The attitudes and beliefs of healthcare professionals on the causes and reporting of medication errors in a UK Intensive care unit

Our aim was to explore the attitudes and beliefs of healthcare professionals relating to the causes and reporting of medication errors in a UK intensive care unit. Medication errors were identified by the unit pharmacist and semi‐structured qualitative interviews conducted with 13 members of staff involved with 12 errors. Interviews were analysed using a model of human error theory. Staff identified many contributing factors, including poor communication and frequent interruptions. Organisational factors included lack of clarity on the responsibility of the second nurse's check for medication administration, lack of feedback on medication errors, and a common and accepted practice of administering medication without a complete medication order. Barriers to reporting included administrative paperwork and lack of encouragement by management. Greater feedback on medication errors seems essential to improve current practice and increase reporting.

[1]  N. Barber,et al.  When do medication administration errors happen to hospital inpatients? , 1997 .

[2]  B. Franklin,et al.  The Frequency and Potential Causes of Dispensing Errors in a Hospital Pharmacy , 2005, Pharmacy World and Science.

[3]  H M Baker,et al.  Rules outside the rules for administration of medication: a study in New South Wales, Australia. , 1997, Image--the journal of nursing scholarship.

[4]  A. Ireland,et al.  Attitudes and beliefs of doctors towards medication error reporting , 2003 .

[5]  D. Hewett,et al.  How to investigate and analyse clinical incidents: Clinical Risk Unit and Association of Litigation and Risk Management protocol , 2000, BMJ : British Medical Journal.

[6]  C. Vincent,et al.  Causes of prescribing errors in hospital inpatients: a prospective study , 2002, The Lancet.

[7]  Charles Vincent,et al.  Applying human factors methods to clinical risk management in obstetrics , 1997, British journal of obstetrics and gynaecology.

[8]  T. Egberts,et al.  Frequency and determinants of drug administration errors in the intensive care unit* , 2002, Critical care medicine.

[9]  M. Arndt.  Nurses' medication errors. , 1994, Journal of advanced nursing.

[10]  T. Stephenson.  The National Patient Safety Agency , 2005, Archives of Disease in Childhood.

[11]  Sue M. Evans,et al.  Attitudes and barriers to incident reporting: a collaborative hospital study , 2006, Quality and Safety in Health Care.

[12]  Brian L. Erstad,et al.  Medication administration errors in adult patients in the ICU , 2001, Intensive Care Medicine.

[13]  John Adams,et al.  RISK HOMEOSTASIS AND THE PURPOSE OF SAFETY REGULATION , 1988 .

[14]  J. Reason.  Human error: models and management , 2000, BMJ : British Medical Journal.

[15]  M. Singer,et al.  Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit , 2005, Critical care.

[16]  N. Barber,et al.  What is a prescribing error? , 2000, Quality in health care : QHC.

[17]  C. Mottram,et al.  A safer place for patients: learning to improve patient safety , 2005 .

[18]  D. DeJoy,et al.  Attitudes and Beliefs , 1999 .

[19]  S. Ridley,et al.  Prescription errors in UK critical care units , 2004, Anaesthesia.

[20]  Bryony Dean Franklin,et al.  Development and evaluation of a medication incidents briefing seminar , 2004 .