Medicine administration errors and their severity in secondary care older persons' ward: A multi-centre observational study

Journal of Clinical Nursing

Volumn 21, Issue 13-14, 2012, Pages 1806-1815

  Kelly, Jennifer ^a,b   Wright, David ^b  

^a QUEEN ELIZABETH HOSPITAL   (United Kingdom)

^b UNIVERSITY OF EAST ANGLIA   (United Kingdom)

Author keywords

Dysphagia; Elderly; Medication; Medicine administration errors; Nurses; Nursing

Indexed keywords

AGED; ARTICLE; CLINICAL TRIAL; GERIATRIC NURSING; HUMAN; MEDICATION ERROR; MULTICENTER STUDY;

AGED; GERIATRIC NURSING; HUMANS; MEDICATION ERRORS;

EID: 84856858043     PISSN: 09621067     EISSN: 13652702     Source Type: Journal    
DOI: 10.1111/j.1365-2702.2011.03760.x     Document Type: Article

References (56)

1. Allan E & Barker K (1990) Fundamentals of medication error research. American Journal of Hospital Pharmacy 47, 555-571.
2. American Society of Hospital Pharmacists (1993) ASHP guidelines on preventing medication errors in hospitals. American Journal of Hospital Pharmacy 50, 305-314.
3. Anderson D & Webster C (2001) A systems approach to the reduction of medication error on the hospital ward. Journal of Advanced Nursing 35, 34-41.
4. Arndt M (1994) Nurses' medication errors. Journal of Advanced Nursing 19, 519-526.
5. Barber N, Alldred D, Raynor D, Dickinson R, Garfield S, Jesson B, Lim R, Savage I, Standage C, Buckle P, Carpenter J, Franklin B, Woloshynowych M & Zermansky A (2009) Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people. Quality and Safety in Health Care 18, 341-346.
6. BBC News (2006) NHS Drug Error 'Crackdown' Urged. Available at: (accessed 15 December 2010).
7. van den Bemt P, Fijn R, van der Voort P, Gossen A, Egberts T & Brouwers J (2002) Frequency and determinants of drug administration errors in the intensive care unit. Critical Care Medicine 30, 846-850.
8. van den Bemt P, Robertz H, de Jong A, van Roon E & Leufkens H (2007) Drug administration errors in an institution for individuals with intellectual disability: an observational study. Journal of Intellectual Disability Research 51, 528-536.
9. van den Bemt P, Idzinga J, Robertz H, Kormelink D & Pels N (2009) Medication administration errors in nursing homes using an automated medication dispensing system. Journal of the American Medical Informatics Association 16, 486-492.
10. British Association of Parenteral and Enteral Nutrition (2004) Administering drugs via enteral feeding tubes: a practical guide. Poster. Available at: (accessed 1 January 2009).
11. Cavell G & Hughes D (1997) Does computerised prescribing improve the accuracy of drug administration? The Pharmaceutical Journal 259, 782-784.
12. Chang Y & Mark B (2009) Antecedents of severe and nonsevere medication errors. Journal of Nursing Scholarship 41, 70-78.
13. Cheek J (1997) Nurses and the administration of medicines. Clinical Nursing Research 6, 253-274.
14. Cohen H, Robinson E & Mandrack M (2003) Getting to the root of medication errors: survey results. Nursing 33, 36-46.
15. Cousins D & Upton D (1993) Do you report medication errors? Hospital Pharmacy Practice 3, 376-378.
16. Dean B (1999) Hospital Medication Administration Errors. Their Simulation, Observation and Severity Assessment. PhD Thesis, School of Pharmacy, University of London, London.
17. Dean B & Barber N (2000) The effects of a patient's own drug scheme on the incidence and severity of medication administration errors. International Journal of Pharmacy Practice 8, 209-216.
18. Dean B, Allan E, Barber N & Barker K (1995) Comparison of medication errors in an American and a British hospital. American Journal of Health-System Pharmacy 52, 2543-2549.
19. DOH (2000) An Organisation with a Memory. HMSO, London.
20. Fair R & Proctor B (2005) Administering Medicines Through Enteral Feeding Tubes. The Royal Hospitals, Belfast.
21. Ferner R & Aronson J (2000) Medication errors, worse than a crime. Lancet 355, 947-948.
22. Fry M & Dacey C (2007) Factors contributing to incidents in medicine administration. Part 2. British Journal of Nursing 16, 676-681.
23. Garrett T & Reeves D (2009) Beliefs and attitudes that influence reporting of clinical interventions by pharmacists. Journal of Pharmacy Practice and Research 39, 99-103.
24. Gethins B (1996) Wise up to medication errors. Pharmacy in Practice 6, 323-328.
25. Gladstone J (1995) Drug administration errors: a study into factors underlying the occurrence and reporting of drug errors in a district general hospital. Journal of Advanced Nursing 22, 628-637.
26. Hand K & Barber N (2000) Nurses' attitudes and beliefs about medication errors in a UK hospital. International Journal of Pharmacy Practice 8, 128-134.
27. Hartley G & Dhillon S (1998) An observational study of the prescribing and administration of intravenous drugs in a general hospital. International Journal of Pharmacy Practice 6, 38-45.
28. Haw C, Dickens G & Stubbs J (2005) A review of medication administration errors reported in a large psychiatric hospital in the United Kingdom. Psychiatric Services 56, 1610-1613.
29. Haw C, Stubbs J & Dickens G (2007) An observational study in medication administration errors in old-age psychiatric inpatients. International Journal for Quality in Health Care 19, 210-216.
30. Ho C, Dean B & Barber N (1997) When do medication administration errors happen to hospital inpatients? International Journal of Pharmacy Practice 5, 91-96.
31. Jackson P, Heywood C, Brennan J, Islam M, Khan S, Sohanpaul R & Wright D (2007) Delivering Oral Medicines to Patients with Swallowing Difficulties in Secondary Care: A Pilot Study. United Kingdom Clinical Pharmacology Association, London.
32. Kelly J & Wright D (2010) Administering medication to adult patients with dysphagia: part 2. Nursing Standard 24, 61-68.
33. Kelly J & Wright D (2011) Medicine administration errors in patients with dysphagia in secondary care: a multi-centre observational study. Journal of Advanced Nursing, In press. Doi:.
34. Kelly J, Eggleton A & Wright D (2011) An analysis of two incidents of medicine administration to a patient with dysphagia. Journal of Clinical Nursing 20, 146-155.
35. Kreckler S, Catchpole K, Bottomley M, Handa A & McCulloch P (2008) Interruptions during drug rounds: an observational study. British Journal of Nursing 17, 1326-1330.
36. Kruse H, Johnson A, O'Connell D & Clarke T (1992) Administering non-restricted medications in hospital: the implications and cost of using two nurses. Australian Clinical Review 12, 77-83.
37. National Patient Safety Agency (2009) Safety in Doses. Improving the Use of Meicines in the NHS. NPSA, London.
38. National Patient Safety Agency (2010) Rapid Response Report NPSA/2010/RRR009: Reducing Harm from Omitted and Delayed Medicines in Hospital. NPSA, London.
39. New South Wales Health Department (2004) Severity Assessment Code (SAC). NSW Health, Sydney.
40. Nixon P & Dhillon S (1996) Medication errors in paediatrics. In UKCPA Progress in Practice Residential Symposium 96, Brighton, pp. 18-19.
41. Nursing and Midwifery Council (2008) Standards for Medicines Management. Nursing and Midwifery Council, London.
42. Ogden D, Kinnear M & Mc Arthur D (1997) A quantitative and qualitative evaluation of medication errors in hospital inpatients. The Pharmaceutical Journal 259, R19-R20.
43. Osborne J, Blais K & Hayes J (1999) Nurses' perceptions: when is it a medication error? Journal of Nursing Administration 29, 33-38.
44. Ridge K, Jenkins D, Noyce P & Barber N (1995) Medication errors during hospital drug rounds. Quality in Health Care 4, 240-243.
45. Rose D (2009) Fatal or serious NHS medication errors double in two years. In The Times Newspapers, London. Available at: (accessed 15 December 2010).
46. Smyth J (ed.) (2006) The NEWT Guidelines for Administration of Medication to Patients with Enteral Feeding Tubes or Swallowing Difficulties. North East Wales NHS Trust, Wrexham.
47. Taxis K & Barber N (2003) Ethnographic study of incidence and severity of intravenous drug errors. British Medical Journal 326, 684-687.
48. Taxis K, Dean B & Barber N (1999) Hospital drug distribution systems in the UK and Germany - a study of medication errors. Pharmacy World and Science 21, 25-31.
49. The National Coordinating Council for Medication Error Reporting and Prevention (2001) NCC MERP Taxonomy of Medication Errors. (accessed 4 March 2010).
50. Wakefield B, Uden-Holman T & Wakefield D (2005) Development and validation of the medication administration error reporting survey. In Advances in Patient Safety: From Research to Implementation, Vol. 4, Programs, Tools, and Products (Henriksen K, Battles J, Marks E & Lewin D eds). Agency for Healthcare Research and Quality, Rockville, pp. 475-489.
51. Walker S & Lowe M (1998) Nurses' views on reporting medication incidents. International Journal of Nursing Practice 4, 97-102.
52. Westbrook J, Woods A, Rob M, Dunsmuir W & Day R (2010) Association of interruptions with an increased risk and severity of medication administration errors. Archives of Internal Medicine 170, 683-690.
53. White R & Bradnam V (eds). (2006) Handbook of Drug Administration via Enteral Feeding Tubes. BPNG, London.
54. Williams S & Ashcroft D (2009) Attitudes of hospital pharmacists to reporting medication errors: insights from focus groups. Poster presentation. In ACCP/EXCP International Congress on Clinical Pharmacy. ACCP, Orlando.
55. Wirtz V, Taxis K & Barber N (2003) An observational study of intravenous medication errors in the United Kingdom and Germany. Pharmacy World and Science 25, 104-111.
56. Wolf Z (1989) Medication errors and nursing responsibility. Holistic Nursing Practice 4, 8-17.