Medication errors Conclusion part 8

Conclusions

• Medication errors result from a combination of factors that often appear trivial or insignificant in isolation, but when compounded may lead to adverse events.
• It is important that institutions reward and encourage leaders who demonstrate characteristics of mindfulness on all levels, to improve nurses’ knowledge of how individual factors contribute to errors and help them develop effective strategies to prevent errors occurring.
• A safe reporting environment that encourages staff engagement to identify contributory factors as well as possible solutions must also be fostered.
• Extensive organisational resources are required to enhance communication, to reduce confusion, to improve knowledge, skill and compliance with policies, guidelines and standards, and to ensure that staff members are less pressurised.
• Nurses and other healthcare providers can contribute individually to patient safety by accessing available resources that will improve their awareness and knowledge of medication errors, encourage them to engage in effective communication with one another and their patients, and foster a safe reporting environment that will enable all staff to learn from safety incidents if and when they occur.

• Acronyms

  NHS: National Health Service
  NPSA: National Patient Safety Agency
  NMC: Nursing and Midwifery Council
  WHO: World Health Organization

• Glossary

  Adverse event: any undesirable medical occurrence in a patient or clinical investigation associated with the use of a pharmaceutical product, but not necessarily causally related.
  Distractions: in this context, a distraction is something which takes a nurse’s attention away from their primary task or activities. For example, noise can be ignored or processed concurrently with the primary task, but may also contribute to medication errors and act as a precursor to an interruption.
  Interruptions: in the context of medication error, an interruption is a halt in the primary activity being performed – medicine administration – to carry out a secondary task, resulting in nurses having to manage a number of tasks simultaneously. Interruptions are one of the main contributing factors to medication errors.
  Medication error: a preventable event related to medication which results in ‘a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient’.
  Mindfulness: paying attention to our present experience in a way that is non-judgmental and kind. A mindful approach involves an awareness of the possibility of failure, respect for all colleagues, an ability to adjust plans in unforeseen circumstances and an ability to accommodate the bigger picture, while maintaining focus on an isolated task.
  Safety culture: where health care systems comprise enlightened leadership, teamwork and a patient-centred approach to care.
  Self-efficacy: the belief in one’s ability to complete tasks and reach goals. There appears to be a significant correlation between a positive attitude towards mathematics, self-efficacy and performance, with feelings of self-efficacy being a stronger predictor of performance than attitude to mathematics.

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