Paper
Thursday, July 22, 2004
Medication Administration Error Reporting: It May Not Be What You Think
Sally A. Bulla, PhD, RN, CNA, BC, George Mason University, Fairfax, VA, USA
| Learning Objective #1: Compare findings of this research with other research on medication administration errors and reporting of errors |
| Learning Objective #2: Discuss some of the reasons cited in research for reporting/not reporting medication administration errors |
Objective: In the 1999 Institute of Medicine report, “To Err is Human”, medication errors were estimated to account for over 7,000 deaths annually. Literature is replete with studies showing that fear is a factor in not reporting. However, studies have also shown that nurses redefine situations so that an error does not need to be reported. My research question was: What medication administration errors do nurses report? Design: This multi-method study used both a quantitative survey and a qualitative interview approach to gain perspective on medication administration error reporting. Population, Setting: The population was RNs with greater than 2 years experience. The setting was a larger military teaching hospital in eastern United States. Variables: Nurses, Medication administration error reporting. Methods: 111 surveys were returned with questions relating to reporting and 7 interviews were conducted to get nurses stories about reporting errors. Findings: Ninety percent of nurses responded that other nurses did not report because of fear but only ten percent had, themselves, not reported an error because of fear. Fifty percent responded they did not report errors if they did not consider the error important enough. In the interviews, one theme dealt with what constitutes a medication error. Participants discussed the idea that if there was no patient harm or the medication could be rescheduled then no error occurred and the fear of “being labeled as a bad nurse” was negated. Conclusions: Medication administration error reporting continues to be a problem despite national attention and efforts to make reporting anonymous. Even with anonymous reporting, this study shows that errors may not be considered important enough to report. Implications: Educators and administrators must reinforce reporting of errors as non-punitive encouraging reporting in an effort to successfully fix “medication systems” to prevent further errors not to punish the “bad nurse”.
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Sigma Theta Tau International
July 22-24, 2004