Contributing factors to medication errors

Active failure

Neglect and carelessness

It was also perceived that experience was not the only factor of increasing medication errors as some nurses believed that these errors might increase even when nurses were experienced:

“Oh...that is a difficult question, I think errors may be caused by experienced people, but this is not necessary...but the people who are more likely to make errors are those

who are also careless...”AY_F

“The similarities lie between medicines, wrong drug preparation,...like miscalculation, unclear order and careless staff” HN-M

This demonstrates that the relationship between a number of different factors contributes to neglect and carelessness, as highlighted in human error theory (Reason, 1990).

Situational factors

Nurse characteristics

Nurses differed in their views regarding the age of the nurse as a positive or negative factor to increase or decrease medication errors. They related experience to age of the nurse and some believed that older nurses were likely to have more experience and less likely to make errors. One of the nurses said:

“…Yes I think the older nurses are doing less error...because of their experience…” BG-M

Less vision and activity as well as memory of old staffs were perceived by other nurses as a stage where nurses may lose some of their memory and vision which could lead to increased medication error:

“…The elderly staff should not be treating some patients…old nurses have less vision and activity not like young staff…” AZ-M

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“…The older memory and focus are not good…” RE-F

Some nurses had other controversial points and believed that memory or concentration may be low even in young people and therefore age alone is unlikely to affect medication errors:

“…Lack of concentration can be in any one old or young, age is not affecting if you are confident and concentrating…” SH-F

Miscommunication (poor handwriting)

Several nurses considered some factors related to the active failures. Of these factors was the absence of a printed order system and unclear handwritten doctors‘ orders which was

considered by seven nurses. As these nurses stated:

“…if the order is new for you, you may misunderstand and have an error…” IN-F “…Doctor writing on the medication sheet not clear…sometimes with more patients and lack

of English language especially for new staff you cannot spend a long time analyzing what doctors write…” AF-F

Local conditions

Local conditions were perceived to impact on medication errors and fell in four main categories; workload, shortage of staff, supervision, and distraction and interruption.

Workload

The workload was also considered, by nurses in the quantitative study, as important factor and was associated with nurse to patient‘s ratio. As these quotations demonstrate:

“…Busy units are more likely to have errors because of workload and also units which use more complicated medications…” AZ-M

“…I would like to say that medication errors could be more common with less experience, high work overload, limited number of the staff, and unclear doctor hand writing…”AL-F

Shortage of staff

The lack of experience of staff was also considered, by nurses in the quantitative study, as an important factor and was associated with high incidence of medication errors and nurses were aware of that. Several nurses were concerned about this, for example:

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“…shortage of experienced staff is important and we have only a limited number of experts who are administering medications properly…” MR-M

“…the shortage of experienced staff is another thing to say…it is really a problem…” BR-M

This is also noted by Lawton (2012) as an issue in relation to staff and staffing levels. The shortage of staff has increased the workload required from these nurses which might be a factor in the increasing errors.:

“...Busy units are more likely to have errors because of workload and also units which use more complicated medications...high work overload, limited number of the staff...”

AZ_M

Nurses recommended increasing staff numbers as strategy to minimise medication errors, as one nurse stated:

“...Should focus on environment...increase staff...qualified staff...”HM_M.

Distraction and interruption

Nurses considered that the distraction and interruption by visitors as well as other staff were important factors increasing errors by nurses administering medications. Nurses in the study agreed that their work area was busy, and crowded with patients and visitors which increased distraction and interruption for nurses. This was considered common in the study settings where the nurses work. As these nurses stated:

―…Yes definitely it will affect…the environment if its crowded and busy with interruption and noise…the area of practice should be fit for practice…” FN-M

“…Some times we are not able to concentrate during the time of administration that’s also one of the factors…” PA-F

Nurses were also concerned about the noise from outside the work area as well as the noise during visiting time:

“...Yes sometimes, noise outside, visiting time may be at time of medication...” AL_F “...The environment is too busy, too noisy, too crowded and the area of medication preparation is not closed...if these things are sorted we will have fewer errors...” RE_F

151 Latent condition

Latent conditions included three main themes; features of working area, unclear policies and procedures, and lack of knowledge and skills.

Feature of working area

Nurses believed that features of the working area, including space and lighting of the drug preparation room ,as factors to influence medication errors. They mentioned that insufficient lighting sometimes limits the nurses‘ ability to read and space can limit nurses‘ ability to organise things. All these factors were considered as increasing the possibility for medication errors:

“…factors like room size, lighting, spaces…” MA

“…Also the environment is too crowded and the area of medication preparation not closed or not well lighted so we cannot read things sometimes…” RE-F

Nurses also mentioned the design and the way the room was designed for drug preparation as a factor. This seems that planning would help to organise nurses‘ work rather than how many meters they have in which to move. For example:

“Another factor would be the way wards are designed to prepare medications for example the medication room...”AZ_M

Noise, as mentioned in the previous category, could also be defined as a latent condition factor, as it can be defined as a feature of the working area (Lawton, 2012).

Unclear policies and procedures

Nurses recognised that policies and procedures played a part in medication administration errors, but they had different views about them with some believing that they were standardised all over the world, or keeping up to date would help and others being unclear about the policies and instructions. As these quotations illustrate:

“…Unclear understanding of procedures and instructions for medications…” BR-M “…Yes, if you update and follow policies and procedures it will help…” MA-F

152 Lack of knowledge and skills

Nurses‘ knowledge and skills to match their nature of work was a factor influencing the extent to which nurses would make medication errors. When nurses were asked about which nurses are more likely to make a drug error than others, the majority considered the lack of knowledge and skills was a key issue and main cause of errors:

“…For me yes, the new staff are making more errors because they don’t have knowledge and skills…” FN-M

“New staff who didn’t get proper education” BR-M

However, nurses also considered experience and education as jointly important and they also talked about lack of knowledge and experience as key and important factors in increasing medication errors. For example;

“…Depends on the experience less experience…less knowledge…less skills will cause the errors.…” RE

“...the new staff usually and those who have less experience are more likely to make error” BR_M