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 signicant cause for concern in healthcare settings. In
Part 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 that
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 be
proffered and the way(s) forward to ensure optimal medication management and patient safety will be
explored from a nursing perspective. The specic aim of this paper is to illuminate the signicant role
that education, in both academic and clinical settings, can play in the preparation of nurses for their roles
in medication management and the marked reduction in errors and improved patient outcomes in this
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 and
care delivery. However, each group must scrutinise its own con-
tribution to the problemof 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 settings
should not be under-estimated. Clinical and educational measures
combined have the potential to yield very positive results in the
challenge that is medication errors in patient care. The synergy of
such collaboration offers the real opportunity to comprehensively
manage this problem from an all-encompassing, holistic per-
spective. Indeed, as highlighted in Part 1 of this paper, it is
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 professional
development in this area, is the role of focussed, tailored education
in medication management to ensure competence in this area and
reduce medication errors. This tailored education in medication
management must have its foundations at the earliest possible
opportunity in the nurses career, ideally at pre-registration (un-
dergraduate) level and must continue beyond registration and
throughout the nurses career. A variety of key educational and
clinical strategies to combat medication errors will now be
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 be
argued that, like other healthcare groups, nursing plays its role in
* Corresponding author. Tel.: 353 1 7008522; fax: 353 1 8612084.
E-mail addresses: joanne.cleary-holdforth@dcu.ie (J. Cleary-Holdforth), ther-
ese.leufer@dcu.ie (T. Leufer).
Contents lists available at SciVerse ScienceDirect
Nurse Education in Practice
j ournal homepage: www. el sevi er. com/ nepr
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
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 to
mention 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 in
a 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 drug rounds had the effect
of substantially minimising interruptions on the drug rounds and it
resultedinthe addedbonus of reducing drug roundtime (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 be
considered. 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
that 65% 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 presented in 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 harmto 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 of tness 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 the
area 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 authors institu-
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 pharmacology
and 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 students perceptions of their particular learning needs in this
area in order to render this endeavour meaningful and benecial to
J. Cleary-Holdforth, T. Leufer / Nurse Education in Practice 13 (2013) 217e220 218
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 link and 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-loading or 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 would ensure 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 clinical
practice, 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 authors department
and continues to be rened and re-modelled to further enhance its
utility. Indeed in their standards for pre-registration nursing edu-
cation document, the NMC (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 knowledge and 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 be
achieved 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
reach nal year with minimal knowledge and skill in this area.
However, such on-going education and development in this area
should not 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 their
less experienced colleagues (Preston, 2004; Scott, 2002). Kapborg
(1994) compared the written drug calculation skills of qualied
and student nurses and found that there was no signicant differ-
ence between the two groups. These ndings would suggest that
experience alone does not necessarily yield competence or
improved skill in this area. It would be an interesting study to
ascertain the reasons for this. Reasons suggested in the literature
include lack of opportunity to practice drug calculations, advances
in technology, medication dispensing and roles of pharmacists all
resulting in a declining need for complex calculations on a regular
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 for
regular (annual) updates, unavailability of regular updates, staff
shortages and budgetary constraints all have the potential to con-
tribute to or indeed exacerbate the problem. It is crucial that
strategies that ensure that competence in drug calculations is
achieved and retained are implemented if medication errors are to
be reduced and patient safety optimised in this area. For example,
a post-registration tool that mirrors the NMCs skills cluster for
medicines management or indeed the previously mentioned ma-
trix, which would describe competencies that need to be attained
or indeed maintained at intervals (i.e. annual basis) in order to
ensure that practitioners levels of competence in this area are
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 Nurses
and Midwives (2009) to support competency attainment post-
registration could perhaps be incorporated in future guidelines.
Other strategies could include the introduction of drug calculation
testing on a regular basis not only throughout the pre-registration
undergraduate programme but continuing consistently beyond
graduation (Wright, 2008). In addition educational updates or in-
formation days on medication management, medication errors and
maths revision programmes on an annual basis could be encour-
aged actively. Release of staff from clinical areas to attend such
educational updates would be benecial.
Wright (2005) proposes the use of online maths tutorials, face to
face tutorials, calculation workbooks and drug calculation taught
sessions as effective strategies to teach drug calculation skills.
These educational strategies are all very do-able, potentially
inexpensive and present very real ways of tackling this grave
problem. It may be pertinent at this juncture to remind ourselves
that each and every nurse is accountable for his/her own practice
and has responsibility to achieve and maintain competence in
practice, including in the area of medication management. These
proposed educational strategies are not optional luxuries, rather
they constitute essential, cost-saving, not to mention life-saving
measures. It is perhaps possible to consider training up key and/
or willing staff members within the care setting to champion safe
medication management and to act as trainers/mentors who would
lead these crucial initiatives, thereby reducing the overall cost of
medication errors to the patient, the hospital and the healthcare
system as a whole.
Conclusion
It is evident from both the statistics presented in Part 1 of this
paper and from the professional literature that medication errors
are a signicant concern for healthcare systems and indeed
J. Cleary-Holdforth, T. Leufer / Nurse Education in Practice 13 (2013) 217e220 219
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 effort to
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.
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