Medication Errors of Nurses in the Emergency Department

Journal of Medical Ethics and History of Medicine
Medication errors of nurses in the emergency department
Seyyedeh Roghayeh Ehsani1, Mohammad Ali Cheraghi2, Amir Nejati3, Amir Salari4,
Ayeshe Haji Esmaeilpoor5, Esmaeil Mohammad Nejad6
1 Department of Nursing, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran;
2Associate Professor, Department of Nursing, Faculty of Nursing and Midwifery, Tehran University of Medical
Sciences, Tehran, Iran;
3Assistant Professor, Department of Emergency Medicine, Imam Khomeini Hospital Complex, Tehran University of
Medical Sciences, Tehran, Iran;
4PhD Student in Disaster & Emergency Health, Department of Disaster Public Health, School of Public Health, Tehran
University of Medical Sciences, Tehran, Iran;
5Department of Medical Surgery, Faculty of Nursing & Midwifery, Medical Branch of Islamic Azad University,
Tehran, Iran;
6PhD candidate in Nursing, International Branch, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Corresponding Author:
Esmaeil Mohammad Nejad
Address: Floor, No. 9, Kavusi Alley, Urmia St, South Eskandari St, Tehran, Iran.
Email: [e-mail]
Tel: [phone]
Fax: [phone]
Received: 08 Nov 2013
Accepted: 11 Nov 2013
Published: 24 Nov 2013
J Med Ethics Hist Med, 2013, 6:11
© 2013 Esmaeil Mohammad Nejad et al.; license Tehran Univ. Med. Sci.
Abstract
Patient safety is one of the main concepts in the field of healthcare provision and a major component of health
services quality. One of the important stages in promotion of the safety level of patients is identification of medica-
tion errors and their causes. Medical errors such as medication errors are the most prevalent errors that threaten
health and are a global problem. Execution of medication orders is an important part of the treatment and care
process and is regarded as the main part of the nurses’ performance. The purpose of this study was to explore the
medication error reporting rate, error types and their causes among nurses in the emergency department.
In this descriptive study, 94 nurses of the emergency department of Imam Khomeini Hospital Complex were
selected based on census in 2010-2011. Data collection tool was a researcher-made questionnaire consisting of two
parts: demographic information, and types and causes of medication errors. After confirming content-face validity,
reliability of the questionnaire was determined to be 0.91 using Cronbach's alpha test. Data analyses were performed
by descriptive statistics and inferential statistics. SPSS-16 software was used in this study and
P values less than
0.05 were considered significant.
The mean age of the nurses was 27.7 ± 3.4 years, and their working experience was 7.3 ± 3.4 years. Of participants
46.8% had committed medication errors in the past year, and the majority (69.04%) had committed the errors only
once. Thirty two nurses (72.7%) had not reported medication errors to head nurses or the nursing office. The most
prevalent types of medication errors were related to infusion rates (33.3%) and administering two doses of medicine
instead of one (23.8%). The most important causes of medication errors were shortage of nurses (47.6%) and lack of
sufficient pharmacological information (30.9%).
This study showed that the risk of medication errors among nurses is high and medication errors are a major
problem of nursing in the emergency department. We recommend increasing the number of nurses, adjusting the
workload of the nursing staff in the emergency department, retraining courses to improve the staff’s pharmacologi-
cal information, modification of the education process, encouraging nurses to report medical errors and encouraging
hospital managers to respond to errors in a constructive manner in order to enhance patient safety
Keywords: medication errors, nurse, patient safety, emergency department

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Introduction
The main goals of care in health care systems
are preservation and promotion of health (1).
Patient safety is one of the main concepts in the
field of health care provision and a key factor in
maintaining the quality of health care services (2).
Preservation of patient safety is a major concern in
health care provision systems (3). According to
Valentin et al. one of the important stages of
raising the safety level of patients is identification
of medication errors and their causes (4). Since the
Institute of Medicine (IOM) raised awareness about
human errors in 2000, many attempts have been
made to improve patient safety, such as epidemio-
logical and etiological identification of medication
errors (5). Medication errors are among the most
prevalent health errors threatening patients’ safety
and are regarded as an index for determining
patients’ safety in hospitals (6). These errors are
one of the five medical errors classified by the
National Institute of General Medical Sciences (7).
The first report related to medication errors was
released in 1940 and attracted the attention of
authorities (8). Based on the conducted studies,
thousands of people die in America due to these
errors every year and financial expenses relating to
medication side effects are near 77 million dollars
in a year (9). Studies indicate that medication errors
increase hospitalization term by 2 days and
increase cost to 2000 - 2500 dollars for each
patient. Most expenses are related to hospitalization
due to inappropriate use of medicines, for example,
drug side effects, failure to take appropriate
medicine and inappropriate administration of
medicine (10). Most medication errors are commit-
ted by nurses (11,12). The reason is that nurses are
the largest therapeutic team and most of them
comply with the drug orders and 40% spend their
time in hospitals administering medicine to patients
(13,14). Medication errors of nurses can lead to
different problems such as unsuccessful and
imperfect treatment, legal problems (15), increase
of term and cost of hospitalization (16), damage to
the professional reputation of nurses (17) and
mistrust of patients and the society in the health
care system (18). Prevalent medication errors
include administration at inappropriate times,
committing errors in prescription of medicine,
overprescribing, failure to follow the proper
prescription, error in drug concentration, and
giving medicine to the wrong patient due to
improper identification of patients (19). Among the
important causes of medication errors are: a)
personal reasons such as stress, fatigue, absentmin-
dedness, error in administration of orders, reduced
attention to details, lack of satisfaction with job and
workplace, shortage of dutifulness or work
consciousness and so on; b) predisposing causes
such as shortage of educated personnel, excessive
overtime, long working days, busy environment,
provision of intensive care etc.; and c) reasons
relating to knowledge and awareness such as lack
of experience or knowledge about medications or
patient’s condition, and incorrect mathematical
calculations (20). Although there are abundant
advantages and ethical bases in elaboration and
reports of nurses’ errors, it is very difficult to
obtain accurate statistics of medication errors due
to nurses’ protection against punishment, mana-
gerial laws regarding detection of errors, absence
of an appropriate reporting and recording system,
and shortage of information (21-23). One study
conducted in England reported a medication error
rate of about 15% and nurses were responsible for
56% of these errors (24). The study by Simpson et
al. showed that 71% of errors were due to imper-
fect prescriptions and 29% were due to dose
calculation of medications, and the most prevalent
types of errors were no administration, inappro-
priate medication, and medication at inappropriate
time (25). In Iran, a study by Penjvini in Sanandaj
showed medicinal errors occurred for 16.7% of the
nurses and the most common types of medicinal
errors were omission of medicine and inappropriate
dosage (26). Overall, in the third world and
developing countries, it is difficult to acquire
accurate estimates due to absence of a proper
recording and reporting system and shortage of
research information, but experts speculate that the
rate of these errors is high, and the increasing
number of complaints against health care team in
courts and to judicial authorities also confirms this
(27). Identifying the types of errors is the first step
toward preventing them, and according to the
findings of this paper, one can face the problem of
medication errors as a nurse or trainer during
professional activity. Accordingly we aimed at
conducting a study on medication errors and their
causes in order to find out the number of recalled
committed medication errors per nurse over the
course of his/her nursing career, and the rate of
medication errors reported to nurse managers using
incident reports, in the nurses of the emergency
department.
Method
In this descriptive study, 94 nurses of the emer-
gency department of Imam Khomeini Hospital
Complex were selected based on census from 30
June, 2010, to 30 June, 2011. This complex is the
largest educational and therapeutic center of the
Tehran University of Medical Sciences (TUMS)

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which accommodates more than 1300 hospital beds
and includes three independent hospitals and a joint
emergency department for those three hospitals.
The information gathering and data collection
tool was the self made questionnaire prepared and
adjusted by the researchers based on literature
reviews and scientific papers (17, 28, 29).
A questionnaire of two parts was prepared as
follows: the first part aimed to collect the demo-
graphic information of the nurses (gender, age,
level of education, work shifts, type of employ-
ment, and years of experience in nursing); the
second part was related to the type and causes of
medication errors.
In this research, medication errors have been
defined as ‘any medication administered or
prepared in a way that deviates from the prescrip-
tion chart, the manufacturer’s instructions and
hospital policy which can be prevented and may
cause injury to the patient’ (30).
Face and content validity of the questionnaire
were assessed by previous studies, books and
through asking 10 members of Faculty of Nursing
of TUMS to comment on the questionnaire, and by
considering their correctional comments. The
reliability of the questionnaire was determined
using Cronbach's alpha test (r = 0.91).
In order to comply with ethical considerations,
the researchers explained the aim of the study to
the study participants and then they were assured
that the information will be confidential; also the
questionnaire was anonymous and participation in
the study was optional.
Inclusion criteria of nurses in this study was
considered as physical and mental health, working
in the emergency department for at least 6 months,
and holding a bachelor’s degree or higher. The
study protocol was approved by deputy of the
research of the Imam Khomeini Hospital Complex.
Data analyses were performed by descriptive
statistics (frequency, mean, median and standard
deviation) and inferential statistics. SPSS software
version 16 (SPSS Inc., Chicago, IL, USA) was
used for statistical analysis and
P values less than
0.05 were considered significant.
Results
All questionnaires were returned to the re-
searchers after being completed. The average age
of the studied nurses was 27.7 ± 3.4 years and their
working experience was 7.3 ± 1.9 years. Of
participants 59 nurses (62.7%) were married, 82
nurses (87.2%) were female, and 42 nurses (46.8%)
had committed medication errors in the past year.
Majority of the nurses (69.04%) had committed
medication errors only once, and most (88.3%)
held bachelor’s degree while the rest of them held
higher degrees. The mean overtime of the study
participants was 83.4 ± 43 hours per month and
54.2% of the nurses had fixed work shifts. The
routine performance in ED is case method.
According to the nurses’ comments, fortunately, no
complication had arisen in most cases of medica-
tion errors (97.5%). The most prevalent type of
medication error was related to errors in infusion
rates, administration of two doses of medicine
instead of one and omission of medicine. In Table
(1), types of medication errors have been reported.
Table 1. Types of medication errors
Medication Error Types Number Percent
Omission of medicine 6 14.2
Medication at inappropriate time 3 7.14
Mistaken medication 5 11.9
Administration of two doses of medicine instead of one 10 23.8
Giving medicine of a patient to another patient 4 9.5
Wrong infusion rate 14 33.3
The most prevalent causes of medication errors
in organizational and human domain is a high
patient -to- nurse ratio in the ward, insufficient
pharmacological knowledge, fatigue resulted from
hard work, and use of abbreviated names (Table 2).
Table 2. Distribution of factors affecting the incidence of medicinal errors
Factors Affecting Medication Errors Number Percent
Medical Factors
Large variety of drugs in the ward 2 4.2
Using abbreviated names 23 48.93
Similarities among drug names 11 23.40
Using some drugs in the rare cases 2 4.20
Different medicinal dosages 9 19.14
Managerial and Human Factors
Fatigue resulted from hard work 9 19.14
High patient -to- nurse ratio 6 12.76