Copyright © eContent Management Pty Ltd. Contemporary Nurse (2009) 31: 176–189.

S tudent’s
CORNER

Prevalence, risk factors, consequences and

strategies for reducing medication errors
in Australian hospitals: A literature review

ABSTRACT The purpose of this paper is to examine medication errors in Australian hospitals
from a nursing perspective.This paper provides a detailed review of past and
current literature to examine prevalence rates and risk factors for medication
errors. It also describes unintended injury or harm, also known as adverse events,
associated with a medication error, and proposes strategies to counteract them.
According to the literature, approximately two percent of patients in an acute
hospital setting will experience a medication error.Administration of medications
has remained a high risk task for registered nurses, and for this reason, the
strategies to reduce error discussed in this paper will be predominantly nursing
focussed.The occurrence of a medication error is a significant issue in the health
Key Words care setting, and although the relative risk of an individual error occurring
nursing; is low, the rate of error remains perceivably high in clinical practice today.
medication With continual technological and pharmaceutical advances, the medication
error; adverse
administration environment is becoming increasingly complex. Given the nature

CN
event; drug;
patient safety; of medication therapy, it is near impossible to avoid all error, human and
risk otherwise.
Received 7 February 2008 Accepted 11 February 2009

INTRODUCTION
n the clinical setting, all too frequent errors
I in the administration of medications are a
persistent problem. As registered nurses have
the responsibility of the final contact with the
JENNIFER EVANS medication prior to administration, they are
Undergraduate student often held accountable for subsequent adverse
Deakin University –
Burwood Campus
events. Administering a medication is the nurs-
Melbourne VIC, Australia ing task that carries the highest risk, and the

176 CN Volume 31, Issue 2, February 2009

 Student corner: Strategies for reducing medication errors in Australian hospitals
consequences of an error can be devastating for
the patient and the nurse (Anderson & Webster
2001).
As well as being a high risk task for nurses, it
is also worth considering that in Australia it has
been reported that about 59 percent of the pop-
ulation are currently taking prescription medica-
tion (Joanna Briggs Institute 2006). So although
the probability of a single adverse drug event
occurring is relatively low, the likelihood of such
an event occurring remains a significant issue
due to the high proportion of people taking
medications (Australian Commission on Safety
and Quality in Healthcare [ACSQH] 2004).
This paper will examine the issue of medica-
tion errors in an Australian clinical context. It
will describe the prevalence, risk factors and
adverse events relating to medication errors.
Many health facilities have implemented strate-
gies to reduce the number of medication errors.
A discussion of the key aspects of these strate-
gies is provided, focussing on nursing priorities.
BACKGROUND
An adverse drug event is defined as an incident
which actually caused harm or injury to a
patient, and can result from an adverse reaction
to a medication or a medication error (ACSQH
2001; Lisby, Nielson & Mainz 2005). A medica-
tion error is any potentially avoidable event
which may involve inappropriate use of medi-
cations (such as carelessness or negligence),
causing actual or potential harm to a patient
(National Coordinating Council for Medication
Error Reporting and Prevention [NCC MERP]
2007; Meadows 2003). It can occur as a failure
to accurately complete an intended action relat-
ing to preparation or administration of a med-
ication, or a complete omission of a necessary
action. A medication error has four distinctive
characteristics: it follows a correctable problem
in medication therapy; given the situation,
the error was relatively foreseeable; the cause
of the error was identifiable; and the cause of
the error was controllable without sacrificing
Volume 31, Issue 2, February 2009
CN
the essential benefits of therapy for patient safe-
ty (Helper & Segal 2003).
Patient safety can be defined as the avoidance
or reduction of actual or potential harm to a
patient in a health care environment (ACSQH
2004). Medication errors jeopardise the wellbe-
ing and safety of patients, therefore it is an
important consideration in the current context.
According to Fogarty and McKeon (2006),
medication errors are a leading cause of patient
harm.The goal of every health care organisation
is the continual improvement of systems to pre-
vent patient harm, and the monitoring of med-
ication errors and potential errors is a large
component of such improvement (NCC MERP
2002). Health care facilities need to monitor
medication errors and investigate causes to
identify strategies for improvement of medica-
tion practices, ensuring maximal patient safety.
In developing appropriate monitoring systems,
it is important to recognise that blaming and
punishing individuals for making errors does
not resolve the underlying cause of the error.
The analysis of the information and data received
from reporting and subsequent actions has the
potential to increase patient safety.
Previous literature on adverse outcomes of
medication therapy promotes the idea that
adverse events are unavoidable. Such events
were an expected price to pay ‘for the ines-
timable benefits’ of modern medication therapy
(Barr 1955: 1453). More recently, Hyman and
Silver (2005: 56) suggest that the high rate
of error in health care is ‘predictable’ and in-
evitable given human involvement. Kalra (2004:
1043) reiterates the more commonly accepted
understanding that a limited amount of error is
unavoidable in any task, and that ‘human fallibil-
ity’ in health care should be accepted. Regard-
less of precautions taken, all diagnostic tests,
procedures and therapies pose considerable risk
to the patient. Human and technological factors
contributing to error cannot be entirely elimi-
nated (Leape 1995b), therefore the view held
by Barr still holds limited credibility today. It is
CN 177
CN Jennifer Evans
hoped that the rigidity of this view is rapidly
disappearing, even though the prevalence of
medication errors remains perceivably high in
clinical practice today.
PREVALENCE OF MEDICATION
ERRORS IN AUSTRALIA
Given the time-critical, delicate and variable
nature of health care, all health professionals
must understand that every patient provides an
opportunity for a serious mistake to be made
(Wolf et al. 2000). In the clinical environment
in Australia, the prevalence of medication errors
is of serious concern (Joanna Briggs Institute
2006).The importance of the statistics outlined
below is highlighted by Fogarty and McKeon
(2006) who identify adverse events due to med-
ication errors as a leading cause of unintentional
patient harm within an acute care environment.
The literature shows a reasonably wide range
of recorded rates of adverse drug events, rang-
ing from one to four percent of hospital admis-
sions. Specifically, clinical indicators show a one
percent chance of adverse drug event occur-
ring, whereas the medical record reviews have
shown two to four percent of admissions are
associated with an adverse medication event
(Runciman et al. 2003).
In 1995, The Quality in Australian Health
Care Study was conducted and it remains the
largest nationally representative study to date
(ACSQH 2004). Using the data contained in the
study, it can be calculated that approximately
two percent of patients will experience a med-
ication error, which is of similar magnitude to
the data presented above, from Runciman et al.
(2003).
Errors can occur at any step in the medica-
tion process (from prescribing to administra-
tion), and an important aspect to consider when
examining the prevalence of medication errors
is the type of error, or at which phase the error
actually occurred. Data from the Australian
Incident Monitoring System shows that over a
quarter of medication incidents occurring in
178 CN Volume 31, Issue 2, February 2009
hospitals were due to omissions of medication,
and 20 percent were as a result of overdosing a
patient. Administering the wrong medication
accounted for ten percent of errors made in
hospitals and incorrect labelling was reported
to be responsible for less than five percent
(Hodgkinson 2006).
In terms of patient safety, the NCC MERP
(2002) stated that there is no acceptable occur-
rence rate of medication errors. The rate of
error can be influenced by many factors which
can increase the likelihood of an error occurring
in specific situations.
RISK FACTORS LEADING TO
MEDICATION ERRORS
Mayo and Duncan (2004) surveyed 983 reg-
istered nurses working in acute care hospitals
to determine their perception of medication
errors.They reported that illegible hand writing
of prescriptions, distraction and fatigue were
the highest contributing factors to medication
errors. A British study undertaken by Fry and
Darcy (2007) identified the most common con-
tributors to error as: unclear prescriptions,
high workload, and a busy schedule with many
pressures. Hand and Barber (2000: 558) identi-
fied ‘personal’, (such as a high level of stress),
‘contextual’ (such as a noisy ward with many
patients) and ‘knowledge base’ as the three im-
portant categories of human error which con-
tributed to medication errors.
As similarly defined by many, human error
involves the failure of intended actions to elicit
a desired response, causing deviation from what
is right or true (Reason 1997; Hansen 2006).
Kleinpell (2001) suggests that many of the fac-
tors leading to medication errors are human
related, such as inexperienced or temporary
staff, caused by a knowledge deficit or inac-
curate documentation. Distractions and other
impeding factors such as fatigue, stress and not
focusing on the task can also have very detri-
mental effects on the patients’ well being and
are known to contribute significantly to human
 Student corner: Strategies for reducing medication errors in Australian hospitals
error in general (Rassin, Kanti & Silner 2005;
Woods 2001).
While human error is very important to
examine, it is equally important to investigate
the context in which the error occurred, that is,
the environment and the specific situation. For
example, although medication errors can occur
with any medication, there are a select few that
are commonly cited to be involved in medi-
cation errors (Hughes & Ortiz 2005; Runciman
et al. 2003). These drug classes include non-
steroidal anti-inflammatories, anticoagulants
and opiods. The pharmacokinetic properties of
many medications may cause them to have a
narrow range at which they are clinically benefi-
cial.This reduced range increases the risk of an
error, as the therapeutic levels can be difficult to
monitor and maintain.
Another contextual factor which may influ-
ence the safety of medication administration is
characteristics of the medications. In 1961 a
mere 656 medications were available to physi-
cians, and in 1995 there was documented to be
over 8000 (Leape 1995a). Today the number is
probably even higher. Many of these medica-
tions have similar sounding or looking names.
For example Meadows (2003) reports that a
patient received 260 mg of Taxol, instead of the
prescribed 260 mg of Taxotere. In this situation
both medications are used for chemotherapy,
but there are many other examples of medi-
cations that sound alike which are unrelated,
such as Serzone (Nefazodone – used to treat
depression), and Seroquel (Quetiapine – used
for schizophrenia). Although the continual med-
ication advancements have produced ‘incal-
culable benefits’ (Barr 1955: 1453), they also
appear to be contributing to the risk of a med-
ication error occurring (Tang et al. 2007).
Just as certain environments increase the risk
of an error occurring, certain patients are con-
sidered to be at a higher risk of experiencing a
medication error than the general population.
Those requiring multiple forms of pharmaco-
logical therapies, elderly, critically ill and paedi-
CN
atric patients often require an increased level of
vigilance in order to avoid potential medication
errors (Hughes & Ortiz 2005; McIntyre & Courey
2007). Paediatric patients have an increased sen-
sitivity to toxicity levels and thus most dosages
are calculated by weight, in significantly smaller
volumes than adults, increasing the complexity
of the calculation. Older adults are at increased
risk in part because the number of medications
taken increases with age, often due to chronic
illness. Interpreting complex prescriptions for a
patient on multiple medications can lead to mis-
interpretation (Benner et al. 2002). Regardless
of whether the individual experiencing the
medication error is in the ‘high-risk’ population
or not, the result is just as unexpected and dev-
astating to all concerned.
A rise in the number of medications available
has seen parallel increases in the level and
volume of medication knowledge expected of
registered nurses. As nurses are ultimately
responsible for any medication they administer,
it is pertinent that their knowledge base is suffi-
cient, encompassing action, side effects and nor-
mal dosage. Education and competency are of
great importance in nursing, especially with
relation to medication administration. Nurses
involved in medication administration must
ensure that their knowledge of current medica-
tions is sufficient and awareness of appropriate
legislations is maintained (Nurses Board of Vic-
toria [NBV] 2007). In its position statement on
the quality use of medicines, the Royal College
of Nursing ([RCN] 1999) states that the admin-
istration of medications is a procedure involving
physiological invasion and may result in unwant-
ed and unintended outcomes to the patient.
Therefore it is imperative that the registered
nurse possess an extensive understanding of
clinical pharmacology, including knowledge of
the mechanical principles of medications and
the ability to contextualise specific therapies in
given situations, enabling appropriate clinical
decisions to be made (Manias & Bullock 2002).
As well as an objective knowledge of medi-
Volume 31, Issue 2, February 2009 CN 179
CN Jennifer Evans
cations being administered, nurses are also
required to comprehend the application of the
medication administration procedure. Mathe-
matical ability is an essential skill for many
aspects of a nursing career, yet a number of
studies have identified insufficient levels of
accuracy (Polifroni, McNulty & Alllchin 2003;
Bruce & Wong 2001). Performing a medication
calculation requires both arithmetic skills and
conceptual skills, including being able to con-
textualise the calculation with relevance to the
patient, medication or clinical scenario (Rainboth
& DeMasi 2006; Bliss-Holtz 1994).This can be a
time-consuming, difficult, and anxiety provoking
task for nursing students and registered nurses
(Pozehl 1996; Bayne & Bindler 1988).
Over the past decade, the health sector has
seen many technological advances, resulting in
changes to nursing practice. Although the skill
is far from obsolete, there has been a decrease
in the frequency of medication calculations
required of a nurse. The increased reliance on
technology has resulted in less demand for
nursing staff to execute medication calculations.
This reduced clinical exposure could potentially
lead to a loss of proficiency (Rainboth & DeMasi
2006; Bindler & Bayne 1991). In 2005 a report
published in Finland indicated that nurses were
aware of their own substandard medication cal-
culation abilities (Grandell-Niemi et al.). Prior
research demonstrating the ability of nurses to
accurately predict their own calculation skills
supports this assertion (Bayne & Bindler). This
lack of discrepancy between perceived and actu-
al ability has been apparent for nearly 15 years,
with potentially incompetent nurses practising
medication calculations on a daily basis.
Although human error is accountable for
some medication errors, it is believed that this
is only a small percentage (Henneman & Gawl-
inski 2004). Unfortunately, because medication
errors attributable to human fallibility are some-
what easier to recognise, misplaced emphasis
contributes to a culture of blame within health-
care organisations (Institute of Medicine [IOM]
180 CN Volume 31, Issue 2, February 2009
2001). This punitive environment can result in
adverse outcomes for the nurse, and indeed the
patient, as damaged confidence can often result
in changes to clinical practise and competence.
More importantly, it fails to address the under-
lying cause of the error such as the work condi-
tions which may have contributed.
ADVERSE EVENTS RELATED TO
MEDICATION ERRORS
Adverse drug events have been estimated to
cost the Australian public $350 million annually
(Hodgkinson 2006). It has been calculated that
adverse drug events consume approximately
one percent of the total sum spent on health
care nation wide (Runciman et al. 2003). Along-
side this, each year in Australia, it is estimated
that general practitioners manage up to 400,000
adverse drug events, many of which could
be related to medication errors (Joanna Briggs
Institute 2006). Many medication errors can
end in tragedy for the patient and family, and
even the health professionals and associated
agency (Wolf et al. 2000).
In 1995, the Quality in Australian Health
Care Study reviewed medical records of over
14,000 patients in hospitals across Australia.
More than half of all occurring medication
errors were considered preventable. In 77.1
percent of cases, the resultant disability had
resolved within a year, and 13.7 percent of cases
resulted in a long term disability. Medication
errors can sometimes cause fatality, reported as
occurring in nearly five percent of cases (Wil-
son et al 1995).
Depending on the clinical situation, medica-
tion errors can have a broad range of effects,
from going unnoticed to causing death. For
example, a patient with an Aspirin allergy was
administered Indocin and developed a non-fatal
respiratory arrest. This event may have been
preventable if allergies and contraindicated con-
ditions were checked first (Hartigan-Go 2006).
Serumbus,Wolf, and Yongblood (2001) report-
ed a paediatric patient who received an injec-
 Student corner: Strategies for reducing medication errors in Australian hospitals
tion of a miscalculated dose of the oral form of
Digitalis and subsequently died. Furthermore,
an older patient with rheumatoid arthritis was
prescribed a 10 mg weekly dose of Methotrex-
ate, but died as a result of receiving a 10 mg
daily dose (Meadows 2003).
Medication errors not only have direct ef-
fects on the patient and their family, but can also
carry significant ramifications for healthcare
professionals, particularly nurses. In all patient
duties, registered nurses are striving to improve
or maintain patient welfare and avoid harm,
therefore when a mistake is made it can have a
drastic effect on the individual. They can lose
confidence and self esteem, feel guilty, ashamed
and embarrassed, as the error is often attributed
to ‘poor professional practise’ (Wolf et al. 2000:
278). Fear and lack of clinical confidence instils
a sense of mistrust and self-doubt, which not
only affects their practise, but also deeply affects
their self-perception.
The experience of a medication error is often
reported as being a ‘deeply traumatic’ experi-
ence in both personal and professional contexts
(Schelbred & Nord 2007: 319). Nurses worry
about the consequences the error may have for
the patient’s life, and for themselves in terms of
losing trust and support from colleagues or fac-
ing professional retributions such as lawsuits,
imprisonment and loss of authority or job. The
concern caused by these potential outcomes has
been reported to contribute to the development
of post traumatic stress disorder and depressive
symptoms.
According to Wolf et al. (2000), healthcare
professionals have a social expectation to be
near perfect, and medication administration
remains a traditional nursing task with high
responsibility. The reduction of medication
errors is a very important issue in a nursing
context as nurses are most often the ones who
perform the final step in medication process. In
Australia and internationally, there has been a
recent intense effort to control medication
errors (Fogarty & McKeon 2006).
CN
NURSING STRATEGIES TO
REDUCE THE OCCURRENCE
OF MEDICATION ERRORS
Hospitals and health care facilities are continual-
ly working towards reducing medication errors
through technology, monitoring and education
(Meadows 2003). As registered nurses are the
professionals who administer the medication,
and often deemed the final ‘line of defence’ in
medication administration, there are many nurs-
ing strategies which can be implemented to
avoid potential medication errors (Rainboth &
DeMasi 2006: 347).
Double checking has long been a strategy
used to minimise medication errors (Anderson
& Webster 2001). Double checking with anoth-
er registered nurse is essential when preparing
and administering a medication; however it does
not eliminate the need for other safety proce-
dures.The Medicines Governance Project (2004)
puts forward arguments as to why double
checking may not be considered a safe tech-
nique. It suggests that the first person to review
the medication order may rely heavily on the
second person, rather than completing an accu-
rate and safe check themselves, creating a false
sense of security. Double checking a medication
order can also cause a ‘confirmation bias’ where-
by the second individual has the tendency to
interpret the information as confirming prior
beliefs. Double checking relies very much on
human effort, thus the risk for error is high. In
the context of medication administration, it is
important that the double checking does not
become an autonomous process and therefore
worthless.
Another traditional method of ensuring
patient safety is the ‘five rights principle’. This
involves five essential checks before administer-
ing a medication – the right medication, dose,
patient, route and time (Crisp & Taylor 2006).
The importance of this principle is demonstrat-
ed by Meadows (2003), who reported the death
of a patient as a result of a massive haemorrhage
after receiving another patient’s prescription for
Volume 31, Issue 2, February 2009 CN 181
CN Jennifer Evans
the anticoagulant, Warfarin. This might have
been prevented if the five rights were vigilantly
followed. Much research has been conducted in
this area and it mostly shows that checking these
five rights helps to ensure safe and effective ad-
ministration of a medication (Wolf et al. 2000).
Conflicting results have also been obtained,
showing that errors still occur when nurses
adhere to the five rights (Smetzer 2000). As in
most clinical scenarios, there is room for human
error and many human factors such as poor
handwriting or lack of experience, can con-
tribute to an inaccurate verification of a right.
Healthcare facilities that do not employ the use
of identification wrist bands (such as aged care
hostels) can have problems with accurate verifi-
cation of identity as verbally questioning the
individual could be tainted by poor hearing or
confusion. Therefore, the five rights on their
own are not enough to prevent high rates of
medication error.
Some literature now refers to the sixth right
of medication administration. Wilson and Di-
Vito-Thomas (2004), propose the sixth right:
right response. This sixth right is intended to
focus on the evaluation of the effectiveness of
the medication, and reiterates the importance
of taking responsibility for the administration of
medications. In clinical scenarios involving pain
control, anticoagulant and antiarrhythmic thera-
pies, the importance of assessing patient res-
ponse is evident.This proposed sixth right is not
applicable in all administration situations; how-
ever, it is important that the medication process
does not end at administration.
Many medication errors are not reported
and thus are undetected, so only a minority of
causes can be identified (Anderson & Webster
2001).The reason many nurses and other health
professionals do not report some medication
errors or near errors, is fear of professional and
personal retributions, which could lead to a
damaged career, reputation or confidence (Wolf
et al. 2000).
The social pressure for health care profes-
182 CN Volume 31, Issue 2, February 2009
sionals to be near perfect appears to have creat-
ed an atmosphere in which mistakes are per-
ceived as intolerable and unacceptable, resulting
in a degree of dishonesty. Given the potential
significance of retribution, (ranging from loss of
job and self-confidence, to an increased level of
vigilance when conducting future medication
administrations), many professionals choose to
conceal the error (Serumbus et al. 2001). The
lack of reporting of errors is a key issue within
the health care system that needs to be addressed.
Wolf et al (2000) suggest that health care
workers need a better understanding of the
personal impact a medication error can have.
Appreciating the anxiety and guilt associated
with the reporting of a medication error would
enable them to develop appropriate support in
a personal and clinical context. This increased
awareness would also need to incorporate a
change in perspective, viewing medication errors
as indicators for continuous quality improve-
ment, rather than an individual’s failure. In
order to do this, medication errors need to
be dealt with in a constructive manner. This
includes exploring underlying causes, further
education or training if required, and support
or professional help to optimise coping mecha-
nisms (Schelbred & Nord 2007).
While the importance of a comprehensive
incident reporting scheme is well recognised in
the nursing community, many reporting schemes
that have been implemented do not elicit very
high levels of response, thus rendering them
inadequate (Cullen et al. 1995). If all medica-
tion errors and potential medication errors are
reported, the system has the ability to identify
and correct problems, sometimes before they
occur (Anderson & Webster 2001). It is also
essential that near-misses are reported, as near
misses occur more frequently than actual ad-
verse events. The NCC MERP (2002) suggest
the following three factors which can affect the
reporting of a medication error: a non-punitive
culture in the health organisation can result in
increased reporting, the varied definitions
 Student corner: Strategies for reducing medication errors in Australian hospitals
among health care organisations can lead to dif-
ferences in classification; and the type of report-
ing and detection system can alter the number
of reports. Anderson and Webster believe that
the reporting system will only reach maximal
effectiveness if the levels of reporting are very
high. In order to achieve these levels, the error
reporting system needs to be run on an anony-
mous basis to avoid the blame culture persistent
in today’s society (Malpass et al. 1999).
Blame and punishment for error is not con-
ducive to learning and can actually condition
people to avoid recognising or reporting errors.
Openness and a non-punitive approach appear
to assist nurses in regaining their confidence fol-
lowing a medication error, whereas facilities in
which individuals are targeted and punished
may result in worsening of emotional response
and unreported errors in the future (Schelbred
& Nord 2007). Therefore punitive reporting
systems for medication errors are unlikely to
effectively address safety issues (Henneman &
Gawlinski 2004).The reporting scheme should
take a systems perspective because the source of
an accident is most often a confluence of multi-
ple system factors, rather than an individual
component (Dekker 2005; Kalra 2004).
Blaming an individual leads to self defensive
behaviour and the obscuring of reported in-
formation as a self-protection mechanism, thus
clarifying the need for an anonymous reporting
system. Natural psychological processes can
give rise to the tendency for health profes-
sionals to attribute all error to human factors
(Billings & Woods 2001). Hindsight bias allows
fellow practitioners to make causal judgements,
involving oversimplifying contextual factors,
leading to human attribution. Not being able
to identify a direct cause for an error causes
human distress due to the implied lack of con-
trol, and blaming an individual feeds the illusory
belief of maintaining control over ‘risky tech-
nologies’ (Dekker 2005: 199).
It is anticipated that high acuity electronic
recording devices will eventually replace hand
CN
written medication charts, providing intelligent
support to administration decisions (ACSQH
2004). In its national consensus statement on
lifelong learning, the Australian Nursing Federa-
tion (2005) recommended that information
technology systems be incorporated into nurs-
ing education.There are other new-technology
techniques such as barcode scanning equipment
for medications and identification bands (Wolf
et al. 2000). Saginur et al. (2008) surveyed
pharmacy directors of 100 Canadian acute care
hospitals and at least 90 percent of respondents
felt that the use of bar-coding technologies
should increase. Although not specifically nurs-
ing related, another strategy is the Comput-
erised Physician Order Entry (CPOE), which
involves typing orders for medications directly
into a computer system. It alerts staff to incom-
patible medications, doses or patient conditions,
as well as eliminating errors made through
interpretation of written and verbal orders. In a
study conducted by Bobb et al. (2004), it was
estimated that 65 percent of prescribing errors
were likely preventable with a basic CPOE sys-
tem. This finding was supported by research
conducted in 1998 by Bates et al., who iden-
tified a significant reduction in the rate of
medication errors with the use of CPOE. In
contrast, Koppel (2005) highlighted several
types of errors that were more likely to occur
with a CPOE system, including dose errors,
which were said to be almost twice as likely to
occur. Shulman et al. (2005) provide an exam-
ple of how in a particular CPOE system, a drop
down dosage menu contributed to a prescription
of 7 mg/kg of diamorphine instead of 7 mg.
With the continual expansion of medication
information, a reliable, accessible and compre-
hensive source of information is an invaluable
tool in nursing (George & Davidson 2005). Per-
sonal Digital Assistants (PDAs) are small elec-
tronic devices which store enormous volumes
of regularly updated information.These pocket
sized tools aid in obtaining referenced material
quickly and easily, providing informational sup-
Volume 31, Issue 2, February 2009 CN 183
CN Jennifer Evans
port for clinical decisions (Huffstutler,Wyatt &
Wright 2002). As demonstrated by Greenfield
(2007), providing immediate access to health
information and data at the bedside increases
the accuracy, speed and safety of nursing care,
decreasing the incidence of medication errors.
The potential of PDA use to improve medica-
tion safety depends on the sufficiency of the
information available. To be considered suffi-
cient, the source must contain specific, accurate
and detailed information, able to meet the
needs of each clinical decision involved in the
process of medication use. One recommended
change to further enhance medication safety
was the inclusion of specific product details
(such as colour, markings and size) in PDA data
sources (Galt et al. 2005).
In 2003, the IOM published a report which
identified the use of information technology as
one of five core areas in which students and
working health professionals must develop and
maintain proficiency. All clinicians need to
understand the limitations of technology and
continue to exercise vigilance in all patient
duties.Whilst computerised technology has the
potential to improve the level of patient safety,
it is also possible that new types of errors will
arise. Clinicians are more likely to ignore exces-
sive warnings produced by PDAs or other such
technology, which may lead to an adverse event
occurring (Gaddis, Holt & Woods 2002). The
reliance on computer systems may also lead to a
reduction in human vigilance, resulting in nurs-
es being less aware of medication characteristics
and possibly making an error they would not
have made otherwise (NHMRC 2006).
Health ministers across Australia supported
the idea of a national drug chart across all Aus-
tralian hospitals as a way to reduce medication
errors related to documentation (Leach 2006).
A study conducted by Leach in 2006 showed a
marked reduction in documentation errors (of
allergies, dose and frequency) and reduced pre-
scription errors when 31 hospitals used a stan-
dardised drug chart. This national drug chart
184 CN Volume 31, Issue 2, February 2009
has now been implemented, bringing with it a
form of safer communication, with a better
understanding of the prescribing process and
strategies to minimise patient harm (ACSQH
2004; 2005).
A strategy that would involve many dis-
ciplines within healthcare is the avoidance of
unsafe abbreviations (Abushaiqa et al. 2007).
Abbreviations that would be deemed unsafe are
those which provide the opportunity for error
to occur through misinterpretation of medica-
tion name, dosage or units. Unsafe abbreviations
are not only misunderstood, but can also appear
to mean something completely unintended
when combined with other surrounding words,
numerals or symbols (New South Wales Thera-
peutic Advisory Group [NSW TAG] 2007).
Meadows (2003) for example, described a patient
who died as a result of an order for 20 units of
insulin being abbreviated to ‘20U’. The U was
mistaken as a zero and subsequently the patient
was injected with 200 units. In order to pro-
mote adequate patient safety, universal and
unambiguous symbols and abbreviations need to
be used consistently (NSW TAG 2006).
The ACSQH (2002) suggest the risk of error
in medication administration from a ward stock
supply is 15–20 percent, a much higher inci-
dence compared to when individual patient
stocks are used (five to eight percent).This evi-
dence suggests that it is a safer option to have
pharmacy staff measure and dispense individual
patient doses. This would also reduce nursing
workload, as medication preparation and ad-
ministration have been reported to consume
nearly 40 percent of nursing shift time (Armi-
tage & Knapman 2003). However, giving the
extra responsibility of measuring individual
doses to pharmacists may act as transference of
the problem, rather than a long term solution.
Mathematical proficiency has been identified
as an area requiring improvement at the tertiary
level (Rainboth & DeMasi 2006), which in-
dicates the need for better mathematical or
numeracy training prior to commencing an
 Student corner: Strategies for reducing medication errors in Australian hospitals
undergraduate nursing program. Mathematical
education should be a prerequisite for any under-
graduate nursing course (Cartwright 1996).The
current lack of formal numeracy demands for
entry into an undergraduate nursing course in
Australia poses an interesting contrast to that
of undergraduate medicine courses. Students
applying to study medicine would not even be
considered for the course without sufficient
mathematical competency, why nursing courses
lack such requirements is mystifying. A study
conducted in Sweden supports the need for
such a prerequisite, showing poorer scores ob-
tained in calculation exercises from undergrad-
uate nursing students without mathematical
backgrounds (Kapbord 1995).
Even though the frequency of medication cal-
culations exists in an inverse relationship with
advancing technology, they are still a vital con-
tributor to the occurrence of medication errors.
In order to rectify the preventable adverse events
occurring as a result of calculation errors,
researchers have identified the need to address
the issue at a tertiary level (Rainboth & DeMasi
2006). Many tertiary institutions are developing
modules to increase the calculation proficiency
of their graduate nurses (Elliott & Joyce 2005).
Educating students from the outset of their
nursing career may help to instil a satisfactory
level of skill, potentially reducing the risk of an
error being made as a registered nurse. It is also
essential that calculation competency is main-
tained post graduation. According to O’Shea
(1999), many healthcare facilities have imple-
mented measures such as periodically testing
calculation ability of nurses in the work place.
Weeks, Lyne and Torrance (2000) state that it is
a critical skill and needs to be reinforced in both
pre-registration educational and clinical domains.
King (2004) interviewed ten nurses emp-
loyed in an emergency care facility about the
educational needs for pharmacological knowl-
edge in nursing. Her results indicated that there
was limited pharmacological knowledge among
participants; recognition of inadequate teaching
CN
in pharmacology was also noted. Improved
pharmacological education has the potential to
increase confidence and proficiency in medica-
tion administration for nurses. Presently there
are no national competency guidelines which
explicitly identify adequate amount and depth
of pharmacological knowledge for nursing prac-
tice (Bullock & Manias 2002); therefore the
development of such competencies is indicated
in order to ascertain appropriate curricular con-
tent at an undergraduate level.
SUMMARY
This paper has reviewed the literature on med-
ication errors in acute care settings with a focus
on Australian prevalence, risk factors, conse-
quences and specific nursing strategies to pre-
vent errors from occurring. Patient safety is a
key consideration in healthcare, which reflects
the nature of a medication error, which can be
controlled without sacrificing the essential ben-
efits of therapy (Helper & Segal 2003).
Labelled as the leading cause of unintentional
patient harm, medication errors are a serious
issue in nursing which needs to be addressed
(Fogarty & McKeon 2006). Although the likeli-
hood of an individual error occurring is seem-
ingly low, the serious nature of the associated
consequences is enough to justify immediate
action. A medication error can produce devas-
tating results, threatening patients’ lives and
jeopardising nurses’ confidence, job security
and job satisfaction.
Registered nurses have a high level of res-
ponsibility in all areas of patient care, especially
administration of medications. The wide range
of pharmaceutical products available and dra-
matically changing technology adds to the
already complex situation (Anderson & Webster
2001). This increasing complexity of the med-
ication administration environment places in-
creased pressure on nurses’ busy schedule and
provides greater opportunity for error to occur.
As nurses have the final contact with the
medication before it is administered to the
Volume 31, Issue 2, February 2009 CN 185
CN Jennifer Evans
patient, it is important that all errors are ade-
quately recognised and specific nursing strate-
gies are implemented to reduce medication
error rates. Although nurses bear a lot of res-
ponsibility and are frequently targeted as the
primary cause of the error, it must be realised
that in the majority of cases, the error can be
attributed to ‘the systems, rather than the indi-
vidual’ (Beyers 2000: 56; Anderson & Webster
2001).
Many strategies have already been imple-
mented in Australia and many are nursing tar-
geted. For example adequate incident reporting
schemes (Anderson & Webster 2001), enhanced
mathematical preparation (Rainboth & DeMasi
2006) and a nation-wide common drug chart
(Leach 2006). The strategies that have been
implemented targeting the reduction medica-
tion error rate have been quite successful, and it
is envisaged that they will continue to do so.
However, due to the nature of nursing and med-
ical care – both human and technological, the
risk of error can theoretically never reach zero
(Leape 1995b).
Acknowledgement
Thank you to Malcolm Elliott and Jane Walker
for their continual support and assistance with
editing.
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