Reducing medication errors in nursing practice part 6

Shift-work length, patient acuity and workload

Research suggests that the number of hours nurses work, length of shifts, patient acuity and high workloads result in nurse fatigue (Suzuki et al 2005, Ulanimo et al 2007). Nurses who engage frequently in competing activities as a result of high workloads and the acute nature of patients’ conditions are more likely to experience distractions and interruptions, focus poorly on work-related activities and potentially make more errors (Tang et al 2007, Hewitt 2010).

The likelihood of errors has been found to be three times higher when staff work 12.5 or more hours in a shift (Rogers et al 2004), and nurses are two and a half times more likely to suffer burnout and job dissatisfaction when regularly working shifts of ten hours or longer (Stimpfel et al 2012). While employers are bound by statutory requirements and organisational policies to limit shift length and hours of work per week, it remains the responsibility of individual practitioners to practise within these boundaries to remain safe (NMC 2010, Fair Work Ombudsman 2014, Royal College of Nursing 2014).

Compared with day workers working regular hours, those working shifts, especially at night, have a significantly higher risk of accidents and near-miss events. This is the result of lower alertness and a greater tendency to experience drowsiness, both of which affect cognitive function (Barger et al 2009). Staff who sleep during the day can optimise sleep time by avoiding exposure to bright light and stimulants, keeping the room dark and using earplugs. Before starting a night shift, staff can increase their wakefulness by exposing themselves to bright light; they can also make use of short occasional sleep periods when on breaks (Barger et al 2009, Rajaratnam et al 2013).

Access to information and guidelines

A number of international studies have found that nurses prefer to approach colleagues for information to aid decision making rather than to access evidence-based resources from reliable databases (Thompson et al 2001, Estabrooks et al 2003, Pravikoff et al 2005, Kosteniuk et al 2006). Reasons for this include (Thompson et al 2004, Dee and Stanley 2005):

• Convenience and time efficiency.
• Perceived lack of computer skills.
• Low confidence levels when using online records that require search word and phrase selection.

A lack of convenient access to policies and guidelines for medication administration is likely to result in poor information-seeking habits, which may contribute in turn to medication errors (O’Leary and Mhaolrúnaigh 2012). A lack of information, training and preparation with regard to using infusion devices can contribute to errors (Mayo and Duncan 2004, Ulanimo et al 2007, Jones and Treiber 2010).

Environmental factors

Environmental characteristics that can lead to problems during administration of medications include:

• Poor lighting.
• High noise levels.
• Restricted storage space resulting in cluttered work surfaces.
• Poor layout of medication rooms.
• Lack of space for preparing and charting medications.
• Lack of privacy in medication rooms.

Each of these factors can be associated with a higher incidence of fatigue, stress, distraction and interruptions (Mahmood et al 2011, Savvato and Efstratios 2014). Environmental factors, therefore, should be considered when planning strategies to minimise medication errors (Savvato and Efstratios 2014).

Drug calculation and administration

Studies have shown that nurses have poor drug calculation skills, which could account for 10-20% of medication errors (Wright 2004, 2005). In addition, it has been reported for more than four decades that nursing students have difficulty with mathematical tasks such as unit conversions, dosage calculations and fluid monitoring (Bindler and Bayne 1984, Worrell and Hodson 1989, Sandwell and Carson 2005).

Two skills have been identified as necessary for accurate drug calculation (Wright 2007):

• First, basic mathematical and computational aptitude.
• Second, the ability to understand clinical information well enough to formulate correctly a suitable mathematical problem to calculate drug dosage.

According to Vagliardo and Schmittau (2008), it is important for practitioners to have a clear understanding of mathematics to be able to estimate, to correctly interpret graphs, proportions, ratios and tables, and to be resourceful in problem solving. Good mathematical understanding means not being dependent on a calculator.

There appears to be a significant correlation between a positive attitude towards mathematics, self-efficacy (the belief in one’s ability to complete tasks and reach goals) and performance, with feelings of self-efficacy being a stronger predictor of performance than attitude to mathematics (Hackett and Betz 1989, Ma and Kishor 1997, Nicolaidou and Philippou 2003). Mathematical-related anxiety is correlated inversely to self-efficacy for complex mathematical tasks, where drug calculations are perceived as difficult (Walsh 2008). Therefore, nurses may be likely to perform less well on complex drug calculations as a result not only of the complexity of a task but also the level of their perceived self-efficacy in relation to undertaking the calculation. Levels of confidence and self-efficacy in completing basic and complex tasks can improve with mathematical practice (Walsh 2008).

Complete time out activity 5

On a scale of one to ten, rate your mathematical ability. Find a good source (online or paper) of drug calculation practice questions to assess your calculation skills.

Once completed your time out activity is saved and stored in "My Modules”.

Learning points

1. Nurses who engage frequently in competing activities, as a result of high workloads and the acute nature of patients’ conditions, are more likely to experience distractions and interruptions, focus poorly on work-related activities and potentially make more errors.
2. The likelihood of errors has been found to be three times higher when staff work 12.5 or more hours in a shift, and nurses are two and a half times more likely to suffer burnout and job dissatisfaction when regularly working shifts of ten hours or longer. Also the nurses working during the night shifts have a significantly higher risk of accidents and near-miss events.
3. Environment characteristics such as poor lighting, high noise levels, restricted storage space, poor layout of medication rooms, lack of space and privacy can be associated with a higher incidence of fatigue, stress, distraction and interruptions.
4. It is important for practitioners to have a clear understanding of mathematics to be able to estimate, to correctly interpret graphs, proportions, ratios and tables, and to be resourceful in problem solving. Levels of confidence and self-efficacy in completing basic and complex tasks can improve with mathematical practice.