most of the nurses even though
anonymity and confidentiality were emphasized. Another limitation of the study is that
the questionnaire did not include the percentage of medication errors verbally reported to
the nurse manager without an incident report. The result of actual medication errors reported to the nurse manager might have been
higher.

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CONCLUSIONS
Human factors continue to be the frequent
causes of medication errors. Bypassing safety
measures during medication administration
and being unfit to work because of exhaustion are the 2 most frequent causes of medication errors perceived by nurses in this study.
The low percentage (mean of 28.9%) of es-

33

timated medication errors reported to the

nurse manager is of concern. Reactions from
nurse managers and peers continue to contribute to nurses failure to report medication
errors. There is a gap between nurses perceived knowledge and their actual knowledge
of medication errors. In this study, IT systems
are perceived to aid in the decrease of medication errors.

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