Poster Presentation

Wednesday, July 11, 2007
9:00 AM - 9:45 AM

Wednesday, July 11, 2007
2:45 PM - 3:30 PM
This presentation is part of : Poster Presentation I
Identifying Error-prone Factors Through Medication Administration Errors
Fu-In Tang, PhD, School of Nursing, National Yang-Ming University, Taipei, Taiwan
Learning Objective #1: understand error-prone conditions and high-alert situations
Learning Objective #2: try snowball sampling method in the study of medication errors

We aimed to encourage nurses to release information about drug administration errors in order to increase understanding of error-related circumstances and to identify high-alert situations. Drug administration errors represent the majority of medication errors, but errors are underreported. Effective ways are lacking to encourage nurses to actively report errors. Snowball sampling was conducted to recruit participants. A semi-structured questionnaire was used to record types of error, hospital and nurse backgrounds, patient consequences, error discovery mechanisms and reporting rates. Eighty-five nurses participated, reporting 259 administration errors. Most errors occurred in medical surgical wards of teaching hospitals, during day shifts, committed by nurses working less than 2 years. Leading errors were wrong drugs and doses, each accounting for about one third of total errors. Among 259 errors, 83.8% resulted in no adverse effects; among remaining 16.2%, 6.6% had mild consequences and 9.6% had serious consequences (severe reaction, coma, death). Errors were discovered mainly through double-check procedures by colleagues and nurses responsible for errors; reporting rate was 62.5% (162/259), and only 3.5% (9/259) was disclosed to patients and families. High-alert situations included administration of 15% KCl, Insulin, and Pitocin; using IV pumps; and implementation of CPR. Snowball sampling proved to be an effective way to encourage nurses to release details concerning medication errors. Survey results suggest that nurses should double check medication administration in known high-alert situations. Nursing management can use snowball sampling to gather error details from nurses in a non-reprimanding atmosphere, helping to establish standard operational procedures for known high-alert situations.

 Key words: drug administration errors, nurse, snowball sampling