This paper explores the clinical practice problem of medication errors. The importance of medication errors is addressed, as well as, how it is significant to nursing practice. Six literature reviews were analyzed and their level of evidence was determined based on the level of the evidence hierarchy. The following evidence-based clinical question: Does the nurse-to-patient ratio influence the number of medication errors made by nurses in the inpatient setting?, is answered in this paper with the help of the six literature reviews.
The clinical practice protocol that is most current was explored, as well as, differences and similarities found in the literature reviews. Lastly, practice change recommendations for the prevention and improvement of medication errors among nursing staff were provided to ensure safe and quality patient care.
Nurses are to provide safe and quality care to the patients that they interact with throughout their careers. One of the most common clinical practice problems that occurs among nurses is medication error, which has become an increasing phenomenon in health care systems.
Hughes & Belgen (2008), revealed that per ten doses of medication that a patient receives, at least one of those medications will be given in error. It is alarming to hear that one-third of medical complications have been related to medical errors (Cheragi, Manoocheri, Mohammadnejad, & Ehsani, 2013). The top three most common medication errors causing patient death are the following the wrong dose (40.9 percent), the wrong drug (16 percent), and the wrong route of administration (9.5 percent) (Hughes & Belgen, 2008). The National Coordinating Council for Medication Error Reporting and Prevention (2013) defines a medication error as follows: ‘Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.
Medication errors can be life threatening, affect patient’s safety, increase mortality rates, increase the length of hospital stay, and can ultimately increase treatment costs. Treatment costs related to medication errors have been found to raise the hospital bill around $2,500 per patient (Cheragi et al., 2013). Providing medications to a patient is a serious responsibility of nurses, and an error in any part of the process can lead to serious consequences (Cheragi et al., 2013). According to Cheragi et al. (2013), nurses spend around 40% of their time in the hospital administering medications. There is not much statistical data on nurses and medication errors, because nurses who preform medication errors are reluctant to report their errors to protect their license and their job. This paper will discuss the relationship between medication error and nurse-to-patient ratio, review current literature, and give recommendations regarding the following clinical question: Does the nurse-to-patient ratio influence the amount of medication errors made by nurses in the inpatient setting? Review of Literature
Literature Review One Regardless of the importance of preventing of medication errors, there is a small number of current studies looking directly at the relationship between nurse-to-patient ratios, as well as medication errors in the inpatient setting. Recently, Driscoll et al. (2018), performed a systematic review examining nurse staffing levels and nurse-sensitive patient outcomes in an acute inpatient unit. Medication errors were included to be one of the nurse-sensitive patient outcomes in this review. Driscoll et al. (2018) defined nurse-to-patient ratios as, ‘the number of nurses working per shift or over a 24 hour period divided by the number of beds occupied by a patient over the same time period; or the number of nursing hours per patient bed days’.
A meta-analysis was done in this systemic review that involved 175,755 patients on high acuity floors. The meta-analysis found that as the number of nurses decreased on the floor, the errors of parenteral medications increased, with some errors causing adverse effects and death to the patients (Driscoll et al., 2018). The overall conclusion of this analysis was that the increased number of nursing staff on an acute floor directly correlates with decreased patient mortality rates, as well as, a decreased number of nurse-sensitive outcomes, like medication errors (Driscoll et al., 2018). This literature review holds the highest level of evidence possible, as it involves a meta-analysis and systemic review. These are the top two levels on the level of evidence hierarchy (American College of Obstetricians and Gynecologists, 2019).
Literature Review Two In a South Korean study, a multilevel logistic regression analysis was performed on 1,816 nurses working in inpatient units of twenty-three hospital systems (Kang, Kim, & Lee, 2016). This analysis explored the correlation between nursing workload and nurse-perceived patient adverse events. Patient adverse events, as perceived by the nurses, included the following: medication errors, patient falls, nosocomial infections, and pressure sores (Kang et al., 2016). The literature review conclusion on medication errors and nurse-to-patient ratios was that hospitals with higher percentages of nurses, who felt that they had adequate staff, experienced 0.28 times fewer cases of medication errors (Kang et al., 2016). This type of literature review falls under level two of the level of evidence hierarchy and provides good authentication of the relationship between medication errors and nurse-to-patient ratios (American College of Obstetricians and Gynecologists, 2019).
Literature Review Three Cho, Chin, Kim, & Hong (2016) completed a cross-sectional study examining the correlation between the nurse-staff level and work environment with patient adverse events. Cross-sectional studies provide the least amount of evidence of causation and fall under the second level of evidence of hierarchy (American College of Obstetricians and Gynecologists, 2019). The adverse events that were included in this study were as follows: administration of the wrong medication or dose to a patient, pressure ulcers, and injury from a fall after admission. Just like the prior study, this study was done in South Korea. The difference was that this was a larger study, including 4,864 nurses spread throughout 58 hospital systems (Cho et al., 2016). The literature review concluded that when a facility has a better work environment, based on the Practice Environment Scale of the Nursing Work Index, and adequate staff, there is a direct inverse relationship with adverse events (Cho et al., 2016).
Literature Review Four A smaller, cross-sectional study performed by Hammoudi, Ismaile, & Abu Yahya (2018) took a different route than the other studies did. This particular study analyzed the factors contributing to the incidence and reporting of medication errors from the perspective of the nurse. Only about two-thirds of three hundred and sixty seven nurses filled out a sixty-five-question survey on medication errors. The main conclusion was that medication errors performed by nurses were mainly associated with likeness in medication packaging, poor nurse-physician communication, pharmacy-related issues, nurse staffing, and transcribing issues (Hammoudi et al., 2018).
In this literature review, nurse-staffing issues were at the bottom of the list for why nurses perceived that medication errors occurred. Those who believed that staffing did affect medication errors felt that medication errors occurred mainly due to short staff and the lack of access to information, limited knowledge, non-adherence to administration guidelines on medications (Hammoudi et al., 2018). The level of evidence of this study falls into the level three due to the size and the participation in the cross-sectional study (American College of Obstetricians and Gynecologists, 2019).
Literature Review Five The next literature review analyzed was a comprehensive, three-step study that investigated and critically appraised interventions from systemic reviews. The interventions included ways to reduce medication errors and improve patient safety. Two reviewers, with the use of the Assessment of Multiple Systematic Reviews protocol, analyzed sixteen systemic reviews (Lapkin et al., 2016). The study concluded that the use of proper education, double-checking, limitation of interruptions, self-administration of medications, technological support, and bar code technology use could decrease medication error (Lapkin et al., 2016). The systemic reviews used in this study were picked as they had the highest quality of evidence, which gave the researchers the best available information needed to determine ways medication errors can properly be reduced (Lapkin et al., 2016). This type of literature review falls into the third level of the evidence of hierarchy due to its comprehensive study in nature (American College of Obstetricians and Gynecologists, 2019). This study was informative but still needed further research done on the true benefit of double-checking medications, self-administration of medications, and the detrimental effects of interruptions during medication passes (Lapkin et al., 2016).
Literature Review Six The last literature review analyzed looked specifically at the use of double-checking medications being beneficial in reducing medication errors. This study intended to determine how often double-checking medications is used when administering high-alert medications, and if it is beneficial (Douglass et al., 2018). The literature review included a controlled study that was randomized and blinded. It falls into the third level in the evidence hierarchy (American College of Obstetricians and Gynecologists, 2019). Forty-three nurses were randomly divided into two different groups, a single-check, and a double-check group. Each group had a multitude of medications they had to administer, and were not told if they had to double-check them or not. They had to follow their hospital policies and their current education when giving the medications. The data was analyzed with the use of the intention-to-treat principle (Douglass et al., 2018). The results showed that all nurses in the double-check groups did use independent double checks, and the single-check group used double-checks with some of their medications that were not needed. The issue with this study is that it was done in a controlled and simulated environment, which could have influenced the behaviors of the nurses (Douglass et al., 2018).
Every hospital and nursing program teaches that there are five rights to medication passes. The five rights are as follows: the right patient, the right drug, the right time, the right dose, and the right route. Following the five rights of medications ensures safe medication practices within a health system (Grissinger, 2010). Many factors can play a role in medical professionals not meetings all five rights of medication distribution. Inadequate system in place can hinder the achievement of following the five rights of medication distribution (Grissinger, 2010). The literature reviews analyzed did not mention the five rights to medication passes directly. The studies performed in the literature reviews focused more on what caused medication errors, and ways that medication errors could be prevented.
The studies do correlate with current practices involving what nurses are held accountable for during medication passes. Nurses are always held accountable for reading the label on the medication packaging, asking for someone to assist them in an independent double-check if indicated, questioning the pharmacy or physician on orders that seem unsafe or unclear, and using bar-code scanning technology to verify the order with the medication in the electronic medical record (Grissinger, 2010). Recommendation
Proper education and training, increasing nurse staffing levels, decreasing workloads, improving the safety climate, and establishing policies and procedures, such as independent double-checks can help decrease the incidence of medication errors. Well-designed medication packaging and labeling systems have also been proven to improve safe medication administration (Hammoudi et al., 2018).
Current practices need to be up-to-date with proper medication administration guidelines and practices. Important practices include things such as independent double-checks for high alert medications, education, and simulation-based training to improve the practice of nurses, and barcode medication administration (Lapkin et al., 2016). Barcode medication administration is a great example of technological support that is proven to reduce medication errors. The bar code on the medication can match the order in the patient electronic medical record, serving as a second check (Lapkin et al., 2016). One last important practice is ensuring a higher level of staff numbers and staff experience to decrease in-hospital mortality from mediation errors (Driscoll et al., 2016).
Humans are fallible, so error should always be anticipated. Errors occur even in the best hospital systems with the top employees. A medication error is a substantial occurrence in hospital systems and can lead to adverse events. These adverse events can be detrimental to patient care, and can even lead to death in some situations. Unsafe nurse-to-patient ratios can influence patient outcomes and cause adverse events. Medication errors are an example of what is included in the category of adverse events that can affect patient outcomes. Adverse events such as medication errors contribute to financial burdens affecting the patient, as well as, affecting the health care system. Simple things such as following the five rights to medication administration and having a well-organized system can promote the safe practice, decrease medication errors, and ensure safe and cost-effective care. The six literature reviews analyzed helped answer the evidence-based clinical question that the nurse-to-patient ratio is indeed influenced the amount of medication errors made by nurses in the inpatient setting.