The Strategic of Role Education

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The strategic role of education in the prevention of medication errors in nursing

Part 2

Joanne Cleary-Holdforth*, Therese Leufer

School of Nursing and Human Sciences, Dublin City University, Collins Ave, Glasnevin, Dublin, Ireland

a r t i c l e i n f o

Article history:

Accepted 30 January 2013

Keywords:

Medication errors

Medication management

Patient safety

Nursing practice

Education

Continuing practice development

a b s t r a c t

It has been established that medication errors are a signi

cant cause for concern in healthcare settings. IPart 1 of this paper the gravity of this problem in addition to the some of the contributing factors were

discussed. The shared nature of the problem across disciplines was highlighted in addition to the po

tential benets of multi-disciplinary collaboration in resolution of the problem. The contribution tha

education can make in this regard is unquestionable both at pre-registration (undergraduate) and post

registration level. A variety of pragmatic proposals will be presented for consideration. In addition

clinical and educational measures that have been shown to reduce medication errors will also b

proffered and the way(s) forward to ensure optimal medication management and patient safety will b

explored from a nursing perspective. The specic aim of this paper is to illuminate the signicant rol

that education, in both academic and clinical settings, can play in the preparation of nurses for their role

in medication management and the marked reduction in errors and improved patient outcomes in thi

area of practice that they can yield.

2013 Elsevier Ltd. All rights reserved

Background

The fundamental purpose of nursing is to ensure patient safety

and at the very least to do no harm. From Part 1 of this article it is

evident that medication errors can and do occur in the healthcare

setting all too frequently. The alarming statistics were clearly pre-

sented and indeed illustrate the global nature of the problem.

Consequently, it can be argued that harm is being done to patients

and that much of this harm is unnecessary in so far as it is pre-

ventable. This problem is clearly multi-faceted in nature and not

unique to one particular group of healthcare professionals. Medi-

cation management is one of the functions in healthcare that is

clearly multi-disciplinary, and therefore collaborative, in nature.

This collaborative approach, when applied to medication man-

agement, has the potential to greatly enhance patient safety andcare delivery. However, each group must scrutinise its own con-

tribution to the problem of medication errors and consider fully any

or all measures that they can adopt in an effort to reduce these

startling statistics. Collaboration, not only within teams but also

across teams is crucial if this problem is to be comprehensively

tackled in earnest. Indeed, the strategic role that nurse education

departments can offer nursing practice teams in practice settingshould not be under-estimated. Clinical and educational measure

combined have the potential to yield very positive results in th

challenge that is medication errors in patient care. The synergy o

such collaboration offers the real opportunity to comprehensivel

manage this problem from an all-encompassing, holistic pe

spective. Indeed, as highlighted in Part 1 of this paper, it i

incumbent on nurses to develop and maintain competencies in

nursing practice and within this, competence is medication man

agement is essential (NMC, 2008; ABA, 2000). Arguably, from

a nursing perspective, embedded within on-going professiona

development in this area, is the role of focussed, tailored educatio

in medication management to ensure competence in this area and

reduce medication errors. This tailored education in medicatio

management must have its foundations at the earliest possiblopportunity in the nurses career, ideally at pre-registration (un

dergraduate) level and must continue beyond registration an

throughout the nurses career. A variety of key educational an

clinical strategies to combat medication errors will now b

discussed.

Tackling the problem from a nursing perspective

It is clear that the problem of medication errors is very signi

cant with profound consequences for all involved. Whilst, it can b

argued that, like other healthcare groups, nursing plays its role i

* Corresponding author. Tel.: 353 1 7008522; fax: 353 1 8612084.

E-mail addresses: [email protected] (J. Cleary-Holdforth), ther-

[email protected](T. Leufer).

Contents lists available atSciVerse ScienceDirect

Nurse Education in Practice

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . co m / n e p r

1471-5953/$e see front matter 2013 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.nepr.2013.01.012

Nurse Education in Practice 13 (2013) 217e220
mailto:[email protected]:[email protected]:[email protected]://www.sciencedirect.com/science/journal/14715953http://www.elsevier.com/neprhttp://dx.doi.org/10.1016/j.nepr.2013.01.012http://dx.doi.org/10.1016/j.nepr.2013.01.012http://dx.doi.org/10.1016/j.nepr.2013.01.012http://dx.doi.org/10.1016/j.nepr.2013.01.012http://dx.doi.org/10.1016/j.nepr.2013.01.012http://dx.doi.org/10.1016/j.nepr.2013.01.012http://www.elsevier.com/neprhttp://www.sciencedirect.com/science/journal/14715953mailto:[email protected]:[email protected]:[email protected]


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contributing to this problem, it is also true to say that, reciprocally,

nursing is integral to the solution. There are a number of areas,

particularly within nurse education and indeed in nursing practice

where opportunities abound to address this situation. A avour of

the literature would suggest that there are a number of key areas

that persistently emerge as contributing factors to this phenome-

non, some of which have been discussed in Part 1 of this paper.

These key areas include interruptions on medication rounds,

poor mathematical skills, pharmacological knowledge decit and

teaching and learning strategies employed within the nurse edu-

cation sector. Each of these problem areas will now be considered

and, where possible, potential strategies to manage them will be

proffered.

As previously mentioned, medication rounds constitute a major

component of clinical nursing practice on any shift. Nurses practice

in an environment that is frequently noisy, busy, prone to dis-

ruption, distractions, not to mention emergencies and one which

does not often lend itself to optimal communication. Nurses car-

rying out medication rounds have to contend with a whole array of

competing pressures and interruptions. These originate from

a wide variety of sources including, doctors, other nurses, patients,

telephone enquiries, visitors, housekeeping personnel vacuuming,

catering personnel distributing meals or collecting trays, not tomention the nurse on the medication round electing to attend to

non-medication round related tasks (Biron et al., 2009; Kreckler

et al., 2008).

Such interruptions and distractions have the potential to pose

a very real safety hazard for patients. First and foremost it is

imperative that nurses recognise how interruptions and distrac-

tions on medication rounds can lead to medication errors and the

resulting ramications for patient well-being.Simple strategies that

could be explored as a means to minimise the level of interruption

include the clear identication of the nurse(s) undertaking the

medication round by way of an item of clothing ( Kreckler et al.,

2008) or a do not disturb sign on the trolley, which clearly in-

dicates that they are not to be interrupted. Indeed the benets of

such a simple measure were clearly demonstrated at a local level ina large Dublin academic teaching hospital afliated with the au-

thors department. It was found that the use of tabards clearly

identifying members of staff undertaking drugrounds had the effect

of substantially minimising interruptions on the drug rounds and it

resultedin theaddedbonus of reducingdrug round time (Beaumont

Hospital Nurse Practice Development Unit, unpublished). The onus

is also on the nurse(s) undertaking the medication round to rein-

force this strategy if interrupted despite these measures.

Pape et al. (2005) suggest that staff members be educated

regarding the importance of not distracting nurses during medi-

cation rounds, thus highlighting the crucial contribution of edu-

cation in this area. Visiting policies that take cognisance of key

times in any particular shift when important duties or re-

sponsibilities such as medication rounds are undertaken could beconsidered. Avoiding conversation with patients that is not related

to the medication round for the duration of the round may reduce

distraction from this source.

Just as the problem of medication errors is an international one,

so too is the problem of numeracy skills amongst nurses, both at

pre- and post-registration level (Rice and Bell, 2005;Trim, 2004;

Grandell-Neimi et al., 2003; Weeks et al., 2000; Hutton, 1998;

Kapborg, 1994). Jukes and Gilchrist (2006) undertook a study to

discover the drug calculation abilities of one group of undergrad-

uate students at an English university. Their ndings revealed that

no student scored 100% on the test and only 35% of students in the

study achieved a score of 7 out of 10 or higher, clearly indicating

that65% of students scored less than 7 out of 10. This concurs with

earlier

ndings reported by Kapborg (1994) who observed that

both student and qualied nurses were not able to accurately cal-

culate all drug dosages presentedin a maths test, with some studies

demonstrating an error rate of at least 10%. Wright (2005)inves-

tigated mathematical skills of student nurses and found that 36.7%

of the students were unable to work out even half of the questions

on the paper. Key areas of difculty identied in that study were

sections on multiplying fractions, ratios and interpreting informa-

tion. Similarly, Bliss-Holtz (1994) found that even when nurses

used calculators to compute drug dosages, they were still unable to

achieve a score of 90% or above.

Again this represents 10% drug error rate in practice, even with

the aid of a calculator. These are indeed very worrying ndings.

Competence in drug calculation is an integral component of safe

medication administration (Andrew et al., 2009). Deciencies in

this skill clearly present a real risk to patient safety as they have the

potential to lead to medication errors, resulting in harm to patients.

This is not an issue conned to the realm of qualied nurses, it has

been identied that nursing students also commit errors involving

medication, tubings and catheters (Institute for Safe Medication

Practices, 2008; Wolf et al., 2006). The Department of Health

(2004)identied the need to reduce the number of drug errors in

the NHS by 50% by 2005. Given the startling statistics in relation to

drug errors in Ireland, a similar stance is undoubtedly and immi-nently required in the Irish healthcare system.

A number of strategies, spanning both the academic and clinical

settings, to address this problem from a nursing perspective could

be considered. Nursing curricula in the higher educational sector

should be scrutinised for content and skill development pertaining

to pharmacology and medication management with particular

emphasis on drug calculations. An evaluation oftness for practice

pre-registration nursing and midwifery curricula undertaken in

Scotland (Lauder et al., 2008) demonstrated that numeracy skills

amongst student nurses were low. It also revealed a degree of

variation across programmes with regard to skill acquisition and

opportunities to practice drug administration.

Recommendations on the basis of these ndings point towards

the need to determine the optimal preparation of students in thearea of numeracy skill. These recommendations mirror those of

Jukes and Gilchrist (2006) who advocate more education and

research in this area if nurses are to be prepared adequately for safe

practice in medication management and on-going development of

skills going forward. Anecdotally, students in the authorsinstitu-

tion consistently express an appetite and indeed a perceived need

for more input on pharmacology and medication management

related content throughout the curriculum. Furthermore it has

been highlighted in the literature that the prole of pharmacology

instruction in the curriculum often appears inadequate (Morrison-

Grifths et al., 2002;Manias and Bullock, 2002) with specic hours

devoted being difcult to distinguish (Page and McKinney, 2007).

This would clearly suggest that there is a need to integrate more

content and dedicate more time to the whole area of pharmacologyand medication management, both in terms of theory and skill

development, in the nursing curriculum.

In keeping with the notion of competence developing over time,

it is prudent to commence dedicated endeavours in the area of

pharmacology/medication management instruction at the earliest

possible opportunity and to continue these endeavours at each

level of the pre-registration (undergrad) programme. An example

of such an endeavour, to which the authors espouse, would be the

facilitation of additional dedicated tutorials on aspects of medi-

cation management. The content of such tutorials should be

determined collaboratively by the students, the nurse educators

and the afliated clinical practitioners. It is invaluable to ascertain

the studentsperceptions of their particular learning needs in this

area in order to render this endeavour meaningful and bene

cial to

J. Cleary-Holdforth, T. Leufer / Nurse Education in Practice 13 (2013) 217e220218


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them, in addition to needs identied by practitioners and educators

familiar with the nursing curriculum.

However, this cannot happen in isolation from practice. It is

imperative that the timing of such input dovetails with clinical

practice exposure where students are frequently afforded the op-

portunity to linkand apply conceptual problems introduced in class

to real life situations. Such constructive alignment of theoretical

content with appropriate clinical exposure would reduce what has

been described as front-loadingor teaching theory out of context

(Schon, 1983;Eraut, 1994) while simultaneously avoiding sending

the novice out with no formal preparation, representing blind

practice (Weeks et al., 2000). This wouldensure a more meaningful

experience with a more enduring result for the students and ulti-

mately, therefore, enhanced safety for patients. Unfortunately the

anecdotal feedback from students in the authors department

would suggest often that these opportunities are not being made

available.

It is imperative that clinical partners providing clinical place-

ments for nursing students endeavour at all times to optimise the

students time in practice, ensuring sufcient exposure to the var-

ious aspects of medication management, including, for example,

participation on medication rounds. It is equally imperative that the

student ensures that he/she maximises his/her time in clinicalpractice, availing of all opportunities for practice development

presented. It is crucial also that such exposure commences early in

the students programme of study. As previously indicated, com-

petence evolves over time and continuous development of

knowledge and skills is essential to ensure that competence is

nurtured and attained. To this end the employment of a matrix that

clearly outlines the activities that students should/should not

engage in, with regard to medication management, while in prac-

tice at each level of their programme could prove very helpful in

guiding both students and their clinical mentors in focussing their

learning in this area of practice.

Such a tool has proved useful at local level in a large Dublin

academic teaching hospital afliated with the authorsdepartment

and continues to be rened and re-modelled to further enhance itsutility. Indeed in their standards for pre-registration nursing edu-

cation document, theNMC (2010)stipulate in their essential skills

cluster for medicines management, that there are specic skills and

knowledge that must be attained and demonstrated incrementally

over the duration of the pre-registration (undergraduate) nursing

programme in order for the nurse to be deemed competent in this

area at the point of registration. Key knowledgeand skills identied

by the NMC in this document include medicines calculations,

application of legal and ethical frameworks to underpin practice,

safe and timely administration of medications, accurate doc-

umentation and underpinning medicines management with best

available evidence, amongst others. They further highlight the

developmental, incremental nature of this learning through their

use of clear descriptors (progression points) illustrating goals to beachieved by the student at specic intervals. Such structured,

punctuated points for opportunities of learning from practice and

reinforcing knowledge through practice in this way has the po-

tential to inculcate the culture of continuous professional devel-

opment (CPD) in the student. Continuing professional development

will be expected over the lifetime of the nurses career. This

approach also, very importantly, offers the very real opportunity to

identify early a student who is struggling with medicines man-

agement and indeed avoid the situation where such a student may

reachnal year with minimal knowledge and skill in this area.

However, such on-going education and development in this area

shouldnot and cannot stop with students. As previously discussed,

qualied nurses make medication errors too. In fact, it has been

found that the more experienced staff are in terms of years

qualied, the more likely they are to make drug errors than thei

less experienced colleagues (Preston, 2004;Scott, 2002).Kapbor

(1994) compared the written drug calculation skills of qualie

and student nurses and found that there was no signicant differ

ence between the two groups. These ndings would suggest tha

experience alone does not necessarily yield competence o

improved skill in this area. It would be an interesting study t

ascertain the reasons for this. Reasons suggested in the literatur

include lack of opportunity to practice drug calculations, advance

in technology, medication dispensing and roles of pharmacists a

resulting in a declining need for complex calculations on a regula

basis in practice (Wright, 2008; Arnold, 1998; Cartwright, 1996

One could also surmise that factors such as a degree of compla

cency creeping in over time, lack of appreciation of the need fo

regular (annual) updates, unavailability of regular updates, sta

shortages and budgetary constraints all have the potential to con

tribute to or indeed exacerbate the problem. It is crucial tha

strategies that ensure that competence in drug calculations i

achieved and retained are implemented if medication errors are t

be reduced and patient safety optimised in this area. For example

a post-registration tool that mirrors the NMCs skills cluster fo

medicines management or indeed the previously mentioned ma

trix, which would describe competencies that need to be attainedor indeed maintained at intervals (i.e. annual basis) in order t

ensure that practitioners levels of competence in this area ar

sustained should be considered. The use of such a tool as a CPD

initiative to steer the practitioners learning and practice in medi

cines management could satisfy the PREP standards for re

registration while simultaneously, perhaps, being awarded appro

val or credits by the NMC, were this to be embraced.

From an Irish perspective, inclusion of such a tool as an activity

alongside those recommended by the National Council for Nurse

and Midwives (2009) to support competency attainment pos

registration could perhaps be incorporated in future guideline

Other strategies could include the introduction of drug calculatio

testing on a regular basis not only throughout the pre-registratio

undergraduate programme but continuing consistently beyongraduation (Wright, 2008). In addition educational updates or in

formation days on medication management, medication errors an

maths revision programmes on an annual basis could be encour

aged actively. Release of staff from clinical areas to attend suc

educational updates would be benecial.

Wright (2005) proposes the use of online maths tutorials, face t

face tutorials, calculation workbooks and drug calculation taugh

sessions as effective strategies to teach drug calculation skill

These educational strategies are all very do-able, potentiall

inexpensive and present very real ways of tackling this grav

problem. It may be pertinent at this juncture to remind ourselve

that each and every nurse is accountable for his/her own practic

and has responsibility to achieve and maintain competence i

practice, including in the area of medication management. Thesproposed educational strategies are not optional luxuries, rathe

they constitute essential, cost-saving, not to mention life-savin

measures. It is perhaps possible to consider training up key and

or willing staff members within the care setting to champion saf

medication management and to act as trainers/mentors who woul

lead these crucial initiatives, thereby reducing the overall cost o

medication errors to the patient, the hospital and the healthcar

system as a whole.

Conclusion

Itis evident from both the statistics presented in Part 1 of thi

paper and from the professional literature that medication error

are a signi

cant concern for healthcare systems and indee

J. Cleary-Holdforth, T. Leufer / Nurse Education in Practice 13 (2013) 217e220 21


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patients worldwide. The striking statistics cannot be ignored and if

the problem is to be truly addressed, each professional group

involved needs to focus the lens on itself, scrutinise its own practice

in this area and identify potential contributing factors in an effortto

begin to address this very serious problem. From a nursing per-

spective, this paper has endeavoured to offer a number of practical

but effective clinical and educational initiatives that may go some

way towards minimising nursings contribution to this multi-

disciplinary problem. A number of the proposed educational ini-

tiatives are equally applicable and benecial to other professional

groups involved in medication management. Ultimately, of course,

a multi-disciplinary, collaborative approach will be required to

denitively tackle this multi-disciplinary challenge. Arguably, going

forward there is immense scope for shared learning and collabo-

rative initiatives which will potentially reduce time and nancial

outlay for all concerned. All of the initiatives highlighted above are

very pragmatic and indeed offer very practical and realistic ways by

which to address and go some way to reducing the extent of the

problem. It is imperative that nurses on both an individual and

group basis are open and committed to these initiatives and that

the organisational culture is one which supports and indeed re-

quires such crucial endeavours of all professions involved.

References

An Bord Altranais, 2000. Code of Professional Conduct for Each Nurse and Midwife.An Bord Altranais, Dublin.

Andrew, S., Salamonson, Y., Halcomb, E.J., 2009. Nursing students condence inmedication calculations predicts math exam performance. Nurse EducationToday 29, 217e223.

Arnold, G., 1998. Renements in the dimensional analysis method of drug calcu-lation problem solving. Nurse Educator 23 (3), 22e26.

Beaumont Hospital Nurse Practice Development Unit. Introducing the Red AlertTabards during medication administration in Beaumont Hospital, unpublished.

Biron, A.D., Lavoie-Tremblay, N., Loiselle, C.G., 2009. Characteristics of work in-terruptions during medication administration. Journal of Nursing Scholarship41 (4), 330e336.

Bliss-Holtz, J., 1994. Discriminating types of medication errors in nursing practice.Nursing Research 43 (6), 373e375.

Cartwright, M., 1996. Numeracy of the beginning registered nurse. Nurse EducationToday 16, 137e143.

Department of Health, 2004. Building a Safer NHS for Patients: improving Medi-cation Safety. The Stationery Ofce, London.

Eraut, M., 1994. Developing Professional Knowledge and Competence. Falmer Press,London.

GrandelleNeimi, H., Hupli, M., Leino-Kilpi, H., Puukka, P., 2003. Medication calcu-lation skills of nurses in Finland. The Journal of Clinical Nursing 12, 519 e528.

Hutton, M., 1998. Nursing mathematics: the importance application. NursingStandard 13 (11), 35e38.

Institute for Safe Medication Practices, April 2008. Error-prone conditions that leadto student nurse-related errors. Nurse Advise-ERR 1, 3.

Jukes, L., Gilchrist, M., 2006. Concerns about numeracy skills of nursing students.Nurse Education in Practice 6, 192e198.

Kapborg, I., 1994. Calculation and administration of drug dosage by Swedish nurses,student nurses and physicians international. Journal for Quality in Healthcare 6(4), 389e395.

Kreckler, S., Catchpole, K., Bottomley, M., Handa, A., McCulloch, P., 2008. In-

terruptions during drug rounds: an observational study. British Medical Journal17 (21), 1326e1330.

Lauder, W., Roxburgh, M., Holland, K., Johnson, M., Watson, R., Porter, M.,Topping, K., Behr, A., 2008. Nursing and Midwifery in Scotland: Being Fit forPractice e The Report of the Evaluation of Fitness for Practice Pre-registrationNursing and Midwifery Curricula Project (Executive Summary).

Manias, E., Bullock, S., 2002. The educational preparation of undergraduate nursingstudents in pharmacology: perceptions and experiences of lecturers and stu-dents. International Journal of Nursing Studies 39 (7), 757e769.

Morrison-Grifths, S., Snowden, M.A., Pirmohamed, M., 2002. Pre-registrationnurse education in pharmacology: is it adequate for the roles that nurses areexpected to full? Nurse Education Today 22, 447e456.

National Council for the Professional Development of Nursing and Midwifery, 2009.Guidelines for Portfolio Development of Nurses and Midwives, third ed. NCNM,Dublin.

Nursing and Midwifery Council, 2008. The Code: Standards of Conduct, Perfor-mance and Ethics for Nurses and Midwives. Nursing and Midwifery Council,London.

Nursing and Midwifery Council, 2010. Standards for Pre-registration Nursing Edu-cation. Nursing and Midwifery Council, London.

Page, K., McKinney, A.A., 2007. Addressing medication errors e the role of under-graduate nurse education. Nurse Education Today 27 (3), 219e224.

Pape, T.M., Guerra, D.M., Muzquiz, M., Bryant, J.B., Ingram, M., Schranner, B.,Alcala, A., Sharp, J., Bishop, D., Carreno, E., Welker, J., 2005. Innovative ap-proaches to reducing nurses distractions during medication administration.The Journal of Continuing Education in Nursing 36 (3), 108e116.

Preston, R., 2004. Drug errors and patient safety: the need for a change in practice.British Journal of Nursing 13 (2), 72e78.

Rice, J.N., Bell, M.L., 2005. Using dimensional analysis to improve drug dosagecalculation ability. Journal of Nursing Education 44 (7), 315e318.

Schon, D., 1983. The Reective Practitioner. Avebury, Aldershot.Scott, H., 2002. Increasing numbers of patients are being given wrong drugs. British

Journal of Nursing 11 (1), 4.Trim, J., 2004. Clinical skills: a practical guide to working out drug calculations.

British Journal of Nursing 13 (10), 602e606.Weeks, K., Lyne, P., Torrence, C., 2000. Written drug dosage errors made by stu-

dents: the threat to clinical effectiveness and the need for a new approach.

Clinical Effectiveness in Nursing 4, 20e

29.Wolf, Z.R., Hicks, R., Serembus, J.F., 2006. Characteristics of medication errors madeby students during the administration phase: a descriptive study. Journal ofProfessional Nursing 22 (1), 39e51.

Wright, K., 2005. An exploration into the most effective way to teach drug calcu-lation skills to nursing students. Nurse Education Today 25, 430e436.

Wright, K., 2008. Can effective teaching and learning strategies help student nursesto retain drug calculation skills? Nurse Education Today 28, 856e864.

J. Cleary-Holdforth, T. Leufer / Nurse Education in Practice 13 (2013) 217e220220


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