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Advice on common mistakes, the potential consequences and ways to improve patient safety, plus why transparency is important if an error occurs
The case of a US nurse found guilty of criminally negligent homicide after administering the wrong drug to a patient would make any nurse shudder.
Nursing Standard. 37, 10, 14-17. doi: 10.7748/ns.37.10.14.s10
Published: 05 October 2022
For those in the UK, it would be akin to being convicted of manslaughter, or the Scottish crime of culpable homicide.
Intensive care nurse RaDonda Vaught had been due to give a pre-scan sedative to 75-year-old patient Charlene Murphey. Instead, she accidentally administered vecuronium bromide, a relaxant used in anaesthetics, resulting in Ms Murphey’s death.
The nurse faced the prospect of up to six years in prison when she was convicted in March 2022. In the end, she was sentenced more leniently, receiving three years’ supervised probation.
The profession came out in her support. The International Council of Nurses condemned what it considered the criminalisation of a medical error, and the American Nurses Association (ANA) wrote to the judge in protest ahead of sentencing.
‘Nurses are anxiously watching this case,’ the ANA stated. ‘They see themselves in nurse Vaught; we see ourselves in nurse Vaught.’
So, just how common are medication errors? Are some more prevalent than others and what would help nurses avoid them?
Medication errors are extremely common in the NHS, with a study in 2018 estimating 237 million such mistakes happen every year in England’s NHS alone.
Researchers from the universities of York, Manchester and Sheffield reported that an estimated 712 deaths result annually from avoidable adverse drug reactions – although errors could be contributory factors in as many as 22,000 deaths a year.
The researchers found that almost three in four medication errors are unlikely to result in harm to patients, but there is little information on the harm that actually occurs as a result of such errors.
Medication errors can happen at any stage of the medicines management process, says Matt Griffiths, medicines management nurse at Royal United Hospitals Bath NHS Foundation Trust.
Procurement, storage (a particular concern in hot wards where storage temperature requirements are exceeded), prescribing, administration and monitoring are all parts of the process where mistakes can happen, he says.
The 2018 study found that most errors with potential to cause harm happen in primary care (71%), which also happens to be where most medicines in the NHS are prescribed and dispensed.
Polypharmacy is a feature in risk, with errors more likely to occur in older people and in patients with multiple conditions.
The medicines most often implicated in hospital admissions and linked to medication errors are non-steroidal anti-inflammatories (NSAIDs); clot-busting anti-platelet drugs; drugs to treat epilepsy and lower blood glucose; diuretics; inhaled corticosteroids; and certain types of drugs to treat heart conditions, for example cardiac glycosides and beta blockers, the study said. Eight in ten resulting deaths were caused by gastrointestinal bleeds from NSAIDs, aspirin, or the blood thinner warfarin.
237 million medication errors occur in the NHS in England every year
Source: BMJ Quality & Safety tinyurl.com/BMJQandS
712 deaths a year in the NHS in England occur as a result of avoidable drug reactions
Source: BMJ Quality & Safety tinyurl.com/BMJQandS
£35 million in damages was paid out by the NHS in England for medication errors from 2015-2020
Source: NHS Resolution tinyurl.com/NHS-med-errors
The three most common types of medication error are incorrect strength or frequency of dose; missing a dose; and the wrong medicine being administered, according to a report by the now-defunct National Patient Safety Agency (NPSA) back in 2007. Together, these accounted for almost 60% of reported drug errors.
Fifteen years on from that report, Mr Griffiths says those common errors continue to affect healthcare services. He has seen many examples of nurses mixing up medications that look or sound alike or have similar names, as well as calculation errors.
The financial impact on the NHS is significant. NHS Resolution received 1,212 claims related to medication errors in the five years to 2020. Of these, 487 led to damages payouts of £35 million, not counting legal fees.
Mark Gagan, a senior lecturer in adult nursing at Bournemouth University and an expert on the legal aspects of prescribing and administering drugs, describes a tragic case of a newly qualified district nurse who was filling in for a colleague and visiting patients with diabetes to give them insulin early in the morning.
An older woman she visited could not find her own syringe, so the nurse grabbed one of her own from her car to administer the drug. She completed the round and went home before realising she had used a much bigger, 2ml syringe, instead of a narrow insulin syringe. As a result, she had given the patient ten times the correct dose.
‘An insulin overdose will kill a patient pretty quickly, and we deal with many powerful drugs every day that can cause harm’
Mark Gagan, senior lecturer in adult nursing, Bournemouth University
‘She immediately called the GP and said she thought she had given too much insulin and he told her he had just certified the patient’s death,’ says Mr Gagan. ‘This was a devastating case and shows how dangerous drug miscalculations can be. An insulin overdose will kill a patient pretty quickly, and we deal with many powerful drugs every day that can cause harm.’
A verdict of unlawful killing was delivered at an inquest, although the nurse was not prosecuted. She chose to leave nursing after the death.
Mix-ups between patients with the same or similar names can also happen, says Mr Gagan. He cites one case in a UK care home where two residents had the same name. They were prescribed the same powerful morphine-based painkiller.
Confusion over patient names
One resident had been on the medication in question for a long time and was receiving a much higher dose. But that dose was given to the other person. It was eight times higher than prescribed, and the resident died.
‘The nurse should have checked the date of birth, as well as the name,’ Mr Gagan says. ‘But familiarity with a workplace, the work and patients can breed complacency. That nurse was struck off by the NMC. Becoming a nurse and distributing medication brings a huge responsibility.’
System issues compromise safety too. An example of this, says Mr Griffiths, is when paper and electronic prescribing co-exist in one system. Medications might be given on a ward but also in theatre or the emergency department where electronic prescribing is not used, and so duplication can occur, he explains.
The impact of missed or delayed doses can be significant, although these are often not recognised as a medication error, Mr Griffiths says.
‘Time is particularly critical for some drugs, particularly insulin, which needs to be administered around the mealtime and not when the drug trolley arrives at that patient’s bed.’
Charity Parkinson’s UK has a long-running campaign called Get it on Time to highlight the devastating consequences of delays to medication for patients with the progressive neurological condition.
Even a 30-minute delay can have serious effects on a person’s health, yet 63% of people living with Parkinson’s do not always receive their medication on time when staying in hospital.
Allowing inpatients who are able to, to administer their own regular drugs can help maintain their normal routine, says Parkinson’s UK. While many organisations do this, too many have out-of-date self-administration policies that have the effect of removing that level of control from the person.
Some mistakes may stem at least in part from the crushing workload many nurses are experiencing. Lack of essential equipment, for example intravenous pumps – or lack of training to use them – may compound nurses’ difficulties. Low staffing levels intensify pressure on individuals’ workloads and increase risk of interruption during drug rounds.
‘Constant interruptions are difficult, and definitely contribute to lapses in concentration and mistakes,’ Mr Griffiths says. ‘It is often a combination of human and organisational factors that contribute to errors.’
When drugs are being administered, the organisation’s local procedure should be followed. This may include, but is not limited to, checking:
» The identity of the patient
» The prescription meets legal requirements, is unambiguous and includes where appropriate, the name, form (or route of administration), strength, and dose of the medicine to be administered
» Issues to do with consent have been considered
» Awareness of allergies or previous adverse drug reactions
» The directions for administration, for example timing and frequency, route of administration and start and finish dates where appropriate
» Any ambiguities or concerns about the direction for administration of the medicine are raised with the prescriber or a pharmacy professional without delay
» Any calculations are double-checked where practicable by a second person and uncertainties raised with the prescriber or a pharmacy professional
» The identity of the medicine and its expiry date
» Adherence to specific storage requirements
» That the dose has not already been administered by someone else, for example the patient or carers
Source: RCN and the Royal Pharmaceutical Society tinyurl.com/RPS-RCN-medicines
Nurses should seek out someone to check their sums, according to the RCN and Royal Pharmaceutical Society guidance on administrating medication (see checklist).
Asking a colleague to double-check calculations is a simple step to reduce errors, adds Mr Griffiths.
‘So often when someone is asked to check something by someone senior or a colleague they know well, they will say it is fine without doing a truly independent check,’ he says. ‘This is a real safety problem. When things need double-checking, it needs to be done properly. So many errors could be picked up if done correctly.’
Ensuring medicines are locked away to prevent theft, tampering or ingestion by confused patients is essential.
Mr Griffiths also calls for good quality intravenous training and supervision, as this is a high-risk area. The NPSA report found that injectable medicines are associated with the greatest number of incidents confirmed as resulting in severe harm or death.
‘This is not surprising, as injectable medicines are often potent medicines, requiring complex dose calculations, methods of preparation and administration, and systems for monitoring treatment,’ the report said.
Other simple steps implemented fairly widely include use of tabards by nurses conducting drugs rounds bearing the instruction ‘Do Not Disturb’, and red arm bands for patients to denote their allergy status.
Nurses’ duty of candour is enshrined in the Code, which states registrants must be ‘open and candid’ when they have made a mistake and must take appropriate action immediately.
Errors should be recorded in the patient’s notes, through incident recording systems and escalated appropriately, says medicines management nurse Matt Griffiths, of the Royal United Hospitals Bath NHS Foundation Trust. The patient, the prescriber and the nurse in charge should all be informed.
This is for the benefit of the patient, but it should also support learning so that the mistake is not repeated. And owning-up at an early stage will count in the nurse’s favour if they subsequently find themselves in a Nursing and Midwifery Council fitness to practise process.
Mr Griffiths urges nursing staff to be open about factors that increase chances of mistakes happening, such as short-staffing or inadequate training. Doing so can provide valuable evidence about the pressures that compromise patient safely.
Highlighting workplace pressures
‘If we are not open as a profession and do not highlight that these incidents are happening, no extra resources to improve the situation will be found,’ he says.
Mark Gagan, senior lecturer in adult nursing at Bournemouth University, adds: ‘We absolutely have to report mistakes. They need to go into the Datix system, they need to be audited and we need to be able to talk about minimise them happening.
‘When I am talking to students, I talk about my own potential mistakes and near-misses. It is important that senior nurses do this. Once you have made an error, even if it does no harm, you never forget it.’
If it is discovered a nurse has tried to cover up mistakes, the NMC will rightly take a firm position, he says. ‘If you are not honest, it is likely to be goodbye to your career.’
It is clear that the scope for medication error is significant, and the impact on the patient, their loved ones and the nurse can be catastrophic.
‘If we are not open as a profession and do not highlight that these incidents happen, no extra resources to improve the situation will be found’
Matt Griffiths, medicines management nurse, Royal United Hospitals Bath NHS Foundation Trust
It is obvious too that prevention is of utmost importance, even if it is not always easy – but if the worst happens, candour is key.
‘When you qualify as a nurse, you are given a huge responsibility when it comes to medication,’ says Mr Gagan. ‘Nurses don’t go into work to cause harm, and the shock when a mistake happens is massive.
‘But to err is human, so early recognition, reporting and total transparency is vital to maintain trust in the nurse and the organisation.’
BMJ Quality & Safety (2021) Economic analysis of the prevalence and clinical and economic burden of medication error in England qualitysafety.bmj.com/content/30/2/96
NHS National Patient Safety Agency (2007) Safety in doses: medication safety incidents in the NHS tinyurl.com/NPSA-4th-medication
NHS Resolution (2022) Learning from medication errors tinyurl.com/NHS-medication-errors
RCN and Royal Pharmaceutical Society Professional (2019) Guidance on the Administration of Medicines in Healthcare Settings tinyurl.com/RPS-RCN-medicines