Nurses' perceptions of factors leading to the discovery of potential medication administration errors.

摘要

Current research in medication administration errors has focused on factors associated with error and retrospective analysis of why such errors occurred rather than description and discovery of potential medication administration errors. Nurses are intimately involved in the administration of medications; therefore an understanding of factors contributing to the discovery of potential medication administration errors is essential. The purpose of this study was to describe nurses' perceptions of ways potential medication administration errors were discovered and to describe their feelings toward reporting of potential errors.;A narrative inquiry research design using a purposive sampling strategy was used to elicit nurses' stories of near miss medication errors. In-depth audiotaped interviews were conducted with 14 registered nurses. Transcribed data were analyzed using narrative inquiry techniques to identify essential elements of the stories (orientation, complication, triggers, evaluation, resolution and coda). Categories and patterns were identified and integrated into a descriptive narrative, culminating in an overarching theme, the Awakening Process.;The Ways of Discovery pattern revealed ways nurses discovered potential medication administration errors through critical thinking, information sharing and researching the complication. Triggers to identification of potential errors included sensory, intuitive, critical thinking and patient questioning. Potential Reporting patterns included tracking and trending, education leading to prevention, punitive issues, and increased paperwork.;Most significant to this research was the emergence of the Awakening Process that began with the discovery and prevention of a potential medication administration error. Upon discovery the nurse experienced an awakening to the potential harm she/he may have caused the patient with a resulting emotional response. The nurse then reflected on the event to analyze and make sense of the potential medication administration error. Nurses considered contextual factors to determine how the error could have occurred. An intentional change in practice resulted with heightened awareness and deliberate or purposeful nursing practice in attempt to prevent future occurrences. Nurse participants recognized the human element as well as system issues inherent in medication administration errors. Implications for nursing should focus on information sharing of near miss trends, incorporation of trigger patterns into curricula, multidisciplinary team prevention and problem solving, and no fault error reporting.