International Journal of Nursing Practice 2011; 17: 548555

RESEARCH PAPER

Developing risk management behaviours for nurses through medication incident analysis
Maree Johnson PhD RN Duong Thuy Tran MIPH

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Clinical Professor, School of Nursing and Midwifery, College of Health and Science, Penrith South DC, New South Wales, Australia

Research Ofcer, School of Nursing and Midwifery, College of Health and Science, Penrith South DC, New South Wales, Australia

Helen Young PhD

Research Assistant, School of Nursing and Midwifery, College of Health and Science, Penrith South DC, New South Wales, Australia

Accepted for publication May 2011 Johnson M, Tran DT, Young H. International Journal of Nursing Practice 2011; 17: 548555 Developing risk management behaviours for nurses through medication incident analysis The aim of this study was to dene risk management behaviours related to medication safety. Mixed methods were used to analyze 318 nursing related medication incidents reported in an Australian metropolitan hospital. Most incidents did not result in patient harm (93%). Omission of medications was the most frequent often related to patient absences from the unit or nurses failing to sign for medications. Thematic analysis resulted in the Medication Safety Subscales including 29 behavioural statements within three domainsadministering medications, storage and management of medications, managing adverse events related to medications. The Medication Safety Subscales can be used by managers, educators and clinicians to reinforce the importance of medication safety. Early action by nurses may reduce patient injury. Key words: medication administration, patient safety, risk management.

INTRODUCTION
Medication safety is an issue of worldwide concern to health consumers and nursing.1 Medication errors are estimated to occur in 620% of all medications administered.1,2 When a medication error occurs, nurses often nd the experience to be traumatic, affecting their personal and professional lives whether or not patient injury

Correspondence: Maree Johnson, University of Western Sydney, Locked Bag 1797, Penrith South DC, NSW 1797, Australia. Email: m.johnson@uws.edu.au No funding or other fees were obtained for this study. 2011 Blackwell Publishing Asia Pty Ltd

occurs.3 Wimpenny and Kirkpatrick note that interest in risk management and patient safety relating to medication errors has resulted from concerns about the impact of medication errors on patients and the organization.1 Risk management behaviour is dened as those behaviours, processes or systems used to minimize errors in practice.4 A systematic review of patient safety interventions relating to medication errors identied that computerized prescribing or incident reporting systems were frequently used to improve safety.5 This study examines medication incidents to identify risk management behaviours that could form behavioural tools for nurses to selfassess their risk management behaviours and thus reduce medication errors.
doi:10.1111/j.1440-172X.2011.01977.x

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Literature review
Medication errors are recognized as the third cause of sentinel events and most of the errors occur in the administration process.6 Researchers have shown that the estimated prevalence of medication errors was 1.4 per admission with omission of a dose (53%), wrong time (43%) and wrong dosage (17%) being the most frequent types.6,7 Certain types of medications increase the risk of errors such as anticoagulants, antidepressants, antibiotics, cardiovascular drugs, diuretics, hormones, corticosteroids and opiates.6,8 Internal and external factors have also been implicated in medication errors with nurses identifying illegible prescriptions, inadequate space for charting and documenting, walking distances to patient rooms, small medication rooms, inappropriate organization of medical supplies, high noise levels in the nursing unit, poor lighting, interruptions and lack of privacy in the nursing stations.1,9 Carlton and Blegen also outlined other systems factors contributing to medication errors such as long working hours and nursing skill mix.6 Studies of interventions are limited beyond electronic prescribing with a recent systemic review and randomized control trial nding that individual patient medication supply, education and training for nurses, use of pharmacists and dedicated administration nurses are effective in reducing of medication errors.10,11 McBride-Henry and Foureur state that interventions to prevent medication errors should address understanding how errors occur, failure to adhere to policy and procedures, number of hours on shift, distractions, lack of knowledge about medications, dosage calculating, workload and care delivery model.2 A contemporary systematic review of 19 studies, undertaken by Wimpenny and Kirkpatrick, concluded that administration from individually labelled medication or administration close to the patient, involving the patient in the administration process through either self-administration or engagement in the checking process, had the potential to reduce errors.1 Although there are multiple contributing factors to medication errors, the interventions available appear to be predominately computerized systems. The direct connection between medication incidents and nurse behaviour has not been adequately addressed in literature. In this study, we analysed medication incidents to identify risk management behaviours that might assist nurses to reduce medication errors. The identied behaviours formed a psychometric scale relating to medication safety.

An incident is dened as an event or circumstance that could have resulted or did result in unnecessary harm to the patient.12

METHOD Design
A mixed methods design blending both quantitative and qualitative data was used. Incidents logged within the Incident Information Monitoring System (IIMS) formed the dataset. The IIMS is an electronic reporting system that allows notication of incidents.13 The dataset included de-identied incidents (n = 2132) from a metropolitan hospital in Australia between 1 July 2007 and 30 June 2008. The most frequently occurring types of errors were falls (27%), clinical management (20%), medication errors (18%), pressure ulcers (8%) and behaviours or human performances (6%). Medication errors related to nurses were identied from incidents notied under the principal category medication errors (n = 384) and those involving a nurse. Initially, two researchers independently reviewed a random sample of 50 incidents (12%) and coded if a nurse was involved in the incident (kappa = 0.82) to establish inter-rater reliability relating to nurse involvement coding. We excluded 66 incidents (17%) as these incidents did not involve a nurse (n = 15), were incorrectly categorized as a medication error (n = 7) or contained insufcient information (n = 44). This resulted in 318 incidents in the analysis, including 259/318 (81%) directly involving nurses, 55/318 (17%) involving a nurse at some point in the incident and 4/318 (1%) implied nurse involvement. Of these 318 incidents, 100 were randomly selected for the qualitative analysis. We further found two duplicates and ve incidents with inadequate description, resulting in 93 incidents available for coding. The de-identied free-text data included a description of the incident, the action taken, minimization strategies, contributing factors and result of incident review by the managers. Incidents were merged into a Word le and then imported into NVIVO version 8 (QSR International Pty Ltd, Doncaster, Australia) for coding.

Data analysis Demographic data

Limited demographic data (age and time of incidents) were available from the database and were descriptively analysed using SPSS version 17 (IBM Australia Ltd, St Leonards, Australia).
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Type of errors, drugs and level of harm

Deductive content analysis techniques were employed to classify types or errors,2 types of drugs14 and levels of harm.15 Following the coding, the frequency (%) of error types and level of harms were calculated and informed the behavioural analysis of the incidents (Table 1).

antibiotics (8%), uid/blood products (7%), hypoglycaemic agents (7%), anti-neoplastic agents (4%) and vitamins/supplement (4%). In relation to route of drug administration for the incidents, 89 (28%) were intravenous, 72 (23%) were oral, 14 (4%) were subcutaneous, 10 (3%) were intramuscular medications and 127 (40%) were insufcient information to code.

Nurses behaviours
Thematic analysis was undertaken using NVIVO8. The coding sequence was (i) what happened, (ii) nurses behaviours and (iii) nurses preventative behaviours (short behavioural phrase or statement). The identied behaviours were then used to shape the content of items on a scale of risk management behaviour relating to medication safety. Ethics approval for the study was obtained from the Health Service and University Human Research and Ethics Committee.

Nurses behaviours
The majority of incidents (and as noted in the types of errors above) reect what is known as problems with the ve Rsright patient, right dose, right route, right time, right medication (35% of incidents).6 All dates, times and drug names and doses have all been replaced with ctitious information.

Administering medications
Typical incidents reported that relate to behavioural statements 112 (Table 2) included: (a) Wrong dose (including additional dose)/wrong route: Nursing staff member gave 5.0 mg IV [intravenously] [Drug B] Doctor charted subcut [subcutaneous] [Drug B] 5.0 mg. Both RNs checking pt [patient] Id [identication] and missed [error in] route of medication. IV Drug C infusion commenced by morning staff and found by afternoon staff to be incorrect concentration. Patient ordered 150 mg. Looked like 200 mg. Gave patient 300 mg. (b) Wrong time: Previous dose of analgesia dated 10/10/08 at 1200 hrs [hours] but was given 12/10/08. Next dose given 12/10/98 as pt [patient] had asked for pain relief. Patient given Drug E 1 h apart. (c) Wrong site for administration although right medication: Patient was administered Drug F drops into incorrect eye. (d) Wrong drug:

RESULT Demographic characteristics

Patients experiencing incidents or near misses were on average 55 years of age (standard deviation 24.76 years). There was a concentration of medication errors between 8 am and 11 am (32%) and between 4 pm and 11 pm (37%).

Error types and level of harm

The types of medication errors (n = 318) identied included: omission of doses (15%), wrong dose (10%) or wrong administration rates (9%), wrong drug (8%), errors in documentation (8%), wrong patient (6%), unauthorized dose/extra dose (5%) and wrong route (4%), errors in dispensing (4%), errors in packaging (4%), dose delays > 1 h (3%) and other types (21%). Errors in calculating doses or infusion rates were infrequent (1%). Most incidents did not result in harm to the patients (n = 243; 77%) (see Table 1). In 52 cases, monitoring or conrmation from medical examination were required to preclude harm. Temporary harm requiring intervention or prolonged hospitalization occurred in 23 cases (7%).

Drug type and route of administration

The drugs reported in these incidents were mainly analgesic agents (27%), anticoagulants/heparin (11%),
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Patient given Drug G by mistake. Patient not charted for this medication.

Table 1 Type of errors and type of harm for 318 nursing-related medication errors incidents Type of harm B. Error occurred but did not reach the patient C. Error reached the patient but caused no harm D. Required monitoring to conrm no harm and/or required intervention to preclude harm E. Temporary harm and required intervention 3 6 10 8 9 4 1 3 1 2 1 2 3 3 1 2 F. Temporary harm and prolonged hospitalization Total (%)

Type of error

Developing medication risk management behaviours

A. Capacity to cause error

7 1 2 1 6 9 1 2 25 54 (17%)

Omission of dose Wrong dose Wrong administration rates Errors in documentation Wrong drug Wrong patient Unauthorised/extra dose Errors in dispensing Errors in storing/packaging Wrong route Dose delayed > 1 h Calculation errors Wrong time Other Total (%) 7 52 (16%) 7 19 (6%)

3 8 (3%)

36 23 17 19 13 8 9 7 4 9 6 2 3 25 181 (57%)

1 4 (1%)

48 (15%) 32 (10%) 28 (9%) 26 (8%) 25 (8%) 20 (6%) 16 (5%) 14 (4%) 14 (4%) 12 (4%) 8 (3%) 4 (1%) 3 (1%) 68 (21%) 318 (100%)

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Types of harm were classied according to the NCCM MERP Index. Types of error were classied according to the McBride-Henry and Foureur2 classication.

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Table 2 Medication safety subscales Administering medications 1. I check the dose on the medication chart and the dispensing bottle. 2. I check the dose when placing the medication into the cup. 3. I check the dose when I close the medication bottle. 4. I conrm the identity of the patient before giving the medication by asking the patient his/her name. 5. I conrm the identity of the patient before given the medication by asking the patient his/her date of birth. 6. I check the route of the drug administration at least three times before giving the medication. 7. I familiarize myself with all-standing medication protocols when coming to a new ward. 8. I challenge/conrm all medication orders that are unusual/abnormal frequency of administration/potential interaction/low dose/high dose. 9. I check the medication chart for weekly or monthly medication orders. 10 I follow up (using triggers such as coloured tags or patient notes) when a patient is absent from the ward during medication rounds. 11. On transferring a patient, I ensure all medications go with the patient. 12. At the end of my shift, I check that I have signed correctly for all medications given. Storage and management of medications 13. I notify senior staff when I accidentally damage S8, S4D drugs (dangerous drugs or drugs of addiction) 14. I check for out-of-date medication. 15. When dispensing measures on bottles are inadequate, I use a syringe to precisely measure liquid medications before given them. 16. I notify the senior nursing staff if any drug count is inconsistent. 17. I ensure all S4D/S8 (dangerous drugs, drugs of addiction) and other medications that need checking are checked by two (2) suitably qualied nursing staff. Managing an adverse event relating to medications 18. I immediately stop/cease the administration of a medication and/or infusion when found in error. 19. I monitor the patients vital signs for any untoward effects for 4-h time period or as directed by the medical ofcer. 20. I conduct regular reviews of the patients vital signs when medication toxicity is suspected. 21. I assess the patient for adverse effects of a wrong dose/wrong drug/wrong route/wrong site. 22. I notify the senior nursing staff of a suspected/known medication error/incident. 23. I notify the medical ofcer when a suspected/known medication error/incident occurs. 24. I notify the pharmacist when the wrong drug has been dispensed for the wrong patient. 25. I notify the pharmacist of medications where the colour or consistency is abnormal/unexpected. 26. When a medication has been omitted, I notify the Nursing Unit Manager. 27. I complete an incident report within 8 h of a suspected or known medication error/incident. 28. I discuss the medication error with the patient when appropriate. 29. I document the error in the patients notes. S8, Schedule 8; S4D, Schedule 4D,

(e) Wrong patient/patient identication: Patient allergic to Drug H (armband in situ). Drug H ordered and given on several occasions. Patient not at bed when rst approached and later returned and incorrectly delivered medications for the patient in the next bed to the patient. (f) Omission or missing dose: Missed medication for 2 days.
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Medication chart missing and staff not following-up the patients course of medications. Misplaced the medication and was not given to patient. Patient was transferred from Ward A to Ward B. Found that patient had not received his regular medications since admission. (g) Omission or incorrect use of signatures on medication charts. Problems with documentation: Not attending to signing chart [after] patient took medications.

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When medication chart check it is already signed by 2 nurses for todays date. (h) Incorrect and unreasonable dose of drug given:

understanding [informed] of error [and issue discussed with them], Increased education [for nursing staff regarding specic patient care related to the incident]. (l) Wrong drug given to patient:

Incorrect and unreasonable dose of drug given due to problems with abbreviations. Medical ofcer needs to document correctly and use hospital approved abbreviations, nursing staff to be educated on correct procedures and clarifying medication prior to administering.

Storage and management of medications

Another major area of incidents related to storage and management of Schedule 4D (S4D) and Schedule 8 (S8) medications (dangerous drugs). It was evident from the incidents that staff routinely reported problems with S4D and S8 medications. Typical incidents reported related to the domain of storage and management of medications and behavioural statements 1317 (see Table 2). (i) Drug count problems: Checked the book and found 10 tablets instead of 9 tablets. Reported to senior nursing staff. Drug K administered instead of Drug L resulting in incorrect count of both S8 drugs. ( j) Drug damage: Ampoule of S8 drug slipped. No uid was in the ampoule when [I] went to retrieve [it] from the oor. Ampoule found cracked in DD [dangerous drug] cupboard, no suspicious circumstances.

Actions taken included: Error realized and intern notied to review pt [patient]. BP [blood pressure] monitored and incident documented. Pt [patient] suffered no ill effects. Staff attended patients observations and then contacted day intern [medical ofcers] to come and review [the patient]. Patient also given more uids to drink patient not on uid restriction. (m) Similarity of brand names between two drugs contributed to the incident: [Nurse reported incident] to nurse manager patient reviewed by medical ofcer. Observations stable. No ill effects [for the patient]. Removal of Drug M from dangerous drug cupboard. Notices displayed in pharmacy room (mounted on cupboard door of S8 stock) informing staff of the 2 drugs, the colour of tablets, strength and that caution needed. (n) Incorrect drug dose given (half the required strength given): Actions taken included: Contacted Ward Medical Team, Monitoring BP [blood pressure] and Hr [heart rate], informed Nurses in Charge. [A lack of communication between nursing staff as a consequence of a team nursing model.] [Nurse stated that this would not of happened] if we had patient allocated nursing.

Managing adverse events in medications

Typical incidents reported that relate to the domain of managing adverse events in medications and related behavioural statements 1829 (see Table 2). Nurses and midwives reported upon the actions taken when they found an error and in many cases these actions might have contributed to the very low occurrence of patient injury. Often, managers (who review the incidents and add their action) also took the opportunity to provide education and support to their staff in a positive manner. Therefore, the management of adverse events became a major section for analysis and a source of potential risk management behaviours. (k) Right drug given at wrong site: Actions described included: Medical Ofcer contacted due to [patient symptom], [Distressed staff supported], Pt [patient]

DISCUSSION
The administration of medications is a major part of the role of the clinical nurse and is an activity prone to error. Although medication errors are not new nor are many of the solutions to these problems, this study has used the analysis of 318 medication incidents to develop a selfassessment scale for nurses to enhance medication safety. Twenty-eight nurse behaviours aimed at reducing medication errors or their effects were identied. These quantitative and qualitative ndings presented reect commonly reported medication errors or incidents within metropolitan hospitals. Most incidents were reportedly administered intravenously 89 (28%) or orally 72 (23%). The predominant types of errors were omission of doses (15%), wrong dose (10%) or wrong administration rates
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(9%), wrong drug (8%), errors in documentation (8%) and wrong patient (6%). The most frequent medications administered and reported in these incidents were analgesic agents (27%), anticoagulants/heparin (11%) and antibiotics (8%). Heparin and anticoagulants are high-risk medications and have been implicated in other studies.8 Mostly intravenous and oral administration routes were reported. These types and aspects of medication incidents are similar to ndings of other researchers and represent an international pattern.2,6,7 Most incidents did not result in harm. Temporary harm requiring intervention or prolonged hospitalization occurred in a small number of cases (7%). The ndings suggest that minimal harm has been in part achieved by the vigilance of the nurses in reporting and acting when an incident has been found reecting the importance of the initial actions taken by nurses. Omissions of medications were frequent and in some cases were an indicator of the absence of the patient from the ward, or a break in the normal routine of the nurse that caused disruption. This high proportion of omissions is reported widely.6 Reminder cards left for patients to call the nurse on returning to the ward have been shown to be effective.16 Another explanation often reported was the nurse forgetting to sign for a medication before leaving the unit. As part of a redesign of clinical handover nurses coming on duty are now actively encouraged to check the medication chart with the outgoing nursing staff to ensure that medications are signed for or other explanations provided.17 Problems with identifying the right patient, drug, route, dose, and time continue and are reported extensively in the literature.6 In addition, there were examples of confusion about medications between family members where the name of patient alone was not a sufcient identier, and the date of birth was required for clarication. The ndings from this study strongly support the use of both the patients name and date of birth as identiers before administering medication. Models of care were also implicated with patient allocation or modular nursing suggested as being more likely to support patient safety.2 Environmental factors were not commonly reported, although one incident did note interruptions as reported by Schelbred.3 A recent study has trialled the use of vests by nurses during medication rounds to reduce interruptions.18 Two of the three domains of risk management behaviour developed to reect the dataadministering medication and storage and management of medicationsrepresent the majority of incidents reported in these data. As noted above, the
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ve Rs remain important, and continuing education is warranted.6 Orientation programmes and regular wardbased in-service and self-assessment using the medication safety subscales (MSSs) developed here are emphasized. Problems with storage and management of medications were evident. The ndings of this study reinforce the considerable efforts of nurses to ensure the correct count of dangerous drugs. Aspects of drug calculations and the handling of dangerous drugs are presented at orientation to most hospitals, and these data suggest that this is effective. Considerable evidence was presented of nurses following the correct procedure when errors were found. The third domain relating to risk management behaviours for nurses, developed from these data, related to managing adverse events. Although the management of adverse events is discussed in the medical literature routinely,4,19 these data suggest that the actions of nurses in managing adverse events is likely to result in a reduced rate of injury to patients. Nurses reported stopping infusions, monitoring patient vital signs, requesting medical ofcers to review the patient, encouraged uids where appropriate, notifying the patient and recording the incident in the patient notes. Similarly, managers were supportive of staff reporting the error, sought to provide education when required or manage the problem by separating similar name drugs. We believed that these behaviours were so prevalent in the incident reporting that there should be a separate domain to highlight the importance of these actions to nurses and encourage nurses to report and act upon a medication error when found. This is the rst time this emphasis on these nursing actions to manage adverse events in medications in nursing has been reported in the literature. The three subscales developed here represent a unique instrument and is part of an overall patient safety instrument being developed by the investigators. Selfadministered risk management behaviours scales have been developed for medical practitioners4,19 and were found to be simple to administer and provided an education message and behavioural benchmarks. The MSS developed here are available to nurse educators, nurse managers and academics to further support the key messages related to medication safety for students and experienced staff. These tools can be used at orientation to remind staff of important issues, or after specic education sessions on dangerous drugs and their management or on how to manage a medication incident when one is suspected. Although much of the nursing and other health

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literature is focused on avoiding medication errors, these data highlight the importance of educating nurses on how quick action can minimize or eliminate patient harm. We acknowledge that the relationship between systems aspects such as patient acuity, skill mix, nursing care models and hours worked, and other environment factors were not considered in this study. However, this study reects an innovative approach to instrument development that allows for a close approximation of behaviours to patient safety outcomes. We believe that the MSS subscales have established face and content validity based on the approach to the development of the items, that is derived from data rather than expert opinion. Further expert panel content and construct validity and reliability testing are proposed. We also conrm that these behaviours are developed from self-reported medication errors, and only observational studies are likely to deliver accurate error rates and descriptions of medication errors. In conclusion, the development of a series of three MSSsadministering medications, storage and management of medications and managing adverse events related to medicationsrelating to medications has been achieved through a mixed-methods approach to incident analysis. Three major strategies to reduce errors are recommended: calling cards on patients bed tables, checking of medication chart signatures by outgoing and oncoming staff at clinical handover and the wearing of administration vests during medication rounds. Early management of a medication incident to reduce patient injury is advocated. Finally, the MSSs have been designed from incident data and can be used by managers, educators and clinicians to reinforce the importance of vigilance by nurses in relation to medication safety.

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