Nurses' role in medication safety

Journal of Nursing Management

Volumn 18, Issue 7, 2010, Pages 853-861

  Choo, Janet ^a,b   Hutchinson, Alison ^c   Bucknall, Tracey ^c,d  

^a UNIVERSITY OF MELBOURNE   (Australia)

^b CHANGI GENERAL HOSPITAL   (Singapore)

^c DEAKIN UNIVERSITY   (Australia)

^d CABRINI INSTITUTE   (Australia)

Author keywords

Decision making; Information technology; Medication administration; Medication error; Medication safety; Nursing

Indexed keywords

ARTICLE; DRUG TOXICITY; HUMAN; MEDICATION ERROR; NURSE ADMINISTRATOR; NURSE ATTITUDE; NURSING; PATIENT CARE PLANNING; SOCIAL ENVIRONMENT;

DRUG TOXICITY; HUMANS; MEDICATION ERRORS; NURSE ADMINISTRATORS; NURSE'S ROLE; NURSING, SUPERVISORY; PATIENT CARE PLANNING; SOCIAL ENVIRONMENT;

EID: 77958477251     PISSN: 09660429     EISSN: 1365263X     Source Type: Journal    
DOI: 10.1111/j.1365-2834.2010.01164.x     Document Type: Article

References (56)

1. Barach P. & Small S.D. (2000) Reporting and preventing medical mishaps: lessons from non medical near miss reporting systems. British Medical Journal 320, 759-763.
2. Bates D.W., Boyle D.L., Vander V.M.B., Schneider P.J. & Leape L.L. (1995) Relationship between medication errors and adverse events. Journal of General Internal Medicine 10, 99-205.
3. Bucknall T.K. & Hutchinson A.M. (2006) Is using an evidence based clinical management tool sufficient for implementing evidence based practice? Worldviews on Evidence-based Nursing 3 (4), 137-138.
4. Cousins D.D. (1998) Medication Use: A Systems Approach to Reducing Errors. Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL.
5. Ferner R.E. (1995) Ss there a cure for drug errors? British Medical Journal 311 (7003), 463-464.
6. Freidson E. (1970) The Profession of Medicine: A Study of the Sociology of Applied Knowledge. Dodd, Mead and Co., New York.
7. Fuqua R.A. & Stevens K.R. (1988) What we know about medication errors: a literature review. Journal of Nursing Quality Assurance 3 (1), 1-17.
8. Gary D.V. (2002) Hospitals make medication errors in 19% of doses. Archives of Internal Medicine 162, 1897-1903.
9. Harne Britner S., Kreamer C.L., Frownfelter P. et al. (2006) Improving medication calculation skills of practicing nurses and senior nursing students: a pilot study. Journal for Nurses in Staff Development 22 (4), 190-195.
10. Hersh W. (2002) Medical informatics: improving health care through information. Journal of the American Medical Association 288, 1955-1958.
11. Institute for Safe Medication Practices (2005) Medication safety alert Available at:, accessed 18 November 2008.
12. Institute for Safe Medication Practices (2008a) The five rights: the not the gold standard for safe medication practices Available at:, accessed 18 November 2008.
13. Institute for Safe Medication Practices (2008b) USP ISMP medication errors reporting program Available at:, accessed 20 March 2007.
14. Institute for Safe Medication Practices (2009) ISMP survey helps define near miss and close call Available at:, accessed 31 May 2010.
15. Institute of Medicine (1999) To Err is Human: Building a Safer Health System. National Academy Press, Washington, DC.
16. Institute of Medicine (2001) Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press, Washington, DC.
17. Keill P. & Johnson T. (1995) Shifting gears: improving delivery of medications. Journal of Nursing Quality Assurance 7 (2), 24-33.
18. Kirk R.C., Goh L.M., Packia J., Min K.H. & Ong B.K. (2005) Computer calculated dose in paediatric prescribing. Drug Safety 28 (9), 817-824.
19. Leape L.L., Brennan T.A., Laird N.M. et al. (1991) The nature of adverse events in hospitalised patients: results of the Harvard Medical Practice Study II. New England Journal of Medicine 324 (6), 377-384.
20. Leape L.L., Bates D.W., Cullen D.J. et al. (1995) Systems analysis of adverse drug events. Journal of the American Medical Association 274 (1), 35-43.
21. Lyndon A. (2006) Communication and teamwork in patient care: how much can we learn from aviation? Journal of Obstetric, Gynecologic, & Neonatal Nursing 35 (4), 538-546.
22. Manias E., Aitken R. & Dunning T. (2005) How graduate nurses use protocols to manage patients' medications. Journal of Clinical Nursing 14 (8), 935-944.
23. Mayo A. & Duncan D. (2004) Nurse perceptions of medication errors what we need to know for patient safety. Journal of Nursing Care Quality 19 (3), 209-217.
24. McCort A., Telsavaara T., Scipio C. & Stanton J. (1995) Issues in teaching older adults how to use computers: the skills needed for younger adults to use computers. Behaviour and Information Technology 14 (2), 107-120.
25. Monroe M.A. & Graham S. (2007) An update: application of human factors concepts in healthcare industry. Paper presented at the Proceedings of the 2005 ASSE Professional Development Conference.
26. National Coordinating Council for Medication Error Reporting and Prevention (2005) NCC MERCP: the first 10 years: defining the problem and developing solutions Available at:, accessed 18 November 2008.
27. Nicholas P., Copeland T.S., Craib I.A., Hopkins P. & Buce D.G. (2008) Learning from error: identifying contributing causes of medication errors in an Australian Hospital. Medical Journal of Australia 188, 276-279.
28. Nieva V.F. & Sorra J. (2003) Patient safety in healthcare organizations: safety culture assessment: a tool for improving. Quality Safe Health Care 12, 17-23.
29. Osborne J., Blais K. & Hayes J.S. (1999) Nurses' perceptions: when is a medication error? Journal of Nursing Administration 29 (4), 33-38.
30. O'Shea E. (1998) Factors contributing to medication errors: a literature review. Journal of Clinical Nursing 8, 496-504.
31. Page A. (2004) Keeping Patients Safe: Transforming the Work Environment of Nurses. National Academies Press, Washington, DC.
32. Pape T.M. (2001) Searching for the final answer: factors contributing to medication administration errors. Journal of Continuing Education Nurse 32 (4), 152-160.
33. Pape T.M. (2002) The Effect of Nurses' Use of a Focused Protocol to Reduce Distractions During Medication Administration. Doctoral dissertation, Texas Woman's University, Houston, TX.
34. Pape T.M. (2003) Applying airline safety practices to medication administration. MedSURG Nursing Journal 12 (2), 77-93.
35. Pape T.M. (2007) Checklists with medication vest or sash reduce distractions during medication administration. Available at:, Retrieved 15 March 2009.
36. Pape T.M., Guerra D.M., Muzquiz M. et al. (2005) Innovative approaches to reducing nurses' distractions during medication administration. Journal of Continuing Education in Nursing 36 (3), 108-116.
37. Park K.S. (1987) Human Reliability: Analysis, Prediction and Prevention of Human Errors. Elsevier, Amsterdam.
38. Proctor R.W. & Zandt T.V. (1994) Human Factors in Simple and Complex Systems. Allyn and Bacon, Needham Heights, MA.
39. Raju T.N., Kecskes S., Thornton J.P., Perry M. & Feldman S. (1989) Medication errors in neonatal and paediatric intensive care units. Lancet 2 (8659), 374-376.
40. Rasmussen J. (1990) The role of error in organizing behaviour. Ergonomics 33, 1185-1199.
41. Reason J.T. (1990) Human Errors. Cambridge University Press, Cambridge.
42. Reason J.T. (1993) The human factor in medical accidents. In Medical Accidents (C.A. Vincent ed.), pp. 768-770. Oxford Medical Publications, Oxford.
43. Reason J.T. (2000) Human error: models and management. British Medical Journal 320, 768-770.
44. Sanghera I.S., Franklin B.D. & Dhillon S. (2007) The attitudes and beliefs of healthcare professionals on the causes and reporting of medication errors in UK intensive care unit. Anaesthesia 62, 53-61.
45. Santell J.P., Hicks R.W., McMeekin J. & Cousins D.D. (2003) Medication errors: experience of the United States Pharmacopeia (USP) MEDMARX reporting system. Journal of Clinical Pharmacology 43, 760-767.
46. Schulmeister L. (1999) Chemotherapy medication errors: descriptions, severity, and contributing factors. Oncology Nursing Forum 26, 1033-1042.
47. Seki Y. & Yamazaki Y. (2006) Effects of working conditions on intravenous medication errors in a Japanese hospital. Journal of Nursing Management 14 (2), 128-139.
48. Shortliffe E.H., Patel V.L., Zhang J. & Freed M. (2000) Slips, mistakes and faulty reasoning: the nature of human errors in medicine Available at:, accessed 2 January 2008.
49. Silva D.O., Grou C.R., Miasso A.I. & Cassiani S.H. (2007) Medication preparation and administration: analysis of inquiries and information by the nursing team. Rev Lat Am Enfermagem 15 (5), 1010-1017.
50. Tsang P.S. & Vidulich M.A. (2003) Principles and Practice of Aviation Psychology. Lawrence Erlbaum Associates Inc., Mahwah, NJ.
51. Ulanimo V.M., O'Leary Kelley C. & Connolly P.M. (2007) Nurses' perceptions of causes of medication errors and barriers to reporting. Journal of Nursing Care Quality 22, 28-33.
52. Uribe C.S., Pathak D.S., Dow M. & Marsh G.B. (2002) Perceived barriers to medical error reporting: an exploratory investigation. Journal of Healthcare Management 47 (4), 263-280.
53. Vincent C. (2003) Understanding and responding to adverse events. New England Journal of Medicine 348, 1051-1056.
54. Vincent C., Taylor Adams S. & Stanhope N. (1998) Framework for analysing risk and safety in clinical medicine. British Medical Journal 316 (7138), 1154-1157.
55. Walker S.B. & Lowe M.J. (1998) Nurses' view on reporting medication incidents. International Journal of Nursing Practice 4 (2), 97-100.
56. Westbrook J.I., Woods A., Rob M.I., Dunsmuir W.T.M. & Day R.O. (2010) Association of interruptions with an increased risk and severity of medication administration errors. Archives of Internal Medicine 8, 683-690.