thesis on medication errors

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Article Contents

Introduction, concept and incidence of medication errors, classification of medication errors, other classifications and types of medication errors, causes of medication errors, medication errors and nursing, results of medication errors, reporting medication errors of nurses, strategies for preventing medication errors, conclusion and recommendations, author contributions, conflict of interest.

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Medication errors: a focus on nursing practice

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Nasr Alrabadi, Shaima Shawagfeh, Razan Haddad, Tareq Mukattash, Sawsan Abuhammad, Daher Al-rabadi, Rana Abu Farha, Suzan AlRabadi, Ibrahim Al-Faouri, Medication errors: a focus on nursing practice, Journal of Pharmaceutical Health Services Research , Volume 12, Issue 1, March 2021, Pages 78–86, https://doi.org/10.1093/jphsr/rmaa025

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Health departments endeavor to give care to individuals to remain in healthy conditions. Medications errors (MEs), one of the most types of medical errors, could be venomous in clinical settings. Patients will be harmed physically and psychologically, in addition to adverse economic consequences. Reviewing and understanding the topic of medication error especially by nurses can help in advancing the medical services to patients.

A search using search engines such as PubMed and Google scholar were used in finding articles related to the review topic.

This review highlighted the classifications of MEs, their types, outcomes, reporting process, and the strategies of error avoidance. This summary can bridge and open gates of awareness on how to deal with and prevent error occurrences. It highlights the importance of reporting strategies as mainstay prevention methods for medication errors.

Medication errors are classified based on multifaceted criteria and there is a need to standardize the recommendations and make them a central goal all over the globe for the best practice. Nurses are the frontlines of clinical settings, encouraged to be one integrated body to prevent the occurrence of medication errors. Thus, systemizing the guidelines are required such as education and training, independent double checks, standardized procedures, follow the five rights, documentation, keep lines of communication open, inform patients of drug they receive, follow strict guidelines, improve labeling and package format, focus on the work environment, reduce workload, ways to avoid distraction, fix the faulty system, enhancing job security for nurses, create a cultural blame-free workspace, as well as hospital administration, should support and revise processes of error reporting, and spread the awareness of the importance of reporting.

Health administrations, all over the world, endeavor to give proper care to individuals when they are ill or to remain healthy. Primary care services are increasingly concentrated at the heart of integrated people-centered health care systems in many countries. [ 1 ] They provide a passage point with a useful framework focused on progressing health planning to ensure safety for individuals and their families. Availability and safe application are basics to accomplish all-inclusive wellbeing criteria and to support the United Nations sustainable development goals, that organize solid lives and advance prosperity for all. [ 2 ]

The therapeutic services’ framework is very unpredictable. It includes basic circumstances of hazard, a collaboration between different experts and institutions, and relies upon huge help from innovations. The attributes of the therapeutic framework may increase the danger of slip-ups and compound the results of these mix-ups. [ 1 , 3 ] In this sense, it is vital to evaluate hazards and harm to patients in the scan for extreme patient wellbeing. The World Health Organization’s meaning of patient wellbeing builds up of which pointless damage or potential harm related to therapeutic services ought to be decreased to a worthy least. [ 4 ]

Healthcare providers consider patient safety one of the paramount priorities in clinical settings. One of the major threats to the well being of patients is medical errors. [ 5 ] One of the main branches of medical errors is medication errors which were demonstrated to be the source of morbidity and mortality in addition to the resulted adverse economic consequences. [ 6–8 ] Patient safety is esteemed as a critical issue for our social insurance framework and human services providers, [ 9 ] and in such manner, medication errors are utilized as a list to survey quiet wellbeing in clinics. In the next sections, we will go through the concept, classification, types, causes, consequences, reporting, and those strategic plans to prevent the occurrence of medication errors.

A medication error is characterized by ignoring the condition of shaping harm, hazard, or any evadable frequency to happen amid the procedure from medicine ordering to patient consumption. [ 10 , 11 ] It might be characterized by National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) as any preventable occasion that may cause, or prompt improper medicine use or patient harm while the medicine is in the control of the healthcare worker, patient, or buyer. [ 12 , 13 ] The measurement of medication errors may vary widely in clinical settings due to the different ways of recognizing and defining the status of medication errors, how to calculate error rates, variation in numerator/dominator, and the process, documentation, and culture of settings technologies. [ 14–16 ]

Medication errors are a global issue where 5.0% is deadly, and almost 50.0% of those are preventable. [ 17 ] The in-hospital incidence for adverse drug events was reported to be high which ranged from 2 to 6 events per 100 admissions. [ 18 , 19 ] Moreover, around 7000–9000 patients’ deaths in the USA each year can be attributed to medication errors. [ 11 , 20 ] However, the rate of patient serious injuries as a result of medication errors among different studies varies, 1–2%, [ 21 ] 9–13%, [ 22 ] 29.0% [ 23 ] and 51.8% [ 24 ] and almost 30.5% death rate per year in the United States because of medication errors. [ 25 ] As indicated by the Institute of Medicine (IOM) of the National Academies in 2006, 400 000 instances of avoidable patient damage because of medication errors happen every year in emergency clinics in the USA. It is noticed that 19% of medication errors in the Intensive Care Units (ICUs) are life-threatening and 42% are considered to be paramount for further maintaining treatment. [ 26 , 27 ] Somewhere in the range of 44 000 and 98 000 emergency clinic patients have been evaluated to kick the bucket every year because of drug errors. [ 28 ] For instance, in the USA hospitals in 1995, the annual spending on medication errors for each hospital was around 2.9 million dollars and a 17% reduction in the error incidence led to 480 000 dollars saving per hospital as in the case of transcription errors. [ 29 ] For example; a patient in an Iranian hospital had given 80 units of insulin instead of eight units which led to the patient’s death, therefore, the government gave 140 million dollars to the patient’s family. [ 14 , 30 ] Add up, the overall cost of adverse outcomes that are associated with medication errors could surpass 40$ billion each year. [ 11 ] Bates et al . stated that medication errors increase the costs for each patient by 2000–2500$ and extend their hospitalization period by at least two days. [ 18 ] The total cost of these errors, including expenses of error, disability, and lost income and productivity, is expected to be between $17 billion and $29 billion per year. [ 31 , 32 ]

Grouping of medication errors occurrence into contextual, modular, or mental (psychological) is considered an ideal protocol to assess how errors happen. Contextual order assesses the specific time, place, medications, and individuals who are included. Modular characterization analyses the manners in how errors occur (i.e, by omission, repetition, or substitution). Mental order is preferred, as it clarifies occasions as opposed to just prescribing them. Its burden is that it focuses on humans as opposed to frameworks wellsprings of errors. The accompanying mental grouping depends on crafted by Reason on errors and there are four distinct types of medication errors. [ 33 , 34 ]

The first type is ‘Knowledge-based errors’ (Learning absence). As it may seem, administering penicillin to the patient without any concise information whether the patient is unfavorably susceptible. Knowledge-based errors that are connected to any kind of knowledge which could be related to expert, specific, or general. As a general knowledge, health care providers should understand that allergic reactions, for instance, could be associated with penicillins, however, realizing that the patient is allergic to penicillin can be considered specific knowledge. On the other hand, experts are those who may know that co-fluampicil has penicillin. As a result, Knowledge-based errors might be provoked when ignoring any of that information. In an Australian examination, correspondence issues with trouble in getting to suitable medication dosing data added to knowledge-based errors. [ 35–39 ] When being educated about medication is being given dispensed to patients could reduce the incidence of medication errors. [ 40 ] Errors can be blocked from occurrence through computerized prescribing entry orders, bar-coded medicine frameworks, and cross-checking by others (for instance, medicine specialists and nurses). [ 41 , 42 ] A study showed that before implantation of electronic Bar-Coded Medication Administration (BCMA-e MAR), wrong time (33.9%), omission (27.7%), wrong technique (18.0%), wrong dose (13.3%), and unauthorized drug (2.9%) were happening frequently. However, after the implementation of BCMA- e MAR, errors have been declined. [ 43 ] In another study, error rates were reduced more than a half after applying BCMA- e MAR. [ 44 ]

The second type is ‘Rule-based errors’ (utilizing a terrible standard or twisting a decent principle). For instance, infusing diclofenac into the sidelong (lateral) thigh instead of being injected into the butt cheek. Appropriate standards and instruction help to keep away from these kinds of errors, as do computerized prescribing frameworks. [ 38 , 39 , 45–47 ]

The third type is ‘Activity-based errors’ (known as slips). For example, when confusion happens between two drugs like diazepam and diltiazem from a medicine store rack. [ 38 , 46 , 47 ] In the Australian examination, most errors were because of slips in consideration that happened amid routine prescribing, dispensing, and administering organization. Slips errors could be minimized through keeping away from distraction, by cross-checking, by naming prescriptions plainly, and by utilizing identifiers, for example, standardized identifications or barcoded); alleged ‘Tall Man’ lettering (when blending lower- and upper-case letters in the same word) which showed to be a good protocol in the prevention of misreading of names, yet tall-man lettering has not been assessed in genuine conditions. [ 48 ] A branch of specialized technical errors of activity-based errors, for instance, as seen in measuring the incorrect amount of potassium chloride into an infusion bottle. Using agendas, safeguard frameworks, and computerized updates could prevent this type of error from occurring. [ 49 , 50 ]

The fourth type is ‘Memory-based errors’ (so-called lapses). For instance, giving penicillin to a patient, with a known history of allergy, but forgetting that the patient is allergic. These are difficult to keep away from; however, computerized prescribing frameworks and cross-checking can reduce the error incidence. [ 50 , 51 ]

Errors might provoke in any stage. [ 52–54 ] Prescribing errors (during drug prescription), transcription errors (wrong/incomplete transfer information from a prescription), dispensing errors (disagreement between medicine dispensed and prescription), administration errors (during drug administration), discharge summaries errors (due to discrepancy between discharged summaries and medical records), and monitoring errors (while taking the medicine of renal and liver). [ 30 ] Karthikeyan et al . reviewed the occurrence of errors among healthcare providers. [ 55 ] (a) Prescribing errors; were presented as follow; drug-drug interaction (68.2%), incomplete prescription (25.0%), monitoring (12.6%), incorrect drug (13.0%), underdose (12.6%), incorrect interval (12.0%), and overdose (7.0%). (b) Nursing errors; as in wrong rate (34.0%), wrong time administration (28.6%), wrong dose (25.3%), medication omitted (24.0%), wrong fluid (22.4%), wrong drug (21.1%), wrong route (19.9%), and wrong patient (19.7%). (c) Pharmacist errors; as in wrong medication (25.0%), excessive dose (23.0%), poor labeling (23%), wrong dosage errors (21.8%), wrong strength (10.8%), wrong quantity (6.9%), and wrong direction dispensing (2.3%). [ 55 ] Prescription and administration types of medication errors are considered common and can contribute up to 65.0%–87.0% of medication errors. [ 56 ] According to the National Patient Safety Agency (2009) in the United Kingdom, it was observed the most prominent kinds of medication errors were 16.0% in prescribing, 18.0% in dispensing, and 50.0% in the drug administration. [ 57 ] Furthermore, medication errors accounted to be 37.6% of administration errors, 21.1% of prescription errors, and 10.0% of transcription errors in Iran. [ 58 ] On the other hand, previous studies showed that in prescription errors mainly occurred at outpatient ward accounted as (39.0–44.0%) and in emergency wards were (60.0–73.5%), however, transcription errors were accounted 16.9% and 13.8% for inpatient and discharged patients, respectively, while discharge summaries errors accounted 16.0–36.0% of (omission, drug name, administration route, drug dose, and drug regimen). [ 59 , 60 ] There were 192 477 medication errors reported by staff from 482 hospitals through voluntary reporting that could occur at any stage. Errors during administration were accounted to be (33.0%), documentation (23.0%), dispensing (22.0%), prescribing (21.0%), and monitoring (1.0%). Also, errors were related to omission (25.0%), dosage (30.0%), unauthorized drugs, and the wrong time, patient, and administration technique. [ 61 ]

Moreover, 0.078 errors per patient, and 0.029 errors per medication mainly because of dosing errors, drug omission, and wrong frequency errors. [ 62 ] A previous study showed that (94.0%) out of 430 errors were omissions and only 6.0% of errors caused a major impact on patients’ life but was not considered as a life–alarming errors. [ 63 ] Medication errors are also related to the problem of wrong phenomena. These incorporate errors of course of medication, doses, timing, patient, and inability to follow up the patient. [ 53 , 64 ]

Prescription errors are a standout amongst the most widely recognized therapeutic errors and their occurrence rate in adult ward accounted to be 5.6 cases per 1000 patients and 14.8 cases per 1000 patients in the pediatrics ward. [ 65 ] As seen, a sample of 57 nurses in pediatric settings, medication errors were 67.0% compared to 56.0% of a sample of 227 nurses working with adults. [ 64 , 65 ] The occurrence of prescription errors in pediatrics is three-times higher than adults. An examination in Canada showed that the number of children who admitted to the emergency clinic accounted to be 5000 because of medication errors and of these, 2500 experienced moderate to serious side effects. [ 66 ] Prescription errors can happen because of human errors just as from fundamental errors and thus is needed for a cautiously monitoring through medication organization. [ 10 ] It is suggested that at whatever point when medication error has occurred it should be reported to the significant manager, and such notice is essential for understanding the reasons for the errors and to enable strides to be taken to lessen such errors later on. [ 67 ] The most frequent types of prescribing errors might be related to the inability to manage the medication and mistaken medication writing. [ 68 ] On the other hand, certain variables add to the high rates of prescription errors in pediatric patients. These incorporate inability to peruse the remedy, distraction, high patient/nurture proportion, and hard to get the accessibility of the right medications as endorsed. [ 65 ] Few investigations have tended to show the rates and reasons for medication errors in grown-up patients, and these examinations have regularly been founded on reports from nursing staff. [ 69 , 70 ] Moreover, few investigations have inspected medication errors from the viewpoint of pediatric nurses. [ 65 ]

The error might be identified with expert practice, which is related to human services items, to systems, or to correspondence issues including prescribing, ordering, item naming, labeling/packaging, preparation, compounding, dispensing, administration, education, and the best possible utilization of medicines. [ 2 , 11 , 71 ]

Patients are sometimes being harmed by incidents despite the safe and effective health services that are provided to them. Medication errors have been considered a global issue and it is essential to focus on the causes, results, and solutions. [ 11 , 72 ] The proportion of medication errors among nurses varies in different studies, it was 57.4% in Ethiopia, [ 16 ] 42.1% in Jordan, [ 15 ] 41.9% in Australia, [ 73 ] and 28.9% in the USA. [ 38 ] Thus, differences in rate are due to differences in organizational reporting systems, and the time frame of studies that have been conducted. Medication errors incorporate not just undesirable impacts from prescriptions, yet additionally incorporate ordering, transcription, dispensing, administration and organization mistakes. [ 11 , 74 ] Medication errors are more barely characterized than unfavorable medication occasions and incorporate mistakes of commission and omission. Errors of commission happen while abusing one of the five privileges of organization: right medication, patient, portion, course, time, and documentation. An error of omission is a mistake that consists of not doing something you should have done, or not including something such as an amount of fact that should be included, or when the patient does not get a drug that was arranged. [ 75 ] In a survey conducted on 1384 nurses in 24 ICUs in the United States hospitals regarding nurses’ perception of medication errors, [ 76 ] the main causes contributing to medication errors are illegible handwriting, mental and physical health, interruption and distraction from patient and co-workers, lack of pharmacological knowledge with problems in calculations, performance deficit, sometimes lab tests are not considered, overtime of working hours, absence of self-awareness, organizational factors (training) and failure to follow protocols. [ 15 , 46 , 53 , 77–88 ] Furthermore, it could be related to execution deficit (36.7%) and impairment of strategies realization, but knowledge, communication, drug distribution, and entry system were accounted for lesser percentages. [ 78 , 89 ] However, interruptions play a big impact on causing medication errors especially during administration. [ 46 ] As it may seem, 1354 errors occurred in 136 hours, which means 10 interruptions per hour. [ 90 ] Besides, registered nurses were interrupted (36.0–57.0%), which accounted from the patients (28.0%), other nurses (25.0%), assistive personnel (10.0%), and physician (9.0%), that led to 7.0% of medication errors from interruptions. [ 65 , 79 ] Moreover, around 20% of hospital registered nurses experienced frequent medication errors because of factors as overload, extra hours, unsatisfactory staffing with low support, and shift length. [ 91 ]

Lack of knowledge and miscalculation of doses are the factors contributing to medication errors. [ 36 , 37 , 39 ] It is noticed that competence skills in drug calculation are prerequisites to nursing registration and examining their learning abilities rather than follow strict protocol which imped nurses thinking skills. [ 11 , 92 ] Moreover, focusing on continuing education with clinical and theoretical support will help in the prevention of medication error occurrence. [ 15 , 93–95 ]

Medication errors are normally characterized as deviations from a doctor’s structure. Sources of errors could be from ordering, prescribing, transcription, dispensing, and administration errors (i.e. when the patient is administered a wrong medicine). Healthcare providers as doctors, medical specialists, pharmacists, unit assistants, and nurses could be related to the incidence of medication errors. [ 96 ] A patient can get up to 18 portions of prescription for each day, and a healthcare provider can regulate upwards of 50 medications for each move. [ 50 , 97 ] This places the healthcare provider at the forefront of administration accountability. [ 98 ]

Nurses are considered critical agents among the medical staff of clinics. One of the real undertakings of nurses is administering medicines to patients. They should be mindful of recognition significance of organized prescription to dodge potential dangers and conceivable complexities coming about because of medicine errors. [ 99 ]

Medication errors in clinics, for the most part, include 3.0–6.9% of hospitalized patients. [ 100 ] Customarily, to maintain a strategic distance from medicine errors, nurses utilized five privileges of the prescription organization; the correct patient, the correct medicine, the correct portion, the correct course, and the ideal time. Following this rule before giving any prescription, can help nurses keep away from the vast majority of medication errors. [ 30 , 52 ]

Most medicine executives are nurses and, in this manner, when errors happen, nurses are frequently considered responsible. [ 101 ] Medicine supervisors can give defend against errors made at any of the past stages, notwithstanding, and are thought to block around 86.0% of errors made by prescribers or medicine specialists. [ 102 , 103 ] Along these lines, nurses give a security guard against medication errors at the same time, can put patients in danger. [ 104 ]

Nurses have a central role in their activities to advance safety and anticipate damage to patients. [ 103 , 105 ] While this of great practice, nurses ought to assess how they work in groups to guarantee that the aggregate frameworks and procedures of training are sheltered and to help and instruct unpracticed partners. [ 46 ]

Even though that the way toward conveying medication to patients requires a joint effort between medical experts, registered nurses, and pharmacists, it is the essential obligation of healthcare providers to protect prescription administration. As indicated by Anderson and Webster administering prescription is the most noteworthy hazard undertaking a nurse can perform and can prompt destroying ramifications for the patient and the nurses’ vocation. [ 106 ] Besides, the mental injury brought about by submitting a medication error can be overpowering to the nurses, they may feel agitated, blameworthy, and panicked. [ 46 ] Therefore, medication errors might not only intend harm to patients, they additionally deface the notoriety of all medical experts in whom patients place their trust. [ 107 , 108 ]

On the off chance that nurses don’t have the fundamental capability on providing important data and capacity for the protection of human wellbeing and life, thus therapeutic errors wind up unavoidable. Notwithstanding these, reasons, for example, numerical deficiency of nurses in the workplace, persistent conditions, restlessness, tiredness, absence of consideration, unsure employment definition, insecure working hours, improper physical conditions, having an extraordinary number of patients, could trigger medication errors. [ 38 , 46 , 53 ]

Execution of medical requests is a critical piece of recovery procedure and patient consideration. Nursing execution is considered a prominent role that impacts patients’ safety. [ 109 ] Certain consequences as an impact on patient safety and treatment expenses will have resulted from medication errorss. [ 110 ] Administration of drugs is likely a standout amongst the most basic missions of nurses since the subsequent errors may have unintended, genuine complication for the patient. [ 111 ] Medication errors can prompt unfriendly results, for example, increased mortality, increased length of hospital stay, and expanded restorative expenses. [ 112 ] Although medication errors can be brought about by all individuals from healthcare providers. Most medical and therapeutic executions are done with the nurses, therefore, nursing medication errors are the most common. Besides, nurses execute most of the therapeutic requests and invest about 40.0% of their energy in the emergency clinic to manage medicines. [ 113 ] In developing and developed countries, the nursing medication error rate is observed to be high. [ 114 ]

Medical nurses are a fundamental piece of the human services group and are in charge of the wellbeing of patients yet sadly, the expansion in complaining from medical nurses and doctors in the previous years is proof of expanded frequency of errors. [ 53 ] On the other hand, no examinations have exhibited solid connections between nurse’s qualities (i.e. age, long stretches of training, and education) and the number of medication errors. [ 115 ] This would appear to show that nurses are conceivably in danger of making a medication error.

It is critical to identify medication error, regardless of whether vital or not, because of identification the error will uncover a disappointment in the treatment procedure which causes another event of hurt. There is additional proof that the demise rate from medication errors is expanding. These increments are not amazing as of late emergency clinics have seen an expanded rate of patients, new medications have developed that are progressively hard to utilize securely and viably, factors that will in general lead to increment the danger of medicine error. [ 116 , 117 ]

At the point when errors are distinguished, they can cause many disappointments because of the inability of how to deal with the resulting error, and they might cause potential harm to patients with disabilities. The backhanded results incorporate harm to the medical nurses as far as an expert and individual circumstances, decreased self-assurance, expanded pressure and clashes at work, lack of quality of the patient’s family to nurse. [ 118 , 119 ] Hence, the need to bring issues to interpret and manipulate the nature and reasons of errors is fundamental and can help nursing chiefs to recognize plans for improving the nature of medication administration, expanding the patient wellbeing, and lessening the extra cost. [ 120 ]

Handling medication is a high-recurrence movement in nursing; the potential for error increments when the normal number of prescriptions builds. Besides, prescription administration is an intricate procedure that is frequently performed under not exactly perfect conditions. Thus, the continuous flow of multifaceted prescriptions could prompt the occurrence of the hazard. [ 11 , 74 ] There is likewise a propensity to accuse people instead of the faulty system. Be that as it may, most medication errors emerge from the requests of doctors, trailed by medical organizations. [ 11 , 121 ]

A previous study about the report referring to the United Kingdom (UK) restorative safeguard associations, showed that 25.0% of all cases were because of prescription errors that included the following accompanying errors: [ 122 ] prescribing and administration errors (miscalculation, contraindicated or unlicensed medication, a wrong dose, or wrong patient), repeat dispensing without legitimate checks, failure to monitor the case, and failure to caution about antagonistic impacts (which may be that as it may, not be viewed as a medicine error).

Reporting the medication errors is critical in improving the medication management process, therefore, it is considered a legal and ethical commitment in each health care settings. Reporting medication errors could provide an effective resource of important information, therefore underreporting errors is observed as a crucial threat. [ 81 , 123 , 124 ] Regardless of whether the nurse is the wellspring of a mistake, a benefactor, or a spectator, associations depend on medical nurses as bleeding-edge staff to perceive and report medication errors. [ 15 ] A previous examination has exhibited underreporting among nurses. Adding to the weight of announcing, over 90.0% are oneself reports. [ 125 ] Moreover, in Israel, 26.0% of medication errors were reported, and 46% were self-reported. [ 126 ] In Taiwan, almost 6000 to 20000 deaths from medication errors, and 10.0% of medical lawsuits were mainly of underreporting. [ 127 ] In Turkey, 66.7% of involved nurses who caused medication errors did not report it. [ 128 ]

Medication administration is a high-risk area of nursing practice. Thus, reporting a medication error is an important step based on awareness and willingness to report it. [ 127 , 129 ] This barrier might be provoked, yet focus on the person rather than a system with fear from adverse outcomes lead to underreporting data. [ 11 , 38 , 52 , 61 , 65 , 77 , 130 ]

Precise detailing of medication errors could result in the avoidance of medication errors. Revealing prescription mistakes is reliant on the nurse’s decision making. Underreporting or not announcing medicine mistakes covers defective frameworks. [ 124 ] Besides, developing structured protocols on drug administration with an un-punitive approach could encourage reporting and improve patient safety. [ 131 ]

At present, self-revealed medication errors give negligible data to associations since disparities, as far as answered to-actual rates, are across the board. Medication errors are normally reported through institutional reporting frameworks, for example, incident reports to give information about the medication errors. [ 132 ]

Reports are created by the medical nurse who distinguishes the error and afterward is sent to the executives, quality divisions, or board offices of hazard. Detailing and reporting the issue is subject to the medical nurse in many ways: [ 117 ] capacity to perceive a mistake has happened, the conviction that the mistake warrants reporting, the conviction that she/he has submitted the error, and eagerness to beat the humiliation and dread of striking back for having submitted a medication error.

Nurses specifically are imperative in evaluating such errors since they are, for the most part, in a situation to see medication errors directly and find a way to lessen the danger of medication errors. [ 133 ] Their uncommon position is regularly fortified by their continuous learning concerning the medications in addition to their strategies regarding planning and controlling the medicines and for checking the impacts of the treatment. [ 11 ] All nurses must get comfortable with different methodologies to forestall or diminish the probability of medication errors. Here are certain techniques to follow:

1. Guarantee the five privileges of the prescription organization

Nurses must guarantee that institutional approaches identified with prescription interpretation are pursued. It isn’t adequate to translate the medicine as prescribed, however, to guarantee the right medicine is recommended for the right patient, right time, the right measurements, through the right course, and planned effectively (otherwise called the five rights). [ 88 , 134 ]

2. Pursue legitimate medication reconciliation techniques

Foundations must have instruments set up for medicine reconciliation while exchanging a patient starting with one establishment then onto the next or starting with one unit then onto the next in a similar organization. Audit and check every prescription for the right patient, right medicine, right measurements, right course, and right time against the exchange (transfer) requests, or medications recorded on the exchange archives. Nurses must contrast this with the Medication Administration Record (MAR). Frequently not all components of a medicine record are accessible for simple confirmation, yet it is of central significance to check with each conceivable source including the releasing or exchanging establishment/unit, the patient or patient’s family, and doctor, to forestall potential mistakes identified with inappropriate reconciliation. [ 135 ]

3. Have the doctor (or other nurses) read it back

This is a procedure whereby a nurse peruses back a request to the recommending doctor to guarantee the arranged medicine is deciphered accurately. This procedure can likewise be completed starting with one medical nurse then onto the next whereby a medical nurse peruses back a request deciphered to the doctor’s structure to another medical nurse as the MAR is checked on to guarantee precision. [ 136 ]

4. Document everything

This incorporates legitimate medicine naming, clear documentation, or appropriate recording of administered medicine. An absence of appropriate documentation for any prescription can result in an error. For instance, a nurse neglecting to report an as required prescription can result in another administration being directed by another healthcare provider since no documentation signifying past administration exists. Perusing the medicine name/label and expiration date of the medicine is additionally another best practice. A right prescription can have a wrong mark or the other way around, and this can likewise prompt a medicine error. [ 11 , 137 ]

5. Guarantee appropriate storage of medications for legitimate adequacy

Health care providers should avoid the medication storage with close or identical names or package on them at the same medication stock rack. Alphabetized drug storage could lead to unintentional confusion. Besides, it is essential to separate ‘high alert’ medications from other medications to avoid ambiguity. Medications that ought to be refrigerated must be kept refrigerated to look after adequacy, and medications that ought to be kept at room temperature ought to be put away in like manner. Most biologicals items require refrigeration, and if a multi-dose vial is utilized, it must be named to guarantee it isn’t utilized past its lapse/expiration date from the date it was opened. Thus, it is recommended to keep it organized and control access to it. [ 138 , 139 ]

6. Consider having a drug guide accessible consistently

Regardless of whether it’s print or electronic is a matter of personal (or institutional) inclination, however, both are similarly significant in giving imperative data on most classifications of prescription, including trade/generic names, therapeutic class, dosing, nursing consideration, side effect, drug-drug interaction and medication cautionary, for example, ‘don’t crush, or give with the meal’. [ 140 ]

7. Know institution policies, regulations, and guidelines

Nurses should be familiar with the policies and guidelines and how to apply them. Since these regulations and policies could provide necessary information regarding drug ordering, transcription, administration, and documentation. Besides, it could provide information for the nurses about black box warnings, look alike, sound alike, and warning labels. [ 138 , 141 ]

As penultimate, medication errors are multifaceted criteria. It is motivated to standardize the recommendation and make it a central goal all over the globe for the best practice. Thus, it is suggested to; (a) get a deeper meaning of the medication errors concept, (b) focus on broader causes outside of the taken picture, (c) converge on clinical settings variations and patient illness severity, (d) include questions related to nurse’s psychology, (c) create a group of expert to publish new guidelines internationally adapted to any changes according to hospital needs. Nurses are the heart of clinical settings, encouraged to be one integrated body to prevent the occurrence of medication errors. Thus, systemizing the guidelines are required such as education and training, independent double checks, standardized procedures, follow the five rights, documentation, keep lines of communication open, inform patients of drug they receive, follow strict guidelines, improve labeling and package format, focus on the work environment, reduce workload, ways to avoid distraction, fix the faulty system, enhancing job security for nurses, create a cultural blame-free workspace, as well as hospital administration, should support and revise processes of error reporting, and spread the awareness of the importance of reporting.

Initiating the idea of the manuscript: Nasr Alrabadi and Razan Haddad. Writing the first draft: Shaima Shawagfah, Nasr Alrabadi, Suzan AlRabadi, Razan Haddad, Daher Al-rabadi, and Tareq Mukattash. Reviewing and approving the final draft: Nasr Alrabadi, Sawsan Abuhammad, Rana Abu Farha, and Ibrahim Al-Faouri.

Not applicable.

The authors declared no conflict of interest.

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• Open access
• Published: 24 April 2024

The effect of electronic medical records on medication errors, workload, and medical information availability among qualified nurses in Israel– a cross sectional study

• Raneen Naamneh 1 &
• Moran Bodas   ORCID: orcid.org/0000-0002-6182-6362 1  

BMC Nursing volume  23 , Article number:  270 ( 2024 ) Cite this article

Metrics details

Errors in medication administration by qualified nursing staff in hospitals are a significant risk factor for patient safety. In recent decades, electronic medical records (EMR) systems have been implemented in hospitals, and it has been claimed that they contribute to reducing such errors. However, systematic research on the subject in Israel is scarce. This study examines the position of the qualified nursing staff regarding the impact of electronic medical records systems on factors related to patient safety, including errors in medication administration, workload, and availability of medical information.

This cross-sectional study examines three main variables: Medication errors, workload, and medical information availability, comparing two periods– before and after EMR implementation based on self-reports. A final sample of 591 Israeli nurses was recruited using online private social media groups to complete an online structured questionnaire. The questionnaires included items assessing workload (using the Expanding Nursing Stress Scale), medical information availability (the Carrington-Gephart Unintended Consequences of Electronic Health Record Questionnaire), and medical errors (the Medical Error Checklists). Items were assessed twice, once for the period before the introduction of electronic records and once after. In addition, participants answered open-ended questions that were qualitatively analyzed.

Nurses perceive the EMR as reducing the extent of errors in drug administration (mean difference = -0.92 ± 0.90SD, p  < 0.001), as well as the workload (mean difference = -0.83 ± 1.03SD, p  < 0.001) by ∼  30% on average, each. Concurrently, the systems are perceived to require a longer documentation time at the expense of patients’ treatment time, and they may impair the availability of medical information by about 10% on average.

The results point to nurses’ perceived importance of EMR systems in reducing medication errors and relieving the workload. Despite the overall positive attitudes toward EMR systems, nurses also report that they reduce information availability compared to the previous pen-and-paper approach. A need arises to improve the systems in terms of planning and adaptation to the field and provide appropriate technical and educational support to nurses using them.

Peer Review reports

Introduction

Clinical/medical error is defined as a preventable adverse effect of medical care, whether it is harmful to the patient or not [ 1 ]. One of the most common types of medical error is medication error [ 2 ]. These errors seriously threaten individual safety and public health in general and are a challenge for the professionals involved. Such errors are responsible for 7000–9000 deaths per year in the United States of America alone, and the cost of medication errors is estimated at over 40 billion dollars per year, which causes a significant burden on the health system and society [ 3 ]. Many people suffer physical and psychological pain due to medication administration errors [ 2 , 3 ].

In Israel, qualified nurses administer prescription medications to patients staying in hospitals. Many measures are taken to ensure the safety of the process of medication administration in hospitals. According to the medication administration procedure in Israel, published in 2016 by the Ministry of Health [ 4 ], every instruction on medication administration should include the date, time, full name of the medication, medication form, dosage, frequency of administration, route of administration, duration of administration, and special instructions if applicable. In addition, administering medication requires the nursing staff to implement a series of actions before administering the treatment itself: address the patient’s sensitivities, compare the details of the instruction with the details of the patient and the medication, pay attention to the patient’s new medication and document the administration of the medication in the patient’s record, specifying the date and time of administration [ 4 ].

Unfortunately, despite all the efforts and steps taken by healthcare providers, clinical errors, including medication errors, do happen. Error rates in medication administration are still high, with consequences of significant disability for the victims [ 2 , 5 ]. Moreover, as a result of these errors, medical staff may experience harm to their self-confidence and work less efficiently, which may lead to more mistakes and further impair patient safety [ 2 , 3 ].

One way proposed in recent decades to prevent or reduce medication errors is the implementation of Electronic Medical Records (EMR) systems in medical centers [ 6 ]. EMR systems include a wide variety of technologies designed to assist medical processes and medical decision-making. EMR is a type of information technology through which doctors and nurses in hospitals can organize large amounts of information about the patient and optimize the use of information in their clinical work [ 6 ].

In general, findings in the literature indicate significant advantages of using EMR in improving the quality of patient care. Among the benefits found are improving patient safety, reducing the frequency of errors, saving time, preventing complications, improving communication between caregivers, and improving connectivity to other systems in the hospital, such as the pharmacy, laboratories, imaging centers, and others [ 7 , 8 , 9 ]. Many studies have found that computerized medical information systems may reduce errors in drug treatment through correct identification of the patient, increasing the availability of relevant medical information to prevent errors, such as drug interactions, as well as increasing access to current information about the patient’s history of the drug treatment and drug sensitivity [ 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 ].

However, the findings surrounding the effect of EMR on medical error reduction are still inconclusive with some studies reporting mixed results. For example, in a study conducted at the American University of Beirut Medical Center looking into 2,883 prescriptions, of which 1,475 (51.2%) were from the period before the implementation of electronic prescriptions (paper prescriptions) and 1,408 (48.8%) from the period after the implementation of electronic prescriptions, it was found that electronic prescriptions were associated with a significant reduction in errors in medication dosage and frequency of medication administration. However, they were associated with an increase in duplication errors [ 19 ]. Other studies report similar findings [ 25 , 26 ]. After looking into a decade of data between 2099 and 2018, Classen et al. concluded that (p. 1) “despite broad adoption and optimization of Electronic Health Record (EHR) systems in hospitals, wide variation in the safety performance of operational EHR systems remains across a large sample of hospitals and EHR vendors, and serious safety vulnerabilities persist in these operational EHRs.” [ 27 ].

Due to the complexity of the management of drug treatment by the nursing staff and the multitude of practices and procedures related to it, studies were carried out examining the subject of the satisfaction of nursing staff with the electronic prescription system. The findings were, again, mixed and inconclusive. Some studies reported an increase in staff satisfaction following gthe introduction of EMRs [ 28 , 29 ], while others reported dissatisfaction stemming from increased workload and burnout [ 30 , 31 ] and difficulty in retrieving and accessing information [ 32 ]. Consequently, some studies report that EMR systems may slow down and consume valuable time away from treating patients [ 33 ].

As evident from the literature, findings are inconclusive, and there is still a need to examine the effectiveness of EMR systems in reducing medication errors, as well as their contribution to patients’ safety and staff functionality. This current study aimed to assess nurses’ perception of EMR systems’ contribution to mitigating medical error, workload, and information availability. The working hypotheses were that nurses perceive the introduction of EMR systems as beneficial to reducing medical errors and workload and increasing information availability, compared with the previous pen & paper system.

STROBE statement

This study adheres to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines.

Study design

This cross-sectional study was performed between February and May 2022. It focused on a large group of qualified nurses in Israel and compared two periods: before and after implementing EMR systems in hospitals. The participants were asked to answer an online survey evaluating the research variables one time by recollecting the period when analog information collection infrastructures were used (pen-and-paper and printed sheets) and another time by addressing the situation during the current period when computerized medical information systems are being used. Differences between the two periods were analyzed for statistical significance. Of note is that most hospitals in Israel transitioned into electronic medical records by the late 2000s, with the last hospital transitioning in the late 2010s. The introduction of the EMR systems expanded the amount of data collected by the medical staff. For example, tracking of previous hospitalizations and reasons for non-administration of certain drugs are currently being collected in the EMR systems but were not recorded or less recorded in the older pen-and-paper system.

Population & sampling

The target population for this study was registered nurses in Israel. According to the Israeli Ministry of Health, there are 70,052 registered nurses as of 2020, of which approximately 60,000 have been working before the introduction of EMR Systems [ 34 ]. The inclusion criteria for this study were being a registered nurse, an adult (over age 18), Hebrew speaking, and having a recollection of the period in which pen-and-paper records were used. Exclusion criteria were not being a registered nurse, minor, non-Hebrew speaking, and having not worked as a registered nurse during the pen-and-paper period or having no recollection of it.

In the current study, we used non-probability sampling to recruit a relatively large number of participants quickly and affordably. We used social media to recruit the participants, as studies have demonstrated the usefulness of obtaining data through social networks [ 35 ]. In addition, the snowball method was used to distribute the questionnaire between colleagues. For the needs of the current research, which requires quick access to a unique (professional) population in a wide geographic distribution, the “snowball” approach was deemed the most practical. In addition, data collection also focused on Hillel-Yafe Medical Center, which experienced a cyber attack in October 2021, causing the entire hospital to resort back to pen-and-paper data management. This created an opportunity to collect data from a more recent occurrence of pen-and-paper utilization in a medical establishment. Emphasis was placed on creating a heterogeneous sample that would represent most of the population by distributing the questionnaire to different groups and cultures, Jews and Arabs.

The minimum sample size was calculated using the WinPepi calculator [ 36 ]. According to Aziz et al. [ 16 ], the incidence of medication errors reported by EMR system users is 0.5%, compared with 2.5% reported by those using analog (pen and paper) systems. Assuming 95% confidence and 99% power, the minimum sample size required is 100. The final sample in this study included nearly six times more participants ( N  = 591). According to WinPepi’s power calculator for paired samples, given the mean difference reported in this study, the current study has a power of 100%.

This study utilized a tool comprising both closed and open-ended questions. The former will be described in the following sub-sections. The latter, representing the qualitative part of this study, was used to understand better nurses’ stances toward EMR systems. This section was constructed of three free text questions: (1) What is your opinion regarding using EMR in your department? (2) In what way does the use of EMR benefit you, if at all? (3) In what way does the use of EMR bother you, if at all? The answers to these questions were analyzed using qualitative methods, according to Shkedi [ 37 ]. This approach to qualitative analysis provides a guide to open-text categorization and theme extraction that closely fits with Israeli (Hebrew-speaking audiences.

Participants were first asked to state whether they had the opportunity to experience administering medication while working with pen & paper prescriptions and documents. The lack of such experience was a criterion for exclusion from the study.

Socio-demographics were assessed using a questionnaire that included the following variables: gender (nominal; male, female, other), age (continuous; calculated using the year of birth), type of nursing staff (nominal; qualified nurse, department manager, deputy manager), seniority (continuous; in years), number of computer systems used in the department (continuous), and type of education (nominal; bachelor’s or master’s degree or higher).

Workload was assessed using a shortened version of the Expanding Nursing Stress Scale (ENSS) by French et al. [ 38 ]. The original questionnaire examines various stressors in nurses’ work and consists of 57 items. One factor in the questionnaire deals with workload. It consists of nine items, and its reliability was α = 0.86. Two of the questionnaire items were not relevant to the topic of the current study and were removed. Therefore, the final shortened version includes seven items on a Likert scale ranging from 1 (“disagree at all” / “very low”) to 6 (“agree to a large extent” / “very high”). An example of an item from the questionnaire: “I don’t have enough time to do what I am required to do.” The workload index was created by averaging the score of all seven items. A higher score means a higher workload. The questionnaire was translated into Hebrew and was validated through a pilot study among a small number of subjects ( N  = 32). Reliability as internal consistency (Cronbach’s alpha) in the pilot phase was 0.955 for the before questionnaire and 0.838 for the after questionnaire. In the final sample, the workload index’s Cronbach’s alpha value was 0.91 (before the implementation of EMR) and 0.86 (after).

Information availability was assessed using a shortened version of the Carrington-Gephart Unintended Consequences of Electronic Health Record Questionnaire (CG-UCE-Q) by Gephart et al. [ 39 ]. The internal reliability of the original questionnaire was α = 0.94 with a content validity index of 0.96. The original questionnaire consists of 36 questions and covers a variety of topics related to the change in the work process due to the implementation of computerized systems in hospitals. One of the issues covered is the availability of the patient’s medical information. For the present study, we selected five items relevant to measuring the availability of information. The rest of the items in the questionnaire were not relevant to the subject of the current study. Items range on a Likert scale from 1 (“do not agree at all”) to 5 (“strongly agree”). Example item: “When you have to make a decision about your patient, is there too little documented information about the patient for you to understand the clinical picture?“. The medical information availability index was calculated as the average of items’ scores after reversing the scores of items #1, 4, and 5. A higher score means greater availability of information. The questionnaire was translated into Hebrew and was validated among a small number of subjects ( N  = 32) from the study population. Reliability as internal consistency (Cronbach’s alpha) in the pilot phase was 0.924 for the before EMR questionnaire and 0.779 for the after questionnaire. In the final sample, the index’s Cronbach’s alpha value was 0.690 before EMR and 0.930 after.

Medication errors were assessed using a shortened version of the Medical Error Checklists questionnaire developed by Tsiga et al. [ 40 ]. The internal reliability of the original questionnaire was α = 0.96. The original tool is constructed of three parts, with each part containing 25 questions. The items represent a variety of medical errors, for example, wrong diagnosis, errors in medication prescriptions, communication failure, etc. Only eight items were found to be relevant for the current study, measuring medication administration errors, and those comprised the final tool used in this study. Items range on a Likert scale from 1 (“do not agree at all”) to 5 (“strongly agree”). Example item: “The prescription of the medication is illegible and unclear.” The medication errors index was calculated as the average of all eight items. A higher score means more errors in administering medication. The questionnaire was translated into Hebrew and was validated among a small number of subjects ( N  = 32). Reliability as internal consistency (Cronbach’s alpha) in the pilot phase was 0.954 for the before EMR questionnaire and 0.903 for the after questionnaire. In the final sample, the index’s Cronbach’s alpha value was 0.820 before the implementation of EMR systems and 0.700 after.

Statistical analysis

The statistical analysis of the results was performed using SPSS Version 28. The analysis included both descriptive and analytic statistics to explore the research hypotheses. This study has no missing data handling due to all items on the questionnaire being mandatory to answer. The statistical tests were chosen according to the variable distributions. Given the large sample size, parametric tests were used even for non-normally distributed measurements. Correlation between continuous variables was assessed using the Pearson correlation test. Associations between categorical and continuous variables were examined using Student’s paired-samples t-test. Multivariate regression analysis was conducted using the linear regression model for all three main dependent variables (medication errors, workload, and medical information availability). Analyses were performed in Enter mode following the negation of multi-collinearity. Only variables found to be associated with the dependent variables in the univariate analysis were introduced into the regression analyses. A p -value of 0.05 or lower was deemed statistically significant in all statistical analyses.

Sample description

In total, 622 nurses entered the questionnaire link, of which 31 (5%) indicated that they did not use pen-and-paper medical records and were subsequently excluded from the rest of the study. The final sample included 591 registered nurses working in government hospitals in Israel, of which 148 men (25%) and 443 women (75%). The average age was 33.92 years (SD 9.24 years), with a median age of 30.5. Most participants were employees at the ‘Sorasky’ Medical Center in Tel Aviv and “Hillel Yaffe” Hospital in Hadera (105 and 327, respectively). See Table  1 for additional socio-demographic breakdown.

Quantitative analysis

The findings show a significant difference in all assessed indices when comparing before the implementation of EMR systems and after, as follows. The perception of the number of medication errors after EMR systems implementation (M = 2.2, SD = 0.72) was reduced compared to before (M = 3.12, SD = 0.73) (t = 24.85, p  < 0.001). The workload after implementation of EMR systems (M = 2.77, SD = 0.92) was perceived as lower compared to before (M = 3.6, SD = 1.07) (t = 15.53, p  < 0.001). In total, this represents a  ∼  30% decrease in both medication errors and workload perception following the introduction of EMR systems. However, in contrast to our hypothesis, medical information availability after the implementation of EMR systems (M = 2.45, SD = 1.35) was lower compared to before (M = 2.6, SD = 0.74) (t = 2.44, p. 0.015). In total, this represents a  ∼  10% decrease in information availability following the introduction of EMR systems.

In order to examine the relationship between socio-demographic variables and the main variables, as a first step, a univariate analysis was performed to explore the association with attitudes after the implementation of the EMR. None of the Demographic variables were significant for workload and medication errors ( p  > 0.05), and all of them were significant for information availability ( p  < 0.001) (see Table  2 ).

For each of the primary dependent variables, a delta score was computed by subtracting the value before EMR systems implementation from the value after. The mean for the delta score of medication errors was − 0.92 (SD 0.90), -0.83 (SD 1.03) for workload, and − 0.14 (SD 0.39) for medical information availability. These delta scores were used for correlation analyses. The results here show that the delta score of workload was positively correlated with the delta score of medical information availability ( r  = 0.21, p  < 0.01) and medication errors ( r  = 0.36, p  < 0.01). In other words, a higher increase in workload was associated with more errors and higher availability of information, or vice versa. In addition, the delta score of medication errors was negatively associated with the delta score of medical information availability ( r =-0.37, p  < 0.01), meaning that fewer medication errors are reported with the increase in medical information availability.

Finally, multivariate linear regression was conducted for each of the three main dependent variables separately - medication errors, workload, and information availability. The analysis was performed to predict the dependent variables after implementation of EMR systems. See the complete results in Table  3 .

Qualitative analysis

In the qualitative section of the research, 82 participants answered three open questions (see methodology). The purpose of the questions was to understand how the nursing staff experienced using EMR systems and its effect on their work. It is important to note that there were contrasting reports in answers; for some participants, a certain feature was a disadvantage, but for other participants, it was an advantage. For example, while one participant claimed that EMR wastes a lot of time in her work, another claimed that it saves her a lot of time. It is also interesting to note that in response to the question about the EMR systems’ benefits, only a few participants reported a decrease in medication administration errors as a response. In the analysis, we categorized several themes that appeared repeatedly in the answers, as will be specified below.

Theme #1: additional workload that comes at the expense of patient care time

A large portion of participants (28 out of 82 who responded to the questions) claimed that the EMR systems require them to devote time to operate them at the expense of time for actual care for patients, such as giving support, communicating with the patient, and responding to their needs, especially when compared to the era of pen and paper prescriptions before EMR implementation. For example - “more information about the patients, less time for nursing care”; “It (EMR system) is excellent but leaves less time to treat the patient physically and emotionally”; “Filling out multiple indices and a lot of screen time that should have been used as a quality time with the patient bothers me.” In fact, some of the participants said that EMR systems add to their workload; for example -“Using information systems has added a lot of additional tasks to our work and at the same time, no personnel has been added; the same number of nurses remain on shifts, which makes me working under stressful conditions because you have to complete both the work in front of the computer and the work with the patient and the family.”

In this context, some participants also complained about the requirement to electronically document many details and indices about the patient that, in their opinion, have no medical meaning. Participants said that many unnecessary indices need to be entered into the system due to various administrative requirements and not for medical necessity.

Theme # 2: limitations and technical faults of the systems

Another kind of feedback was related to technical problems or slowness of the systems, for example - “Only the quality of the system and the equipment disturbs me; for example, the slow transition between windows”); Communication failures between systems, connection problems due to internet connection dependency, for example - “very interrupting when there is no Internet access”), and problems during a power outage or the collapse of the system - “Computing failures. System collapse. Power failures. Software failures. Too many versions”; “Everything is fine and lovely until there is a power outage; computer crashes; slow computer. It is just terrible. In the age of paper records, there was less writing and less information. But the basic important information was there. I do not recommend going back to paper, but there’s a need to take care of a good backup system with the necessary information that will come into action in the event of a malfunction”. Participants wrote about other computer malfunctions, such as bugs in the systems that cause them to get stuck and waste a lot of time as a result, for example - “Using Computers is excellent. But the Chameleon system has a lot of bugs and often gets stuck. Wastes a lot of time during the shift…”.

Theme # 3: the human factor as a source of problems in the operation of EMR systems

Finally, a theme related to the human factor emerged from participants’ feedback, namely the use of computerized systems by the medical and nursing staff. It was claimed that the physicians do not enter the medical instructions into the system in a straightforward manner or that necessary instructions are missing, or critical information about the patients is missing, for example - “… there are still lots of mistakes in writing instructions”; “sometimes the staff does not enter information properly, and sometimes critical information about the patients is missing.” Other nurses reported that their colleagues copy data from each other to save time filling them out, for example - “because it takes more time to fill out indices, many times poor indices are copied from nurse to nurse instead of filling out the correct data”). Others stated that older staff members have difficulty acquiring skills for using the EMR systems due lower digital literacy, for example - “You need full control in computer skills, which makes it difficult for older nurses to use them (EMR systems)”; “It is important to note that there are older employees who do not get along with the computer and it will be difficult for them to work and use the computer. This has a negative effect on the work of others in the department”).

The current study examined the effect of implementing EMR systems on the extent of errors in medication administration by qualified nursing staff and on other variables related to patient safety, namely the availability of medical information and the workload imposed on nursing staff. In line with the study hypotheses, we found that EMR systems reduce errors in the administration of medications and reduce workload. These findings correspond with the prevailing position in the literature on the effectiveness of EMR systems in reducing errors in prescriptions and medication administration [ 11 , 41 ]. It is important to emphasize that, unlike most studies on this topic, the extent of errors in the present study was measured based on an approximate perception of nursing staff and not as an exact quantitative measure. However, similar approaches in the literature are reported [ 42 ].

The findings suggest that workload decreased for the most part following the implementation of EMR systems. This decrease in workload can be explained by the fact that computerized systems save the need to physically run around to receive and transfer various materials such as laboratory tests, imaging, drug prescriptions, etc [ 43 ]... Nevertheless, the findings suggest that there is also a disadvantage. According to some participants’ reports, EMR systems require a lot of handling time, which comes at the expense of care for the patients and their families. This finding partially aligns with the findings of a meta-analysis performed by Moore et al. [ 44 ], which concluded that computerized medical systems increase the time nurses spent documenting medical records. Furthermore, in the same meta-analysis, it was found that even after the implementation of the EMR systems, there were nurses who preferred to continue documenting manually and viewing the older pen-and-paper method as faster and more accesible.

However, other studies included in Moore’s meta-analysis [ 44 ] claim that EMR systems contributed to the redistribution of nurses’ working time so that they devoted more time to direct patient care and communication with family members than dealing with medical records. These studies further claim that this resulted in greater satisfaction and a sense of meaning in their work. Arguably, the findings of the current study contradict this. It is possible that part of this discrepancy in findings can be explained by the type of system used since the type of EMR system has a decisive effect on the required documentation time [ 43 ]. Other studies also found, in line with the current study, that EMR systems harm the workflow of the team since they require multi-tasking, distract nurses from their primary work, and reduce the contact and interpersonal relationship with patients, negatively affecting the satisfaction of both the patients and the staff [ 45 ]. Another support for the findings of this current research is found in a study among doctors in the USA who claimed that one of the main reasons for burnout of doctors, which often results in leaving the job, is the need to spend too much time documenting information in EMR systems [ 46 ].

There may be a need to find ways to reduce the required documentation during a shift and document only vital medical information. This is important to avoid a situation where nurses devore extended periods of time during their shifts sitting in front of the computer instead of providing care and attention to patients and communicating with families. It should be noted that although the workload in this study is subjective and relies on the nursing staff’s report, it is, in fact, a preferred measurement for this topic [ 43 ].

In contrast to our hypothesis, medical information availability dropped after implementing EMR systems. These findings are slightly surprising as most studies on the subject found an improvement in the availability of medical information following EMR systems [ 32 ]. This finding may also highlight some of the backlash reported by nurses concerning the difficulty of managing the work with EMR systems during their shifts.

Alongside this, we found that other variables can explain part of the reduction in information availability. For example, nurses responding to our questionnaire who are working in the Intensive care and emergency departments reported significantly less information availability after the introduction of EMR systems. Arguably, in departments dealing with urgent or intense cases, there is a greater need for high-speed information transferring [ 43 ]. It may be critical if the EMR system is slow or gets stuck, as is sometimes the case with such systems and as reported by some of the nurses. Indeed, the literature accounts for technical deficiencies of systems, such as slowness, failures, systems crashes, communication problems, and difficulty integrating between the EMR system and others [ 32 ]. Moreover, the literature reports that EMR systems sometimes contain too many complicated and less vital functions [ 32 ]. It may be necessary to tailor the computerized information systems specifically to these departments so that they offer a “lean” or easier interface that will allow for faster extraction of vital medical information. It is also a good idea to make sure that there is sufficient backing to operate the systems for cases of communication or electricity faults so that crucial information remains available in these situations as well.

The decrease in information availability after EMR implementation can also be explained by insufficient training for staff to use those systems properly. As reported by participants in the qualitative section of the study, departments have elderly staff memebers who have difficulty operating and controlling computerized systems. Similar findings were also found in previous studies [ 32 ]. The findings of the present study are in line with the accumulated findings that indicate a fundamental need to think and redesign some of the EMR systems from the perspective of the end users, as well as to provide appropriate training and support for using them.

Limitations and future directions

This study has several limitations. First, the sampling method in the current study was not probabilistic and was based on convenience and the snowball method exposed the sample to selection bias and may not fully represent the population. Second, the dependent variables were measured subjectively, i.e., as an experience or impression of the study participants. Such tools are naturally exposed to biases since the impressions of the respondents do not necessarily accurately reflect the objective reality in the hospitals. Memory bias should be considered for reports concerning the time before EMR systems implementation. In addition, there may be reporting bias due to the unwillingness to report the actual occurrence of medical errors.

Third, this study measured only three variables. Although these are three main variables in understanding the phenomenon being investigated, it must be assumed that additional variables are required to obtain a broader and more detailed picture of the computerized systems in a hospital. It is useful to specifically and directly examine variables such as the quality and accuracy of medical information [ 32 ] or the time of documentation of medical information [ 47 ]. It is also possible to distinguish between different types of medication errors and examine each of them individually, for example, errors in identifying the patient, dosage, or how the medication is administered.

Conclusions

This study provides mixed results regarding the research hypotheses. The findings support the hypotheses stating that Electronic Medical Records (EMRs) are perceived by Israeli nurses to reduce medical errors and workload, compared to the older pen-and-paper approach. However, the findings do not support the third hypothesis since the findings show that EMRs were perceived to decrease information availability compared to the pen-and-paper era.

The findings in this study show the great benefits of using EMR systems in hospitals in Israel, as well as the difficulties and challenges associated with them. To the best of our knowledge, no systematic research has yet been done on this subject in the State of Israel, and therefore, the findings of the current study are highly important for decision-makers.

The findings show that the implementation of EMR systems in Israel contributes to reducing errors in the administration of medications by qualified nursing staff from the point of view and the direct experience of the nursing staff themselves. This means that these systems contribute to saving lives, and therefore, their importance for hospitals is tremendous. In addition, according to nurses, the systems reduce the workload imposed on the staff. However, the findings present difficulties on two levels. The first is the need for multi-tasking, which harms nurses’ work. This difficulty is manifested in the fact that too much time is required to document medical information in computerized systems, which comes at the expense of time directly caring for patients and their families. This situation may harm the nurses’ morale and may cause burnout at work. The second level is the complexity and slowness of the systems, which may reduce the availability of medical information when it is necessary to retrieve quickly, which is especially problematic in departments of surgery, intensive care, and emergency medicine, where a lot of medical information is needed urgently and immediately.

The findings raise a need for rethinking and redesigning these systems while thinking about the end users, as well as a need for dedicated training for their use by end-users of different digital literacy backgrounds. Future research can focus on developing methods for assimilating knowledge and skills to use computerized systems in a way that considers age and digital literacy and evaluates their effectiveness. In addition, future research will be able to examine the effectiveness of changes and improvements in the computerized systems, particularly the development of “lean” versions of the interfaces for departments where quick information retrieval is required.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

UCE-Q-Carrington-Gephart Unintended Consequences of Electronic Health Record Questionnaire

Electronic Health Record

Electronic Medical Record

Expanding Nursing Stress Scale

PS-Electronic (medication) Prescription Systems

Health Management Organization

World Health Organization

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Acknowledgements

The authors wish to thank Hillel Yafe Medical Center for their support in access to respondents. In addition, we thank the Sourasky Medical Center for its support in recruiting a large number of nurses as respondents. This work was done in the context of a Master of Public Health thesis of the first author under the supervision of the last author.

No funding was received for this research.

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Department of Emergency & Disaster Management, School of Public Health, Faculty of Medical and Health Sciences, Tel-Aviv University, 39040, Tel-Aviv-Yafo, Israel

Raneen Naamneh & Moran Bodas

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Contributions

RN designed the study, collected the data, analyzed the data, interpreted the results, and wrote the draft of the manuscript. MB supervised the process, approved the methodological approach, critically reviewed the draft, and approved it. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Moran Bodas .

Ethics declarations

Ethics approval and consent to participate.

This study was approved by the ethical committee of Tel-Aviv University (approval No. 0003647-1, from 29 July, 2021). All participants completed an informed consent prior to providing their response. All responses were retained anonymously.

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Moran Bodas is a Senior Lecturer at the Department of Emergency & Disaster Management, School of Public Health, Faculty of Medicine, Tel-Aviv University. He is the former director of the National Center for Trauma & Emergency Medicine Research at the Gertner Institute. Raneen Naamneh is a registered nurse who successfully graduated from the School of Public Health after completing her thesis reported in this paper.

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Naamneh, R., Bodas, M. The effect of electronic medical records on medication errors, workload, and medical information availability among qualified nurses in Israel– a cross sectional study. BMC Nurs 23 , 270 (2024). https://doi.org/10.1186/s12912-024-01936-7

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Medication Errors: Causes and Consequences Essay

Introduction, the main factors of medication errors, current initiatives in reducing medication errors, issues that interfere with the implementation of improvements, communication issues related to medication errors.

Although medication errors are infrequent in clinical practice, they present a severe threat to the patients’ safety. To cover all aspects of medication errors, this presentation will include several significant points on the issue. First, the presentation includes an overview of the problem and its risks to the patients’ safety. Next, the presentation provides an explanation of the main factors that contribute to medication errors, according to the peer-reviewed literature. The presentation will include information about current initiatives geared towards reducing the number of medication errors and the issues that interfere with the implementation of the initiatives. Then, the presentation will define communication issues that relate to medical errors and, lastly, provide a conclusion with an overview of the discussion on the subject.

The medication errors are included in a separate area of issues in the clinical practice due to the high risks to the patients’ safety and complexity. According to Gracia et al. (2019), the index of global medication errors is 1.93%. The main areas of concern that present the highest level of risk for the patients are concentrated in the administration of antibiotics (8,15% error rate) and administration of medications delivered via nasogastric tubes (11,16% error rate) (Gracia et al., 2019). Overall errors in duration, concentration, and infusion rate of medications are presented in 2.94% of cases (Gracia et al., 2019). The medication errors in Intensive care units present the most danger to the patients’ safety due to the critical nature of the patients’ diseases and the potentially severe consequences of medication errors.

There is no clear criterion for the causes of medical errors, so there is no possibility to clearly state the main factors that influence the number of medication errors. However, there is clear evidence of some factors that significantly impact the occurrence of medication errors. First, the human factor plays a major role in medication errors. The wrong understanding of the drugs qualifies as an error, late provision of medication from the schedule, wrong dose calculations, lack of double-checking, and low adherence to protocols also qualify as medication errors.

Most of the reports state that majority of medication errors happen in the stage of medication administration. However, there are several cases of medication errors occurring during the steps of prescription and transcription. At this stage, the factors that predict medication errors include distortions like the use of abbreviations, lack of a dose in the prescription, and scheduling of antibiotics administration.

Nurses’ low level of knowledge of the drugs they use in patients’ treatment is a frequent reason for medication errors. According to Gracia et al. (2019), a low level of drug knowledge is a common issue, as the majority of nurses’ training programs imply that the medication errors occur predominantly in the pharmacotherapeutic administration stage. The use of high-level clinical judgment helps to prevent the occurrence of medication errors. Critical thinking, double-checking, a high level of cautiousness and adherence to protocols, and increased interaction with patients and other professionals can help eliminate the human factor of medication errors.

Although human-related errors are a big part of the issue, they follow as consequences of the existing system. The medication system as a whole needs to be revised in order to improve the situation with medication errors. U.S. Food and Drug Administration (FDA) currently encourages reducing mediational errors by eliminating confusing drug names, introducing concise labeling and different containers for drugs with multiple strengths, and providing directions with prescriptions. In the recent changes made to reduce confusion in medications, FDA required the manufacturers to put barcodes and allowed healthcare professionals to check the correct dosage and administration of medications through barcode scanning. FDA states that consumers should understand and be informed about what drug they are using and for which purposes; they also are free to express their concerns about certain medications to the manufacturers.

Current initiatives focused on preventing medication errors in clinical settings are presented either by a set of strategies geared towards redesigning the system or training programs for healthcare professionals that increase their knowledge of drugs. A significant point in preventing medication errors is the introduction of electronic medical records and electronic prescriptions. Due to the fact that a considerable amount of misinterpretation occurs because of illegible writing, the use of electronic information helps to eliminate misunderstandings of prescriptions. However, the problem of the absence of thorough directions and instructions with prescriptions remains. A number of centers offer education courses on pharmacotherapy and error prevention for healthcare professionals. The strategies for improvements in medication errors should include redesigning the system and increasing the level of drug knowledge among healthcare professionals.

Among the issues with implementing improvements in medication errors, the primary reason is the high cost of improvements. In an article by Vilela and Jericó (2019), the authors attempted to calculate the cost of implementing medication error-preventing technologies in a high-complexity hospital. As an improvement implementation, the authors used 13 preventive technologies divided by three stages of administration, prescription, and dispensing, and the price included the cost of labor and findings required for materials and equipment.

According to the research, the average cost of implementing preventive technologies per year is around R$10.259.505,10 (almost 2 million in US dollars) (Vilela & Jericó, 2019). The exact cost divided for each patient is estimated to be around R$ 55,72 per year, or 10 United States dollars. The most costly improvements in terms of labor are the implementation of its technology and the introduction of an electronic prescription system. In terms of material and equipment expenses, improved infusion pumps and electronic medication dispensing systems are the most expensive.

Although there could be environmental-related reasons for the medication errors or individual person-related reasons, the most common area for the occurrence of medication errors is communication. Due to a lack of effective communication between healthcare professionals and patients, the flow of important data about patients’ allergies, medication history, and other vital details stops. The most frequent communication issues related to medication errors include mistakes in medical documentation, clinical handover, informal communication, and an overall misunderstanding of orders. As almost half of the medication errors occur due to communication issues, the situation could be improved without the implementation of expensive equipment through training programs on effective communication.

In conclusion, the presentation defined the main factors of medication errors: healthcare personnel’s low level of knowledge of the drugs, communication-related issues like mistakes in medical documentation, misinterpretation of orders due to illegible handwriting, and lack of instructions. The high cost of implementing improvement technologies prevents the progress of eliminating medication errors. Without significant funding, the healthcare system could improve the situation with medication errors through training on effective communication.

Gracia, J.E., Serrano, R.B., & Garrido, J.F. (2019). Medication errors and drug knowledge gaps among critical-care nurses: a mixed multi-method study. BMC health services research, 19(1), 1-9.

Vilela, R., & Jericó, M. C. (2019). Implementing technologies to prevent medication errors at a high-complexity hospital: analysis of cost and results . Einstein, 17(4), 1-7.

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Skepticism Is Healthy, but in Medicine, It Can Be Dangerous

By Daniela J. Lamas

Dr. Lamas, a contributing Opinion writer, is a pulmonary and critical-care physician at Brigham and Women’s Hospital in Boston.

I arrived at the hospital one recent morning to find a team of doctors gathered just outside a patient room. The patient was struggling — his breaths too fast and too shallow. For days we had been trying to walk the line between treating the pain caused by his rapidly growing cancer and prolonging his life.

Overnight he had worsened. His family, wrestling with the inevitability of his death, had come to a tentative plan, and I needed to make sure that his wife understood what was ahead. I explained that if we inserted a breathing tube, as she had decided overnight, her husband would be sedated. When the rest of their family arrived in Boston, we would take out the tube and he would die. We would not be able to wake him up — to do so would only cause him to suffer.

At this, his wife stiffened. Why wouldn’t he be able to wake up? I explained that his cancer was so advanced that to wake him would be to give him the conscious awareness of drowning. I watched as she took me in, this doctor she had never met before, telling her something she did not want to hear. Her expression shifted. “Why should I believe you?” she asked me. And then, her voice toughening: “I don’t think that I do.”

The room was silent. My patient’s wife looked into her bag, rooting around for a tissue. I glanced down at my feet. Why should she believe me? I was wearing sneakers with my scrub pants, and I found myself wondering whether she would have trusted me without question if I appeared more professional, or if I were older or male. Perhaps, but there was so much more at play in that moment. This was not just about one doctor and one family member, but instead, about a public for whom the medical system is no longer an institution to be trusted.

We are at a crossroads in medicine when it comes to public trust. After a pandemic that twisted science for political gain, it is not surprising that confidence in medicine is eroding. In fact, trust in medical scientists has fallen to its lowest levels since January 2019. As a result, more people are seeking out less conventional voices of “authority” that hew closer to their beliefs. Robert F. Kennedy Jr., a longtime vaccine skeptic campaigning for the presidency, is finding double-digit support in some polls and has made medical freedom a recurring theme of his candidacy.

But our medical system relies on trust — in face-to-face meetings as well as public health bulletins. Distrust can lead doctors to burnout and can encourage avoidable negative outcomes for our patients. This is partly what is driving increasing rates of measles among unvaccinated children , failure to follow recommended cancer screening and refusal to take lifesaving preventive medications . There are no easy solutions here. But if we do not find ways to restore and strengthen trust with our patients, more lives will be lost.

This is relatively new terrain for American physicians. When I was in medical training, we did not talk much about trust. During my early years as a doctor, I barely trusted myself and in fact felt uncomfortable with the responsibility I had to keep my patients alive. Only recently have I found myself thinking about what happens when this ephemeral ingredient in the doctor-patient relationship is lost.

Medical skepticism is not the same as medical nihilism. The data behind the drugs doctors prescribe and the decisions we make need not be the purview of us alone; the public has the right to review the numbers and to make their own decisions about risk and benefit. But when that skepticism shifts into abject and irreparable disbelief, we see some patients make dangerous decisions. And when doctors respond with frustration, that only further separates us from those patients.

Trust can sometimes be repaired by clearly presenting facts and figures, but it is about more than explaining numbers. We tell patients things about the body that are unseen. We recommend lifestyle changes and medication to treat or to prevent problems that may not be felt. Surgeons refer to a profound version of trust called the surgical contract: the idea that when people go under the knife, they are allowing their surgeon to make them sicker — to cut them open — in order to make them better. That trust must be earned.

In emergencies, patients don’t have the luxury to choose whom to trust, and medical decisions must happen hastily, in minutes even. So part of our job is to build rapport quickly. That becomes harder, impossible even, when we enter into the climax of a medical crisis to find that whatever trust our patient may have once had long ago has been eroded. Many of our patients started their medical journeys wanting to believe in their doctors. But then the medical system that they wanted to trust failed them, in small ways and large, from haphazardly rescheduled appointments to real medical error. How do we begin the process of repair, both as a profession and as individuals, when time is short?

In medicine, we talk about the idea of shared decision-making, in which medical decisions are arrived at jointly by doctor and patient, in contrast to the paternalistic tone of years gone by. As doctors, we do not tell our patients what to do — instead we offer them the information necessary for them to choose the path that is right for them.

For all our training, our medical knowledge is useless if our patients are unwilling or unable to believe what we have to offer. And that isn’t a fault of our patients, no matter how bothered we might become. This is a fault of a system that does not deserve our patients’ blind faith, of a surrounding political milieu that has turned scientific fact into fiction in many people’s minds.

That is how I found myself in that room, early that one morning, with my patient’s wife, her disbelief and the weight of the decision hanging between us. I knew so little about her. I did not know her history or her interactions with the medical system. I did not know the story of her husband’s diagnosis and treatment, or whether he had struggled to find care for his cancer. In our fractured system, I was just meeting her that day. I had no way to make her trust me, except to sit with her, to give her what little time with her husband we could. And to hope that regardless of what came before, she would choose to believe what I was telling her.

I am not certain what she believed, but she chose against intubation. Her husband lived until the rest of his family came anyway. And when he died, they left without a word, carrying with them his bags of belongings and — I can only hope — faith that we had done the best we could.

Daniela Lamas is a contributing Opinion writer and a pulmonary and critical-care physician at Brigham and Women’s Hospital in Boston.

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Medication errors: problems and recommendations from a consensus meeting

Here we discuss 15 recommendations for reducing the risks of medication errors:

• Provision of sufficient undergraduate learning opportunities to make medical students safe prescribers.
• Provision of opportunities for students to practise skills that help to reduce errors.
• Education of students about common types of medication errors and how to avoid them.
• Education of prescribers in taking accurate drug histories.
• Assessment in medical schools of prescribing knowledge and skills and demonstration that newly qualified doctors are safe prescribers.
• European harmonization of prescribing and safety recommendations and regulatory measures, with regular feedback about rational drug use.
• Comprehensive assessment of elderly patients for declining function.
• Exploration of low-dose regimens for elderly patients and preparation of special formulations as required.
• Training for all health-care professionals in drug use, adverse effects, and medication errors in elderly people.
• More involvement of pharmacists in clinical practice.
• Introduction of integrated prescription forms and national implementation in individual countries.
• Development of better monitoring systems for detecting medication errors, based on classification and analysis of spontaneous reports of previous reactions, and for investigating the possible role of medication errors when patients die.
• Use of IT systems, when available, to provide methods of avoiding medication errors; standardization, proper evaluation, and certification of clinical information systems.
• Nonjudgmental communication with patients about their concerns and elicitation of symptoms that they perceive to be adverse drug reactions.
• Avoidance of defensive reactions if patients mention symptoms resulting from medication errors.

In July 2008, a group of individuals interested in medication errors met in Erice, Sicily, at the invitation of Giampaolo Velo, who organized the meeting. They discussed the problem intensively over 2 days. From this emerged EMERGE, The Erice Medication Errors Research Group. The group resolved on two initial courses of action: to formulate recommendations in the field of medication errors and to prepare this special issue of the British Journal of Clinical Pharmacology , in order to highlight in more detail all aspects of the problem.

Here we list 15 recommendations that emerged from the meeting in Erice. A common theme was the lack of specialist clinical pharmacologists and clinical pharmacists to teach and train others, to carry out research, to monitor for medication errors, and to oversee the implementation of remedial procedures.

Education and assessment

Student education.

There is evidence that changes in the style of modern medical school curricula in the UK may have reduced the visibility of traditional scientific disciplines that underpin safe prescribing, such as pharmacology and clinical pharmacology. There is also evidence that poor knowledge and preparation underlie a proportion of errors made by junior doctors and that focused education in prescribing can improve performance [ 1 – 3 ]. It is also a perception among medical students that of all the clinical skills that they will be expected to practise after graduation, the one for which they are least well prepared is prescribing [ 4 , 5 ]. It is clear that high-quality learning can flourish in different styles of curriculum. However, whatever the setting, learning should be based on enthusiastic leadership, ample sessions that focus on safe prescribing practices, and provision of online learning resources, including a limited student formulary.

Recommendation 1: provision of sufficient undergraduate learning opportunities to make medical students safe prescribers

Much of the medical school curriculum is devoted to the acquisition of knowledge, and sometimes its application to the skills required in the clinical environment is forgotten. Students should be encouraged to practise relevant clinical skills as soon as possible. These might include taking medication histories, writing new prescriptions and reviewing lists of established prescription medicines in relation to the patient's clinical history, calculating drug doses, and preparing and administering medicines under supervision.

Recommendation 2: provision of opportunities for students to practice skills that help to reduce errors

Medical students are often unaware of the potential hazards posed by medicines when they are prescribed in error, or of the frequency with which this occurs. They should be taught about drugs that are used commonly and pose particular challenges (e.g. anticoagulants, insulin, diuretics), how to monitor the effects of drugs so that potential dangers can be avoided, and the important contribution to error reduction made by good communication and record keeping.

Recommendation 3: Education of students about common types of medication errors and how to avoid them

Taking an accurate medication history

An accurate medication history is an important element in patient safety. Inaccurate histories, particularly on admission to hospital, can lead to prescribing errors, such as duplication of drugs or unintended discontinuation of medications, with consequent unwanted interactions, failure to detect drug-related pathology, and loss of efficacy of established therapy. In all, 67% of medication histories have at least one prescription error, 22% of which have the potential to harm the patient significantly [ 6 ]. Specific drugs are associated with increased risks of errors in the drug history; these include commonly prescribed agents such as anticoagulants and analgesics [ 7 ].

A medication history should elicit specific information from the patient [ 8 ]. This should include the details of all prescription medications, over-the-counter drugs, and herbal and other alternative remedies. Drug allergies and previous intolerances should be accurately documented; the dose of the drug, the reaction suffered, and its temporal relation to the drug should be described and susceptibility factors should be sought [ 9 ]. The history should be supplemented by examination of the patient, looking for the effects of drugs, and, when appropriate, by relevant laboratory investigations [ 10 ]. In addition, one should attempt to ascertain adherence to treatment, from the patient, general practitioner, or family, recognizing that accurate information may be difficult to obtain.

Pharmacists obtain better medication histories than physicians [ 11 ] and reduce the rate and severity of medication errors during acute admissions [ 12 ]. Furthermore, pharmacists attending medical or surgical post-take (admission) ward rounds improve drug history documentation, reduce prescribing costs, and prevent adverse drug reactions [ 13 ].

Recommendation 4: Education of prescribers in taking accurate drug histories

Assessment of skills

Prescribing is probably the practical skill that is most commonly required of all new doctors, but of all the skills that newly qualified doctors are expected to have mastered, they are least confident about prescribing. Medical schools should have effective assessments in place that discriminate between students who have sufficient knowledge and skills for safe medication practices and those who do not. The required standard will differ to some extent, depending on the level of supervision available after graduation. Postgraduate assessment should also be encouraged, as part of appraisal.

Recommendation 5: Assessment in medical schools of prescribing knowledge and skills and demonstration that newly qualified doctors are safe prescribers

Identifying hazardous systems

Hazards abound in clinical practice. They include:

• Hazardous drugs These need not be new drugs; well-established drugs are often subject to medication errors.
• Hazardous patients Patients present several risk factors for medication errors; there is limited knowledge about how to estimate individual patient risk, although elderly patients constitute a readily identifiable group.
• Hazardous professionals There is a lack of specialists (clinical pharmacologists and clinical pharmacists) trained in the specific problems of medication safety. Consequently, many prescribers are not adequately trained in practical prescribing.
• Hazardous settings Some settings are more susceptible to involvement in medication errors, such as nursing homes, geriatric home care, surgical departments, intensive care units, and ambulatory care.

Hazardous drugs Several studies have confirmed persistent problems in prescribing well-established medications [ 14 ]. Although there is often a huge amount of knowledge about such medications, less attention is paid to the major safety problems. In some cases safer alternatives to some older risky medications (e.g. warfarin, amiodarone) are not available. Prescribing habits can also be influenced by local habits and advertisement (for example, the use of pentoxifylline in 20% of older adults in the Czech Republic, even though it is not approved in several European countries [ 15 ]).

Recommendation 6: European harmonization of prescribing and safety recommendations and regulatory measures, with regular feedback about rational drug use

Old patients Many problems that lead to medication errors particularly affect elderly patients, in whom cognitive impairment, renal insufficiency, dependence on carers, and polypharmacy are the major predictors of drug-related hospital admissions. Instruments for determining individual patient risk, particularly in patients with multiple comorbidities and several susceptibility factors, are not available for clinical use. There is a lack of professionals specifically trained in geriatrics, geriatric pharmacology, and pharmacoepidemiology. Clinicians do not routinely apply even basic safety recommendations [ 14 ], and insufficient attention is paid to well-known risks. There have been few studies on the long-term efficacy in elderly patients of safer low-dose regimens for frequently used medications [ 16 ]. In practice, most substances are usually prescribed in too high doses or in low-dose regimens with no evidence of primary or secondary long-term benefit in elderly patients. Drug formulations that contain low doses are less often available.

Recommendation 7: Comprehensive assessment of elderly patients for declining function [ 17 ] Recommendation 8: Exploration of low-dose regimens for elderly patients and preparation of special formulations as required Recommendation 9: Training for all health-care professionals in drug use, adverse effects, and medication errors in elderly people

Involving clinical pharmacists

Hospital care takes place in a complex and hierarchical organization encompassing different disciplines, which converge at the bedside. Many findings, decisions, and actions take place simultaneously and often acutely. In hospitals, medication and other errors can have many different causes and explanations and often occur at the bedside, where the different disciplines interact. Incidental distraction of attention is likely, and in the case of a specialized activity, such as checking and administering medicines, can lead to suboptimal performance. These types of errors typically occur in the absence of the pharmacist.

In the past few decades, the profession of clinical pharmacy has developed the specialism of pharmaceutical care, which aims at ensuring optimal individual pharmacotherapy and appropriate and errorless drug handling. Involvement of clinical pharmacists in almost the entire medication process, from dispensing to administration to the patient, can reduce medication errors [ 18 ]. This can be achieved through special medication ward rounds [ 19 ], the use of computer-assisted and barcode-controlled bedside dispensing (see below) [ 20 , 21 ], and an extra check whenever a pharmaceutical formulation is modified before administration (e.g. crushing a capsule for a patient with an nasogastric tube [ 22 ]), entered via an unusual route, or injected into an intravenous line.

Recommendation 10: More involvement of pharmacists in clinical practice

Using uniform prescription forms

Although electronic prescription systems (see below) can improve prescribing quality, they are expensive and can generate new types of errors [ 23 ]. Integrated prescription forms have also been developed for use in hospitals, with the aim of reducing errors in prescribing and drug dispensing. The prescription is handwritten by the doctor and countersigned by the nurse after administration. The potential advantages are that a single sheet of paper contains all the necessary information about the patient's care, transcription is avoided, communication between physicians and nurses is simplified, and feedback control is facilitated. Although training is required, it is not time-consuming. In addition, uniform prescription charts can be easily implemented at low cost. To improve communication between medical staff and nurses, cooperation should be encouraged, verbal prescription should not be allowed, and only a limited number of abbreviations should be permitted. Feedback control must include immediate notification of errors by medical staff and pharmacists (potential harm deriving from prescription) as well as nurses (incorrect writing), while the prescriber can monitor actual drug administration [ 24 ]. Frequent (e.g. daily) review of prescriptions allows identification of potential harm from drug–drug interactions and adverse drug reactions. Audits should be performed periodically to evaluate the appropriateness of the procedures and encourage implementation of the prescription form [ 25 ]. Most errors made by junior hospital doctors occur shortly after they come to a new hospital; national prescription forms would help to mitigate this effect.

Recommendation 11: Introduction of integrated prescription forms and national implementation in individual countries

Bar-coded medication administration

Before the administration of a medication in hospitals and other institutionalized care settings, the ‘five rights’ must be verified: the right patient, drug, dose, route, and time. Traditionally, the nurse does this by visually checking the medicine and the patient. However, there is evidence to suggest that this traditional method does not adequately protect the patient from medication-related harm. About 35% of all medication errors occur at the administration stage, and these errors are more likely to affect the patient than errors introduced at earlier stages [ 26 ].

In bar-coded medication administration a nurse typically scans a bar code on the employee identification badge, the patient's wristband, and the medication to be administered. The portable computer at the bedside sends the information to a server, which checks the prescription. The system can generate warnings or approvals, provide administration instructions and information about the drug, or deliver reminders for further actions. After administration, the system documents the activity in the patient's medication record for future use.

Case studies and anecdotal reports suggest that bar-coded medication administration can produce significant reductions of at least 50% in the number and types of medication administration errors [ 26 – 28 ]. Besides patient safety, secondary reasons for implementing bar-coded medication administration include improved workflow, documentation, billing, and public relations.

Although this technology has considerable potential to reduce medication errors, the risk of creating new kinds of errors should be minimized [ 29 ]. It is important, for example, that nurses use the technology systematically after it has been implemented [ 30 ].

Monitoring for medication errors

Prevention is ideal, but detection of errors that have occurred is also necessary, in order to identify those that are common in the particular setting, to identify their sources, and to prevent them from happening again.

Monitoring for drug harm is systematic assessment aimed at detecting and sometimes quantifying the harm [ 31 ]. It can be pre-emptive (systematically evaluating new medicines for potential risks of error), or by examination of spontaneous reports, or experimental. Regulatory agencies are explicitly asked to consider medication errors in Risk Management Plans [ 32 ], but strategies for doing so are not well developed and there have been hardly any studies devoted to techniques for monitoring medication errors during routine practice [ 33 , 34 ]. ‘Look-alike’ errors are regularly reported with new medicines [ 35 ], despite the availability of strategies to reduce them [ 36 ]. Physicians do not regularly review prescription charts and should be encouraged to do so [ 37 ], while nurses are less effective at detecting medication errors than pharmacists [ 38 ].

We can infer that some monitoring takes place with spontaneous reporting schemes, such as those run by the National Reporting and Learning System in the UK and the Medication Errors Reporting Program in the USA, because warnings of serious potential hazards usually indicate the number of relevant events [ 39 ]. However, sophisticated statistical analysis of the sort that is now standard in pharmacovigilance does not seem to be used. This may partly be the result of a failure to classify reported events by the underlying failure modes and so allow common features to be drawn out. Systems for the investigation and reporting of deaths in which medication errors play a part are also weak.

Recommendation 12: Development of better monitoring systems for detecting medication errors, based on classification and analysis of spontaneous reports of previous reactions, and for investigating the possible role of medication errors when patients die

Communication

Interprofessional communication.

With the dawn of the digital age, the process of communication has undergone a profound change. As the amount of information increases, the need for effective means of communication becomes paramount. It is therefore nowadays becoming increasingly difficult to find a person who does not make daily of use e-mail, mobile telephony, and chat or social networking services (such as Facebook or My Space). Yet medical professionals are not yet fully benefiting from modern technology, as exemplified by the delays and increasing costs of implementing IT technology in health-care and other systems in the UK [ 40 , 41 ]. One of the concerns usually named among the reasons for this is the problem of information safety in digital communication, coupled with the high sensitivity and confidentiality of medical information, which becomes exacerbated outside of closed computer networks.

However, digital communication is not only fast, convenient, and inexpensive, but can also provide a high degree of security, through the use of encryption algorithms. The secure e-mail provider Zmail is a fine example of a service that offers an economical and secure means to send medical information over the internet. In addition, most broadband telephony providers are also integrating encryption options into their services, making them more attractive for use in medical communication (such as telemedicine and long-distance telephony). Finally, as the options for digital communication become increasingly available, reliable, and secure, they will also be increasingly used for sending medical information.

Published research strongly suggests that modern information systems have a substantial role in preventing medication errors at each step of the medication process. Computerized order entry and decision support systems reduce errors at the prescription stage by producing legible orders, by ensuring the correct dose and route, and by providing point-of-care alerts about potential drug allergies or drug–drug interactions. In a closed-loop system, the electronic orders are automatically transmitted to the pharmacy, altogether eliminating errors of transcription. Automated dispensing devices and robots ensure that the medication being dispensed is matched accurately against the physician's order. Bar-coded medication systems facilitate the verification of the ‘five rights’ by nurses during the administration stage (see above).

The usefulness of information systems derives from their ability to organize and link multiple pieces of information with consistency and reliability. A good informatics-enabled medication process will spare the clinicians repetitive boring tasks, so that they can focus on complex clinical decision-making and communicating with each other and their patients.

It must be clearly understood that information systems are not a panacea. A few studies have reported that if not implemented and monitored appropriately, they can lead to increased chances of errors, due to problems such as a faulty computer interface, miscommunication with other systems, lack of adequate decision support, and other human errors (e.g. lack of knowledge, distractions, and typing errors).

Recommendation 13: Use of IT systems, when available, to provide methods of avoiding medication errors; standardization, proper evaluation, and certification of clinical information systems

Communicating with patients

Patients' attitudes to medicines influence the ways in which they use them [ 42 ]. Some carry out their own evaluations of prescribed medicines, using their own criteria [ 43 ]. Up to 50% are non-adherent, in the sense that they do not take the medicine ‘as prescribed’, and few solutions to this longstanding problem have been identified [ 44 ]. Blind adherence to medication can lead to harm if patients are insufficiently informed about the dangers of prescribed medicines [ 45 ]. All of this suggests that it is better to engage with patients' own evaluations and aim for shared goals rather than ignoring or condemning ‘non-adherence’. Such an approach requires further research and development.

As far as medication errors are concerned, patients and their carers will usually be the first to notice any observable problems that result, although they will probably be unable to distinguish between medication errors and adverse drug reactions. Little is known about how patients understand drug-related problems or how they make attributions of adverse effects. Some research suggests that their cognitive models of adverse drug reactions are closely related to models of illness perception [ 46 ]. The elements of such models are cause, symptom, time, consequence, and cure. Attributions of adverse drug reactions are related to people's previous experiences and to their level of education. The evidence suggests that, on the whole, patients' reports of adverse drug reactions are accurate [ 47 ]. However, they do not report all the problems they perceive and are more likely to report those they do perceive as being severe. Patients may not report problems attributed to their medications if they are fearful of doctors' reactions, and some authors have proposed the use of a symptom checklist to elicit patients' reports of suspected adverse drug reactions [ 43 ]. Doctors, for their part, may respond inappropriately to patients' concerns, for example by ignoring them [ 48 ], and professionals' inappropriate emphasis on adherence may be dangerous when a medication error has occurred.

Recommendation 14: Nonjudgmental communication with patients about their concerns and elicitation of symptoms that they perceive to be adverse drug reactions. Recommendation 15: Avoidance of defensive reactions if patients mention symptoms resulting from medication errors.

Competing interests

None to declare.

The meeting in Erice was partly funded by the International School of Pharmacology of the ‘Ettore Majorana’ Foundation and Centre for Scientific Culture, Erice, Sicily, Italy.