Purpose:

While medication errors have received extensive national attention in recent years, there is little definitive research to identify either what the probable causes of these errors are or the evidence-based interventions to eliminate them. The purpose of this research was to identify factors contributing to medication safety gaps in a complex acute care setting.

Significance:

Evidence must be utilized to drive professional practice, develop safe and efficient medication administration processes, and promote clinical quality and patient safety. The CNS is key in evaluating systems and improving processes to reduce errors.

Background/Design:

This was a multiphased exploratory qualitative research design.

Methods:

A Human Factors Process Analysis was used. It consisted of 3 phases: (1) analysis of medication error reports, (2) observation of work flow on 3 inpatient units, and (3) solicitation of insights through focus groups held with staff nurses. Each phase of the research informed subsequent phases.

Findings:

Key elements that could contribute to medication errors were identified in various systems and processes. These include the physical environment, leadership, education and competence, culture, and individual accountability.

Conclusions:

A significant strength of this research was the unique collaboration between CNSs and human factors researchers. A human factors perspective helped to identify critical issues contributing to errorsand system flaws. This collaboration resulted in a synergistic analysis of workflow patterns and uncovered some difficulties nurses routinely encounter. Future systems should be designed to optimize professional performance while mitigating unsafe individual performance that occurs outside established parameters of practice.

Implications for Practice:

The researchers' utilized knowledge gained from this study to recommend systems improvements for the safety of administering medications. Immediate interventions that can be implemented to enhance patient safety are identified. Effective educational tools for nurses highlighting safety in the medication administration process will be developed. This study will also lead to future research utilizing simulated scenarios.