1. Burke, Kathleen G. PhD, RN

Article Content

The University of Pennsylvania School of Nursing, the Hospital of the University of Pennsylvania, the Infusion Nurses Society, and the American Journal of Nursing held an invitational symposium in Philadelphia on July 16 and 17, 2004. The goals of the symposium were to determine research priorities and to make clinical education and policy recommendations to ensure safe medication administration.


The symposium, supported by a conference grant from the Agency for Healthcare Research and Quality (AHRQ 1 R13 HS14836-01) and by unrestricted grants from manufacturers of pharmaceuticals and other products designed to promote safe medication administration, was attended by 40 nursing and professional experts. Nurses in clinical practice, administration, education, and research, as well as leaders in regulatory and consumer sectors and representatives from industry (for example, product manufacturers), addressed the following objectives:


* to describe the state of the science on safe medication administration


* to delineate barriers to safe administration of medication


* to develop approaches to overcoming barriers to safe medication administration


* to identify gaps in research aimed at facilitating and improving the safety of medication administration by nurses


* to recommend clinical, educational, research, and policy priorities to ensure best practices for safe medication administration in a variety of settings, including pediatrics and geriatrics


* to create strategies for disseminating the findings and recommendations to nurse researchers, nurse educators, clinical nurses, health care professionals, policymakers, industry leaders, and advocacy groups




In 2000 the Institute of Medicine (IOM) report To Err Is Human: Building a Safer Health System drew national attention by estimating that medical errors are the eighth-leading cause of death in this country each year.1 Medication errors are the most common types of such errors,2 accounting for more than 7,000 deaths annually.1 It's estimated that five medication errors occur per 100 medication administrations.3 Adverse drug events (ADEs) occur at an estimated rate of 6.5 per 100 hospital admissions; 28% are considered preventable.4


One of every three ADEs related to medication errors occurs when a nurse administers medications.5 Classen reported that 56% of medication errors are related to prescriptions.6 Nurses were blamed for medication errors even when the source was traced to the prescriber of the medication.7 IV medications and infusion pumps are also being increasingly viewed as safety concerns.8, 9


Most medication errors occur at patient care-transition points. Nurses serve important roles at such points, which include hospital admission, transfer from one unit to another, and discharge to home or another facility. During these transitions, the transfer of medication information often is incorrect or incomplete.10 An estimated 46% of all medication errors occur during such transitions.11


Although physicians, pharmacists, sociologists, and psychologists have conducted and published extensive research on safe medication administration, publications in this area from a nursing perspective are scant. The nursing literature has focused primarily on the potentially adverse consequences of the nursing shortage, without specifically addressing the science of human errors.12


Lucien Leape, MD, MPH, an advocate of systems-based approaches to reducing health care error from Harvard School of Public Health, has discussed the increased frequency of adverse events and the significance of using organizational systems in reporting errors.13 Yet a scientific approach to this issue has not been proposed. Other researchers have independently investigated nurse staffing levels and their relationship to quality of care, mortality, and morbidity.14, 15 Although the research teams discovered correlations between staffing ratios and patient outcomes, they did not specifically address measurable relationships between nurse staffing levels and medication error and safety.


A recent study examined how nurses' work environments affect medication errors.16 It demonstrated the prevalence of extended work periods and considered the effect of this on patient safety. The researchers found that the risk of making an error increased when hospital nurses worked more than 12 hours per shift, worked overtime, or worked more than 40 hours per week.


Since 1996 the IOM has made a concerted effort to assess and improve the quality of health care in the United States. In three reports, the IOM addressed this quality initiative,1 presented a vision for effecting change in the health care system,17 and identified the need for transforming the work environments of nurses.18 Among the topics covered were the effects of extended work shifts, mandatory overtime, and caregiver fatigue on care quality; nurse staffing issues (including education levels and nurse-patient ratios); workplace processes such as documentation of patient care; data support systems; and communication among health care team members.


The Joint Commission on Accreditation of Healthcare Organizations' National Patient Safety Goals for 2005 and 2004 address several areas related to medication administration.19 The relevant 2004 goals include improving the accuracy of patient identification, the effectiveness of communication among caregivers (for example, by standardizing abbreviations, acronyms, and symbols used throughout an organization), and the safety of high-alert medications. New goals for 2005 include one that specifies "accurately and completely reconcil[ing] medications across the continuum of care."19


The American Nurses Association (ANA) has spearheaded national quality initiatives. Also, the American Organization of Nurse Executives conducted an audio series titled "Creating a Culture of Safety" in December 2000. The ANA sponsored Leape to speak about patient safety and medical errors at its 2002 convention. On September 24, 2002, ANA president Barbara Blakeney testified before the IOM committee working on the report Keeping Patients Safe: Transforming the Work Environment of Nurses, stating that nurses "must have decision-making authority and professional autonomy at the point of care delivery" and that "it is time to actively invest in research around staffing, fatigue, safety, and outcomes."20



The symposium began with two presentations that were followed by a reception. Victoria Rich, PhD, RN, presented an overview of research and practice issues regarding safe medication administration. Ilene Corina, president of Persons United Limiting Substandards and Errors in Health Care (PULSE) of New York, described tragedies caused by errors in health care delivery and discussed the importance of the educated consumer in reducing the risk of errors.


On the second day, three scheduled speakers summarized the state of the science on safe medication administration, including gaps in existing research and directions for future research. Participants were able to review the speakers' papers beforehand. After each presentation, a respondent made brief remarks. The papers covered the following topics:


* barriers to safe medication administration (Ronda G. Hughes)


* barriers to safe administration of infused medications (Christine R. Agius)


* medication reconciliation across settings (Jane H. Barnsteiner)



An industry panel then addressed the role of technology in overcoming systems issues, as well as professional issues at various points of care. Symposium participants formed small groups to talk about the gaps in research and the barriers to safe medication administration faced by professionals in nursing practice, education, administration, and policy. For each barrier, the groups listed three ways that it has been traditionally approached and suggested five new approaches. From these eight possibilities, each group selected the three best strategies to overcome, reduce, or eliminate the barrier.



During a plenary session, each group presented the barriers it had identified (see Table 1, page 5) and recommended numerous strategies to address the most common barriers (see Table 2, page 6). Symposium participants also identified and prioritized areas for research (see Table 3, page 8).

Table 1 - Click to enlarge in new windowTABLE 1 Common Barriers to Safe Medication Administration
Table 2 - Click to enlarge in new windowTABLE 2 The Seven Most Significant Barriers to Safe Medication Administration and Strategies to Address Them
Table 2 - Click to enlarge in new windowTABLE 2 The Seven Most Significant Barriers to Safe Medication Administration and Strategies to Address Them (Continued)
Table 3 - Click to enlarge in new windowTABLE 3 Priorities for Research On Safe Medication Administration
Table 3 - Click to enlarge in new windowTABLE 3 Priorities for Research On Safe Medication Administration (Continued)

After discussing issues that had been raised during the symposium, participants were enthusiastic about empowering nurses to work toward safer medication administration. This effort begins with dissemination of the information generated at the symposium.




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