Literature Review | Medication Errors

The focus of my scholarly project is to address the following clinical question: Does improved barcode scanning reduce serious medication errors for patients with acute medical and psychiatric conditions who are inpatients in a PMU? The focus of this literature search is to describe studies supporting current information about medication errors and, and more precisely, medication administration errors. The ability of state-of-the-art information technology to reduce serious medication administration errors is debated. Examples of subjective publications and relevant research-based reports on bar coding for medication administration and the bar code medication administration system are evaluated.

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A fundamental role of nursing professionals is to ensure the receipt of quality care, as well as the patients’ safety throughout the duration of their hospitalization. Similarly, patients expect quality care to be provided by their caregivers. Nurses are most intimately involved in the delivery of general health care practice, yet also are in the position to assume responsibility for the care of a patient in the acute phases of terminal illnesses and diseases, which put more demand on the nursing role. Within the last decade, the U. S. healthcare system has undergone a great scrutiny, both politically and societally, as a result of various reports and statistics that indicate a lower quality of care being provided and higher incidence rate of medical errors by healthcare professionals resulting in harm/injury to a patient (Institute of Medicine (IOM), 2000; Kohn, Corrigan & Donaldson, 1999). More specifically, in 1999 there were between 44,000 and 98,000 reported deaths in hospitals nationwide attributed to preventable medical errors by hospital healthcare professionals (IOM, 2000). Due to these alarming statistics and scrutiny by healthcare policies and insurance providers, researchers have honed in on the issue and potential strategies to addresses the issue of medical errors. Specifically, researchers have worked aimlessly to better understand the issue of medical errors by identifying and further specifying variables associated with higher reports of incidence rates of medical error and providing recommendations on approaches to better remedy the issue of medical errors in hospital-based settings by nurses (Leape et al., 1991; Thomas et al., 2000).

A Brief Overview. Nationwide reports of hospital statistics and ongoing research have identified medical errors to play a significant role in the current state of the U. S. healthcare system, which is being scrutinized for poor quality of care, staff shortages, and inability to ensure continual patient safety. Medical error(s), per the IOM report, can be defined as, “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim” relative to a patient’s treatment on behalf of hospital healthcare professional(s) (Kohn et. al., 1999, pp.54). Such examples may include admission of incorrect dosage of patient medication, adverse drug interactions, patient falls, wrong-site surgical procedures, pressure ulcers, and death of the patient. Researchers have honed in on the broad issue of medical errors by categorizing the various types of medical errors reportedly experienced by patients while under hospital care. One type of medial error that is to be of particular concern is that of medication errors, as it accounts for two-thirds of all medical errors reported and the most common type reported in patient questionnaires on their hospital experience (Low & Belcher, 2002).

Medication Errors. Research on medication errors, results, and resolutions has been continuous for over three decades. The Harvard Medical Practice Study was commence in 1984 using data from a random sample of hospitals in New York State (Brennan, et al., 1991).(For purposes of assessment here this study will be referred to as the New York study.) Added analysis of data from the New York study by Leape et al., (1991) found difficulties associated with drugs were the highest (19.4%) non-operative source of adverse events (Leape et al., 1991). Even though those drug related events were defined to be mainly unpreventable, due to unexpected reactions such as drug allergies, or to anticipate side effects of treatment such as chemotherapy, in a third publication Leape and colleagues (1993) suggested that drug related adverse events receive additional consideration in error prevention research.

Additional research was piloted in Utah and Colorado, grounded on data collected in 1991 and endeavored to reproduce the New York state methodology (Thomas, et al., 2000). From a layered convenience sample of hospitals, a random sample of discharges were selected by medical personnel and accepted for additional review if potential adverse events were exposed. Adverse events related to medications were discovered to have the second greatest frequency (19.3%), second to operative causes. Thomas and colleagues reasoned that the risk for adverse events, predominantly duet medications was comparatively unchanged since the New York study. They agreed with the recommendation of the New York study team that new system-level methodologies to develop patient medication safety were desired (Leape et al., 1995).

Classen, Pestonik, Evans, & Burke (1991), Bates, Cullen, et al. (1995), directed three successive studies and Bates, Boyle, et al. (1995), added innovative evidence regarding rates of adverse drug events. These were prospective studies but used dissimilar denominators for measuring adverse drug events. Each study also engaged different adverse discovery methods.

Classen and colleagues (1991) established a computerized monitor that was programmed to catch possible adverse drug event indications, for example, abnormal laboratory results and specific medications when discontinued or ordered. On a regular basis, a pharmacist examined the records of patients recognized as having experienced a potential event. Only adverse drug events (as opposed to medication errors) were stated. A total of 731 adverse drug events were identified in 648 patients over 36, 653 admissions for an adverse drug events rate of 1.67%, or 1 adverse drug event per 50 admissions.

The first study by Bates, Cullen, et al. (1995) concentrated on adverse drug event occurrence and recognized adverse drug events through a blend of independent and encouraged self-report and regular chart reviews. Corrected rates of 6.5 adverse drug events per 100 admissions were recorded or one adverse drug event per 15 admissions. A total of 334 medication errors were connected with 247 recognized drug events in; a second article describing that study (Leape et al., 1995). Based on 2,412 patient-days, there were 0.02 errors per patient-day or one error per 64 patient-days.

The Bates, Boyle, et al. (1995) study more carefully examined the association between medication errors and adverse drug events using self-report and patient chart reviews. A total of 5 adverse drug events occurred over 379 admissions, a rate of 1.3% or 1 adverse drug event per 76 admissions. Overall, 530 medication errors were identified over 1704 patient-days, indicating 0.3 medication errors per patient-day, or about 1 error per 3 patient-days.

Although these three studies donated to existing knowledge concerning medication errors and drug events, the absence of consistency of methods and how error rates were calculated has been a barrier to stronger understanding of the scope of the medication error problem. Nevertheless, Bates and colleagues in two different studies (1995aand 1995b) continued to scrutinize the medication errors in more detail, further revealing suitable efforts for reducing errors.

Nursing Medication Administration. The two studies discussed in the earlier section also offered some information on how errors were disseminated by the phase in the medication process. At one hospital Boyle, et al. (1995) recognized 530 errors in 10, 000 medication orders. The dissemination of errors was missing does (53%), other dose errors (15%), route (5%), and frequency (8%).

In the second study, Bates, Cullen et al. (1995) classified adverse drug events, and a medication error related with each by step in the medication process. Ordering errors (56%) and administration error (34%) accounted for the bulk of the medication errors. From this same data, the incidence of medication adverse events (MAE) was described in a total of 334 errors: wrong dose (27%), wrong medication (12%), wrong time (7%), and wrong route (2%) (Leape, et al., 1995).

These conclusions had suggestions for designing information technology interventions focused at the ordering and administration steps. Predominantly designed to control ordering errors, computerized provider entry programs became the theme of development and research.

Not long ago, a study piloted in a randomized sample of hospitals in Colorado and Georgia recognized types of administration errors by observation (Barker, 2002). Generally, there were 605 MAEs observed in the administration of 3, 216 doses. The MAEs were disseminated as follows: wrong time (43%), omission (30%), wrong dose (17%), and unapproved drug (4%). The authors determined those findings reinforced the Institute of Medicine’s report of unnecessary medication errors.

Bar Coding Innovation. Limited evidence was obtainable from health care literature on the success of bar coding for medication administration but the technology has been testified to decrease error in other industries (Bates, 2000). Over the last few years, publications have conveyed reductions in medication error rates in hospitals that have embraced medication administration bar code applications (Puckett, 1995; Thielke, 2003). The outcomes and deductions have incomplete value due to their subjective nature but do demonstrate how bar code innovations for medication administration have been coordinated, developed, and rationalized by some hospitals as a hopeful approach to reducing medication errors. Two articles will be reviewed here as examples of the kind of information available about the effectiveness of bar coding for medication administration.

A patented bar code system was implemented as a piece of point-of-care information system in one regional medical center (Puckett, 1995). After choosing the patient’s name or scanning the wristband bar code, and the medication bar code, the medication system would approve the match for the patient, medication, dose, route, and time. If an error were discovered, the system would create an alert to the nurse. Founded on incident report data this facility reported total medication error rates per number of doses administered pre-implementation (0.17%), after using the bar code scanning for one year (0.07%), and after 2 years of use (0.05%). Correcting for patient days, reductions in wrong drug (33%), wrong time (43%), and omitted doses (52%) were conveyed. No changes in rates occurred for the wrong patient (5%) or wrong dose (18%). There was no information about the timeframe expended to measure for change, for instance, one year post-implementation or two years.

A second illustration came from a university medical center that used a different brand-named bar code system (Thielke, 2003). One unit with twenty-eight beds directed the system. No timeframe was specified for elapsed time between measurement goals. The author conveyed an annualized error rate pre-implementation of 9.09% based on direct surveillance for seventeen days. The report projected that 11, 518 medication administration errors could be eliminated yearly for that unit, from13, 340 to 1,822 annually. The stated change in types of medication errors were reduced significantly over time: wrong dose and wrong dosage form errors decreased by 100%, by reductions for omitted doses (92%), wrong time (77%), and wrong drug (51%).

In contrast, a more methodically demanding review of research-based bar coding literature was accomplished as part of a review of a variety of information technologies designed to reduce medication errors and adverse drug events (ADE) (Oren, Shaffer, Guglielmo, 2003). Seven prospective studies from 1988 to 1997 met the criteria for inclusion in the review, but none was explicitly about bar code medication administration systems. In its place, materials management, pharmacy inventory, dispensing and data entry, and billing were where the applications were implemented. Five of the studies measured medication errors and ADEs as outcomes. This article did not offer details of those studies maintaining a positive influence on errors and ADEs, but decided that the current research was not satisfactory enough to draw any conclusions concerning the efficiency or advantages of any of the technologies on reducing medication administration errors.


This literature review is characteristic in its demonstration of the progression of the research on the frequency of medication errors and adverse drug events to explicit medication administration error incidence. Studies of medication errors described the dispersal of errors by phase of the medication process, in which medication administration had the second highest rate of occurrence. Contained within the medication administration phase, the variety of medication administration errors was also described.

The pre-bar coding studies have supplemented the knowledge about the scope of problems with medication administration. Evolving information technology strategies to decrease medication administration errors has been endorsed. Subjective and research studies on one intervention, bar code scanning was undertaken. Comparison of the research and subjective reports exposed a continued gap in data detection methods, measurement, and analysis, revealing the state of science in this arena and prospects for improvement. These studies illustrate that much work remains to be completed before significant comparative analysis of outcomes can transpire.

The overall quality of the research on medication errors remains to be a matter of debate because of the various methodological approaches utilized within the research and in turn, the discrepancies in data from one study to another. The primary strength underlying the medication research is the ongoing efforts to better identify and specify various components of such a broad topic. The research has assisted in advancing the terminology used to discuss medication errors with hopes of providing a more unified definition in order to increase the framework from which nurses work from and improve the amount of barriers associated with reporting medication errors among nursing and healthcare professionals alike. Despite the advances in the terminology and efforts of researchers focusing on this topic, there remains to be a strong foundation from which statistical information can be obtained and in turn, has impeded the strategically based approaches being implemented in hospital settings to address/rectify this issue. However, the basis of the research on potential solutions is promising in that the majority of the research points to the use of information technologies, in conjunction with various other measures, have shown to be associated with a decrease in reported medication errors. With more concise methodological and statistical data, it is without a doubt that ongoing research will be better able to address the use of medication errors and itsaa‚¬a„? impact on overall patientsaa‚¬a„? perception of quality of care, in order to eradicate the skepticism surrounding the quality and efforts of the U.S. healthcare systems and itsaa‚¬a„? associated healthcare professionals, particularly the role of the nurse.