Errors Associated with the Rights of Medication Administration at Hospital Settings

Aims & Objectives: To investigate the associations between nurse-related medication errors by examining: (a) the Rights of medication administration and hospital units, (b) the Rights of medication administration and drug classes, and (c) interactions between hospital units and drug classes regarding the Rights of medication administration. Background: Medication errors are associated with the five Rights of medication administration (right patient, right drug, right dose, right time, and right route), hospital units, and drug classes, however these factors are not often examined simultaneously. Design & Methods: 1,273 medication error incident files from the risk management departments of five acute-care community hospitals in the southwestern United States were analyzed. Descriptive statistics and the Chi-square test were used in data analysis. Results: Giving medications at the wrong time was the most frequent cause of error in medical surgical units (54.1%) and intensive care units (51.7%). Errors related to cardiovascular drugs were commonly due to wrong dosages (40.2%) and wrong time of administration (40.2%). In addition, errors related to wrong dosages of antimicrobials were strongly associated with errors in intermediate care units (46.4%) and medical surgical units (52.1%), while wrong dosages of cardiovascular drugs were highly correlated with errors in intensive care units (49.0%) and intermediate care units (50.0%). Conclusion: Interactions between hospital units and drug classes were found in regard to being associated with the Rights of medication administration, especially with errors in wrong time and wrong dose. Relevance to clinical practice: To reduce medication errors and improve patient safety, continuing education for nurses regarding basic pharmacology, factors contributing to medication errors such as drug classes and hospital units, and preventing medication errors should be a priority. Medication administration policies and guidelines should be continuously updated and enforced.


Introduction
Medication Administration Errors (MAEs) are among the most common medical errors in health care settings. They affect patient safety, mortality rates, length of hospital stays, and related costs [1][2][3]. Serious, preventable medication errors occur in 3.8 million inpatient admissions and 3.3 million outpatient visits every year in the United States, costing approximately $20.6 billion annually [4]. The Institute of Medicine estimated that approximately 7,000 deaths per year in the US were attributed to preventable medication errors [5].

Background
A medication error is defined as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to prescribing, ordering, dispensing, administering, or monitoring the drug" [6]. Nurses are the largest group of health professionals and have the last opportunity to prevent medication errors [7]. It is reported that approximately 64.6% of nurses have committed MAEs. However, 39.9% of medication errors by nurses are not reported, indicating the incidence of nurse-related medication errors is higher than reported [8].
In hospitals, there are five stages of the medication process: ordering/prescribing, transcribing and verifying, dispensing and delivering, administering, and monitoring and reporting [5]. Nurses are involved in all stages of the medication process except ordering/prescribing. Our study concentrated on the "administering" stage and examined nurse-related medication errors [9]. During the administering stage, specifically, Five Rights of Medication Administration (Five Rights) are emphasized in several nursing guidelines to prevent and reduce nurse-related MAEs [10]. They are right patient, right drug, right dose, right time, and right route. Errors associated with these Five Rights may be grouped differently, from Five Rights to 15 Rights however, based on the data collected, we added documentation errors and wrong technique, along with the Five Rights, to create a total of Seven Rights in our study [11].
Studies show that nurse-related medication errors often take place during the medication administration process, such as wrong time, wrong dose, or by omission of the medication [12][13][14]. These medication errors usually occur in hospital units and are often associated with drug classes. Medical surgical units, Intensive Care Units (ICU), Intermediate Care Units (IMCU), and Emergency Departments (ED) are among the most error-prone hospital units [15][16][17]. Further, drug classes related to MAEs vary among hospital units, although cardiovascular drugs, antibiotics, electrolytes, analgesics, and anti-diabetics are the most common drugs associated with MAEs [15,[18][19].
To find a successful intervention to decrease MAEs, potential causes of MAEs need to be identified. According to the Reason's conceptual model, the causes of MAEs in hospitals are a combination of active failures (e.g. errors caused by individuals via unsafe acts, slips and lapses, knowledge and rule-based mistakes, or violations) and latent conditions (e.g. amount of workload and skill mix, general work environment, communication, and organizational decisions) [20]. As said by the Swiss Cheese Model of system accidents, "the system produces failure when a hole in each slice momentarily aligns and permits trajectory of accident opportunity" [20]. The causes of MAEs in hospitals could be explained from aligning a series of barriers in terms of latent conditions of error-prone hospital units, drug classes, and active failures of the Seven Rights. Many studies have identified the cause of errors in hospital settings however most of them focus solely on one single factor, such as Rights of Medication Administration (Rights), hospital unit, or drug class [15][16][17][18][19].
Nevertheless, medication errors may well be related to multiple factors. For instance, a specific Right may be associated with a certain drug class or a hospital unit. MAEs in more errorprone hospital units may be associated with a particular drug class that is related to certain Rights. From this standpoint, much of the research on MAEs has important limitations. Moreover, most existing studies have been based on subjective, self-reported surveys potentially with inherent reporting bias [21][22]. Others are based on retrospective chart reviews that may affect the validity and reliability of the data [14]. Direct observation is often used in studies and may introduce the Hawthorne effect that nurses being observed may act differently in the presence of an observer [10,12,23]. Studies based on objective incident reports often have very small sample sizes that seriously limit the generalizability of their findings [10,14].
This study, based on medication error incident reports, examined associations between: (a) the Rights and hospital units, (b) the Rights and drug classes, and (c) potential interactions between hospital units and drug class on the Rights. Volume 2018; Issue 01

Data
Data were extracted from a prior study being described elsewhere [24]. In that study, the case group was the medication error group which included medication incidents and associated nurses. The control group included nurses who did not have medication errors. Medication error incident information was obtained from medication error files kept at the risk management departments of five short-term acute community hospitals in the Southwestern region of the United States [24]. Our study only focused on the medication error case group that included information for 1,276 medication error incidents. After three records with missing values were excluded, the final number of observations was 1,273. The study was approved by a university's institute review board and the Western Institutional Review Board.

Measures
This study examined MAEs during the administration stage, which predominantly falls into the nursing scope of practice [7]. We categorized the Seven Rights according to the administration phases. They were reflected by wrong dose (e.g. wrong infusion), wrong time (e.g. wrong frequency, wrong duration of medication administration, omission of dose), documentation error or wrong documentation (e.g. medication given without order), wrong route (e.g. administration of dose in a different form or doses given in the wrong site), and wrong technique (e.g. exclusion or incorrect performance of a procedure ordered by the prescriber immediately before administration of each dose of medication) [22].
The hospital units where MAEs occurred most often were cardiology, the Emergency Department (ED), Intensive Care Units (ICU), Intermediate Intensive Care Units (IMCU), medical-surgical, and maternity. We followed the Anatomical Therapeutic Chemical (ATC) system to classify drugs as cardiovascular, antimicrobial, endocrine, and neurologic [25]. In addition, consequences of MAEs were grouped into four categories, from the least to the most severe: 1) potential to cause harm, 2) error affected the patient but did not cause harm, 3) need to increase patient monitoring but no harm, and 4) temporary harm but treatment needed.
Results of our classification of the data were summarized using descriptive statistics. Associations of the Seven Rights with hospital units and drug class were examined by the binary analysis using the Chi-square test. Due to small numbers in some hospital units and drug classes (n < 30 for hospital unit and n < 30 for drug class), we only applied the Chi-square analyses on more frequent hospital units, drug classes, and the Seven Rights. They included MAEs related to wrong time/dose, documentation errors, the medical-surgical unit, IMCU, and ICU. Also included were cardiovascular, antimicrobial, and endocrine drug classes, as well as electrolytes. Further, we analyzed medication errors in regard to associations of hospital units, and the Seven Rights and drug class, respectively.

1.
Our study shows that wrong time, wrong dose, and documentation errors are the most frequent inaccuracies noted during medication administration. Furthermore, the associations between the Seven Rights and hospital units exist. Errors as a result of administering a medication at the wrong time tend to happen in ICUs and medical-surgical units. ICUs contain potential risk factors for MAEs. Multiple high alert medications are typically given to patients in ICUs in addition to complicated clinical procedures [26][27]. Frequent changes in substances and doses are required in fast paced medical care in ICUs [28]. There are also potential organizational risk factors that include patientto-nurse ratios [29]. Medical-surgical units have similar potential risk factors in terms of heavy patient loads [18]. Many distractions and time constraints are other risk factors for MAEs in Medicalsurgical units [18]. Therefore, MAEs caused by wrong time such as omission of dose tend to happen more in hospital units that require higher attentions.
Our findings also show associations between drug classes and the Seven Rights specifically, cardiovascular drugs, antimicrobials, endocrine drugs, and electrolytes. Errors with antimicrobials are mainly due to wrong time. During a patient's hospital stay, the dosage of antimicrobials must be adjusted by nurses, doctors, or pharmacists based on laboratory test results time by time. Therefore, clear communication among healthcare providers and precise dosage calculations based on updated orders in compliance with protocols, are critical to avoid antimicrobial-related MAEs [30]. MAEs with medication errors relating to electrolytes and endocrine drugs are also highly associated with wrong time. Concentrated electrolytes are the most common MAEs related to electrolytes, however, our study showed omission of doses or medication given at the wrong time is more strongly associated with errors regarding electrolyte administration. Endocrine drugs such as insulin are widely used in critical and intensive care patients in order to reduce morbidity and mortality [31].
Maintenance of optimal insulin concentration is a critical task. These findings are further expanded by examining potential interactions with hospital units. In regard to hospital units, electrolyte-related MAEs due to wrong time tend to happen in Medical-surgical units. It is reported that the frequent need for rapid life-saving responses may contribute to wrong time and documentation errors in medical-surgical units [26]. Our study also showed MAEs with endocrine drugs due to wrong time tend to happen in ICUs. MAEs regarding electrolytes and endocrine drugs may be a result of organizational and environmental factors rather than individual skills or knowledge [13,20,30,32].
Medication given in wrong doses prevails in MAEs. Our study showed MAEs in ICUs and IMCUs tend to happen with cardiovascular drugs as a result of the wrong dose. Insufficient knowledge of correct dosage has been identified as a main cause of MAEs with "high alert" medications such as heparin [13,30,32].
Other research also indicates that more than half of the nurses did not read syringe markings at eye level when mixing medications [10]. Documentation error is prominent with antimicrobials in ICUs and with cardiovascular drugs in IMCUs and Medicalsurgical units. Again, frequent changes in dose and substance of antimicrobials and cardiovascular drugs may affect the verbal and written prompts, especially in fast paced hospital units such as ICUs and Medical-surgical units [29].
Our findings indicate that error prone drugs such as cardiovascular drugs, antimicrobials, electrolytes, and endocrine drugs all need frequent dose adjustment and maintenance of optimal concentration. Therefore, it is critical that these medications be administered at the right time with the right dose in order to reduce MAEs. Our study also showed that hospital units with complex medication administration and complicated clinical procedures such as ICUs and Medical-surgical units are more prone to MAEs. Therefore, associations between hospital units and drug classes regarding the Seven Rights revealed from our study suggest that the amount of workload may be one of the aligned holes that allow MAEs as the Swiss Cheese Model of system accidents stated. Without adequate health professionals (e.g., the high number of beds per nurse ratio), fast paced hospital units with complex interventions and increased patient admissions may contribute to nurses not being able to administer medication at the right time and provoke documentation errors [29]. In fact, many studies have identified heavy workload as an important contributor to MAEs [33,34]. Even though our study did not measure the effect of workload on MAEs specifically, our findings may indicate that the high bed-to-nurse ratio is a possible underlying contributing factor to MAEs which merits further research [9]. For example, since antimicrobials are listed as time-critical medications that should be administered at strict time intervals with frequent dose adjustments, we observed that giving antimicrobials at the wrong time is associated with IMCUs and medical-surgical units [35].
Existing research also reports that the low patient-to-nurse ratios in medical-surgical units makes the administration of medications on a strict timeline difficult [10]. Therefore, a heavy workload may indeed be one of underlying causes of the Seven Rights related MAEs that are also associated with drug class, and hospital unit.
The study had limitations. First, data were collected without a predefined medication error tracking form; therefore, variations in categorizing medication errors across different hospital systems existed, which might, to a certain extent, affect the accuracy of assigning root causes of medication errors. In addition, the data were obtained from five hospitals in the Southwestern United States, which limited the generalizability of the results. Future research on "at the time of medication error" as a contributing factor of nurse related MAEs is needed to examine the associations between nurse shifts and incidents of MAEs. Future research should also investigate relationships between the bed-to-nurse ratio/nurse workload and medication errors.

Implications for Nursing Practice and Policy
Medication administration errors due to wrong timing are sometimes inevitable considering the synchronized drug administration timeline, frequent dose changes with antimicrobials, and certain features of hospital units, like inadequate staffing [10]. Use of the Electronic Health Record (EHR), which can alert nurses during the medication administration phase of required dosage changes and drugs that are outside the acceptable administration window, is one approach to avoid wrong-time errors [36]. Although many hospitals are using EHRs, some may not have the means or capability to alert nurses about drugs outside the acceptable administration window, high-risk drug alerts, or drugs that require dosage changes.
Identifying hospital units where medication administration errors frequently occur provide more specific alerts to nurses for avoiding potential medication errors. Strengthening related training and education should then follow, as Huckels-Baumgart and Manser point out that roots of medication error chains include inattention and lack of training [14]. Nursing education on drug classes associated with medication errors with regard to the more frequent Rights provides guidelines for proper medication administration. For example, educational materials in nursing pharmacology curriculums specifically focusing on medication administration errors associated factors (e.g., drug class, hospital unit, and combinations of those factors) will be helpful to reinforce and stress the issue. It is also recommend offering more targeted nursing training and continuing education programs that emphasize medication administration error prevention's knowledge, skills, techniques, and approaches.
Policies and programs should target hospital units and drug classes for reducing medication administration errors with regard to the Seven Rights. The awareness improvement training such as Plan-Do-Study-Act and an educational program developed based on actual reported medication error incidents may enable nurses to reduce preventable medication administration errors and improve patient safety [35].
Since medication administration errors may be caused by combinations of certain latent conditions with regard to hospital units and drug classes, errors related to the Seven Rights may be minimized by alleviating the heavy workload of nurses. Mandated nursing staffing to patient ratio legislation and reduction of workloads should be considered. These have been shown to reduce medication administration errors related to human factors such as fatigue from lack of sleep, working too many hours, and time constraints [10,15,[37][38].

Conclusion
This study, collecting more accurate medication error information from hospital's risk management departments, supports previous evidence that medication errors continue to exist in hospital settings and prove to be more common in some units than others. Examining the Seven Rights, hospital units, and drug classes simultaneously enabled us to identify potential factors associated with medication administration errors. Findings from this study may assist hospital administration and staff in developing practical and effective strategies to reduce medication errors and improve patient safety.