A Cost-Effective Approach to Preventing Medication Errors: Nurses’ Clinical Reasoning

In the 1990s, research into medication errors focused on systems and identified nurses as crucial to intercepting those errors before they reached patients. Now, a new study reveals the clinical reasoning practices and processes nurses use successfully to prevent medication errors.

They are:

  • educating patients about the medication prescribed for them;
  • taking into consideration all factors related to the patient;
  • advocating for patients with the pharmacy;
  • coordinating care with physicians;
  • independently reconciling medications with patients’ records;
  • verifying medications and doses with colleagues;
  • coping with interruptions and distractions;
  • interpreting physicians’ orders;
  • documenting near misses; and
  • communicating openly with physicians, pharmacists and other team members.

The study, funded by the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative and published in the January 2012 issue of Qualitative Health Research, identifies six care practices and four work environment management practices that nurses on medical-surgical units described as preventing medication errors and improving patient safety.

The study was conducted by Geri Dickson, PhD, RN, founder and director of the New Jersey Collaborating Center for Nursing at Rutgers, and Linda Flynn, PhD, RN, FAAN, professor and associate dean for graduate nursing education at Rutgers. They conducted interviews with 50 staff nurses from medical-surgical units in ten hospitals that were part of a larger study on the impact of nurses’ care on the number of medication errors on medical-surgical units.

“Nurses and patients, working together, are the best line of defense to prevent medication errors from reaching the patient,” said Flynn. “By ensuring that their patients know what medication they’re receiving, in which doses and why, nurses not only empower and inform their patients, they involve them in the health care process and their own care. When patients ask questions about changes in medication dosages or mention that they’ve never been given a particular medication before, it can raise a red flag for the nurse to double-check charts and records, and to check in with her or his physician and pharmacist colleagues.”

Missing medications and timeliness of medication delivery were identified as serious problems that nurses must overcome to keep patients safe. While hospital pharmacies have schedules for delivering medication, nurses’ work doesn’t always conform to that schedule and sometimes patients have x-rays or other tests that interfere with patients’ taking medication on time. Some solutions nurses employ are calling the pharmacy repeatedly, marking a drug to be given immediately and retrieving the medication themselves.

“Nurses in the study also identified communication with doctors, pharmacists and other nurses as an indispensable part of preventing medication errors and ensuring patient safety,” added Flynn. “That means that nurses also take responsibility for developing good relationships with all members of the health care team, so that when they have to locate missing medication, double-check doses or ask questions about new medications, they get the answers they need when they need them.”

The study identifies an emerging model of medication safety practices and processes that are based on nurses’ clinical reasoning and a foundation for developing interdisciplinary, institutional policies to prevent system medication errors. The investigators suggest:

  • Revamping health provider education to foster a team approach to care, that includes learning the basics of errors theory and experience working together in clinical problem-solving exercises; and
  • Encouraging nurses to move beyond the “five rights” of medication administration to use clinical reasoning to protect their patients from harm.

INQRI supports interdisciplinary teams of nurse scholars and scholars from other disciplines to address gaps in knowledge about the relationship between nursing and health care quality. It is helping to advance the recommendations of the Institute of Medicine’s landmark report, The Future of Nursing: Leading Change, Advancing Health, which include fostering interprofessional collaboration and preparing and enabling nurses to lead change. By requiring research teams to include a nurse scholar and at least one scholar from another health care discipline, INQRI not only fosters interprofessional collaboration, the Initiative also ensures that diverse perspectives are brought to bear in research.

The Interdisciplinary Nursing Quality Research Initiative is funded by the Robert Wood Johnson Foundation. To learn more, visit www.inqri.org or follow on Twitter at @INQRIProgram.