medicine administration errors and their severity in secondary care older persons’ ward: a...

ORIGINAL ARTICLE

Medicine administration errors and their severity in secondary care

older persons’ ward: a multi-centre observational study

Jennifer Kelly and David Wright

Aim and objectives. To assess the severity of medicine administration errors to older patients.

Background. Severity of medicine administration errors has been determined in a variety of settings but not in care-of-older-

person wards, which this study aims to do.

Design. Undisguised observational study.

Participants. Sixty-two nurses were observed administering oral medicines to 625 patients.

Interventions. Data were collected on the preparation and administration of oral medicines. Thirty-five cases of error were

selected and analysed for their severity.

Results. In the 65 drug rounds observed 2129 potential drug administrations were made to 625 patients, of which 817 doses

(38Æ4%) were given incorrectly (95% CI = 36Æ3–40Æ4). The overall mean harm score of the 35 incidents analysed was 4Æ1 (range

1Æ1–8Æ6, SD 1Æ8) on a scale of 0–10.

Conclusions. The number and severity of MAEs observed is high compared with previous studies.

Relevance to clinical practice. There is a need to decrease the number and severity of MAEs, by increasing nurse awareness

and error reporting.

Key words: dysphagia, elderly, medication, medicine administration errors, nurses, nursing

Accepted for publication: 23 February 2011

Introduction

Of considerable concern in recent years has been the

number of medicine administration errors (MAEs) in UK

hospitals (DOH 2000). In 2000, approximately 4% of

hospital inpatients experienced an adverse event resulting

from a medication error related to prescribing, dispensing or

administration (Ferner & Aronson 2000). This resulted in

the Department of Health stating that serious errors in the

use of prescribed drugs should be reduced by 40% by 2005

(DOH 2000) and to help achieve this the National Patient

Safety Agency (NPSA) was set up. This independent body

runs a mandatory reporting system for logging all failures,

mistakes, errors and near misses across the health service.

Since it was set up there has been a significant year-on-year

increase in reporting of medication incidents with 72,482

medication incidents being reported in England in 2007,

50% of which were administration/supply errors (National

Patient Safety Agency 2009). However, the aim of the

organisation to reduce serious errors is not being achieved

so easily. There were 36 deaths in 2006 from medication

errors (BBC News 2006), 37 in 2007 (National Patient

Safety Agency 2009) and a doubling of serious and fatal

errors between 2005–2007 (Rose 2009).

Authors: Jennifer Kelly, MSc, RGN, DipNEd, Tissue Viability

Clinical Nurse Specialist, Department of Dermatology, Queen

Elizabeth Hospital, Norfolk and PhD Student, School of Pharmacy,

University of East Anglia, Norwich; David Wright, PhD, BPharm,

PGCHE, Professor in Pharmacy Practice, School of Pharmacy,

University of East Anglia, Norwich, UK

Correspondence: Jennifer Kelly, Tissue Viability Clinical Nurse

Specialist, Dermatology Clinic, Queen Elizabeth Hospital, King’s

Lynn, Norfolk PE30 4ET, UK. Telephone: 01553 613613 ext. 2821.

E-mail: [email protected]

� 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing 1

doi: 10.1111/j.1365-2702.2011.03760.x

MAEs can be defined as a deviation from the prescriber’s

order as written on the patient’s drug chart (Allan & Barker

1990). Several observational studies based on Allan and

Barker’s definition have been performed which between them

identify a MAE rate in the UK in adult general wards of

3–8% (Dean et al. 1995, Ridge et al. 1995, Gethins 1996,

Cavell & Hughes 1997, Ho et al. 1997, Ogden et al. 1997,

Dean 1999, Taxis et al. 1999, Dean & Barber 2000).

However, Allan and Baker’s definition is limited because

nurses should not blindly follow what has been prescribed

and are expected to use their professional judgement to

ensure medicine administration is clinically appropriate and

safe (Nursing and Midwifery Council 2008). Also, what

constitutes a MAE varies from study to study making

comparisons difficult. For example, some studies include

time errors (Gethins 1996, Nixon & Dhillon 1996), for

example, the medicine is given one hour earlier or later than

it was prescribed for, whilst other studies ignore them. Time

errors can have a significant effect on the MAE rate; for

example, Nixon and Dhillon (1996) found if they excluded

time errors, their MAE rate dropped from 16Æ6% and 12Æ9%

to 5Æ6% and 4Æ5%, respectively. The reason some researchers

omit time errors is that they are considered less serious than

other MAEs (van den Bemt et al. 2002) and in many case

they are irrelevant. For example, does it matter whether

the patient has their daily dose of furosemide at 08.00 or

09.30? The focus of MAE research on the number of errors

can be misleading and over inflate the problem. It is the

severity of the errors which is important from the patient’s

perspective.

A literature review found 11 studies where the researchers

have attempted to measure the severity of MAEs (Table 1).

As can be seen different methods have been used to score

errors, making it hard to compare results. Dean (1999)

developed a quick, valid and reliable method for scoring

medication error severity that does not require knowledge of

actual patient outcomes and this is used in three of the studies

in Table 1 (Dean & Barber 2000, Taxis & Barber 2003,

Barber et al. 2009). The development of a validated approach

to estimating error severity enables the observer to intervene

prior to the nurse making the error rather than requiring the

effect of the error to be observed.

It can be seen that the severity of MAEs in the older person

in a secondary care setting has not been determined. This

population receives more medicines on average than younger

persons and has the additional complexity of an increased

prevalence of dysphagia due to conditions such as stroke and

Parkinson’s disease. The majority of medicines are prescribed

for administration via the oral route and in older persons who

have swallowing difficulties but a patent oral route nurses are

frequently required to alter the oral formulation prior to

administration (Kelly & Wright 2010). This may be via

dispersion in water, crushing or mixing with food. In some

cases, the manipulation may be inappropriate and contrary to

the published standard approaches (Fair & Proctor 2005,

Smyth 2006, White & Bradnam 2006).

We carried out a multi-faceted research study that

demonstrated that although the number of errors for older

patients in the secondary care setting was very high the

number of errors in those patients with dysphagia was

significantly higher (Kelly & Wright 2011 in press). The part

of that study reported here aimed to determine the severity of

identified errors.

Method

This study was carried out on one stroke and one care of

older people ward in each of four hospitals in East Anglia.

The hospitals were a convenience sample selected on the basis

that the observer (JK) could get to the hospital in time for the

07.00 drug round. The wards were selected by staff working

in each hospital with the aim of observing as many patients as

possible with swallowing difficulties (the focus of the parent

study). A total of 62 nurses were observed administering oral

medicines during early morning and lunch time medicine

rounds (Table 2). The medicine rounds varied in length from

30 minutes for the lunchtime ones through to three hours for

the early morning ones. The nurses were fully aware of the

reasons for the study and the data that was being collected.

Their written consent was obtained prior to starting the drug

round and all nurses approached agreed to take part.

Contrary to many other similar studies (Dean et al. 1995,

Ridge et al. 1995, Gethins 1996, Cavell & Hughes 1997, Ho

et al. 1997, Ogden et al. 1997, Dean 1999, Taxis et al. 1999,

Dean & Barber 2000, van den Bemt et al. 2009) the observer

was a nurse rather than a pharmacist and it was anticipated

that being observed by a fellow nurse would be less stressful

for the nurses, resulting in more natural behaviour.

All the observations were carried out by one researcher

(JK) using two printed proforma (one for oral administration

and one for enteral) to ensure consistency of data collection.

The proformas were used to record the details of the oral

medicines that were administered including dose, route,

formulation and preparation, including tablet crushing,

capsule opening, tablet dispersion, addition to food and

viscosity of liquid medications. Both proforma had previ-

ously been tested in a small study (Jackson et al. 2007) and

then piloted in one drug round for the purpose of this study.

As no changes were made to the proformas as a result of the

pilot, the results of the pilot were included in the analysis of

J Kelly and D Wright

2 � 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing

the results (Table 2). To identify errors the nurses’ practice

was compared with what had been prescribed. However, as

the medicine prescription often does not include directions

on how the medicine should be prepared and this aspect is

particularly important for patients with swallowing difficul-

ties and enteral tubes, the nurses’ performance was also

compared with best practice guidelines (British Association

of Parenteral and Enteral Nutrition 2004, Fair & Proctor

2005, Smyth 2006, White & Bradnam 2006) to identify

errors.

In line with similar research (Dean 1999, Haw et al. 2007)

the observer (JK) intervened in incidents where there was

potential for patient harm but these incidents were still

recorded as errors. All observed MAEs were classified using

an adapted version of the 11-point system based on the

American Society of Hospital Pharmacy’s system (American

Table 1 Medicine administration error severity studies in adults

Study Method

Error severity

Minor Moderate Severe

Ogden

et al. (1997)

Observation of 131 MAE involving oral drugs on

two medical wards in UK hospital. Scored with

six-point scale.

73Æ3%

(score 1/2)

26Æ7%

(score 3/4)

0%

(score 5/6)

Hartley and

Dhillon (1998)

Observation of 254 cases of prescribing/administration

errors of IV drugs on one medical and two surgical

wards in UK hospital�

78% 17Æ3% 4Æ7%

Dean and

Barber (2000)

Observation of 188 cases of MAE of oral drugs on one

surgical and one medical ward in a UK teaching

hospital. Scored with a validated 11-point scale

84%

(score < 3Æ0)

16%

(score 3Æ0–7Æ0)

0%

(score > 7Æ0)

Taxis and

Barber (2003)

Observation of 212 IV preparation/administration

errors in 10 wards in 2 UK hospitals. Scored with a

validated 11-point scale

39Æ2%

(score < 3Æ0)

59Æ4%

(score 3Æ0–7Æ0)

1Æ4%

(score > 7Æ0)

Wirtz

et al. (2003)

Observation of 77 IV preparations (MAE 22%) and 63

IV administrations (MAE 27%) in UK hospital*

27%

(score < 35)

74%

(score > 35)

Wirtz

et al. (2003)

Observation of 126 IV preparations (MAE 23%) and

109 IV administrations (MAE 49%) in German

hospital*

31%

(score < 35)

67%

(score > 35)

Haw

et al. (2005)

Retrospective review of 103 MAE reports using a

5-point scale in a large UK psychiatric hospital

83Æ5%

(grade 1–2)

15Æ5%

(grade 3)

1%

(grade 4)

van den Bemt

et al. (2007)

Observation of 242 MAE in five learning disability units

in the Netherlands. Scored with nine-class NNCMERP

taxonomy of medication errors (The National

Coordinating Council for Medication Error Reporting

and Prevention 2001)

100%

(class A–C)

0%

(class D–F)

0%

(class G–I)

Barber

et al. (2009)

Observation of 153 errors of monitoring, prescribing,

dispensing and administering drugs in 55 UK care

homes. Scored with a validated 11-point scale

Mean score for

prescribing errors

2Æ6, for

administration 2Æ1and for dispensing

2Æ0 (score < 3Æ0)

Mean score for

monitoring errors

3Æ7 (score 3Æ0–7Æ0)

0%

(score > 7Æ0)

van den Bemt

et al. (2009)

Observation of 428 MAE in three nursing homes in the

Netherlands. Scored with nine-class NNCMERP

taxonomy of medication errors (The National

Coordinating Council for Medication Error Reporting

and Prevention 2001)

47% (class A–C) 53% (class D–F) 0%

(class G–I)

Westbrook

et al. (2010)

Observation of 1067 clinical MAE involving all drug

administrations in two hospitals in Australia. Scored

with New South Wales five-point scale (New South

Wales Health Department 2004)

79Æ3% (level 1) 20Æ0%�

(level 2 and 3)

0Æ84%

(level 4 and 5)

*Scale not stated.�Scale not used.�Figure calculated from information given.

Original article Medicine administration errors and their severity in secondary care older persons’ ward


Society of Hospital Pharmacists 1993). Errors were thus

classified as omissions, unordered drugs, wrong drugs, extra

doses, incorrect doses, incorrect formulation, incorrect route,

incorrect preparation, incorrect timing of administration,

deteriorated medicines and other. The MAE rate was

calculated using the equation:

Total number of drug errors observed

¼ Observed errors� 100

Total opportunities for error

To calculate the potential harm score a purposeful selec-

tion of a sample of 25% of the observed non-time errors were

assessed using the method validated by Dean (1999). Two

senior clinical pharmacists, an experienced doctor working in

General practice and a clinical nurse specialist who is also a

qualified non-medical prescriber were sent the brief descrip-

tions of the 35 incidents together with a covering letter. They

were asked to rate each incident in terms of their potential

clinical significance. They were asked to score each incident

on a scale from 0–10, where 0 should be given to an incident

which will have no effects on the patient and 10 should be

given to an incident that would result in death. They were

asked to mark the visual analogue scale clearly by either

circling the appropriate number or placing a clear mark

anywhere between the numbers. They were told to assume

that all the patients were adults on either a care of older

people or stroke ward. The four clinicians scored the patients

independently and, although they knew that other profes-

sionals were being approached, they were unaware who they

were or what profession they were. Once all four sets of

scores were returned their mean was calculated and was

recorded as the harm or severity score for that error. This

methodology has been shown to have a generalisability

coefficient of 0Æ83, that is, there is an 83% agreement on

MAE severity between any two assessments, irrespective of

the judge and the occasion on which the case was assessed.

Based on 16 medication errors with known outcomes Dean

(1999, p. 217) graphically demonstrated a clear relationship

between actual patient outcomes and judges’ scores, leading

her to suggest that an error given a score of less than 3Æ0

would be likely to result in an outcome of minor severity,

between 3Æ0–7Æ0 an outcome of moderate severity and above

7Æ0 the outcome would be severe.

The Mann–Whitney U-test, a nonparametric test was used

to identify if there was a difference between the mean severity

scores for patients with and without dysphagia. Patients were

described as dysphagic if they had been assessed by a Speech

and Language therapist or a nurse trained to undertake

swallowing assessments, as having difficulty swallowing

liquids or solids and requiring alteration of the consistency

of their food, fluids or medication. Ethical approval was

gained from West Kent Research Ethics Committee prior to

commencing the study and again after initial data collection

to allow analysis of the severity of the errors observed.

Written consent was obtained from the nurses prior to

observation.

Results

A total of 65 drug rounds involving 2129 potential drug

administrations were observed to 625 patients (Table 2). Of

the 2129 potential medicine administrations 817 doses

(38Æ4%) were given incorrectly (95% CI = 36Æ3–40Æ4). The

most common error was either administration of the medi-

cine over an hour early or more usually over an hour late

(Table 3). Excluding time errors there were 228 errors

(10Æ7%; 95% CI = 9Æ4–12Æ0). Two hundred and eighty three

patients experienced at least one drug error (45Æ3%; 95%

CI = 41Æ4–49Æ3), which reduced to 126 (20Æ2%; 95%

CI = 17Æ0–23Æ3) when time errors were excluded.

Sixty-four of the 228 non-time errors observed were

duplications (e.g. on two separate occasions involving two

different patients a nurse omitted a dose of furosemide) and

some involved the mixing of several drugs leading to several

Table 2 Summary of drug rounds observed in the clinical areas

Hospital 1 2 3 4

Total

Teaching Yes Yes No No

Type of ward Stroke

Older

people Stroke

Older

people Stroke

Older

people Stroke

Older

people

No. of beds 16 28 37 37 30 34 34 29 245

No. of different nurses observed 8 8 8 7 8 7 8 + pilot 7 61 + pilot

No. of drug rounds observed 8 8 8 8 8 8 8 + pilot 8 64 + pilot

Total no. of patients 41 97 67 104 82 66 95 73 625

Total no. of drug administrations 127 368 180 355 242 246 349 262 2129



errors as each individual drug was given incorrectly, but only

one incident. Omitting the duplications this gave us 143

different non-time related incidents of which 35 (25%) were

purposively selected so as to ensure that all types of error

were included as well as an equal number of errors involving

dysphagic and non-dysphagic patients. Table 4 shows 10

examples of the incidents analysed together with their mean

harm scores. Ten incidents (28Æ6%) were classified as minor

(score < 3Æ0), 24 (68Æ6%) as moderate (score 3Æ0–7Æ0) and

one (2Æ9%) as severe (score > 7Æ0).The overall mean harm

score of the 35 incidents was 4Æ1 (range 1Æ1–8Æ6, SD 1Æ8) on a

scale of 0–10.

The mean severity scores for patients with and without

dysphagia were compared using Mann–Whitney U-test and

no statistically significant difference was found in the severity

of errors experienced between the two groups (Table 5).

Discussion

Number of errors

Time errors, where the medicine was over one hour earlier or

later than prescribed, were the most common type of error

identified and in many instances this is not a problem for the

patient. However, it can be a significant problem for those

patients who require their medicines at specific times, for

example, those on anti-Parkinson drugs. Several of the

patients in this study did have Parkinson’s disease and one

of them forms the focus of a critical incident analysis (Kelly

et al. 2011). Time errors were largely due to either inappro-

priate times being stated on the medication chart for

example, 06.00 am when the round started after 07.30 am,

or they were due to the length of time taken to complete the

round from start to finish.

Table 4 Mean severity scores of 10 scored observed MAE incidents

Incident Mean score

The nurse gave 625 mg of co-amoxiclav to the wrong patient. 8Æ6The nurse dispensed and signed for the prescribed 8 am capsule of 250 mg of vancomycin. The capsule was still on the

patient’s bedside cupboard at 10 am when the researcher left the ward.

7Æ0

The patient was prescribed 200 mg of meptazanol but the nurse gave 400 mg. 6Æ6The nurse dispersed together in water 20 mg omeprazole, 75 mg aspirin, 4 mg perindopril and 25 mg spironolactone. She

added a proprietary thickener (Thick & Easy�) to produce a pudding like consistency before administering the mixture to

the dysphagic patient by spoon.

6Æ3

The nurse gave 1G of paracetamol to the wrong patient. 5Æ5The patient was prescribed 5 mg (2Æ5 ml) of oramorph. The nurse used a measuring cup to measure it and gave 4 ml (8 mg). 4Æ8The nurse crushed a 125 lg tablet of digoxin with a pestle, added water and administered via NG tube, without flushing the

tube before or after administration.

4Æ4

The patient was prescribed 300 mg enteric-coated aspirin. The nurse gave 75 mg dispersible aspirin. 3Æ6The patient was prescribed 20 mg fluoxetine, but the nurse failed to give it. 2Æ3The patient was prescribed and given 5 ml of nystatin suspension for oral thrush. 1Æ1

Table 5 Comparison of severity scores for

non-dysphagic and dysphagic patientsStatus n Minimum Maximum Mean

Standard

deviation

Non-dysphagic severity score 17 1Æ1 8Æ6 4Æ035 2Æ0109

Dysphagic severity score 18 1Æ1 7Æ0 4Æ128 1Æ6492

Table 3 Medicine administration errors

Error type

Total

Number %

Wrong route 0 0

Deteriorated drug 0 0

Unordered drug 2 0Æ3Wrong drug 2 0Æ3Extra dose 3 0Æ4Wrong dose 25 3Æ1Wrong form 38 4Æ7Omission 40 4Æ9Other 53 6Æ5Wrong prep 65 8Æ0Wrong time 589 72Æ1

817 100



It was usual for medicine rounds, especially early morning

rounds, to last for 2–3 hours and therefore it was not

possible for the nurse to administer the medicine within an

hour of the prescribed time. Reasons for the long duration of

the medication rounds however require exploration.

Although older patients are likely to receive a substantial

number of medicines and this will explain a significant

proportion of the time taken, the extra time required to

prepare medicines for administration to older patients may

also contribute to the prolonged duration of medicine

rounds. Additionally, the nurses were frequently interrupted.

This further prolonged the medicine round as well as

distracting the nurse which itself can increase the number

of MAEs (Cheek 1997, Fry & Dacey 2007, Kreckler et al.

2008, Westbrook et al. 2010). For those patients where dose

timing is important alternative interventions require identi-

fication and this may involve prioritisation of such patients

in the medicine round.

The response of some nurses to the long time taken to give

medicines to difficult patients was to dispense and sign for the

medicine and then leave it by the bedside with the intention

of returning to administer it later. This contravened the

policies of all four Trusts and on 28 occasions the medicine

was still at the bedside when JK left the ward, up to two and a

half hours after the nurse dispensed it. The fact that the

medicine has been signed as being given, when it some cases it

is not, makes it difficult for the prescribers to evaluate the

effectiveness of the treatment and if carried out repeatedly

could lead to loss of control of the patient’s disease.

Given that this study is relatively small snapshot of practice

and the presence of the researcher may have exerted a

Hawthorne effect on the behaviour of the nurse, it is of some

concern that without intervention by the observer four

patients would have received either the wrong drug or an

unprescribed drug, 28 patients either the wrong dose or an

extra dose and in 40 instances the drug would have been

unintentionally omitted. Furthermore, the nurses concerned

would have been totally unaware that they had made an

error.

Severity of errors

This study identified a mean severity score of 4Æ1 out of a

potential score of 10 for 35 MAEs, excluding time errors.

Our error severity score is high compared with a recent study

of patients in care homes which used the same methodology

and identified a mean harm score of 2Æ1 (range 0Æ1–5Æ8)

(Barber et al. 2009). However, patients in hospital are

usually sicker than those in care homes and often require

more potent drugs which have the potential for greater harm

if given incorrectly. Despite this, a study involving 188 MAEs

on a surgical and medical ward identified a low mean harm

score of 1Æ9 (range 0–5Æ6) (Dean 1999, Dean & Barber 2000)

using the same methodology. One explanation for this

difference is that the patients in our study are older and

were seen by the scorers as more susceptible to adverse events

due to age-related changes in pharmacokinetics and pharma-

codynamics. Also, the scorers had no clinical patient details

on which to base their scoring, as ethical approval did not

allow collection of this information and so it is possible that

they based their scores on worse case scenarios and hence

generated a high mean harm score.

The third study that used the same methodology as

ourselves (Taxis & Barber 2003) involved IV drugs and

although a mean severity score is not identified in the article, it

is would appear from Table 1 that our distribution of severity

scores is similar to theirs. This finding is unexpected as

intravenous drugs by their very nature are fast acting and

difficult to ‘retrieve’ and they tend to be used for patients who

are seriously ill and already having difficulty maintaining

homeostasis, thus making for greater risk of severe errors. As

already suggested above, the raters in our study may have

over-scored the error severity. Alternatively, our severity

scores involving oral medications are valid and as serious as

those involving intravenous medication. Preparing and admin-

istering medicines to patients with dysphagia and via enteral

feeding tubes is complex and probably of similar complexity

as preparing and administering intravenous medication.

However, although this complexity is likely to increase the

error rate it does not explain the degree of severity, especially

as we found no difference between dysphagic and non-

dysphagic patients’ mean error severity scores.

A recent Australian observational study examining the

preparation and administration of 4271 medications to 720

patients found a significant association between the number

of interruptions nurses had whilst administering the medicine

and both the number of clinical errors and their severity

(Westbrook et al. 2010). Although interruptions were not

measured in our study as already discussed drug rounds took

a long time and the nurses were frequently interrupted.

Arguably the longer the drug round, the greater the oppor-

tunity for interruptions and thus the greater the chance of

errors with an increased risk of the errors being severe.

However, research in the United States has concluded that

severe and non-severe MAEs may have different antecedents

(Chang & Mark 2009). The 6-month study of reported

MAEs in 279 nursing units found that as the number of

degree-prepared nurses increased severe medication errors

(defined as errors that required increased nursing interven-

tion) decreased, but that non-severe errors did not decrease.



Furthermore, they found that there was an optimal propor-

tion of degree-prepared nurses (54%) and that more was not

better, that is, the relationship is curvilinear. This may

explain the higher number of moderately severe errors in our

study as only 35Æ2% of the nurses in our study held a degree

(Kelly & Wright 2010). However, a criticism of Chang and

Mark’s study is that it is based on error reporting and the

number of errors recorded probably says more about the

reporting behaviour of the nurses than the actual incidences,

with more severe errors being reported more frequently

because they are too serious to conceal.

Another possible explanation for the higher severity score

found in this study is the use single-handed drug administra-

tion. When nurses give intravenous drugs it is recommended

practice for two registered nurses to be involved in checking

the drug (Nursing and Midwifery Council 2008). As a result,

harmful errors are more likely to be prevented. In compar-

ison, current practice for general medicine drug rounds is for

one nurse to prepare and administer the medicines, with no

second person to detect and prevent errors. A 46-week cross-

over study in Australia comparing error rates when medicine

was administered by two nurses as against a single one

detected 319 errors among 129,234 medications adminis-

tered (Kruse et al. 1992). The MAE rate per 1000 medica-

tions administered by a single nurse was 2Æ98 (95%

CI = 2Æ45–3Æ51) and was statistically significantly higher than

2Æ12 (95% CI = 1Æ69–2Æ55) per 1000 for two nurses.

A time and motion study found that an additional

17.1 hours of nursing time was required per 1000 medica-

tions administered if two nurses were used (Kruse et al.

1992). The authors concluded that as the errors were

relatively minor the reduction in error rate was insufficient

to justify the cost. However, drug administration is one of the

highest risk areas of nursing practice (Wolf 1989, Gladstone

1995) with the potential for significant harm due to both the

number and severity of MAEs, as found in our study. It is

therefore illogical to remove a system redundancy fail safe to

save 20 minutes on a drug round. Chang and Mark (2009)

argue that on units with more registered nurse hours there is

increased surveillance and supervision of each other’s per-

sonal performance and thus fewer chances of error although

they were not able to demonstrate a significant relationship to

either severe or non-severe errors.

Error reporting

Although all four hospitals had policies and procedures in

place that require staff to report any relevant medication

errors, none of the nurses observed made any attempt to do

so during the time that the observer was present. It is

important that medication errors are reported so that both

individual practitioners and departments can learn from the

incident and appropriate changes can be put in place. If errors

or near misses are not reported it is difficult for Trusts to put

strategies in place to reduce errors. However, a survey based

on 81 questionnaires given to trained nurses identified that

63% of respondents were not sure what constituted a

medicine error and the author concluded that many errors

went unreported (Gladstone 1995), as here. Research involv-

ing 4000 nurses in the US found a similar problem (Wakefield

et al. 2005) as did research involving pharmacists (Cousins &

Upton 1993, Garrett & Reeves 2009). The main reasons for

reporting failure is fear of reprisals and disciplinary action

(Arndt 1994, Gladstone 1995, Walker & Lowe 1998,

Osborne et al. 1999, Hand & Barber 2000, Cohen et al.

2003, Wakefield et al. 2005) and the time and effort required

to complete incident forms (Anderson & Webster 2001,

Wakefield et al. 2005, Williams & Ashcroft 2009).

Limitations

Our study is limited to observations of four hospitals in East

Anglia and to only Care of the Older people wards and Stroke

units. The findings cannot necessarily be extrapolated to other

settings. Furthermore, the findings are based on a relatively

small sample of 2129 medicine administrations and 35

incidents. The findings should thus be viewed as a pilot study,

which would benefit from repetition with a larger sample.

Our study in line with many others concentrated on non-

time errors. However, a recent report identified that between

September 2006–June 2009 the NPSA received reports of 27

deaths, 68 severe harms and 21,383 other patient safety

incidents relating to omitted or late medicines (National Patient

Safety Agency 2010). Of particular concern are omission or

delayed administration of antibiotics and anti-fungals and

anticoagulants (National Patient Safety Agency 2010). A group

of patients for who delayed administration of medicines is a

particular problem is patients with Parkinson’s disease, a group

of patients particularly relevant to our study as they frequently

suffer with dysphagia. If this client group do not get their

medicines on time they experience lose of function including

decreased swallowing ability. This is being highlighted by the

Parkinson’s disease Society’s ‘Get it on time’ campaign.

Relevance to clinical practice

The MAE rate and severity scores found in this study were

higher, even when time errors are excluded, than similar

previous studies. This has implications for MAE research as

although it is important to reduce the MAE rate, it is more



important for the patient and the health service to reduce the

more severe errors to minimise patient harm. To this end,

future research needs to concentrate on identifying the causes

of moderate to serious errors, so that they can be reduced. To

enable this it is imperative to encourage nursing staff to

increase their own self-awareness when carrying out medicine

rounds, so that they are aware of the near misses and errors

that they make and that they report them.

Acknowledgement

The PhD is funded by an unrestricted grant from Rose-

mont Pharmaceuticals. The company were not involved

in the study design; they have no right of access to the

data and exercise no control over the publication of any

results.

Contributions

Study design: JK, DW; data collection and analysis: JK and

manuscript preparation: JK, DW.

Conflict of interest

None.

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