Nurses Use Repetitive Processes to Catch Medication Errors

Heather Comak, for HealthLeaders Media , October 30, 2009

Each year, medication errors are responsible for 7,000 patient deaths and cost the healthcare system $2 billion. Even more shocking, perhaps, is the knowledge that nearly 50% of potential medication errors are caught before making it to the patient. Of those potential errors, 87% are intercepted by nurses.

Linda Flynn, RN, PhD, associate professor at the University of Maryland School of Nursing, recently led a study concerning medication errors and how the practice environment and the level of nurse staffing affect medication error rates. Flynn, also the project director and principal investigator of this Interdisciplinary Nursing Quality Research Initiative (INQRI)-funded study, presented on the topic during an INQRI Webcast on October 7. INQRI, a project of the Robert Woods Johnson Foundation, was created to examine nurses' impact on patient safety.

"Nurses are the safety net that keeps patients safe from experiencing a medication error," said Flynn. "Our question was, what are the factors that impact this nursing safety net—what are the factors that help nurses in doing their job to intercept medication errors before they reach the patient, and what are the factors that serve as barriers to this safety net?"

Flynn's study focused on identifying the costs and implications of medication errors. Her team from the New Jersey Collaborating Center for Nursing at Rutgers University's College of Nursing did so by examining both work environments and nurse staffing situations. Broken down into three separate parts, the study received participants from 14 hospitals in New Jersey.

Ultimately, the study revealed that medication errors are expensive, averaging more than $6,000 extra spent on patients who experience a medication error (not necessarily an adverse drug event). Additionally, nurses employ four distinct medication safety processes to help themselves find medication errors before they reach the patient. These processes were enhanced when the nurses felt that their work environment was supportive, giving them time to effectively use these processes.

What processes do nurses use to catch medication errors?

The first part of the study examined what it is that nurses do specifically during their everyday jobs to prevent medication errors from reaching the patient. Flynn and her team interviewed 50 staff nurses from 10 hospitals, transcribed the interviews, and analyzed the lines of text for patterns and commonalities. They found that nurses take seven routine steps in the name of medication safety:

  1. Conduct independent review of the medication administration record (MAR) in comparison with the medication order

  2. Perform a focused assessment of the patient prior to administering medication

  3. Question rationale

  4. Prioritize face time with physicians

  5. Encourage patients and families to be the last line of defense for a medication error

  6. Advocate with pharmacy to ensure timeliness of medication delivery.

  7. Clarify orders/handwriting with physicians

Of these processes, Flynn and her team found that numbers 1, 3, 5, and 7 were significantly associated with fewer medication errors. Additionally, there was overwhelming evidence that these practices were enhanced when the nurses worked in a supportive staffing environment.

For more on this story, please see the December issue of Briefings on Patient Safety.

Heather Comak is a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety, as well as patient safety-related books and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals. Contact Heather by e-mailing

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