Journal of Medical Ethics: Medication Errors in Emergency Departments

This report presents a descriptive study conducted on 94 nurses in the emergency department of Imam Khomeini Hospital Complex, Tehran, Iran, examining medication errors. The study, published in the Journal of Medical Ethics and History of Medicine, investigated the prevalence, types, and causes of medication errors among nurses. Findings revealed that 46.8% of the nurses had committed medication errors in the past year, with infusion rate errors and administering incorrect dosages being the most prevalent. The study identified factors such as nurse shortages and insufficient pharmacological knowledge as key contributors to these errors. The research highlights the need for increased staffing, workload adjustments, retraining, and improved error reporting to enhance patient safety in the emergency department setting. The study used a researcher-made questionnaire and statistical analysis to derive its conclusions, emphasizing the significance of addressing medication errors as a major concern in healthcare.

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

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Insufficient education 2 4.2
insufficient pharmacological knowledge 13 27.65
False medicinal calculations 4 10.63
Illegibility of patients records 7 14.89
Illegibility of physicians’ prescriptions 4 8.51
The rate of under-reporting of medication errors
by nurses was 72.7%. Examples of the reported
medication errors by nurses were presented in table
3. There was no statistically significant relationship
between demographic specifications (age, gender,
education) and job specifications (type of ward,
work experience, monthly overtime) and medica-
tion errors committed by nurses ( P > 0/05).
Table 3. Examples of reported medication er-
rors by nurses
- Mistaken infusion rate of nitroglycerine and
dopamine
- Reconstituting antibiotics in dextrose 5%
serum instead of normal saline
- Giving nitrocontin tablet instead of warfarin
- Giving 80 mg aspirin tablet instead of 325 mg
aspirin tablet or vice versa
- Preparing 10000 units heparin instead of 5000
units
- Intradermal injection of insulin instead of
subcutaneous injection
- Venous injection of antibiotics such as cefazo-
lin and ceftriaxone instead of venous infusion
(microset)
- Giving 6.4 mg nitrocontin tablet instead of 2.6
mg tablet
Discussion
This study showed that half of the nurses com-
mitted medication errors. The extent of medication
errors committed by nurses in different studies
varied from 67% in Stratton et al. study (31), 43%
in the study by Lisby et al. (32), 42.1% in the study
by Mrayyon et al. (7) to 10% in the study by
Koohestani et al. (17). The great difference in
medicinal error rates in this study compared to
similar findings in other countries can result from
the negative reaction of colleagues, trainers and
managers after giving reports (33), lack of medica-
tion monitoring, absence of a proper recording and
reporting system (6), bad condition of patients,
unpleasant physical conditions, noise and over-
crowding (34).
The results of this study showed that the most
common errors were associated with wrong
infusion rates and giving two doses of medicine
instead of one. In a study in Jordan, the most
common types of medication errors were wrong
patient and wrong dose (35). In a study on the
incidence of medication errors among Iranian
nurses, Nikpima et al. concluded that the most
common medication errors were wrong do-
sage,medication omission and medication adminis-
tration at inappropriate times (6). Cheraghi et al.
detected 64 nursing medication errors including
mistaken infusion rates (44%), inappropriate
dosage (23%) and wrong administration times
(12%) (21).
According to our findings, shortage of nursing
staff, inadequate pharmacological knowledge and
fatigue resulting from high workload were among
the managerial and human factors associated with
medication errors. Hosseinzadeh et al. suggested
the most important reasons for medication errors as
shortages of nursing staff, nursing burn-out and
high workload (36). Al-Shara observed that many
medication errors were due to heavy workload
(41.4%) and new staff (20.6%) (35). In contrast,
Stratton et al. reported that only 5% of the nursing
staff considered lack of knowledge as an effective
factor affecting the incidence of medication errors
(31). In a study in United States, 42% of the nurses
mentioned that there was no factor causing their
error while 23.6% referred to carelessness and
distraction of nurses, and 11.3% referred to long
working hours as the factors causing medication
errors (30). Anoosheh et al. reported that 69 nurses
and nursing managers believes that factors such as
unsuitable work shifts, shortage of manpower,
shortage of suitable equipment, performance of
duties unrelated to the care role of nurses and lack
of awareness caused working errors in nursing
(37). Carelessness of nurses during execution of
drug orders is a very important subject which is
affected by different factors such as fatigue caused
by high work load. It seems that changes are
required in the working conditions of nurses in
order to reduce human errors (16). In different
studies, inadequacy of job training and insufficient
knowledge of the graduates are mentioned as the
causes of medication errors (38).
The results of this study showed that use of
abbreviated names and similarities in drug names
were among the medical factors associated with
medication errors. Micro et al. studied the process
of drug prescription in internal wards for two years
and mentioned that the most prevalent causes of
medication errors were illegibility of drug orders in
patient records (13.3%), error in preparation of
drug (30%) and error in prescription of drugs
(28.3%) (40). All of these errors are related to
pharmacological information and many nursing
researchers mention raising nurses’ pharmacologi-
cal knowledge as a serious strategy for reducing
medication errors, and conclude that updating the
information of nurses and nursing students about

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medicines and in particular new medicines can be
an important factor in reducing medication errors
(41). Lack of pharmacological knowledge is one of
the most important factors affecting medication
errors, although the risks relating to medicines and
their side effects are not limited to the nurses and
many defects can be found during prescription,
distribution and execution of orders (42).
In this study, 72.7% of the nurses never reported
these errors. The rate of reporting medication errors
among nurses was far less than the medication
errors they had made. A study conducted in Jordan
by Mrayyan et al. revealed that 42.1% of the nurses
had made at least one medication error in their
career (7). In other studies, the number of medica-
tion errors reported by the nurses was less than the
real value (43). Although the disparity between the
number of medication errors committed in the
emergency department and their reporting rate is
desirable to the authorities, it can be quite worri-
some for the therapeutic system. Report of medica-
tion errors can prevent potential harms to patients
and is also regarded as a valuable information
source for preventing similar medication errors in
the future. The most important motivation of
reporting medication errors should be protection of
the health and safety of patients and prevention of
potential harmful effects of medicines in patients
(17).
It is evident that the low rate of medication
errors is desirable for authorities, but it should be
noted that minimization of the gap between errors
and their report should also be considered as an
important matter. Studies show that medication
errors are one of the important problems in health
care system and more importantly, prevention of
these errors depends on their accurate report (37).
In addition, these reports can be a way of better
managing medication errors and preventing their
emergence in the future. It should be noted that
executive managers and trainers should not
consider the negative undesirable results of these
reports and punish the nurses, but they should try to
remove the barriers of report and should ethically
and legally compensate for the damages and side
effects caused by nursing errors as far as possible
(44). For this purpose, nurses should consider the
principle of honesty as a virtue based on Aristotle’s
teachings and should be encouraged to report
medication errors considering patient’s benefit, that
is, perform an ethical task for maximization of
benefits (45).
Although the confidentiality of demographic
and information data was ensured and all identifia-
ble data such as name and surname were eliminat-
ed, the participants may have provided incorrect
answers to the questions as a result of fear of
disclosure which can be considered as the limita-
tion of our study.
Conclusion
Today, reducing medication errors and improv-
ing patient safety have become common topics of
discussion in health care systems. Despite in-
creased attention to patient safety and the quality of
health care services, medication errors are still
frequent in the ED. 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. The rate of reporting
medication errors among nurses was far less than
the medication errors they had made and this
indicates a gap between the actual rate of medica-
tion errors and the reporting rate among nurses. We
recommend increasing the number of nursing staff,
adjusting the workload of the nurses in the emer-
gency department and retraining courses aiming to
improve nurses’ pharmacological information, and
to modify the education process, encourage nurses
to report medical errors and encourage hospital
managers to respond to errors in a positive ethical
and logical manner in order to enhance patient
safety.
Acknowledgement
This paper was enacted on 25 June 2010 under
registration No. M/P/524 in the office of the
research deputy of Imam Khomeini Hospital
Complex of TUMS, and was completed on 7 July
2011 (letter No. M/P/673). We hereby appreciate
all nurses participating in the present research who
sincerely cooperated in obtaining the results.
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