Nurse Likelihood to Report a Medication Error

Tuesday, 23 July 2013: 1:30 PM

Francine K. Kingston, DrPH, MSN, RN-BC
Clinical Training & Development, Texas Children's Hospital, Houston, TX

Learning Objective 1: Describe the study research question and methodology.

Learning Objective 2: Synthesize the results of this study into a set of implications for nursing leaders in both the practice and academic arena.


From a better understanding of factors that contribute to the likelihood of a nurse to report an error, interventions can be identified to help increase reporting in order to learn from error and reduce the possibility of similar error. To learn from the lived experience of the nurse, the research question became, “What factors contribute to a nurse’s likelihood to report an error?”


A qualitative research study was conducted to explore the medication error experience. Structured group interviews were conducted using open-ended questions. A total of 54 registered nurses participated.  


Several themes emerged around a nurse’s likelihood to report a medication error:

  1. The nurse’s foremost concern is the wellbeing of the patient;
  2. If managers are supportive in response to error, a nurse is likely to report again;
  3. Nurses want to be held accountable for their errors;
  4. Nurses are more likely to report in an environment perceived as non-punitive;
  5. Nurses struggle with wanting to be perfect;
  6. Nurses engage in a process of reconciliation between wanting to be perfect and yet having just made a medication error;
  7. Nurses question their own competence after making an error; and
  8. Nurses want to be involved in synthesizing error reports. 


Findings have implications for both schools of nursing and health care organizations:

  • Theories of human performance, complex systems, production pressure, and high hazard industry should be incorporated into the undergraduate curriculum and reinforced in health care organizations;
  • Education and training should be available to managers who immediately counsel the nurse who has made an error;  
  • Procedures used in reporting should be evaluated in order to promote the most efficient and most private process possible;
  • Structures and processes should be put into place to engage the bedside nurse in synthesizing and interpreting the data around medication error; and feedback provided to demonstrate that organizations can learn from error and change long standing traditional practices.