Medication error in medical surgical ward. A reflective account

Author: Iloka Benneth Chiemelie
Published: 30th August 2015

Chapter 1

Introduction

Research background

The definition of medication error can be presented in its most simplified state as any avoidable event that can potentially result in the improper use of medication or hazard to the patient, with which the responsibility to avoid such can be relayed to the patient or health care professional (Hicks et al., 2004). The potential occurrence of medication error can come during different stages in the drug delivery process, which can be classified as prescribing, transcribing, dispensing and administration (Jarman et al., 2002).

No matter the stage of occurrence, one thing that is for sure is that it is possible to occur and it can happen at any stage in the drug delivery process. For every medication error that occurs, it is estimated that 9 out of every 10 cases results in adverse drug events and as such the focus of this paper will shift towards understanding the adverse drug event cases, while references will also be made to the avoidable cases that representing the remaining 1 out of 10 as estimated in medical research (Jarman et al., 2002)

The safety of patients and other related initiatives have led to the development of safety cultures that are designed to protect patients from harm, and it is also increasingly becoming a major focus in health quality improvement and other healthcare related topics. Publications on medication errors and it subsequent result in adverse drug reactions and drug-related admissions have been in health publications since early days of the 1960s [Hurwitz, 1969;  Seidl et al., 1965] and lately, interest have also increased in terms of identifying the right strategies for the prevention and reduction medication related errors and its subsequent results to adverse drug events (Hepler, 2003; Knudsen et al., 2007; Morris and Candtrill, 2003; Schnipper et al., 2006).

A reported emerged in the US in 1991, and the report was titled: To Err is Human, as presenting by the Institute of Medicine (an independent NGO organization that is based in the USA). An astonishing discovery was made from the report and it claimed that 44,000 to 98,000 patients die annually in the USA due to medication errors and adverse drug events (Kohn et al., 2000). Since that discovery, a number of numerous other studies have been made in the hospital ward setting with reporting rating ADE aspect of the medication error to be in the range of 2.5% to 30.4% (Raschetti et al., 1999; Bhalla et al., 2003; Chan et al., 2001; Schwake et al., 2009), and meta-analysis from the same finding have also shown that fatal aspect of the ADE reactions occurred in 0.32% of the patients (Lazarou et al., 1998). The potential of these percentage rising is also there as a result of the changes in the pattern diseases and subsequent increase in the availability and consumption of medications. Clearly, this is very serious issue in the medical setting as it could be the single direct error that has a very serious impact on the life of humanity. The only effect of medication error is not juts morbidity and mortality of patients, but it also causes an increase in medical cost due to the prolonged treatment that the affected patient will have to receive in the hospital (Bates et al., 1995; Classen et al., 1997; Leape et al., 1991; Bates et al., 1997).

In the Malaysian setting, the biggest measure in terms of the commitment to patient’s safety that the Malaysian Ministry of Health has towards patients comes in the creation of the Patients Safety Council in 2003 which is designed to ensure that the citizens have access to safe health case (MOH 2012). The guideline that this council closely follow is the recommendations that have been made by the World Health Organization’s (WHO) Alliance for the safety of patient, which recommended strategies and programs for maintaining patients’ safety (MOH 2012). In terms of their aim, the council made known that it desire to develop a national, electronic database system that will be used for the purpose of reporting and documenting medical errors in hospitals in order to promote a transparent and fair system for the confidential reporting of such incidence, and analyze the incidence as a means of learning new ways that they can be avoided in the future, as well as devising the right strategies for improving the safety and quality of patients, and publishing reports on adverse effects as it relates to the patients’ safety (MOH 2012).

Basically, the growing concern of the seriousness of medication error in the ward and other place have increased interest towards the understanding of the necessary factors that can be used to reduce these negative influence and increase the chances of survival even when such an error occurs. The question is not a matter of when; instead the focus should be on why and how the issue occurs and this serves as the main background for this paper.

About the researcher

The researcher began journey as a medical nurse in 2004 after three years in nursing school. Currently, the researcher is attached with one of the top private medical center in northern zone of Malaysia. The researcher also has high experience in working in critical care unit and medical surgical ward for the past ten years. Most of the times, the researcher is attached to busy medical surgical ward which consist of thirty beds. There are normally two staffs and one nurse aiding every shift per day, and sometimes the staffs can increase to four, depending on the demand for their service.

Research objectives

From the research background, it was made known that a study in the USA found that 44,000 to 98,000 patients die annually due to medication errors and adverse drug events (7). Since that discovery, a number of numerous other studies have been made in the hospital ward setting with reporting rating ADE aspect of the medication error to be in the range of 2.5% to 30.4% (8-11). The scary aspect of the whole story comes in the form of the case of medication error actually being on the rise. On that note, the purpose of this research is to conduct a reflective analysis of the incidence of medication errors that have occurred in numerous hospitals across the world. In view of that, the purpose of this research is to:

1.      Understand why medication errors occur in the world with reference to factors that influences such occurrence; and

2.      Understand how medication errors occur in the wards with reference to the factors that influences such occurrence.

Such a understand of why and how medication error occur in the hospital ward will help to develop the right solution to mitigating the negative influence posed on the lives of patients by such occurrences and then develop the right strategy for mitigating these negative influence through a safer approach to medication.

The underlying fact is that the issue of medical error is caused by a number of factors, of which some of these factors include fatigue, interruption, lack of experience and even mistakes from the side of the patient. In any case, the issue is not to understand the causes of medication errors in the wards, but the focus is on the best way that such errors can be limited or possibly eradicated by providing the necessary supports through gained understanding from the findings that will be based in this study.

Justification of chosen research topic and impact on career of nursing students

The nursing field just like any other life science and medical field deals with understanding ways that human lives can be improved and the overall life span increased. For every human being on earth, there isn’t any doubt to the fact that everybody has his or her own purpose of being alive and this makes it very inhumanly for these purpose to be short lived as a result of other people’s recklessness. 

On the ground of the above discussion, it becomes very much clear that any study conducted to understand ways that human lives span can be improved; through a reflection of errors that have occurred in the past in the medical setting is very significant as it can contribute immensely towards an increased understanding of these errors and development of the right strategy to prevent them. Sequel to that, it becomes clear that the chosen topic is justifiable because it will help in the development of the right strategy for preventing medical errors in the wards through a gained understand of how such errors occurred in the past.

To the nursing students, this is very important because the ward is an area that is mostly occupied by nurses and they are also responsible for administering medications in the wards. As such, a review of past cases as will be presented in this research will help them to understand how medication errors have occurred in the past and also help them to ensure that they don’t make such mistakes in their own career time.

Understanding what reflection is all about

Reflection can be stated to involve the description, analyzing and evaluation of ones though, assumptions, beliefs, actions and theories (Fade 2005). Considering the fact that the aim of placement is for the purpose of promoting clinical reasoning, the need for analytical and evaluation skills in students becomes very important (McClure 2005), and reflection is the key to the development of reflective practices. There are assumptions that reflection as a process involves the part of learning, but it is also a skill that needs to developed and enhanced.

Scholars have looked at what constitutes reflection and the identification made by Schon (1987) is that reflection can be in two different types, with the firs being reflection-in-action (thinking on your feet) and reflection-on-action (retrospective thinking). He also made the suggestion that practitioners make use of reflection when they encounter situations that seem to be quite unique, and when the individuals might not be well positioned to apply theories or techniques that have been previously learnt through formalized education.

Many authors have also moved to present their own definition on what reflection is all about, and Dewey (1933) is one of those authors with the definition that reflection is an active persistent and careful consideration of any belief or supposed form of knowledge that exists in the form of light of the grounds for supporting it and providing necessary conclusions that are used to measure the way forward.

Boud et al. (1985) has a different view of what reflection is all about by defining it as a generic term used for intellectual and reflective activities in which an individual is forced to engage in an active exploration of experiences with the aim of defining new understanding and appreciation.

In another definition, Reid (1993) also signed with the same view of reflection as an active process rather than a passive thinking, and it led to the definition of reflection as a process of reviewing an experience that one had in the practices in order to present a description, analysis, evaluation and informal learning about such practice. Kemmis (1985) is one of the authors that have supported Reid’s view of what reflection is all about by arguing that it is positive active process that is designed to review, analyze and evaluate experiences with focus on drawing theoretical concepts of previous learning and provides an action plan in the process for future experiences.

Figure 1: increasing capacity as a self-directed reflective practitioner

Source as adapted from: Powell (2004)

From the above figure, it can be understood that reflective learning in the critical view is nurtured through the establishment of relationship between teacher and leaner, between learner and learner, and between both the subjects under study. Powell (2004) made this identification of the optimal relationship as shown above to be mutual, open and challenging, contextual awareness and comprised of dialogue (Brockbank & McGill 1998).

The basic understanding gained from this analysis is that reflection deals with the things of the past in order to develop the things for the future. This is to say, that one looks back at how things have been done in the past and develop the right platform for a better future from the understanding gathered through the experiences encountered in the past. Similarity, this study is designed to reflect on the mistakes that have been made in the surgical ward with focus on medication error, and then develop a better surgical ward that is free of these errors through the design of a new strategies that doesn’t permit for such error to reoccur in the future.

Chapter 2

Literature review

To err they say is human, and the medical practitioners in the medical surgical ward are also human. This raises a big eye blow with respect to what will happen is these human in the medical ward actually err with respect to the medication being administered to their respective patients. In that case, it is clear that patients will be much safer if we concur with this reality of potential err in the medical ward and design the clinical tasks in such a way that errors are reduced in the ward. Such a design will involve an understanding of the issues that can result to an unforced error in the medical ward by either the attending clinician or the supporting staff. Medication error can occur in all the phases of acute care. Research have shown that about 20% of patient will likely have a harmful error in their preadmission medication history and this can lead to result to a subsequent medication disorder during the time of their return admission (Tam et al., 2005). During the admission in hospitals, the errors attributed for drug prescription has been measured to be at least 3% (Lesar et al., 1990; Bobb et al., 2004), and other direct observation have raised this rate to 19% for drug administration in the hospital (Barker et al., 2002). Specifying this error rate, research has found that there is a 2% error rate for intravenous infusion in the critical care centers (Rothschil et al., 2005). Once the patients have been discharged, about 25% of these patients will also have an error in their discharge of prescriptions when compared with their hospital medications (Schnipper et al., 2006). Although different methods and measures have been used in these studies, a collective messaged is being delivered that the possibility of having a hospital admission that is free of medication error is fart diminishing. However, Sanjay et al. (2012) gave some kind of comforting message that despite the high level of medication errors that occur in hospitals, most of these errors don’t seem to cause serious harm to the patients involved. The most common error as also note by Sanjay et al. (2012) comes in the form of delayed drug administration that results from a missing dose. The medication errors that are more serious have a high potential of harming the concerned patient and have been described as “potential adverse drug events.” Sanjay et al. (2012) presented an example by stating that 10-fold error in in the administration of morphine concentration is more serious when compared with a 10% error of the same administration. “Preventable adverse drug events” is the term used to describe medication errors that can actually cause harm. For every medication errors, research have found that there are between 4 and 10 potential adverse drug events and 1 preventable adverse drug event (Bates et al., 1995). About 1%-2% of patients will eventually experience a preventable adverse drug even while in the hospital but this depends on the methods and the definitions used (Kanjanarat et al., 2003). It is the responsibility of the husband however, to bear any form of fallout with respect to legal actions that are brought against them as a result of medication error.

In terms of understanding what medication error is all about, numerous definitions exist that can be used to describe the concept, and these definitions have been published in researches and literatures. One of such definition that is frequently employed medical professionals is that medication error is any shift from the medication orders made by the physician, as contained in the patient’s chart (Headford et al 2001; Mark and Burleson 1995), which fails to put into consideration the fact that prescription errors can lead to medical administration errors (Davydov et al 2004; Headford et al 2001; Wilson et al 1998). In any case, the most cited definitions in literature are those developed by nurses and defined by Wolf (1989), as mistakes that are associated with e4ugw and intravenous solutions that are made during the process of prescribing, transcribing, dispensing and administering of drug preparation and distributions (Wolf 1989, p.8).

These errors can be classified as either an act of omission or commission, and they can include the following: wrong drug; wrong route; wrong dose; wrong patient; wrong timing of drug administration; a contra-indicated drug for that patient; wrong site; wrong drug form; wrong infusion rate; expired medication date; or prescription error. These errors can occur both intentionally or unintentionally (Wolf 1989). While the unintentional aspect of the error is somewhat understandable, the fact that it can occur intentionally raises fear as to how medical practitioners deal with the lives that have been committed into their hands and why they could create medication error intentionally.

Since the focus of this paper is on medical surgical ward, the focus will also shift slightly on intravenous therapy which are normally prepare immediately before being administered to the patient. This form of therapy can involve the dissolution of power, dilution or transfer of injection fluids form its original vial or ampoule into a container (a syringe or an infusion bag). This is very much common in the surgical wards especially as anesthetics are being administered to the patient prior to surgical operation in order to limit pains that will occur from the surgical process. The significant issue here is that these processes normally pose numerous opportunities for errors to occur. In the past three decades, investigation was conducted by Breckenridge to understand the preparation and administration of intravenous therapy in hospital wards in the UK (Breckenridge, 1979). His report presented a summary with the view that medication error in the ward is as a result of lack of information, guidelines and also inadequate prescription which will eventually result in poor quality of health care given to the patients. Following his report, other studies have also been conducted in the same field to understand the causes of drug administration and medication errors. Some of these studies conducted an investigation of medication errors as it related to intravenous drug administration errors with one of the studies finding that 151 (84.4%) errors were observed in 179 drug administrations (O’Hara et al., 1995), and another reported an error of 24.7% in 320 observed preparations and administrations cases in hospitals (Hartley and Dhillion, 1998). 49% is the figure for error rate found by a recent study of 430 drug preparation and administration cases (Taxis and Barber, 2003). The finding of error rates in intravenous drug administration are actually higher than those found in oral medication, which are between 3% and 8% (Dean et al., 1995; Taxis et al., 1999). Other studies have also been conducted to investigate the preparation and administration of intravenous drugs in the intensive care units (ICU). For instance, a study in a Switzerland pediatric ICU also found 18% error in 231 cases that were observed (Schneider et al, 1997). Another study was also conducted in France in 2009 and the finding revealed 6% error in the observed events. Each of these administration that where considered in the error rate comprises of different events. The calculation approach for this error rate involves dividing the number of errors by the number of events that occurred. In the USA, another study was also conducted and it found that 21% error occurred from 100 preparation events observed (Tissot et al., 1999; Thur et al., 1972). In the case of USA, observation related to aseptic techniques were also included and the finding from the study is that majority of the nurses did not follow the technique (Hoppe=Tichy et al., 2002). However, it is very difficult to compare the error rates obtained from these studies as a result of the differences in the methods, settings and definitions used in the study.

Factors contributing to medication error

A number of factors can led to medication error in the surgical ward and these factors are normally divided into different sub-groups as: those that are caused by system errors, and those that are caused by the health care professionals. Another issue that can be examined in the context of the contributing factors is the incident reporting in the hospital. On that note, these sub-groups are as discussed below.

System issues

Hospitals are very complex and made up of both human and technologies (Clancy 2004a,b; Freedman Cook et al 2004; Singer et al 2003; Anderson and Webster 2001). Such system can be viewed as comprising of components such as: design, equipment, procedures, operators, supplies and environments (Anderson and Webster 2001), and error can occur within any of these components at any given point in time.

Even on its own, the medication process is a very complex sub-system within the hospital. As such, the process of prescribing, preparing and administering medications is dependent on numerous processes that are designed with the intention to ensure that the respective patients obtain appropriate treatment. However, if there is an occurrence of problem in any phase of the process, either in the organizational system on in the process of medication, it increases the possibility of a patient not being able to receive the right medication and on that hand it will compromise the safety of such patient.

Experts have joined hands with researcher to identify a number of issues in that system that will have a likely impact on a patient’s safety when it comes to administering medications, and such include: the patient’s acuity level, availability of nursing staffs, access to policy documentation and medication (See table 1). Due to these issues that have been identified with the system, acute-care organizations have designed a number of system strategies in order to reduce the number of errors that are originating from medication processes in the surgical ward  (Freedman Cook et al 2004; Sokol 2004; Brush 2003; Revere 2003; Singer et al 2003; Orser 2000). Some example of these strategies include making purchases for a single type of intravenous medication pump that will grand access to a specific computer program in the process of altering the settings of the pump (Brush 2003; Orser 2000). The unfortunate side is that little research exists for the process of evaluating the effectiveness of these strategies towards reducing medication errors.

Table 1: Issues in the system that contributes to medication errors

IDENTIFIED SYSTEM ISSUES	SUPPORTING RESEARCHES
Lack of necessary staffs	Committee on the work environment for nurses and patient safety (2004) Vincent (2003) Dean et al (2002) Wakefield et al (1998) Blegen and Vaughn (1998) Leape et al (1995)
Acuity level of patients	Dean et al (2002) Leape et al (1995)
Lack of access or inadequate access to medication information and policy	Clancy (2004b) Committee on the work environment for nurses and patient safety (2004) American Academy of Pediatrics (2003) Andersen (2002) Cohen and Cohen (1996)
Physical environments such as: lightning, and facilities for drug preparation.	Hicks et al (2004) Brush (2003) Dean et al (2002) Poster and Pelletier (1988)
Organizational culture	Bagian (2004) Committee on the work environment for nurses and patient safety (2004) Freedman Cook et al (2004) Singer et al (2003) Vincent (2003) Baker (1999b)
Channels of communication	Committee on the work environment for nurses and patient safety (2004) American Academy of Pediatrics (2003) King, Paice, Rangrej, Forestell and Swartz (2003) Tissot et al (2003) Vincent (2003) Baker (1999b) Vincent et al (1998)
Organizational routines	Andersen (2002) Baker (1994) Raju et al (1989)
Culture for reporting of incidents	Berntsen (2004) Bulla (2004) Freedman Cook et al (2004) Lamb (2004) Mayo and Duncan (2004) Suresh et al (2004) Frankel et al (2003) Webster and Anderson (2002)Anderson and Webster (2001) Pape (2001) Baker (1997) Day et al (1994) Davis (1990)
Pharmaceutical issues	Traynor (2004) Brush (2003) Tissot et al (2003) Orser (2000) Wakefield et al (1998)

There have been a shift internationally in the part decades with relation to how adverse events and medication administration errors are understood in the medical surgical wards, and this is featured with an increasing attention geared towards understand errors that are related to the organizational system (Vincent 2003; Institute of National Academies 1999). Veterans in the United States Health Administration (Bagian 2004; Vincent 2003), followed more recently by their British counterparts in the National Health Systems (National Patient Safety Agency 2003), have completely adopted a new change in their approach towards adverse events.

Instead of placing high focus on the culpability of the patients, more attention is geared towards the issues that contribute to error in the system, as an attempt designed to address the gap and failing within the system on its own (Vincent 2003). The overall essence of this is geared towards focusing on how to improve the system in order to avoid errors, instead of assigning blames on given people, and this have led to a marked decrease in the occurrence of medication related errors (Bagian 2004).

Professional issues

The issues that result to medication error as a result of individuals’ professionalism are varied and have different dimensions from which it can be viewed. These issues are as contained in the table below.

Table 2: Personnel issues that contribute to medication errors

IDENTIFIED PERSONNEL ISSUES	SUPPORTING RESEARCHES
Their understanding of how errors occur	Mayo and Duncan (2004) Tissot et al (2003) Vincent (2003) Andersen (2002) Wakefield et al (1998) Wilson et al (1998) Segatore et al (1994)
Their lack of understanding documents containing policy and procedures on medical administration	Hicks et al (2004) Tissot et al (2003) Dean et al (2002) O'Shea (1999) Wakefield et al (1998) Cohen and Cohen (1996)
Number of hours on shift	Mayo and Duncan (2004) Tissot et al (2003) Dean et al (2002) Raju et al (1989)
Distractions and interruptions	Hicks et al (2004) Tissot et al (2003) Wakefield et al (1998) Segatore et al (1994)
Lack of knowledge about medications	King (2004) Tissot et al (2003) Andersen and Webster (2002) Meurier et al (1997) Leape (1995)
Dosage calculating	Oldridge et al (2004) Wong et al (2004) Preston (2004) Schneider et al (1998) Segatore et al (1994)
Workload	Hicks et al (2004) Mayo and Duncan (2004) Anderson and Webster (2001) O'Shea (1999) Meurier et al (1997)
Mode of care delivery	Hicks et al (2004) Dean et al (2002) Jarman et al (2002) O'Shea (1999) Bates et al (1998) Ridge and While (1995)

These literature that have explored the issues of medication errors as it related to professional have on frequent notes, linked these issues to specific traits of these professionals, focusing on their individual attributes, level of skills and competencies (Preston 2004; Pape 2001; O'Shea 1999; Ernst, Buchanan and Cox 1991). A good example comes in the form of reports stating that an individual practitioner can contribute to medication error as a result of their lack of knowledge about the medication and processes involved (Tissot et al 2003; Meurier, Vincent and Parmar 1997; Leape 1995). With respect to the lack of knowledge, it can include their inability to calculate medication dosage accurately, and researchers have found that this can led to an increase in the potentiality of nurses to make an error. The importance of this is highly raised in the pediatric settings and neonatal intensive care units where the determination of drug dosage is based on the body size of the patient.

Incidence reporting

Earlier on, it was made known that understanding the influence of this with respect to medication error is worthy and the issue of reporting medication errors have been extensively discussed in literatures (for instance, Bulla 2004; Freedman Cook et al 2004; Lamb 2004; Suresh et al 2004; Frankel, Gandhi and Bates 2003; Vincent and Coulter 2002; Webster and Anderson 2002; Anderson and Webster 2001; Pape 2001; Baker 1997; Fonseka 1996; Day et al 1994; Davis 1990).

The acknowledgement in this literature comes in the form of understanding that most of the medication errors and accidents are not reported and even the near-miss incidences are never reported at all. To some extent, this have been linked to the act that most of the incidence reporting in history makes it mandatory that individuals should identify themselves, and when they are directly involved, they have to accept the responsibility for those errors, irrespective of the circumstances that surround  it.

There have been discussions by nurses and other health care professionals participating in studies that have stated that they are afraid of the consequences that will arise from their reporting of medication error because numerous disciplinary actions and ramifications exist in the medical settings (Vincent 2003; Arndt 1994). Baker (1997) was the one to highlight that as a result of this fear, nurses have reverted to embrace their own version of what they think is medication error. The author continued by stating that nurses now engage in processes that are designed to negotiate between institutional policy and the constraints that govern their everyday practices.

Another issues that have discussed to extensively influence incidence reporting is that format of the forms of such reporting, and many of this have been structured in such a way that issue in the system are not identified. This has led to suggestions from both researchers and practitioners that the form of incidence should be changed in order to incorporate the identification of system issues and have also proposed anonymous reporting as the solution as well (Bulla 2004; Suresh et al 2004; Anderson and Webster 2001).

Documentations on these strategies illustrate that it has the potential of increasing the likelihood for practitioners to eliminate reporting errors as well as near miss errors (Suresh et al 2004; Vincent 2003). Such an approach to the issue of incidence reporting also increases the opportunity of practitioners to discover factors that can potentially contributed to errors within the system (Bulla 2004; Lamb 2004; Suresh et al 2004; Vincent 2003; Anderson and Webster 2001; Day et al 1994). Authors such as Baker (1999a) and Lamb (2004)  have also made the assertion that if the reporting mechanisms that focuses on single individuals are not changes, the changes of addressing systems issues will be reduced and it will remain invincible across the globe.

Routes for administering medication

The Kansas City Department for Health (2009) presented numerous methods for serving medication in their manual titled: Administering medication for the non-professionals. The methods presented in these manuals will be used in this paper and they are:

Oral medication – this is the method of administering medication in which the medicine (liquid or solid) is passed through the patient’s oral cavity. The specific procedures for this form of medication are:

1.      The medical will usually be taken with full glass of water

2.      Medications that are long-acting should not be broken, crushed, or chewed prior to swallow.

3.      Liquid medications should be given in the prescribed dosage.

4.      When liquid medications don’t have dosage form, proper procedures need to be followed in the process of pouring the medication.

5.      The drug should be placed in the middle of the tongue, sublingual or buccal in order to aid easy swallowing.

6.      If the patient has difficulties with swallowing, other methods should be adopted.

 Opthalmic method – this is the form of medication in which the patient is administered directly through the eyes. This form of medication is only for liquid medications that normally float in the eyes for cleansing purpose.

Ear medication – this is the form of medication that is applied directly through the ear. In most cases, it is in liquid form except for where powered medications are used to cover wounds and aid healing in the ear.

Nasal method – just like the ear medication, drugs are administered to the body directly through the nose. Just like the ear medication as well, the format is normally in the form of drops of spray, except for special cases where powered medication are applied to aid healing of wounds.

Others – besides the sense organs, other routes for administering medications include tropical medication, virginal and rectal suppositories, and inhalation and Nebulizer Treatment. No matter the form of medication route adopted, the process of administering medication can be either by:

1.      Swallowing – the medication is swallowed by the patient by using water or other supporting liquids that will aid the intention to swallow (soft drinks). In the context of medical setting, only water is approved because of its pureness and cleansing capabilities as compared with other liquids that can be mixed with chemicals that hinder the functional ability of the medication. This is the most common form of medication and it is easier than other forms. However, it is

2.      Injection – this is a process by which liquid medication is being injected into the patient’s veins through syringe. This is the most effective form of medication because the drug is passed through the veins and as such activates medication process instantly.

3.      Infusion – in the event that the medication is too big to be passed through a syringe instantly and the patient is too weak to swallow, the medication can be infused into the patient’s veins and slowly passed into the patient. This is most common with “medical drips” that are infused for the purpose of activating a patient’s energy level.

4.      Inhalation – where the other processes doesn’t seem to worm (for instance asthmatic patients), the drugs can be inhaled by the patient by spraying it in the air close to the patient’s nose. It is most effective for sudden attack such as those experienced by asthmatic patients.

Models of reflection

In the earlier discussion, it was highlighted that reflection is a very important aspect of an individual’s career building steps. The reason for such was based on the understanding that when an individual is able to look back at past events, then the person will be better positioned t understand the mistakes that happened in the part and develop a better future by limiting the potentiality of such mistakes to reoccur in the future. However, these discussions failed to highlight certain models that might be used to conducted reflective practices. The need for models is very important because it can help serve as the right bridge for enhancing the outcome of the process by making sure that it is undertaken in the right manner. Some of these models are as discussed below.

Gibbs reflection model

Figure 2: Gibbs reflection model 

Source as adapted from: Gibbs’ (1988)

From the above figure 2, the need to adopt models in reflection can easily be visualized. This is based on the fact that the model touches all aspects of the past events that guts feelings might eliminate if such was adopted. The elements contained in the Gibbs’ model are:

Description – the individual needs to understand what happened in the past, reviewing the causes and the actual outcome as it related to the event that is being reflected upon.

Feeling - based on the description above, the individual can then determine if such event was good or bad and understand the actual factors that resulted to such feelings.

Evaluation – this is the reflection of what should have been done to avoid the outcome from the experience or enhance the outcome in essence.

Analysis – based on the conducted evaluation, the need to change will be analyzed by measuring the expected outcome of such change.

Conclusion – this is the stage at which the decision to change takes place and the individual in this case will set up the change platform

Action plan – the change platform is executed to reality at this stage.

KUBLER-ROSS’ GRIEF CYCLE

Figure 3: Kubler-Ross’ Grief Cycle 

The grief cycle presented above illustrates the events that occur in the process of reflection, and it revolves around the individual accepting that things are not supposed to be done the way it was done, and as such feeling depressed and angry in the process of bargaining for reaching an acceptance level in the course of establishing stability with the present in order to build a better future. This model focuses more on the events that takes process in the process of reflection and not the whole reflective process.

Kolb’s Learning Cycle

Figure 4: Kolb’s learning cycle

Source as adapted from: Kold (1984)

Still on the model of reflection, Kolb’s learning cycle as illustrated in the figure 4 above shows that reflection is a process that involves numerous components in order to be achieved. This is because the individual in question needs to flash back and understand the issue as it occurred, decide on the way forward, but also understand in the process that the way forward should not be linked to experiences that have failed in the past. It is something that requires a high level of cognitive thinking ability, making it mandatory for decisions that will influence the future to be based on past experience.

Decision rule: Gibbs’ reflection model

From the above analysis, three models have been looked into and it can clearly be seen that all these models represent high level of influence on effective reflection that will yield efficient outcome. However, all these models will not be used in this case and the decision is to adopt Gibbs’ reflection model. While it can be argued that the adopted model is very complex in the sense that it integrates numerous sub-groups together in the process of conducting the reflective exercise, it will be argued that such complexity makes it advantageous as it will allow for all facets of the events to be reviewed thoroughly. The benefit of such is that the final decision to change will be based on a thorough reflection, making these finding very sold in application and yield.

Chapter 3

Application of Gibbs model of reflection

Description

The suggestion presented in literature is that nurses play an important role in the surveillance and prevention of medication error (Rothschild et al, 2006). This is because the most common type of adverse effect in the medical setting in terms of medication error is the frequency in morbidity and preventable death as it occurs in hospitals (Adams and Koch, 2010). Gurwitz et al (2003) presented a report stating that 38% of medication errors are either serious or fatal, while another 42% are preventable.

Nurses have been described as responsible for 26% to 38% of medication errors that occur in the hospitals (Leape et al, 2002; Bates, 2007), and on that account, they have important role to play towards ensuring that the patients receive safe treatment. In the researcher’s view, the above figure can be stated to be right based on personal experience. This is because the nurse is the last person that can check medications and ensure that they are correctly prescribed and dispensed before any administration to the patient (Davey et al, 2008).

However, the researcher (a practicing medical nurse, hereinafter referred to as “nurse” for the whole of chapter 3) in this case made the terrible mistake of endangering a patient’s life as a result of poor communication. It was on a very fateful Friday evening (around 5pm), just less than 1 hour before the nurse dismisses for the day (as the nurse dismiss by 6pm). A 43 year old patient was admitted into the hospital and needed urgent medical diagnosis of which the nurse is responsible to ensure the smooth diagnosis of the patient. As the nurse was rushing through the process in order to return home, the diagnosis which was done to the patient who came with chest pain missed out the compression on her spinal cord. However, the Medical Doctor in charge of the patient recognized two week later while going through the patient’s file that the diagnosis was missed. The outcome while it required for urgent operation was no longer necessary because the patient had already become paraplegic. The Medical Doctor was very much saddened by the event and the nurse wasn’t in control of issue considering the fact that a written report must be written by the nurse, stating what occurred, and accepting responsibility for further consequences from such occurrence. On that account, the nurse rushed to fellow nurses and other staffs in fear and sort for their advice on how they think things can be changed in order reduce the consequences. It is a memory that has since then felt to go off the nurse’s mind, but have positively improved the performance as the nurse is now very cautious with any diagnosis and professional activities in order to reduce the potential of reoccurrence.

Feeling

Following the discovery, the nurse never felt at ease based on the recognition that it is a matter of life or career. Either the patient gets well or the nurse could be potentially dropped from medical practices. It was more of an emotional trauma because the weight of the outcome is very heavy and could entail further consequences in the Malaysian court of law. If charged under the Malaysian law, the consequences can begin with hefty fine down to potential jail terms. All these though meant that the nurse had no choice by to just pray to God and wait for the outcome of the whole scene, while hopping that fate will not be farfetched with positive outcomes.

Evaluation

This is a very sad experience for everybody. This is based on the understanding that if the spinal compression was noticed earlier, the patient wouldn’t have been made paraplegic. The fact that the life of a patient was so negatively transformed is something that is not acceptable in the settings and standards of the hospital. The event led to the nurse being put under strict surveillance in the diagnostic roles. Basically, the reasons for this as acknowledged by the nurse is the rush to get back home following an already exhausting day. This meant that the nurse couldn’t focus on the whole diagnosis process and was forced to rush the process. The outcome as is evident is very negative and discouraging. On the positive side, the nurse has improved since the occurrence. This is based on the understanding that the nurse has now become very conscious of diagnostics process, eliminating any factor that might influence the outcome of the process negatively and focusing on the safety of patients later than going back home on time. The nurse even work extended shifts in some cases without complaints and helps fellow staffs when the need arises without worries. As such, it can be seen that the event has effectively improve the nurse’s working career and the safety of patients.

Analysis

A number of discoveries can be made from this case. The first of such is that working hours in the nursing world can be very hectic and as such led to higher increase in medication errors. Thus, nurses need to keep the cool in order to limit the potential of such hectic working conditions leading to the lives of people being put in high danger. Medication administration has been described as probably the highest risk task that can be conducted by nurses (Anderson and Webster, 2001), and this is based on the understanding that numerous complexities exist when it comes to properly managing the welfare of patients under our care. On that account, it is important that nurses should make their fellow staffs aware whenever they are down with the hectic task

Conclusion

From the above analysis, it is clear that this medication error could have been averted if the nurses took extra time to concentrate on the assigned duty instead of thinking of what will happen after work. The indication above, based on the confession from the nurse clearly shows that the incidence occurred because the nurse wasn’t focused on the duty any longer as the main desire is to return home after work. Additionally, it can be stated that the workload also influenced the medication error because the nurses accounted to being tired at the moment and rushing back to rest. If the nurse was not subjected to hefty workload, the nurse would not have felt tired and would not be in rush at the same time. Thus, the case could have been averted.

Studies such as those conducted by Anderson and Webster (2001) and Brown (2001) have shown that the case of workload influencing medication error in the surgical ward is very much possible as they pointed out that the number of nurse staffing in some of the wards are very low, forcing the staffed nurses to be subjected to high stress, pleasure and fatigue emanating from prolonged working hours. The end product is that these nurses will slowly start to lose their focus and start taking certain things for granted as they seek to find a resting space. The outcome can be fatal as shown in the confession of the nurse in this study. As such, it will be concluded that the reason for the medication error is the nurse was already exhausted and yet forced to complete the job. This could easily have been averted by increased staffing of nurses that will ensure a nurse takes over from his supporting staff once the staff starts to weight down.

Action

Prior to discussing any potential action plan in case of reoccurrence, the nurse would like to reiterate that such an incidence is unlikely to reoccur. This is because the nurse has learned numerous a lot form the event and have further developed into a more reliable and efficient professional that is very much bothered by the life of patients being brought to the hospital. On that account, the nurse is very critical of any diagnosis and tries to find any missing link in the process of defining the right outcome from the diagnosis. However, there is also the need to plan on possible action if such incidence occurs again as “failing to plan has for long been known to be planning to fail.” The action that will be taken by the nurse in future event is that the nurse will focus on the designated work and ensure that all energy (even if it is the last remaining energy) are geared towards medical efficiency and enhancing the safety of the patient’s health care. In any case, the nurse had internalized this action because this is the present process adopted toward the undertaking of all designated assignments. This can also be linked to improved efficiency and effectiveness in terms of how the nurse manages health related issues. On the positive side, it must be reckoned that since the event, the nurse nor any other staff on the care of the affected nurse has never experienced or being involved in another medical related error with respect to either putting the patient in high danger or even minor health issues.

                                                                       Chapter 4

Recommendations

The Wong-Baker FACES pain rating scale is one of the rating scales used to understand how painful an event is to somebody. Originally, it was designed for medical uses in children to understand how painful they are in order to measure the extent of their medical condition, but this have also been expanded into other medical areas for the purpose of understanding how painful an event is to the person who passed through the event in order to measure how the person can move forward.

Figure 5: Wong-Baker FACES pain rating scales

From the above scale, the nurse’s rating is 10 because it is the worst experience the nurse has ever had on the professional level. As such, it influenced the change factor positively and helped the nurse understand reasons to be very careful with respect to patients’ safety in healthcare. In order to continue this push towards a better healthcare, other nurses and medical professional are recommended to adopt the nine rights of medical administration which will eliminates changes of wrong medication and diagnosis.

The nine rights

Most of the nurses in the medical settings will probably be very much aware of the five rights in medication administration that is the right patient, drug, dose, route and time (Eisenhauer et al, 2007). However, studied have shown that there is more to medication rights than the five rights (Cox, 2000), and this recommendation will focus on the seven rights as identified in recent years.

Identify the right patient

It is very much obvious that medication must be administered to the right patient for whom it has been prescribed for. However, having medications administered to the wrong patient is very common in the medical settings. A possible reason for this has been identified in the study conducted by Lisby et al (2005) in which it was shown that medical and surgical wards in a Danish university hospital recorded an alarming 36% of medication hat where administered to patients without any previous verification to determine whether the patient where right for the medication. The eventual outcome of such process is that patients will likely get administered with the wrong medication and this error can lead to the negative issues discussed earlier.

On that account, safe health care will start with the right patient as it is the only way in which the medication can actually be effective at the start. As such, it is recommended that nurses in the medical and surgical ward should be very conscious with this and ensure that they administer medications to the right patients. This can be done by eliminating the issue highlighted in the case of the Danish Hospital above by having a direct conversation with the patients and understanding what their issues are first before proceeding to administer any medication to them.

Right drug

A number of indications have been made from researches that as many as one out of every three medications errors involves the patient being administered with the wrong medication (Selbst et al, 1999; LaPointe and Jollis, 2003). Nurses are not qualified legally to handle drug prescription and if they are not sure about the drug prescribed, they should not administer it without checking the correct name with the prescriber. The issues of wrong drug administration can emanate from the nurse not seeing the handwriting of the prescriber correctly or from wrong diagnosis as is the case of the nurse contained in this study. However, the focus is on understanding hot to increase the health of patients and this is by ensuring that patients are administered with the right medication, with the nurse having responsibility of ensuring that prescriptions are correct and clarifications should be made in cases where there are issues with respect to understanding the prescription.

Right route

Earlier in this case, a number of routes for administering drugs where mention with the types of drugs generally described to be either solid or liquid. Nurses are only allowed to administer drugs via the prescribed routes, but in some cases the prescriber can offer the nurse choices (IV/PO). On the ground that choices exist, the nurse needs to understand associated differences between these routes such as their rate of absorption or time of action. Understanding the right route is as important as any other process in drug administration because it is only through such that the nurse will be able to administer the drug in a way that it would yield reflex and immediate actions that will be used to achieve the intended outcome.

Right dose

Researches have also found that one third or more of every medication error arises from wrong dosage being administered (LaPointe and Jollis, 2003; Tang et al, 2007). The significance of this figure implies that the need to be cautious while reading prescribe dosage. Wrong dosage is without a doubt of high threat to the safety of any healthcare. This is because under dose administration will potential flow down medical healing and can cause more harm to the safety of the patient, while over dosage will cause adverse effects, side reactions and even serious acute conditions to the patient, which makes it very important that nurses come to mind the need to administer the right dose for the patient.

Right time

In order to ensure therapeutic serum levels, medication must always be administered at the correct time. The administration of medication on wrong time is as such one of the ways in which medical error can occur. Findings from studies shows that the administration of drugs at the wrong time accounted for 31% of all medication errors (Dean, 2005), with antibiotics ranking the highest of group of drugs associated with medication error as a result of the fact that they commonly prescribed in the medical settings but administered at different times (Tang et al, 2007). On that account, it is evidence that the need to administer drugs at the right time is important and it is recommended that nurses should stick with the prescribed time in order to avoid medication related errors in the medical surgical wards.

Right documentation

Whenever a nurse administers a medication, it is expected of the nurse to sign the medication chart as prove that the medication has been administered. If the nurse reverts to signing the medication chart prior to the administration, then the nurse is at risk because the patent can refuse to take the medication, which leads to the chart stating a different thing form what actually went on. Additionally, the nurse might find it difficult to cancel out the already signed chart and it could be easily be perceived by the doctor that the patient is under the correct medication while as the patient is suffering from poor medication. The outcome can be very disastrous especially in cases whereby the patient needs the drug in order to remain active.

Right action

In the process of administering a medication, the nurse should make use of personal experience to ensure that the drug has been prescribed for the right reasons. For instance, it is not appropriate for a nurse to administer an antibiotic for a viral infection, nor it is appropriate for antiviral drug to be administered for a bacterial infection. Such minor issues can end up causing complications in the health of the patient as reduced reflex reaction can prevail as the patient will end up not being given the right medication. The outcome of such process is the main reason why it is necessary that nurses should take extra time to ensure that the right action is being undertaken and make necessary corrections in cases where they feel that the prescribed action is as supposed with respect to the issue that is being treated.

Right form

Medications are available in different forms and as such can be administered in different forms as well. For instance, paracetamol comes in different forms such as tablets, capsules, caplets, syrup, suppositories and ampoules for intravenous administration. The fact is that having medications in different forms can lead to some forms of medication being very confusing. Indeed, there is documented cases in which cough medication for oral administration have been administered mistakenly in an intravenous form (Cohen 2006). The issue in this case is that the prescriber didn’t specify any route for which the medication can be administered, leading to the medication being dispensed in a syringe by a pharmacist; the nurse was not familiar with oral syringe while the patient had an intravenous cannula, so the nurse had the assumption that the medication should be administered that way. Clearly, it can be seen that nothing is very simple in the process of administering a drug, which means that extra measure should be taken with respect to all processes involved in drug administration even to the extent of ensuring that the form of administration is correct.

Right response

Following every administered medication, the nurse should take extra time to monitor the progress of the patient with respect to the medication in order to ensure that the response is as expected from such drug. The process of monitoring the right response could involves cases such as measuring the patient’s blood glucose level, vital signs or other physiologic parameters like the urine output test (Wilson and Devito-Thomas, 2004). Once all other factors as discussed above are right, the response on its own will be right. if any negative response is noticed, the nurse should be quick to recheck other factors in order to ensure that the actual drug was administered to the right person, at the right time, via the right route, in the right form and complying with other right elements.

Basically, the understanding presented in this recommendation is that the medical nurse and other practitioners should ensure that medications are done under the right settings. For everything to be correct, the right settings as described above must be adhered with in the case where lack of adherence will influence the outcome of the process negatively, leading to further complication and medical related issues that can cause adverse event reactions on the patient involved. However, it must be noted that such is not so easy and extra care must be taken by the nurse at all times to reflect true professionalism in the practice of medication administration. The job of the nurse extends far beyond administering whatever medication is prescribed, but also extend to ensuring that whatever is being given to the patient is what is expected for the conditions of illness the patient is facing and also take time to monitor progress of administered drugs in order to ensure that the outcome is as expected or make necessary corrections where mistakes seems to be prevailing. It is believed that strict adherence to these rules will enhance the medical environment by creating a safer health care system for the patients, which features reduction in medication related error and a subsequent increase in positive outcome from medication processes.

Chapter 5

Conclusions

In the introductory stage of this paper, medication error was defined to be any activity which shifts the right medication procedures and increases risk for the patients in the outcome of a medical process. As such, the topic was chosen as to gain an understanding on the medication errors that occur in the medical surgical wards. However, it was considered necessary that the researcher conducts such study from a personal view point because it would help advance the overall outcome of the research by presenting meanings in a way that it was personally experienced instead of pure theories and references from other studies.

Reflective writing is the adopted method, with reflection earlier defined as going through past experiences, gathering information about the past experience and using the gathered information to design a better way forward. The understanding is that for a reflection to occur, there must have been a past event that the reflector is reflecting on and the purpose of reflection is to gain an understanding on how things can be changed for the better in both the present and the future.

On that account, the study was based on a reflective review of past occurrence from the side of the researcher. Prior to the review, it was made known based on existing literature and past studies that medication error is very common in medical surgical wards and this is due to a number of issues such as wrong diagnosis, wrong prescription, fatigue, lack of knowledge and experiences, wrong information from the patient, and other factors.

The reflection showed that the researcher ignored compression on the spinal cord of a patient following diagnosis and before the issue could be corrected the patient has already become paraplegic. This led to the nurse being subjected to high pleasure and criticism from the medical doctor and other staffs, and also forced to report the incidence and acknowledge responsibility for further actions that might result from the case. This is a turning point in the professional career of the researcher as the experiences resulted in a change towards increased efficiency and safety in the health care facilities.

The reason for the incidence as confessed by the researcher is because of fatigue resulting from prolonged working hours, which meant that the nurse was so keen to go back before the patient arrived but had to diagnose the patient as there was no supporting nurse. The outcome involves negligence of something that mattered most in the process and a resultant paraplegic condition to the patient.

On that account, recommendations were made by the nurse following the incidence that other nurses should always ensure that the medical surgical ward is handled in such a way that the safety of patient is the core of processes in the wards. This involves setting the right environment and adhering to the right standards in the system.

In conclusion, medication error is a common case in the medical surgical ward, but this should be addressed in order increase the safety of patient and it is possible by working together as a team to promote surgical safety instead of criticizing the mistakes made by a staff.

References

Adams M, Koch R (2010) Pharmacology connections to nursing practice. Pearson, New Jersey.

American Academy of Pediatrics. 2003. Prevention of medication errors in the pediatric inpatient setting. Pediatrics, 112(2):431-436.

Andersen, S. 2002. Implementing a new drug record system: a qualitative study of difficulties perceived by physicians and nurses. Quality in Health Care. 11(1):19-25.

Anderson, D., and Webster, C. 2001. A systems approach to the reduction of medication error on the hospital. Journal of Advanced Nursing. 35(1):34-41.

Armitage, G. and Knapman, H. 2003. Adverse events in drug administration: a literature review. Journal of Nursing Management. 11:130-140.

Arndt, M. 1994. Research in practice: how drug mistakes affect self-esteem. Nursing Times. 90(15):27-30.

Ashcroft, D., Brirtwistle, M., Cooke, J., Hingley, K. and Moore, P. 2003. When do medication errors occur and who reports them? Analysis of a web-based incident reporting scheme in secondary care. The International Journal of Pharmacy Practice 11:R86.

Bagian, J. 2004, August 17. Patient safety – why bother? Paper presented at the conference: When things go wrong: medical and legal aspects of root cause analysis. Auckland, New Zealand: New Zealand Law Society and the School of Medicine, University of Auckland.

Baker, H. 1994. Nurses, medication and medication error: a ethnomethodological study. Unpublished Doctoral thesis, Central Queensland University, Rockhampton.

Baker, H. 1997. Rules outside the rules for administration of medication: a study in New South Wales, Australia. Image: Journal of Nursing Scholarship. 29(2):155-159.

Baker, H. 1999a. Medication errors: where does the fault lie? In S. Hunt and R. Parkes (eds.), Nursing and the quality use of medications (pp. 73-85). St Leonard’s, Australia: Allen & Unwin.

Baker, H. 1999b. Quality use of medicines: changing the system. In S. Hunt and R. Parkes (eds.), Nursing and the Quality Use of Medicines (pp. 98-113). St Leonard’s, Australia: Allen & Unwin.

Barker KN, Flynn EA, Pepper GA, et al. Medication errors observed in 36 health care facilities. Arch Intern Med 2002 ; 162 : 1897-903.

Barker, K., Flynn, E., and Pepper, G. 2002b. Observation method of detecting medication errors. American Journal of Health-System Pharmacy. 59, Dec 1:2314-2316.

Barker, K., Flynn, E., Pepper, G., Bates, D., and Mikeal, R. 2002a. Medication errors observed in 36 health care facilities. Archives of Internal Medicine 162,16:1897-1904

Bates D (2007) Preventing medication errors: a summary. American Journal of Health-System Pharmacy 64(14) (Suppl 9 S3-S9).

Bates DW, Boyle DL, Vander Vliet MB, et al. Relationship between medication errors and adverse drug events. J Gen Intern Med 1995 ; 10 : 199-205.

Bates, D, Spell, N, Cullen, D, et al., The costs of adverse drug

Bates, D., Leape, L., Cullen, D., Laird, N., Peterson, L., Teich, J., et al. 1998. Effect of computerised physician order entry and a team intervention on prevention of serious medication errors. JAMA. 280(15):1311-1316.

Bates, DW, Cullen, DJ, Laird, N, et al., Incidence of Adverse Drug Events and Potential Adverse Drug Events: Implications for Prevention. Journal of the American Medical Association, 1995. 274(1): p. 29-34.

Berntsen, K. 2004. Valuable lessons in patient safety: reporting near misses in healthcare. Journal of Nursing Care Quality. 19(3):177-179.

Bhalla, N, Duggan, C, and Dhillon, S, The incidence and nature of drug-related admissions to hospital. Pharmaceutical Journal, 2003. 270(7246): p. 583-586.

Blegen, M. and Vaughn, T. 1998. A multisite study of nurse staffing and patient occurrences. Nursing Economics. 16(4):196-204.

Bobb A, Gleason K, Husch M, et al. The epidemiology of prescribing errors: The potential impact of computerized prescriber order entry. Arch Intern Med 2004 ; 164 : 785-92

Boud D, Keough R and Walker D (1985) Reflection: Turning experience into learning. Kogan Page.

Brockbank A and McGill I (1998) Facilitating Reflective Learning in Higher Education. Higher Education. 39(4):489-491.

Brush, K. 2003. Upgrading systems design to reduce medication administration errors. Clinical Nurse Specialist. 17(1):15-16.

Bulla, S. 2004, July 22-24. Medication administration error reporting: it may not be what you think. Paper presented at the 15th International Nursing Research Congress. Dublin, Ireland.

Chan, M, Nicklason, F, and Vial, JH, Adverse drug events as a cause of hospital admission in the elderly. Int Med J, 2001. 31: p. 199-205.

Clancy, T. 2004a. Navigating in a complex nursing world. JONA. 34(6): 274-282.

Clancy, T. 2004b. Medication error prevention. JONA'S Healthcare Law, Ethics, and Regulation. 6(1):3-14.

Classen, DC, Pestotnik, SL, Evans, RS, et al., Adverse Drug Events in Hospitalized Patients: Excess Length of Stay, Extra Costs, and Attributable Mortality. JAMA, 1997. 277(4): p. 301-306.

Cohen M (2006) Medication error: unfamiliar syringe, wrong route. Nursing2006 36(3): 14.

Cohen, M. and Cohen, H. 1996. Medication errors: following a game plan. Nursing 96 26(11):34-37.

Committee on the Work Environment for Nurses and Patient Safety. 2004. Keeping the patient safe: transforming the work environment of nurses. Washington: The National Academies Press.

Cox J (2000) Quality medication administration. Contemporary Nurse 9(3-4): 308-313.

Davey A, Britland A, Naylor R (2008) Decreasing paediatric prescribing errors in a district general hospital. Qual Saf Health Care 17(2): 146-9.

Davis, M. 1990. Dealing fairly with medication errors. Nursing90, March:42 43.

Davis, P., Lay-Yee, R., Briant, R., Ali, W., Scott, A. and Schug, S. 2002. Adverse events in New Zealand public hospitals 1: occurrences and impact. The New Zealand Medical Journal. 115(1167):275-281.

Davydov, l., Caliendo, G., Mehl, B. and Smith, L. 2004. Investigation of correlation between house-staff work hours and prescribing errors. American Journal of Health-System Pharmacy. 61(1):1130-1134.

Day, G., Hindmarsh, J., Hojna, C., Roy, G. and Ventimiglia, N. 1994. Improving medication administration through an enhanced occurrence reporting system. Journal of Nursing Care and Quality. 9(1):51-56.

Dean S (2005) Medication errors and professional practice of registered nurses. Collegian 12(1): 29-33.

Dean, B., Schachter, M., Vincent, C. and Barber, N. 2002. Causes of prescribing errors in hospital inpatients: a prospective study. The Lancet. 359:1373-1378.

Dewey J (1933) How We Think. Henrey Regney.

Eisenhauer L, Hurley A, Dolan N (2007) Nurses’ reported thinking during medication administration. J Nurs Scholarsh 39(1): 82-7.

Ernst, M., Buchanan, A. and Cox, C. 1991. Drug errors: a judgment of errors. Nursing Times. 87(14):26-30.

Fade S (2005) Learning and Assessing through Reflection. http://www.practicebasedlearning.org/resources/materials/docs/RoyalBromptonV3.pdf

Flynn, E., Barker, K., Pepper, G., Bates, D. and Mikel, R. 2002. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. American Journal of Health-System Pharmacy. 59, Mar 1:436-446. Fonseka, C. 1996. To err was fatal. British Medical Journal. 313:1640-1642.

Fortescue, E., Kaushal, R., Landrigan, C., McKenna, K., Clapp, M., Federico, F., Goldman, D. and Bates, D. 2003. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics. 111(4):722-729.

Frankel, A., Gandhi, T. and Bates, D. 2003. Improving patient safety across a large integrated health care delivery system. International Journal for Quality in Health Care. 15:i31-i40. Freedman Cook, A., Hoas, H., Guttmannova, K. And Joyner, J. 2004. An error by any other name. American Journal of Nursing. 104(6):32-43.

Gibson, T. 2001. Nurses and medication error: a discursive reading of the literature. Nursing Inquiry. 8(2):108-117.

Gurwitz J, Field T, Harrold L, Rothschild J, Debellis K, Seger A et al (2003) Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 289(9): 1107-16.

Headford, C., McGowan, S., and Clifford, R. (2001). Analysis of medication incidents and development of a medication incident rate clinical indicator. Collegian. 8(3):26-31.

Healee, D. 1999. Medication errors: understanding the risk. Unpublished Master of Arts (Applied) thesis, Victoria University of Wellington, New Zealand.

Hepler, CD, Understanding Adverse Drug Therapy Outcomes, in Preventing Medication Errors and Improving Drug Therapy Outcomes: A Management Systems Approach., Hepler, C.D. and Segal, R., Editors. 2003, CRC Press: Boca Raton, Florida.

Hicks, R., Becker, S., Krenzischeck, D. and Beyea, S. 2004. Medication errors in the PACU: a secondary analysis of MEDMARX findings. Journal of PeriAnesthesia Nursing. 19(1), 18-28.

Hicks, R., Becker, S., Krenzischeck, D. and Beyea, S. 2004. Medication errors in the PACU: a secondary analysis of MEDMARX findings. Journal of PeriAnesthesia Nursing. 19(1), 18-28.

Hunt, S. Parkes, R. (Eds.). 1999. Nursing and the Quality use of medicines. St Leonard’s, Australia: Allen & Unwin.

Hurwitz, N, Admissions to hospital due to drugs. Br Med J, 1969. 1: p. 539-540.

Institute of National Academies. 1999. To err is human: building a safer health system. Washington, D.C. The National Academies Press. Jarman, H., Jacobs, E., and Zielinski, V. 2002. Medication study supports registered nurses' competence for single checking. International Journal of Nursing Practice. 8:330-335.

Jarman, H., Jacobs, E., and Zielinski, V. 2002. Medication study supports registered nurses' competence for single checking. International Journal of Nursing Practice. 8:330-335.

Kanjanarat P, Winterstein AG, Johns TE, et al. Nature of preventable adverse drugevents in hospitals: a literature review. Am J Health Syst Pharm 2003 ; 60 : 1750-9.

Kemmis S (1985) Action Research and the Politics of Reflection. In: Boud D et al (1985) op cit.

King, R. 2004. Nurses' perceptions of their pharmacology education needs. Journal of Advanced Nursing. 45(4):392-401.

King, W., Paice, N., Rangrej, J., Forestell, G. and Swartz, R. 2003. The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients. Pediatrics, 112(3):506-509.

Knudsen, P, Herborg, H, Mortensen, AR, et al., Preventing medication errors in community pharmacy: frequency and seriousness of medication errors. Qual Saf Health Care, 2007. 16: p. 291-296.

Kohn, L, Corrigan, J, and Donaldson, M. 2000: Institute of Medicine: Washington DC.

Lamb, R. 2004. Open disclosure: the only approach to medical error: open, honest, and timely disclosure should be the only approach to medical error. Quality and Safety in Health Care. 13(1):3.

LaPointe N, Jollis J (2003) Medication errors in hospitalized cardiovascular patients. Arch Intern Med 163(12): 1461-66.

Lazarou, J, Pomeranz, BH, and Corey, PN, Incidence of Adverse Drug Reactions in Hospitalized Patients: A Meta-analysis of Prospective Studies. JAMA, 1998. 279(15): p. 1200-1205.

Leape L, Epstein A, Hamel B (2002) A series on patient safety. New Engl J Med 347(16): 1272-73

Leape, L., Bates, D., Cullen., J., Cullen, J., Cooper, H., Demonaco, T., Gallivan, R., Hallisey, J., Ives, N. and Laird, G.,1995. Systems analysis of adverse drug events: ADE prevention study group. JAMA 274(1):35-43.

Leape, LL, Brennan, TA, Laird, N, et al., The Nature of Adverse Events in Hospitalized Patients. N Engl J Med, 1991. 324(6): p. 377-384.

Lesar TS, Briceland LL, Delcoure K, et al. Medication prescribing errors in a teaching hospital. JAMA 1990 ; 263 : 2329-34.

Lisby M, Nielson L, Mainz J (2005) Errors in the medication process: frequency, type, and potential clinical consequences. Intern J Qual Healthcare 17(1): 15-22.

Mark, B. and Burleson, D. 1995. Measurement of patient outcomes: data availability and consistency across hospitals. JONA 25(4):52-59.

Mayo, A. and Duncan, D. 2004. Nurse perceptions of medication errors: what we need to know for patient safety. Journal of Nursing Care Quality, 19(3):209-217.

McClure P (2005) Reflection on Practice. http://www.practicebasedlearning.org/resources/materials/docs/reflectiononpractice.pdf

Meurier, C., Vincent, C. and Parmar, D. 1997. Learning from errors in nursing practice. Journal of Advanced Nursing. 26:111-119.

Ministry of Health. 2001a. Reportable Events: guidelines. Wellington. Ministry of Health. Australian Journal of Advanced Nursing 2006 Volume 23 Number 3

Ministry of Health. 2001b. Toward clinical excellence: learning from experience: a report to the Director-General of Health from the Sentinel Events Project Working Party. Wellington. Ministry of Health. National Patient Safety Agency. 2003. Seven steps to patient safety: a guide for NHS staff. Retrieved September 17, 2004 from: http://www.npsa.nhs.uk/admin/publications/docs/sevensteps_overview(2).pdf

Morris, CJ and Cantrill, JA, Preventing drug-related morbidity – the development of quality indicators. J Clin Pharm Ther, 2003. 28(4): p. 295-305.

Oldridge, G., Gray, K., McDermott, L. and Kirkpatrick, C. 2004. Pilot study to determine the ability of health-care professionals to undertake drug dose calculations. Internal Medicine Journal. 34:316-319.

O'Neill, M. 2004. ACC medical misadventure errors: drug administration. Wellington. Accident Compensation Corporation.

Orser, B. 2000. Reducing medication errors. Canadian Medical Association Journal, 162:1150-1151.

O'Shea, E. 1999. Factors contributing to medication errors: a literature review. Journal of Clinical Nursing. 8:496-504.

Pape, T. 2001. Searching for the final answer: factors contributing to medication administration errors. Journal of Continuing Education in Nursing. 32(4):152-160.

Poster, E. and Pelletier, L. 1988. Primary versus functional medication administration: monitoring and evaluating medication error rates. Journal of Nursing Quality and Assurance, 2(2):68-76.

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

Raju, T., Kecskes, S., Thorndon, J., Perry, M. and Feldman, S. 1989. Medication errors in neonatal and paediatric intensive-care units. Lancet. 2(8659):374-376.

 Raschetti, R, Morgutti, M, Menniti-Ippolito, F, et al., Suspected adverse drug events requiring emergency department visits or hospital admissions. Eur J Clin Pharmacol, 1999. 54: p. 959-963.

Reid B (1993) “But we’re doing it already”. Exploring a response to the concept of reflective practice in order to improve its facilitation. Nurse Education Today. 13:305-309.

Revere, L. 2003. Integrating six sigma with Total Quality Management: a case example for measuring medication errors. Journal of Health Care Management. 48(6):377-392.

Ridge, H. and While, A. 1995. Neonatal nursing staff time involved with medication-related activities. Journal of Advanced Nursing. 22:623-627.

Rothschild J, Hurley A, Landrigan C, Cronin J, Martell-Waldrop K, Foskett C et al (2006) Recovery from medical errors: the critical care nursing safety net. Joint Commission Journal on Quality and Patient Safety 32(2): 63-72.

Rothschild JM, Keohane CA, Cook EF, et al. A controlled trial of smart infusionpumps to improve medication safety in critically ill patients. Crit Care Med 2005 ; 33 : 533-40.

Sanjay, G., Ajay, K.S., and Bhavana, S. (2012), “Medication errors in medicine wards in a tertiary care teaching hospital of a hill state in India.” Asian Journal of Pharmacy and Life Science ISSN 2231 – 4423 Vol. 2 (1), Jan-March,2012.

Schneider, M., Cotting, J. and Pannatier, A. 1998. Evaluation of nurses’ errors associated with the preparation and administration of medication in a pediatric intensive care unit. Pharmacy World Science, 20(4):178-182.

Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006 ; 166 : 565-71.

Schnipper, JL, Kirwin, JL, Cotugno, MC, et al., Role of Pharmacist Counseling in Preventing Adverse Drug Events After Hospitalization. Archive of Internal Medicine, 2006. 166: p. 565-571.

Schon D (1987) Educating the Reflective Practitioner. Josey Bass.

Schwake, L, Wollenschläger, I, Stremmel, W, et al., Adverse drug reactions and deliberate self-poisoning as cause of admission to the intensive care unit: a 1-year prospective observational cohort study. Intensive Care Med, 2009. 35(2): p. 266-274.

Seddon, M. and Merry, A. 2002. How safe are our hospitals? The New Zealand Medical Association, 115(1167). Retrieved 24 August, 2004 from:www.nzmz.org.na/journal/115-1167/268

Segatore, M., Millar, M. and Webber, K. 1994. Medication out of control? The Canadian Nurse, September:35-39

Seidl, LG, Thornton, GF, and Cluff, LE, Epidemiological studies of adverse drug reactions. Am J Public Health, 1965. 55(8): p. 1170-1175.

Selbst S, Fein J, Osterhoudt K, Ho W (1999) Medication errors in a pediatric emergency department. Pediatr Emerg Care 15(1): 1-4.

Singer, S., Gaba, D., Geppert, J., Sinaiko, A., Howard, S. and Park, K. 2003.

Sokol, P. 2004. Transforming the workplace environment: Port Huron Hospital's transformation model. Nursing Economics, 22(3):152-154.

Suresh, G., Horbar, J., Plsek, P., Gray, J., Edwards, W., Shiono, P., Ursprung, R., Nickerson, J., Lucey, J. and Goldmann, D. 2004. Voluntary anonymous reporting of medical errors for Neonatal Intensive Care. Pediatrics, 113(6):1609-1618.

Tam VC, Knowles SR, Cornish PL, et al. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ 2005 ; 173 : 510-15.

Tang F, Sheu S, Yu S, Wei I, Chen C (2007) Nurses relate the contributing factors involved in medication errors. J Clin Nurs 16(3): 447-57.

The culture of safety: results of an organization-wide survey in 15 California hospitals. Quality and Safety in Health Care. 12(2):112-119.

Thomas, E. and Peterson, L. 2003. Measuring errors and adverse events in health care. Journal of General Internal Medicine, 18:61-67.

Tissot, E., Cornette, C., Limat, S., Mourand, J., Becker, M., Etievent, J., Dupond, J., Lacquet, M. and Woronoff-Lemsi, M. 2003. Observational study of potential risk factors of medication administration errors. Pharmacy World Science. 25(6):264-268.

Traynor, K. 2004. Enforcement outdoes education at eliminating unsafe abbreviations. American Journal of Health-System Pharmacy, 61:1314-1315.

Vincent, C. 2003. Understanding and responding to adverse events. New England Journal of Medicine. 348:1051-1056.

Vincent, C. and Coulter, A. 2002. Patient safety: What about the patient? Quality in Health Care. 11:76-80.

Vincent, C., Taylor-Adams, S. and Stanhope, N. 1998. Framework for analysing risk and safety in clinical medicine. British Medical Journal, 316:1154-1157.

Wakefield, B., Wakefield, D., Uden-Holman, T. and Blegen, M. 1998. Nurses perceptions of why medication administration errors occur. Medsurg Nursing, 7(1):39-44.

Webster, C. and Anderson, D. 2002. A practical guide to the implementation of an effective incident reporting scheme to reduce medication error on the hospital ward. International Journal of Nursing Practice, 8:176-183.

Wilson D, DeVito-Thomas P (2004) The sixth right of medication administration: right response. Nurse Educator 29(4): 131-32

Wilson, D., McArtney, R., Newcombe, R., McArtney, R., Gracie, J., Kirk, C., et al. 1998. Medication errors in paediatric practice: insights from a continuous quality improvement approach. European Journal of Pediatrics, 157:769-774.

Wirtz, V., Taxis, K. and Barber, N. 2003. An observational study of intravenous medication errors in the United Kingdom.