Impact of Human Factors on Nursing Errors: A Comprehensive Review

The increasing awareness of medical errors as a significant concern in healthcare has highlighted the need for rigorous examination of contributing factors. Nursing errors, often resulting from complex interactions among various human and systemic factors, pose serious risks to patient safety. This essay explores these dynamics by reviewing relevant literature, identifying common causes of nursing errors such as communication breakdowns, inadequate staffing, and system inefficiencies, and proposing evidence-based strategies to mitigate these issues. By focusing on the integration of human factors engineering principles into healthcare practices, this analysis aims to provide insights into improving patient safety and enhancing overall care quality.

Running head: MEDICATION ERROR AS SAFETY INDICATOR OF HEALTH
MEDICATION ERROR AS SAFETY INDICATOR OF HEALTH
Name of the student:
Name of the university:
Author note:

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MEDICATION ERROR AS SAFETY INDICATOR OF HEALTH
Introduction:
Patient safety is the main motto of all healthcare centers. However the same remains the
most prominent issue in health policy and public debate. Different types of factors become
responsible for adverse patient outcomes when they are not followed properly (Nezamodini et al.
2016). Different types of falls, wrong site surgery, drug transfusion reaction, post operative
sepsis, development of pressure ulcer, and wound infection are some of the factors. Moreover
catheter related infections, preventable deaths due to inappropriate caring, skin tears, hand
hygiene compliance are also some others. However among the factors, the most important
concern which had been noted in most of the healthcare centers of the nation is medication errors
(Dolansky et al. 2013). Medication errors have various types of negative outcomes which not
only affect the reputation of the hospitals and the career of the nurse but can lead to preventable
patient deaths and poor quality lives of patients. In the present working center, medication error
has been identified as the main cause of concern for the organization. It is thereby used as an
indicator which can be used to analyze the intensity of the patient safety adherence rules
followed by healthcare professionals (Vaismoradi et al. 2015). This would be followed by a
proper improvement plan for the development of the culture of maintenance of medication
administration safety. An evaluation plan should also be proposed to monitor the change and
improvement made by the healthcare professionals in their practices and efforts made by the
organization for the development of patient safety after changes. All these would ensure
development of the culture of safety in the healthcare center ensuring the best care for patients.

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Medication administration: (Indicator of patient safety)
Medication administration is the complex as well as a multistep process which involves a
large number of activities. It encompasses prescribing, transcribing as well as dispensing and
administering drugs and at the same time monitoring the patient response to ensure safety of the
patients (Alenius and Graf, 2016). In any step, an error may take place which may affect the
entire course of medication administration severely compromising the patient health. In busy
shifts nowadays, different nurses are found in hurry as they have to handle multiple patients at
the same time. Often their multitasking can lead to severe issues when they either miss out
medication or administer wrong medication or follows improper procedures for medication.
There has been also reported incidents like many of medication error occur at the prescribing
state and also some are intercepted by pharmacists and other staffs beside nurses as well (Jun and
Lee 2014). Administration errors are accounting for about 26 to 2% among different types of
medication errors and these errors are seen to be conducted mostly by the nurses as they are the
ones who are responsible for providing medication to patients. Therefore mostly the nurses
should be most careful among the different healthcare professionals.
Literature review:
Often large numbers of factors are responsible for the occurrence of the medication
errors. One of the most important factors which are identified is inappropriate or incomplete
patient information. Often nurses do not complete the patient information chart or the medical
history of the patients is not taken completely (Lane et al. 2014). As a result, important
information gets missed out which have significant effect on the health of the patient. A patients’
name, age, birthday, allergies, weight, current labs results, vital signs and others are very

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important as they might alter the medication procedure of the patients. When such information
goes undocumented, it may harm the patients. Recent researchers are of the opinion that proper
barcode scanning of the patient’s armbands help in patient’s identity and at the same time can
confirm the reduction of the medication error related to patent information. However, several
issues regarding barcode scanning has been noted as it increase medication administration times.
Moreover the system is also not completely fail proof (Hwang and Park 2014).
Another factor that is also observed by researchers to cause medication errors are
inaccurate drug information. Often accurate and current drug information is not advisable to
caregivers or they do not develop their skills and knowledge to follow current information about
drugs. This information can come from protocols, text references, order sets, medication
administrations records and patient profiles (Karavasiliadou et al. 2014). Moreover computerized
drug information systems are also important to follow properly. Researchers are of the opinion
that nurses need to show patience and proper concentration while handling drugs so that they can
avoid wring administration of drugs thereby preventing adverse events (Van Boggaert et al.
2014).
Another issue that leads to medication errors is inadequate communication.
Miscommunication among the physicians, nurses and pharmacists often act as barriers in
effective drug information availability and therefore this should be verified. Improper
communication mainly rises from power struggle, excessive burden from over work, lack of
situation awareness and other all lead to improper information sharing for which ultimately the
patients’ lives are compromised (Scott and Henneman 2017). Many researchers are of the
opinion that in such cases SBAR method helps in minting patient safety by proper jotting down

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of information and passing of such information to different healthcare professionals which
ensures safe practices.
Another issue that also results in medication errors is drug packaging, labeling as well as
nomenclature. Often it has been noted that different healthcare centers have incidences where
nurses have delivered improper medicine to the patient mainly due to the medicines sounding
alike or looking alike (Leufer and Claery-Holdforth 2013). Medications are not sometimes
maintained in clearly labeled unit dosage packages for institutional use which result in confusion
among the nurses. Moreover, in busy schedules nurse remain in hurry and in such situation,
medication errors become common (Ignatavicius and Workman 2015). Proper methods need to
be adopted to strategically handle such cases and reduce the medication errors.
There are also many environmental factors which also remains responsible for different
medication errors. These include inadequate lighting as well as different cluttered work
environments. Moreover increased patient acuity as well as distractions during drug preparation
and during drug administration is also a reason for medication error (Makary and Daniel 2016).
Caregiver stress and fatigue also contribute to this. Heavier workloads, nursing shortage, burning
outs and others also increases workloads which have physical and mental impacts on nurses.
These result in medication errors.
Another issue which is also noted to be contributing in medication errors are insufficient
staff education and their competency. Continuing education of the nursing staffs is extremely
important for the nursing staffs for reduction of the errors (Raymond et al. 2017). Medications
which are new to the facility should be taken as the priority areas as well as teaching domains.
Proper learning with the help of the medication related policies as well as the procedures and

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protocols should remain updated to very nursing professionals. Moreover nursing grand rounds
are also ensured for proper adherence to medication guidelines (Lewis et al. 2013).
The way about how medication error acts as indicator of health:
The first way is to conduct medical reviews. It can be conducted manually as well as
electronically using text mining and text words. This would mainly involve searching for notable
events in electronic medical records, resources for performing reviews, monitoring the variability
in the terms used to label adverse events, spelling mistakes and others. Moreover a Meta-analysis
of the comparison rate of detection of non pharmacist as well as pharmacists reveal a high level
of adverse event detection by pharmacists (Alenius and Graf 2016).
The second way is the voluntary reporting of the adverse events which can be used to
measure the rates of medical errors and also adverse events. This has been stated by researchers
to be one of the most useful and beneficial method as adverse event reporting allows
professionals as well as the monitoring committee to learn from errors and saves financial cost of
reporting.
The third way is by direct observation at the bedside of the patients. This helps in
detection of errors made by omission. It helps to note errors in stages like prescription, delivery,
dispensing, administration, and monitoring. This helps in noting errors which have been not
reported by voluntary reporting
The fourth way is the traditional method where narratives of patients are noted to
measure whether ant medication error had taken place during their care in the hospital. Besides,
the hospitals may also conduct closed ended survey or open ended interviews to patient, family

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members and also the nurses for quantitative measuring of the issue and taking steps accordingly
(Jun and Lee 2014).
Improvement plan:
It has been seen that in my recent working area, complaints are noted by the family
members who have stated that the conditions of their patients have deteriorated over the stays.
They have mainly resulted from wrong medications given. Moreover, the nursing leaders have
also noticed that nurses are providing medication through wrong routes which are harming the
conditions of patients. Following this, they wanted to research further on the error indicator more
and therefore with the advice of the nursing leaders, the organization decided to implement an
improvement planning procedure (Garrouste et al. 2015). They used medication error as an
indicator for measuring the patient safety outcomes and wanted to implement proper guidelines
and initiatives so that adverse outcomes of the patients due to medication error can be prevented.
For this, they adopted the PDSA cycle which was made popular by Dr W. Edwards Deming who
is regarded by many as the father of the modern quality control. It is mainly called the PLAN-
DO-STUDY- ACT-CYCLE which is the four step model.
The first step is called the PLAN step. In this step, the main issues need to be identified
and accordingly plans are to be made. A research team was established with the main duty of
observing the practices of the healthcare professionals and noting the discrepancies observed in
the processes of the medication administrations. Secondly, they were also asked to note the
patient’s narrative about their experiences of their stay in the hospitals and would be interviewed
about what they perceive of the skills and methods of medication administration by the
professionals. Thirdly, they were also appointed to check the documents which are administered

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by the nurses regarding patient information, medication charts and others to see how they are
maintained and whether the nurses are following proper guidelines to do so. Fourthly, separate
nursing interviews were conducted to understand their view, experiences, incidents and other that
they want to discuss about regarding medication errors so that they could help the organization
with better strategies. After thorough analysis, certain issues were noted. These included
improper communication between the nurses to be one of the major factors. Both power struggle
and absence of communication skills resulted in the contribution of medication issues. For this
communication skills workshops needed to be arranged. For overcoming power struggles,
individuals were planned to be summoned for a meeting to disclose their issue with others and
resolve their distances resulting in proper relationship development. Secondly, another issue that
came to light was inappropriate practices by the nurses which were not according to the modern
guidelines. The old nurses were not accustomed with the new medications and did not know how
to administer them. They were using random procedure as they have no idea about the correct
routes of administration. For them, continuous professional development courses should be
introduced so that the senior nurses get the scope of developing ideas about the new medication
incorporated in care practices which would ensure reduction in medication errors. Thirdly,
another issue was observed by the researchers. They found that nurses were completely burned
out. They were stressed and fatigued due to overtime as nurses to patient ratio was not justifiable
to maintain patient safety (Noland and Carmack 2015). For all these, they were becoming
distracted and cannot concentrate on their work. For this, the employers and the managers should
conduct a meeting and introduce incentive schemes which would provide them enthusiasm to
work hard. Moreover, more recruitment should be done so that nurse to patient ratio is just to
maintain patient safety. Fourthly, all the cases which are reported would be discussed in a week’s

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meeting so that every nurse can understand the harmful effects that may occur and they would be
also suggested with proper guidelines which would be taught to them by nurse leaders so that
they do not continue such practices.
The next stage is called the “Do” stage. In this stage, small scale study needs to be
conducted in order to understand the probable outcomes of the strategies. The communication
workshops will be held thrice a week where mentors would help them learn communication
skills which are important to avoid miscommunication. Proper developments of relationships are
also important for overcoming the power struggle and for this meetings would be help bi weekly
where nurses would be requested to clear out their concerns and provide valuable feedback to
each other so that transparency is maintained between every individual (Roth et al. 2017).
Moreover, the open-mindedness between the nurses, more effectively they will be able to
interact and communicate for which medication errors will lessen. The next strategy that needs to
be implemented is the introduction of training sessions for the continuous professional
development for the senior nurses. They would be held thrice a week for 2 to 3 hours. These
classes will be helping the nurses to accommodate themselves with the present set of medicines
which had arrived in the market. This will also help the nurses gather knowledge about the recent
discoveries made in the field of medicines and also help them to know the proper administration
routes and dosages. The third strategy that would be implemented is the development of proper
plans by the administrative system and financial departments. They would provide proper
incentive systems which would be helping in developing enthusiasm in the nurses and would
also motivate them to work beyond the organizational goals. Motivation by the leaders and also
financial incentives will be helping in making them adhere to the rules of medication and make
them dedicate themselves more. Moreover, the organization’s human resource department should

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maintain proper nurse patient ratio and also allocate proper initiatives so that work overload does
not occur. Physical and mental impacts on nurses have negative effects on patient safety and
therefore human resource management should allocate more nurses so that work gets equally
distributed and no nurses get burnt out. Moreover, lastly an open discussion forum can be
arranged on weekends where the leaders would discuss their observations throughout the weeks
and thereby discuss the incidents with the nurses helping them to identify their mistakes. They
would also suggest the alternative action they could have taken in the scenario so that they can
also learn the various ways they could have taken which would have prevented the adverse
effects on the patients (Starmer et al. 2014). This discussion class would help them to learn from
the mistakes already made.
Evaluation plan:
The next stage is called the Study phase. In this phase, the strategies which are
implemented are reviewed. After reviewing the strategies, the results should be analyzed and
initiatives should be taken about what is learnt by the participants. For proper evaluation of the
result of the strategies, the hospital organization would be developing a monitoring committee
which would be comprised of experienced personalities of healthcare who would be assessing
the results. Firstly, the mentors of the communication workshop classes would be called for
meeting weekly along with the reports of the nursing professionals. The reports would be
containing the developments made by them in their communication skill which would help the
experts to understand the response of the nurses and the enhancement of skills they made.
Secondly, the training procedures of the continuous professional development would be
monitored and the reports of the development would also be taken from the trainers. These
would help the experts to understand whether the strategies are resulting in positive effects or are

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failing to meet the goals (Wright and Khatri 2015). The functioning of the human resource
department in allocation of the nurses should also be judged over the quality of the skills of the
nurses who are recruited. Moreover, they would also verify that the nurse patient ratio is
maintained or not, so that overload of work or stress or fatigue is not experienced by them.
Moreover, the qualities of the discussion forums will also be noted so that experts can be sure
that evidence based solutions are provided by the nursing leaders and also taking part in
development of their knowledge and skills. The most important part of the evaluation of the
strategies is to conduct interviews of the nursing professionals with open ended questionnaires
about the strategies taken for them. These would help to know their perceptions that whether
they are really helping them or required further development of modification of the plans
(Noland et al. 2017).
The next part of the cycle is the stage called ACT. This stage mainly helps to act over the
evaluation results and implement any changes if required in the strategies. The experts of the
monitoring committee will develop a file with the results if the evaluation. Following this data in
the file, important strategies will then be altered if required. If no changes are required these
strategies would be continued until the incidence of medical errors is reduced (Wright and Khatri
2015).
Conclusion:
From the entire discussion, it is quite clear that medical errors are one of the most
important indicators for patient safety and hence the quality of care provided. With the rising
incidence of patient mortality and poor quality life due to medication administration, researchers
have become quite concerned. They have discovered many factors like inappropriate

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communication, improper trainings of nurses, lack of proper environmental surrounding, fatigue
and stress, and many others result in wring medication administration. Hence, my organization
(where I work) has used the PDSA cycle to implement strategies, test their results and alter the
strategies when requited. With the help of the steps, the improvement plan can be successfully
established which will bring out positive results. Conducting of continuous professional
development classes for the senior nurses will give them scope to learn about correct procedures
that need to be followed during medication administration. Also conducting of communication
workshops will help in breaking the barriers faced by different professionals while
communication. This will ensure reduction of medical errors that occur due to absence of proper
communication or due to absence of communication skills. Moreover, the HRM departments
should be ensuring proper nurse patient ratio to reduce fatigue and stress in nurses and decrease
workload which will reduce medical errors. Discussion forums are also helpful to maintain
patient safety.

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