• Home
• Articles
• Essays
• Add site

Typical Drug Errors in Nursing

Drug errors in nursing


INTRODUCTION

Acquired competency in drug administration is an integral criterion for entry to the professional register (NMC, 2004). However, it is not a skill that professional nurses reflect on daily, unless a problem related to actual or potential errors (Birch & Culshaw, 2003). In acknowledging that administration of medicines needs attention, Scott (2002) notes that a lack of stringent management on drug policy in recent years has led to a relaxed attitude amongst those professionals who prescribe and administer drugs. This in turn has led to an increase in errors being reported by the Audit Commission (2001). Approximately 1200 people died in 2001 in England and Wales as a result of drug errors, a rise of 500% over the last decade. Concern for public safety is reasonably justified. To promote public confidence, nurses urgently need to address why drug errors (both potential, near misses and actual errors), can and do occur in practice.

Successful strategies used by other industries for reducing errors have also been recommended for health care. Research that used teamwork, decision support, and checklists borrowed from the airline industry can contribute value to health care safety efforts (Agency for Healthcare Research and Quality (AHRQ, 2001). Pilots follow checklists directing appropriate actions, and do not engage in conversation unrelated to the flight during take-off and landing. Airline research indicates that errors have occurred most often because of failure in this type of teamwork and coordination. Similar complex work encountered in health care also requires teamwork and other strategies borrowed from aviation. Thus, nurses could potentially prevent errors by using safety checklists and other passes during critical times. Reducing unnecessary conversation and other distractions would be an additional mechanism for medication safety. To that end, redesigning the healthcare workplace to avoid interruptions has the potential to prevent errors and will be discussed in this assignment.

Administration of medication is a key element of nursing care. Every day some 7,000 doses of medication are administered in a typical NHS hospital (Audit Commission, 2002a). A fifth of all clinical negligence litigation in the UK stems from errors in the use of prescribed medicines (Audit Commission, 2002b). Safer use of medicines is a key element in the Government's drive to increase quality and safety of care. The publication 'Improving Medication Safety' (Doh, 2004) stems from the commitment, first set out in ‘an Organisation with a Memory' (Doh, 2001??) to reduce the frequency of serious medication errors.

The nature of modern healthcare means that nursing care is often delivered in a busy and disruptive environment (Pape, et al, 2005). My placement was based on a very busy medical admissions ward. Unfortunately, much of our tasks as nurses and on my particular placement required a depth of concentration in order to avoid the occurrence of errors. Armitage & Knapman (2003) pointed out that nurses spend up to 40% of their time administering medications. It is unsurprising then to find that several studies have suggested that patients are not always receiving the correct drug, at the correct time and at the correct dosage (Hartley & Dhillon, 1998, MORE). The costs of drug errors are varied; from the obvious human costs to the patient, their family and the administering nurse, to the financial impact on the National Health Service (NHS) which Farrar (1999) estimates is over 1.6 million pounds per hospital per year, finally we should also consider the increasing loss of public trust in healthcare professionals. When we consider this along with the fact that error rates for intravenous drug administration are as much as 27% (Hartley & Dhillon, 1998, NEW REF) Clearly, the potential for error in drug administering on the hospital ward makes this a problem of concern for nursing staff everywhere (ref). And there is certainly a strong argument for change (REF).

The Nursing and Midwifery Council (NMC, 2004) emphasizes the individual responsibility of the nurse to ensure that they practice safely and correctly when administering medications. Unfortunately, we have limited control over the environment in which we deliver care, so how do we as nurses change our environment in order to allow us to have the time and lack of distractions necessary to perform safe drug administration? This paper will attempt to answer this question by examining the issue of medication errors, exploring the various contributing factors and how they can be avoided. It will also discuss and critically analyse management strategies for implementing change in the healthcare setting. Examples from clinical placements will be discussed, and for reasons of confidentiality will be referred to as 'the patient' or nurses will be refereed to as a psynomynie at all times. This is in accordance with the Nursing and Midwifery Council's (NMC) Code of Professional Conduct (2004). Because of limitations in the word count I am unable to address all the contributing factors associated with drug errors. In this assignment it is argued that errors are not caused by any one factor but are multifaceted in nature. This assignment will endeavour to answer the question what can be done to promote safer drug administration?

In NHS system hospitals have been told to do more to cut out medication errors after figures showed 40,000 mistakes a year are made (BBC News, 2006).


Environment Distractions:

Williams (1996) found that distraction were cause of many drug errors, in a study by (ref) of x amount of nurses it was found that …… distractions influenced work………
However, (ref) study of x amount of nurses arfues with these findings suggesting that
(ref) further suggest…….

In reality it is very difficult for nurses to have any influence on distractions either from patients or staff etc and as suggested by Castledine (2006) it is diffcult for the nurse to be able to influcence them.

HOW CAN DISTRACTIONS BE OVERCOME:
PAPE (2005) good arguments
Number of nurses used in study
What problems were observed
How were they selected
What the study did
What study found out
Was sample size small
Were nurses selected at random
AMERIACN CAN IT BERELATED TO UK
Experiences on ward using system
What do I conclude

Interruptions and distractions are often cited as a contributory factor to medication errors (Walters, 1992; Davis, 1994, Williams, 1996). Unfortunately, there is little research available on the actual link between distractions and rate of error, and that which is available is conflicting. Scholz (1990) (REF) found that there was no link between task interruption and medication errors. However, Conklin et al (1990) (REF) found that nurses often perceived distractions to be contributing to an increase in errors. Regardless of the availability of research, common sense would dictate that any task involving medication administration should be undertaken with the nurse's full concentration. Trim (2004) described the ideal environment in which to deliver nursing care as having the least distractions possible with low noise levels. Such factors are often outside the individual nurses control, however the literature does suggest a number of systems approaches to deal with the constant interruptions from other members of the multi-disciplinary team, visitors and patients at times when the nurse needs to concentrate most.


WHAT WAS THE PURPOSE OF THE STUDY

Pape et al (2005) study was based on a study where focused protocols and teamwork significantly reduced distractions they discussed the use of signage to draw attention to the need for concentration during drug rounds. The idea was introduced into a hospital in the USA, where the signs were placed at strategic areas including medication trolleys. At the same time new protocol was introduced to the ward that required nurses to avoid conversation and prevent interruptions during drug admini-stration. The same protocol was copied to other members of the multidisciplinary team in an effort to gain their co-operation in avoiding interruptions. The introduction of the signs and the protocol had the desired effect, resulting in a substantial drop in the number of interruptions and distractions during drug administration. However the study did not discuss whether this drop in interruptions actually translated into a drop in errors. Although the studt was based in America the findings can be related to UK nursing, as environmental factors in drug administration effect nurses everywhere.


TABARD SYSTEM

A similar strategy was introduced into a busy medical admissions ward whilst I was on clinical placement in the acute setting. The idea being that any nurse administering medications would wear a tabard that declared that they could not be interrupted as they were administering drugs. As with the study by Pape et al (2005), there were both positive and negative reactions to such an intervention. Nurses were responsible for their own tabards and this meant they had to take them home to launder them. This was the first stumbling block as some nurses would often forget their tabard at home and have to proceed on the drug round without it. Pape et al (2005) discussed the reluctance of some nurses in their study at adopting the new protocol as they felt that it might slow them down. Some of the nurses felt that the change was unnecessary, especially those who felt that they were not making mistakes following the old system. The signage and protocol were accepted by the majority of the nurses and seemed to make a positive impact on the environment. Unfortunately the same cannot be said of the tabard system, as it was abandoned once the nurse who had championed the idea left the ward to take up a new post. Why are nurses so reluctant to accept change? It has been said that if a person believes that the costs to themselves outweigh the perceived benefits, then the motivation to change is poor.
Not accepting change. Despite the generally held reservations about the value of the change, there was a variety of responses amongst the staff, which can be analysed in terms of personality characteristics. From working with Jane and Anne, I perceived them to have a generally positive outlook on life, which was reflected in them trying to see what was good about the change, or how the situation could be improved. In contrast, Carol and Gill seemed to be more negative, trying to find fault in the new system without looking for solutions. This accords with Arvey et al’s (1989, cited by Cooper, 2002) finding that people have characteristic tendencies to have positive or negative views on life, which affects job satisfaction, and reflects a distinction that Templar (2006) makes of some people tending to be "part of the problem" whereas others strive to be "part of the solution". It was also interesting to see that Sarah and Julie's reaction to the change reflected who they were working with. One day, they were with Carol and Gill, and spoke negatively about the changes, whereas the following day when Carol was off work, and they were working with Jane, Sarah and Julie were came up with ideas for making the changes work better. This exemplifies how people can feel the need to conform to the opinions of others around them, as described by Cardwell, Clark & Meldrum (2003), McIlveen & Gross (1998).

Therefore, although all were affected differently and for different reasons, the process of change and the details of the changes certainly appeared to affect motivation and stress levels within the team. Reductions in motivation and increases in stress are factors that Porter (2004), Hackman & Oldham (1979, cited by Huber, 2000), Sarafino (2006) and Shields & Ward (2000) agree can result in people taking more time off sick or being more likely to leave their job. Thus even if the changes were to make the ward more efficient in terms of patient throughput, the benefits may be lost by the need to cover for staff absences or to recruit new staff.


AIRLINE INDUSTRY

The DOH (2000) suggests that we look to ideas from the airline industry in how to learn from error and maximise client safety. Airline research has shown that most errors have occurred as a result of a breakdown in teamwork and co-ordination. In response the airline industry has placed increased emphasis on maintaining teamwork and clear lines of authority, with safety checklists and a policy of no-conversation at take off and landing, which are critical times for the pilot. Pape et al (2005) advise that similar techniques could be employed such as the use of safety checklists when administering medications and the avoidance of interruptions. They even go on to advise that the workplace should be designed so as to avoid distractions, with designated areas for drawing up and calculating drug dosages. Such areas, known as treatment rooms or clean sluices were a common feature during my placements in the acute setting. However, they were often busy with more than one nurse needing to use them at the same time, and often in groups of two to enable them to adhere to policy by having two person checks for intravenous or controlled medications.


SAFE PRACTICE

There is no doubt that technological innovations have saved and extended the lives of many patients. But, increasingly, high-tech health care has had negative effects – often unexpected – on the health and quality of life of patients. An instructive example is the introduction of a simple piece of technology such as the latex glove. Our move away from commonsense procedures, such as hand-washing, has contributed to a high incidence of infection in hospitals.

The case described included the 2 persons checking for IV drug and controlled drugs who were in the room full of noisy people. Therefore the distractions took place. As the nurse is accountable for their own actions and therefore they should be able to ask for less noise and not answer someone when they are dispensing controlled drugs, the less noisy room is required for ensuring safe practice.

Inappropriate pharmacological intervention, such as the over-prescription of antibiotics, has also contributed to the increase of 'super' infections due to the creation of new, resistant strains of bacteria. Increased pharmacological technology has also produced an increase in errors in drug dispensing. Drug 'events', as they are referred to in health care, now make up the majority of accidental or adverse incidents in hospitalised patients in the UK (Castledine, 2006). These drug errors occur mainly during ordering and dispensing, which appears to point to practitioner error but has been shown to be caused mainly by faulty systems (Castledine, 2006).


QUALITY ASSURANCE

A study investigating the number of drug-related hospital admissions found equally concerning data. Each year at least 80 000 hospital admissions are due to medication-related problems. But while such outcomes are extremely concerning and costly, there would be little debate about the positive impact drugs have had on mortality rates and quality of life globally.

There has been a flood of litigation, particularly in the UK, relating to the health problems created by technology. A settlement trust of $4 billion in the case of Dow Corning (who manufactured silicone breast implants) was judged to be inadequate compensation for the chronic illnesses which have damaged so many women's lives (Castledine, 2006). Manville, the industrial giant which manufactured asbestos – which causes mesothelioma – is bankrupt from litigation with an increasing number of cases emerging as the full impact of asbestos-related disease is revealed. Electromagnetic field radiation, which surrounds us daily through our electrical appliances, undergoes ongoing investigation for its links with cancers, as do a number of potential environmental hazards such as hydrocarbons and hydrochlorofluorocarbons (HCFCs), all part of the technological evolution (Castledine, 2006). Increased litigation, ironically, has meant an increased use of technology for screening and diagnosis in the UK, with the spiral CT scan being used to diagnose relatively simple conditions such as an inflamed appendix.


RISK MANAGEMENT

A particular hallmark of anaesthesia is that the decision maker does not just "write orders" but is involved directly and physically in implementing the actions decided upon. Executing these actions requires substantial attention and may in fact impair the anaesthetist's physical ability to perform other activities (e.g., when an action requires a sterile procedure). When performing actions, a variety of errors of execution (slips), may occur (Hutton, 2003). In case if the risks due to slips in anaesthesia have been addressed through the use of engineered safety devices that physically prevent incorrect actions. For example, newer anaesthesia machines have interlocks that physically prevent the simultaneous administration of more than one volatile anaesthetic agent. Other interlocks physically prevent the selection of a gas mixture containing less than 21% oxygen (Hutton, 2003).

Successful dynamic problem solving in anaesthesia requires the supervisory control level to initiate frequent revaluation of the situation. The initial diagnosis and situation assessment can be incorrect, especially when the available cues do not precisely identify a problem. Even actions that are appropriate for the problem are not always successful, and they sometimes cause serious side effects. Furthermore, there is often more than one problem to deal with at a time. Only by frequently reassessing the situation can the anaesthetist adapt to dynamically changing circumstances. The revaluation process returns the anaesthetist to the "observation" step of the process model, but with specific assessments in mind (Hutton, 2003):
• Did the actions have any effect (e.g., did the drug reach the patient, or could there have been a problem with the intravenous infusion)?
• Is the problem getting better, or is it getting worse?
• Are there any side effects of the actions?
• Are there any additional problems that were missed before?
• Was the initial situation assessment or diagnosis correct?

The process of continually updating the situation assessment and of monitoring the efficacy of chosen actions is termed situation awareness, a concept that has been used extensively in aviation.


NURSES RESPONSIBILITY AS ACOUNTABLE

Howver in a study by (ref) x amount of nurses were selected by ramdom etc this study found that two practitioners checking did not always prevent errors because………
In view of this Timms (2004) suggests that
Is this difficult to implement in practice (MY EXPERIENCES)


REPORTING ERRORS:

Another recommendation from the Audit Commission (2001) report, that is supported by Scott (2002), advocates the importance of honest reporting of errors by nurses, but only if by their honesty they are not subjected to disciplinary action. The NMC (2004) is also clear in its advice and states that it is important for an open culture to exist in order to encourage the immediate reporting of errors or incidents in the administration of medicines. Unfortunately as Anderson & Webster (2001) recognises the predominant approach for dealing with error is for employers to blame the individual. However this only makes professionals wary of reporting such incidents, particularly if they face a ruined career as a consequence. EXAMP:E FROM PRACTICE. IN an attempt to overcome this problem in incident reporting, Webster & Anderson (2002) recommend adopting an anonymous, long-term reporting of system problems in a non-punitive environment. The systems problem approach calls for safety initiatives that focus on improving the wider system in which professionals work. Webster & Anderson (2002) advocate local action planning as a proactive measure (Appendix 1), thus enabling professionals to identify risk factors and find solutions within their daily practice. Obviojslt research and a debate on this approach would be worthwhile if drug errors are to be reported honestly and immediately by all health professionals.


STUDIES:

Armitage (2005) carried out an observational qualitative research study on drug errors, he wanted to know the prevalence of drug errors to improve professional competencies. He stated the drug errors should not be used to ruin a climate of openness and trust, or to blemih a nurses' reputation when an observation reveals failures in the procedure. Howver Navarlaz-Diaz & Gomez-Segui (2005) differ with Armitage (2005) in the overall judgements that he makes on observational research primarily. Evidence exists to show that subjest behaviour and study outcomes are altered as a result of the subjects' awareness of being under observation. This is known as Hawthornes Effect and was first identified in the 1930s (Mangione-Smith 2002). Therefore this effect distorts completely the value of any alternative approach: What is the sense of an observational study where participants consent has been given if validity is not guaranteed?


REPORTING

My experice. Whilst om lacemnt an incident occurred where a nurse gave the wring dose if INR, she was very upset about this incident and frightened for her reputation, she reported this incident and very soon all the nurses knew on the ward and instead of them understanding that mistakes happen the majority of nurses believed she was incompetent. This call to question that nurses repect pateitns confidentiality but not so much staff members confiedntiallity, yet the NMC (2004) do staste that nurses need to respect colleagues confidentiality too. Mayeb reasearchers need to Look at the blame culture of reporting.

What was my experience from practice. Whilst on placement an incident nearly occurred when the nurse dispensed the tablets, she was then called to take a phone call, when she retuenred about 5 minuted later she opend up the drugs trolley and was about to give the man in the next bed the meds, thankfully the patient was aware and informed her and also she would have know she was making a misteke as she checked the ID band but this brings to question the idea of reporting near misses, as (ref) suggest we can learn immensely from these QUOTE ABOUT INDUSTRIES. Howver there is often a reluctance with the nhs to report incidents as (ref) claims there is often a culture of blame, nurse assume they will be in serious trouble and defer away from reporting for fear of re-precausins.


CIVAS

It has been suggested that there may be technological solutions and that pharmaceutical manufacturers could adapt their products in order to help nursing managers in their quest to lessen drug errors (Castledine, 2006). Innovations such as ready to use pre-filled syringes and infusions, diluent products that can be permanently connected to drug vials during administration, ampoules and vials with flag labels that can be transferred to easily label syringes and infusion bags are some of the steps already taken by drug companies in order to help the nurse to avoid errors and could be introduced more widely (Cousins et al, 2005). Hospital pharmacies also have a role to play in helping nurses to reduce error. The introduction of pre-mixed intravenous drugs in solution has lowered the risk of errors on the ward, as the nurse no longer has to struggle to find and follow protocols for mixing different drugs with their ideal diluents. In a UK study Taxis & Barber (2003) found that errors occurred at a rate of 49% in the preparation and administration of intravenous medications alone. The introduction of the CIVAS (Centralised Intravenous Additive System) has moved a difficult and risk prone aspect of drug administration away from the nurse and into the hands of those best suited for the role, a simple and cost effective, but valuable solution. The number of intravenous drugs supplied by the CIVAS service is currently limited and further study is required to investigate the implications of broadening the service to include all intravenous medications, thereby presumably further lowering the risk of error. Although providing pre-mixed drugs does remove some of the risk, it is still the responsibility of the nurse to consult the specific guidance for administering the drug, as they need to be aware of its actions as well as any possible side effects relevant to the individual patient and their current condition. No amount of pre-prepared drugs can absolve the nurse of the responsibility of correctly following guidelines and protocols for safe drug administration.
>Cost/benfit analysis
>does CIVAS de-skill nurses if it is a limited service?
Importnce of BNF the IV administration handbook the need for nurses to adhere to guidelines. (NMC acountablility)


BARCODES

In the USA, drug errors are being tackled by more technological means. Regulations introduced by the Food and Drug Administration (FDA) require that identifying bar codes are present on all prescription and over the counter medications in order to reduce hospital drug errors (Lafleur, 2004). The idea behind it is that the practitioner has a hand held scanner, which can scan and read a patient's prescription, match it to the bar code on the patient's identity bracelet and the bar code on the medication itself. The scanner checks that it is the right drug for the right patient at the right dose at the right time, if it isn't then an alert appears on the computer screen. However it should be emphasised that technology can never replace caregiver diligence. Lafleur (2004) cautions against letting technological support replace good practice and critical thinking skills. Although the bar code and scanner allow the nurse to make sure that the drug and dosage are correct, it is unable to answer the other pertinent questions required before administering a drug to a patient. These being; why was this drug ordered for this patient and what are its desired effects, does the patient show signs of benefiting from the medication, what about side effects and are there any specific laboratory results that need checking before the administration of the drug (Lafleur, 2004).

Following the introduction of the bar code system in a hospital in the USA certain concerns were raised (Roark, 2004). The nurses found that using the bar code system took up significantly more time than traditional checking methods. The system was also prohibitively expensive to introduce, the FDA estimated that the installation cost in the average US hospital was 13.7 million dollars. Whilst the financial cost saving through reduced medical errors was estimated to be 2.35 million per year. Even though the system was costly, and was found by the less computer literate staff to be difficult to use, it did successfully reduce drug errors. To introduce such a system into the UK a very thorough cost-benefit analysis would be required to justify such a move. Based on the American figures it would take nearly 6 years for the hospital to recoup costs. It is also important to consider that technology in terms of hardware and software both date quickly, with the lifespan of the hardware being three years or less, instituting a bar code system is certainly costly. Conversely we need to measure the human benefits, what price can we put on life? In the recent climate of funding shortage in the NHS with trusts struggling to finance drugs such as Herceptin it raises ethical questions, in terms of distributive justice for all users of the NHS, who decides what is best?

Clearly more study and emphasis needs to be placed on finding and implementing simple and cost effective methods to reduce drug errors, such as signage and protocols for checking. In light of the success of the American signage intervention, and its relative low cost and simplicity to implement, it is imperative to question why the similar 'tabard system' here in the UK, was not successful. So, why the reluctance to change in this case? Pape et al (2005) quoted 'if you keep doing the same old things, you will get the same old results' (p111). Considering the cost and frequency of medication errors, this is certainly motivation enough for change, as to continue are we are, is unthinkable. Unfortunately, according to the DOH (2000) the NHS is notoriously bad at learning from past mistakes and implementing changes to overcome these errors. A starting point in overcoming this is to examine change theory in order to understand why we resist change and how nurse managers can overcome this in order to develop a more effective and safer NHS for everyone.


CHANGE THEORY

Lewin’s change theory (1951, in Murphy, 2006) suggests a bottom up approach, emphasising the necessity of the full participation and involvement of all staff that will be potentially affected by change, in order to increase their likelihood of accepting the change. There has been some criticism of this however as not all organisations have the freedom to allow their staff such a degree of participation and some changes may be so great as to need to be more authoritarian in nature (Burnes, 2004). However, in the case of both the signage and tabard systems, local management such as ward managers & lead nurses were driving the change amongst their small teams, which did not necessitate too much involvement from higher management such as directors or even government.
Lewin (1951, in Murphy, 2006) talks of change in relation to three stages unfreezing, moving and refreezing. The unfreezing stage is the stage at which the nursing staff would have recognised a need for change, such as the dissatisfaction with the level of distractions on the ward during drug rounds, and the rate of medication errors and begun to develop the motivation to change the status quo. Cutcliffe and Bassett (1997) recognise that not everyone is receptive to change, and this was certainly a feature in both the USA study on signage and my experience with the tabard system. Mullins (1996) states that this resistance to change is often motivated by fear, conflicting goals or even the idea of being inconvenienced. This last point was key in both the tabard and the signage system, as some nurses felt that the new system asked more from them in terms of time and commitment, such as additional laundry which they would have to finance themselves, or the extra time taken over following new checklists. It has been recommended that in order to overcome the doubters in a group, the lead nurse or change agent must first gain their trust and respect through involving them in discussion (Sullivan & Decker, 1992). This discussion can be used as an opportunity for any staff that are uncomfortable with the change to become involved in the process and participate by informing decisions about any change that may affect them (Mullins, 1996) (REF). Bernhard & Walsh (1990) (REF) found that effective communication was crucial when instituting change as it helps the manager to establish therapeutic relationships with their team members. Once established, these relationships can help the manager to overcome any barriers to change (Stuart & Sundeen, 1995) (REF). It is interesting to consider how as nurses we often accept the importance of fostering such relationships with our patients, yet overlook the value of fostering therapeutic relationships with our colleagues. Surely we have a professional duty to each other as well as our patients, as such relationships can only serve to make us more effective as a team and hence deliver better nursing care.

Forcefield analysis is useful at the unfreezing stage as it can be used to identify what the nurses would hope to gain from the change (known as driving forces) and to weigh this up against any perceived difficulties (known as restraining forces).


CLINICAL QUALITY ASSURANCE

Once the nurse manager has identified the restraining and driving forces they should consider them individually to assess their strengths (Tomey, 2000). Determining which are the major factors for or against change, the manager can then begin to plan strategies to address them one by one. In the case of the tabard system, the argument against self-laundering became symptomatic of the reluctance to change and perhaps if alternative arrangements could have been made for the laundering of the tabards, much of the reluctance could have been overcome. In is not unreasonable to suggest that the tabards could have been laundered under the same system as surgical scrubs. This would mean that there could be clean tabards easily available for each nurse at each shift. Or even cost permitting to consider disposable tabards. Once this issue was resolved, the manager could have progressed onto the next issue, and so on. Not forgetting to emphasise the strengths of the driving forces, and the other possible gains for the nurses involved in the change, such as training opportunities. Baulcomb (2003) suggests strategies such as empowering staff through training to enhance their skills, as this can help them to overcome any doubts they have about their ability to perform new tasks or accept new roles. The manager could also support and develop individual members of the team to champion aspects of the change, especially those who had identified management skills as a key area for attainment in their personal development plans. This would give them the opportunity to develop their own management skills allowing them to progress through the skills gateways required within Agenda for Change. The effective use of the team in facilitating change is one of key aspects of Lewin's change model, and the one which Baulcomb (2003) states makes it most ideal model for change within healthcare management. Geller (2000) argues that once those required to change have been provided with adequate evidence of the benefit of implementing the change that they will abide by it. This would seem to make sense in the culture of nursing as all that we do is essentially informed by evidence. Hence, once the team have agreed that the positive effects of the change outweigh the negative effects then change can begin with the moving stage.

Lewin (1951, in Murphy, 2006) defined the moving stage as being the transition from the current situation to the desired situation; this is the stage where the change is implemented. The final stage of the process is known as the refreezing stage, where the change becomes the accepted norm. It is at this stage that the manager or leader would need to evaluate the effect of the change in order to determine whether the change goals have been met (Goodwin, 1996) (REF). This is also a valuable opportunity to keep the change momentum going, by evaluating and either celebrating the success of the change or if necessary establishing further changes to ensure that the desired goals are achieved.
It has been said that to ensure safe practice there needs to be strong leadership, as employees are influenced by the attitude and policies of their managers (Pape et al 2005). This was demonstrated when the nurse who was championing the tabard system left the ward and was replaced by a leader who did not embrace the change in the same way, resulting in the loss of impetus by the staff and the change being abandoned. In order to encourage the acceptance of change, managers should create an environment where change is accepted as a welcome and positive tool for developing and improving the clinical area and this attitude should be demonstrated by example (Benis et al, 1976 in Broome, 1998). This makes the nurse leader's primary role to identify opportunities for change, then involve and gain the nursing staff's commitment to the change and thereby as a team create new more effective systems for delivering nursing care. This is undoubtedly easier said than done, as any change agent would certainly risk making themselves 'unpopular' amongst those who fear and resist change. Thus, the manager would have to consider their own force-field analysis for change as instituting the change would certainly carry some personal cost to them, hence the need for the manager to also have a strong desire to embrace the change as without this, it would certainly be difficult if not impossible for them to maintain the impetus to institute the change and lead by example.


CONCLUSION

Currently, staff nurses are under increasing pressures almost daily, with numerous and complex functions expected of each individual. Medication errors often occur because of high noise levels, distractions, interruptions, ineffective communication, lack of focus and teamwork. Safety begins with strong leadership and management principles. Employees will emulate the attitude and follow the policies of those in administrative and leadership roles. Evidence-based strategies borrowed from the airline industry can prevent errors within the nursing unit.

This assignment has highlighted the multifaceted nature of drug error. Such errors are costly in terms of increased hospital stay, patient harm, lives lost and are a source of personal anxiety to the professional nurse, with careers possibly ruined as a consequence.
To avoid developing complacent and relaxed attitudes towards drug administration, nurses should be prepared to challenge existing working practices through proactive action planning (Appendix 1). Mangers also need to ensure that safety rules are identified ad stringently observed by all the professionals involved.

Honest reporting of drug errors and near misses where the potential for error has been identified is the way forward. However, this can only take place if the incident-reporting system is conducted in a non-punitive environment. Nurses at all levels need to promote public confidence and reduce drug errors where possible. Taking a common-sense approach to minimizing error has been suggested.

In conclusion, it is apparent that medication errors are a complex and persistent problem associated with nursing practice. The Department of Health (DOH, 2000) attempted to highlight the cause of errors in healthcare delivery, in their document 'An Organisation with a Memory'. They concluded that human error, rather than causing mistakes, was itself caused by the failure of the systems that are in place to safeguard our patients. This would seem to place responsibility for reducing errors on the management teams within the NHS. However attractive an option it is to shift individual blame, the nurse is professionally accountable for their own practice and should certainly consider their own role in risk assessment and error prevention (NMC< 2004). A group effort to tackle the issue would seem the most sensible and more enlightened recourse, rather than the ‘us and them’ scenario that often dogs employer/employee relationships.

The introduction of signage and checklists to limit the number of disruptions, whilst ensuring that nurses followed medication administration protocol proved valuable, cost effective and simple to implement. In contrast the failure to maintain the introduction of the tabard system, demonstrated the importance of effective leadership in ensuring the acceptance of change. Overall, it is felt that more research is needed to find simple, inexpensive methods to reduce errors and advocate and empower nurses to make changes.
The assignment has illustrated the different reactions of nurses to the change process itself and to the specific aspects of the change. As argued, it is usual for people to feel stressed at a time of change, however, the change in their working conditions and role are likely to be mean that many of the nurses will be negatively affected by the new system of care, albeit for different individual reasons. In the longer term, it is possible that the effects on their job satisfaction and stress levels may impact their motivation, attendance and desire to stay within their roles, thus potentially incurring greater personnel costs.

Perhaps what actually needs to change is the attitude of staff when faced with change as well as the actions of staff administering drugs. It is reasonable to assume that each nurse responsible for medication administration is aware of the need for accuracy and the focus required to concentrate on such a task, maybe what is needed is more encouragement for the nurse to be empowered enough to be able to request and expect not to be interrupted when approached during drug rounds. As patient safety is one of the biggest challenges that the NHS faces at present. As health professionals we have to ensure that all the care we provide in hospital and in the health service is as safe as possible (ref).




References

BANNING, M (2006). Medication errors: professional issues and concerns. Nursing Older People. 18, 3, 27-34

POLIFRONI, E.; MCNULTY, J. & ALLCHIN, L. (2003). Medication errors: more basic than a system issue. Journal of Nursing Education. 42, 10, 455-458

IGNATAVICIUS, D. (2000). Asking the right questions about meditation safety. Nursing. 30, 9, 51-54

PENTIN, J. & SMITH, J. (2006). Drug admonistration. Drug calculations: are they safer with or without a calculator. Britush Jornal of Nurisng. 15, 14, 778-781

HILLSDEN, I. & FENTON, G.S. (2006). Improving practice and patients safety through a medication systems review. Qulaity of Primary Care. 14, 1. 33-40
PARISH, C. (2006). Being nice is not good enough for good leadership on the wards. Nursing Standard. 20, 41, 6

MORROW-FROST, C. (2006). Nurses’ knowledge of commonly used drugs: a clinical audit. Emergency Nurse. 13, 10, 32-37

CASTLEDINE, G. (2006). The art and science of drug administration. British Journal of Nursing. 15, 1, 59

HARMER, M. (2006). Electronic prescribing prevents mistakes. Nursing Standard. 20, 10, 38

COPPING, C. (2005). Preventing and reporting drug adminstration errors. Nursing Times. 101, 33, 32-34

CHRISTIAN, S.; GYVES, H. & MANJI, M. (2004). Electronic prescribing. Care of the Critically Ill. 20, 3, 68-71

GUY, J.; PERSAUD, J.; DAVIES, E. & HARVEY, D. (2003). Drug errors: what role do nurses and pharamacst have in minim,ising the risk? Journal of Child Helathcare. 7, 4, 277-290
PRESTON, R.M. (2004). Drug errors and patient safety: the need for a change in practice. British Journal of Nursing. 13,2, 72-78

DIAZ-NAVARLAZ, T. & SEGUI-GOMEZ, M. (2006). Commehtry on Armitage, G. (2005) drug errors, qulaittaive research and some reflections on ethics. Journal of Clinncial Nursing. 14, 869-875

EVANS, S.; BERRY, J. & SMITH, B. (2006). Attitudes and barriers to incidnent reporting: a collaborative hospital study. Qulaity and safety in health care. 15, 1, 39-43

COPPING, C. (2005). Preventing and reporting drug administarion errors. Nursing Times. 101, 33, 32-34

ARMITAGE, G. (2005). Drug errors, qulaittaive research and some refelction on ethics. Journal of Clincial Nurisng. 14, 7, 869-875

WOLF, Z. & SEREMBUS, J. (2004). Medication Errors: ending the blame-game. Nursing Management. 35, 8, 41-48

HAINSWORTH, T. (2004). Improving medication safety. Nursing Times, 100, 7, 26-27

PRESTON, R. (2004). Drug errors and patient safety: the need for a change in practice. Brtish Journal of Nursing. 13, 2, 72-78

CASSIDY, M. (2002). Oops, we did it again. World of Trish nursing. 10, 6, 18
SCOTT, C. (2001). Avoiding drug errors. Professional Nurse. 17,7, 8



ARMITAGE, G. & KNAPMAN, H. (2003). Adverse events in drug administration: a literature review. Journal of Nursing management, 11(2), 130-140.

BAULCOMB, J. (2003) Management of change through force field analysis. Journal of Nursing Management, 11(4), 275-280.

BAYNE, T. & BINDLER, R. (1988) Medication calculation skills of Registered Nurses. Journal of Continuing Education in Nursing, 19(6), 258-262.

BBC NEWS (2006). "NHS drug error 'crackdown' urged" Posted August, 10, 2006. Retrieved February 5, 2006. Web-site: http://news.bbc.co.uk/1/hi/health/4780487.stm

BENIS, G. (1976) The Planning of Change. Holt, Rinehart & Winston, cited in BROOME, A. (1998) Managing Change, 2nd edition. London, Macmillan Press.

BERNHARD, L. & WALSH, M. (1990) Leadership: The key to Professionalisation of Nursing, 3rd edition. London, Mosby.

BINDLER, R & BAYNE, T. (1984) Do baccalaureate students possess basic mathematics proficiency? Journal of Nursing Education, 23(5), 192-197.

BINDLER, R. & BAYNE, T. (1991) Medication calculation ability of registered nurses. Journal of Nursing Scholarship, 23(4), 221-224.

BURNS, B. (2004) Kurt Lewin and the planned approach to change: re-appraisal. Journal of Management Studies, 41(6), 977-1002.

CASTLEDINE, G. (2006) The art and science of drug administration. British Journal of Nursing. 15(1), 59.

CHENGER, P. (1988) Nursing students in Alberta: their mathematical abilities. Association for Australian Rural Nurses, 44(1), 17-22.

CONKLIN, D. (1990) Medication errors by nurses: contributory factors. Association for Australian Rural Nurses, 46(1), 8-9.

CONTI, A. & BEARE, P. (1988) Performance on a mathematics/ drug calculations test: relationship to subsequent reported medications errors. Journal of Nursing Staff Development, 4(2), 54-58.

COUSINS, D. (2005) Medication errors in intravenous drug preparation and administration: a multi-centre audit in the UK, Germany and France. Quality & Safety in Health Care. 14(3). 190-5.

CUTLIFFE, J. & BASSETT, L. (1997) Introducing change in nursing: the case for research. Journal of Nursing Management, 5(4), 241-247.

DAVIS, N. (1994) Concentrating on interruptions. American Journal of Nursing, 94,14.

DEPARTMENT OF HEALTH (2000) An organisation with a memory. London, Department of Health.

DEPARTMENT OF HEALTH (2004) Building a Safer NHS for Patients: Improving Medication Safety. London, Department of Health.

DIMOND, B. (2004) Accountability and medicinal products, Part 4: professional issues. British Journal of Nursing. 13(6). 337-40.

FARRAR, K. (1999) Pill-popping extravagance. Health Management, October, 18-19.

FERNER, R. (1995) Is there a cure for drug errors? British Medical Journal, 311(7003), 463-464.

GELLER, E. (2000) The psychology of safety handbook. Florida, Lewis Publishers.

GIROTTI, M. (1987) Medication errors in an adult ITU. Heart and Lung, 16(4), 449-453.

GOLD, D., ROGACZ, S. & BOCK, N. (1992) Rotating shift work, sleep and accidents related to sleepiness in hospital nurses. American Journal of Public Health, 82(7), 1011-1014.

GRAY, J. & JACKSON, G. (2004) The development of an online quiz for drug calculations. Nursing Times, 100(4), 40-41.

GREENFIELD S., WHELAN, B. & COHN, E. (2006) Use of dimensional analysis to reduce medication errors. Journal of Nursing Education. 45(2): 91-94.

HARTLEY, G. & DHILLON, S. (1998) An observational study of the prescribing and administration of intravenous drugs in a general hospital. International Journal of Pharmacy Practice, 5, 91-96.

HO, C.; DEAN, B. & BARBER, N. (1997) When do medication errors to hospital inpatients? International Journal of Pharmacy Practice, 5, 91-96.

HOGKINSON, B.; KOCK, S. & NAY, R. (2006). Strategies to reduce medication errors with reference to older adults. International Journal of Evidence based healthcare. 4, 1, 2-41

HOWELL, M. (1996) Prescription for disaster. Nursing Times, 92(34), 30-31.

HUTTON, M. (2003) Calculations for new prescribers. Nursing Standard, 17(25), 47-52.

HUTTON, B. (1998) Nursing mathematics: the importance of application. Nursing Standard, 13(11), 35-38

JARMAH, H.; JACOBS, E. & ZIELINSKI, V. (2000). Medication study supports registered nurses competence for single checking. International Journal of Nursing Practice. 8,16, 330-335

JENKINS, D.; CAIRNS, C. & BARBER, N. (1993) The quality of written inpatient prescriptions. International Journal of Pharmacy Practice, 2, 176-179.

JONES, J. & BROWN, R. (1986) A survey of the 12 hour nursing shifts in 25 North Carolina Hospitals. Journal of Nursing Management, 17(5), 27-28.

KAWAMURA, H. (2001) The approaches to factors which cause medication error. Japanese Journal of Cancer and Chemotherapy, 28(3), 304-309, cited in ARMITAGE, G & KNAPMAN, H (2003). Adverse events in drug administration: a literature review. Journal of Nursing management, 11(2), 130-140.

KEILL, P. & JOHNSON, T. (1993) Shifting gears: improving delivery of medications. Journal of Quality Nursing Assurance, 7(2), 24-33.

KININGER, T. & REEDER, L. (2003) establishing ROI for technology to reduce medication errors is both a science and an art: The business case for medication safety. Healthcare Financial Management. Cited in GREENFIELD, S., WHELAN, B. & COHN, E. (2006) Use of dimensional analysis to reduce medication errors. Journal of Nursing Education. 45(2): 91-94.

LAFLEUR, K. (2004) Tackling med errors with technology. RN. 67(5). 29-34.

LEAPE, L. (1995) Systems analysis of adverse drug events. Journal of the American Medical Association, 274(1), 35-43.

LESAR, T. BRICELAND, L. & STEIN, D. (1997) Factors related to errors in medication prescribing. Journal of the American Medical Association, 277, 312-317.

LEWIN, K. (1951) Field Theory in the Social Sciences. New York, Harper & Row, cited in MURPHY, F. (2006) Using change in nursing practice: a case study approach. Journal of Nursing Management, 13(2), 22-25.

LONG, G. & JOHNSON, C. (1981) A pilot study for reducing medication errors. Quality Review Bulletin, 7(4), 6-9, cited in ARMITAGE, G & KNAPMAN, H (2003). Adverse events in drug administration: a literature review. Journal of Nursing management, 11(2), 130-140.

LUDWIG-BEYMER, P. (1990) The effect of testing on the reported incidence of medication errors in a medical centre. Journal of Continuing Education in Nursing, 21(1), 11-17.

MANNO, M. & HAYES, D. (2006) Best-practice interventions: how medication reconciliation saves lives. Nursing. 36(3): 63-4.

MULLINS, L. (1996) Management and Organisational behaviour, 4th edition. London, Pitman Publishing.

NURSING AND MIDWIFERY COUNCIL (2002) Guidelines for the administration of medicines. London, NMC.

O’SHEA, E. (1999) Factors contributing to medication errors: a literature review. Journal of Clinical Nursing, 8(5), 496-504.

PAPE, T. (2005) Innovative approaches to reducing nurses' distractions during medication administration. Journal of Continuing Education in Nursing. 36(3). 108-16.

PEARLSON, J. (1988) development and implementation of systematic monitoring of medication errors. Journal of Nursing Quality Assurance, 2(2), 77-81.

POLIFRONI, E. MCNULTY, J. ALLCHIN, L. (2003) Medication errors: more basic than a system issue. Journal of Nursing Education. 42(10). 455-458

PRESTON, R. (2004) Drug errors and patient safety: the need for a change in practice. British Journal of Nursing, 13, 72-78.

RAJU , T. (1989) Medication errors in neonatal and paediatric intensive care units. Lancet 2(8659), 374-376.

ROARK D. (2004) Bar codes & drug administration: can new technology reduce the number of medication errors? American Journal of Nursing. 104(1): 63-6.

ROSEMAN, C. & BOOKER, J. (1995) Workload and environmental factors in hospital medication errors. Nursing Research, 44(4), 226-230.

ROSS, L. (2000) Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Archives of Disease in Childhood, 79, 56-58.

SCOTT, L. (2006) Effects of critical care nurses' work hours on vigilance and patients' safety. American Journal of Critical Care. 15(1): 30-7.

SCHAUBHUT, RM. & JONES, C. (2000). A systemic approach to medication error reduction. Journal of nursing care quality. 14, 3, 13-27

SCHOLZ, D. (1990) establishing and monitoring an endemic medication error rate. Journal of Nurse Quality Assurance, 4(2), 71-85.

SCTROHECTER, S. (2003). Medication Management. Nursing Management. 34, 12, 34-38

SEGATORE, M.; MILLER, M. & WEBBER, K. (1994) Medication out of control. The Canadian Nurse, 90(8), 35-39.

STUART, G. & SUNDEEN, S. (1995) Principles and Practice of Psychiatric Nursing, 5th edition. St Louis, Mosby.

SULLIVAN, E. & DECKER, P. (1992) Effective Management in Nursing, 2nd edition. California, Addison-Wesley.

TAUNTON, R. (1994) Patient outcomes – are they linked to Registered Nurse absenteeism, separation or work load? Journal of Nursing Administration, 24(4), 48-55.

TAXIS, K. & BARBER, N. (2003) Ethnographic study of incidence and severity of intravenous drug errors. British Medical Journal, 326, 684.

TOMEY, A. (2000) Guide to Nursing Management and Leadership, 6th edition. St Louis, Mosby.

TRIM, J. (2004) Clinical skills: a practical guide to working out drug calculations. British Journal of Nursing. 13(10). 602-6.

VAN DEN BEMT, P. (2000) Risk factors for the development of adverse drug events in hospitalised patients. Pharmaceutical World Science, 22(2), 62-66.

WALTERS, J. (1992) Nurse's perceptions of reportable medication errors and factors that contribute to this occurrence. Applied Nursing Research, 5(2), 86-88.

WEEKS, K., LYNE, P. & TORRANCE, C. (2000) Written drug dosage errors made by students: the threat to clinical effectiveness and the need for a new approach. European Journal of Paediatrics, 157(9), 769-774.

WILLIAMS, A. (1996) How to avoid mistakes in medicine administration. Nursing Times, 92(13), 40-41.

WORRELL, P. & HODSON, K. (1989) Psychology: the battle against dosage calculation errors. Nurse Educator, 14(2), 27-31.
WRIGHT, K. (2006). Barriers to accurate drug calculations. Nursing Standard. 20, 28, 41-45
9407

Posted by: Andrea Louise

Best Custom Writing Sites

Sites that provide custom writing services are better alternative to downloading pre-written paper samples, especially if you temporarily can't handle writing your own paper for some reason, and can not afford risking your course and reputation for plagiarism detection failure. The prices for custom written essays are affordable, but if you need 15-pages long master level report overnight, you better prepare to spend a noticeable sum.