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Study: Nurses use repetitive processes to catch medication errors, improve patient care

Patient safety

Supportive environment, hours per patient day factors in error prevention

After reading this article, you will be able to:

  • Describe the methods nurses use to catch medication errors
  • Identify the barriers nurses must overcome to catch medication errors

Each year, medication errors are responsible for 7,000 patient deaths and cost the healthcare system $2 billion. Even more shocking, perhaps, is the knowledge that nearly 50% of potential medication errors are caught before making it to the patient. Of those potential errors, 87% are intercepted by nurses.

Linda Flynn, RN, PhD, associate professor at the University of Maryland School of Nursing in Baltimore, recently led a study concerning medication errors and how the practice environment and the level of nurse staffing affect medication error rates.

Flynn, project director and principal investigator of the Interdisciplinary Nursing Quality Research Initiative (INQRI)–funded study, presented on the topic during an INQRI Webcast October 7, 2009. INQRI, a project of the Robert Wood Johnson Foundation, was created to examine nurses’ effect on patient safety.

“Nurses are the safety net that keeps patients safe from experiencing a medication error,” said Flynn.

The study attempted to answer a few questions: What are the factors that impact this nursing safety net? What are the factors that help nurses in doing their job to intercept medication errors before they reach the patient? And what factors serve as barriers to this safety net?

The study focused on identifying the costs and implications of medication errors. Flynn’s team, from the New Jersey Collaborating Center for Nursing at Rutgers University’s College of Nursing in Newark, did so by examining work environments and nurse staffing levels. Broken down into three separate parts, the study received participants from 14 hospitals in New Jersey.

The study revealed that medication errors are costly, averaging more than $6,000 extra spent on patients who experience a medication error (not necessarily an adverse drug event). Additionally, nurses employ four distinct medication safety processes to help find medication errors before they reach the patient.

These processes were enhanced when the nurses felt that their work environment was supportive, giving them time to effectively use these processes.

What processes do nurses use to catch medication errors?

The first part of the study examined what nurses do specifically during their everyday jobs to prevent medication errors from reaching the patient. Flynn and her team interviewed 50 staff nurses from 10 hospitals, transcribed the interviews, and analyzed the lines of text for patterns and commonalities. They found that nurses take seven routine steps in the name of medication safety:

1. Conducting independent review of the medication administration record (MAR) in comparison with the medication order. This is a process that, in most hospitals, is conducted by nurses who work the night shift. The nurses who were interviewed predominantly worked the day shift and said that although this review was done systematically in their hospitals, they felt an obligation to double-check that the medications they had on their order sheet actually matched the orders, said Flynn.

2. Making a focused assessment of patients prior to administering medication. Nurses recognize that patients’ conditions are dynamic and medications that were originally prescribed may no longer be appropriate.

3. Questioning rationale. This critical thinking activity requires nurses to ask why a specific medication may have been ordered by the physician prior to administering it.

4. Prioritizing face time with physicians. Most nurses in the study said they tried to see the physicians when they were on their floor so they could be aware of any changes in their patients’ medication regimens or care plans.

5. Encouraging patients and families to be the last line of defense for a medication error. “They spent time each day educating patients and their families about what they were taking, why they were taking it, and any changes in their medication regimens so that if [they] saw something that looked unusual or hadn’t been described or explained to them, they would raise the red flag and ask questions,” said Flynn.

6. Coordinating with the pharmacy to ensure timeliness of medication delivery. There is often a mismatch between nursing and pharmacy systems.

7. Clarifying orders with physicians. Nurses ask physicians to rewrite orders written in illegible or confusing handwriting or those that do not use standard abbreviations.

Of these processes, Flynn and her team found that numbers 1, 3, 5, and 7 were significantly associated with fewer medication errors. Additionally, there was overwhelming evidence that these practices were enhanced when the nurses worked in a supportive staffing environment. This factor was stronger even than nurse staffing levels, says Flynn.

“All five subscales of the practice environment scale were significantly and independently associated with a higher level of nurses’ medication safety processes, both before and after adjusting for nurse staffing,” says Flynn.“The effect of the practice environment was much stronger than the effect of RN staffing levels, which is good news for us because there is a limit to the number of nurses we can recruit and hire.”

The five scales that make up the total practice environment that Flynn referred to are: foundations for quality, relationships with physicians, participation in decisions, adequate staffing, and a supportive manager.

Nurse staffing levels were associated with nurses’ increased use of processes to prevent medication errors, but the magnitude of its effect was smaller, she said.

Barriers to preventing medication errors

Through the course of the study, Flynn’s team found that two main barriers often impeded nurses’ ability to catch medication errors and keep patients safe: interruptions and a poor nursing-pharmacy interface.

Interruptions disrupt the MAR process and reduce the ability to catch potential medication errors coming from other sources.

To read more about Flynn’s medication safety ini‑ tiative and the methods she used for her study, visit


Adapted from Patient Safety Monitor (Briefings on Patient Safety), December 2009, HCPro, Inc.