Quality/Patient Safety

One-third of a national sample of hospital staff nurses made an error or near error over a 1-month period

During a 28-day period, one-third of a random national sample of 393 full-time hospital staff nurses reported making a medical error or near error, according to a study supported by the Agency for Healthcare Research and Quality (HS11963). Patient consequences ranged from relatively benign mishaps to potentially life-threatening events. As part of a national study that examined the relationship between staff nurse fatigue and patient safety, nurses kept a daily log that included errors or near errors that happened during their work shifts.

Overall, 119 nurses (30 percent) reported making at least one error, and 127 (33 percent) reported at least one near error, for a total of 199 errors and 213 near errors during the study period. The majority of errors and near errors involved medication administration, and many nurses attributed these mistakes to heavy patient loads and distractions and interruptions while preparing medications. However, over one- third of medication errors involved procedural errors (18 percent), charting errors (12 percent) and transcription errors (6 percent). This suggests the need for further examination of the way we currently deliver health care, cautions Ann E. Rogers, Ph.D., R.N., of the University of Pennsylvania School of Nursing.

Although 61 percent of the nurses only reported one error during the study period, 45 nurses reported making between two and five errors, and one nurse reported a total of eight errors. Also, 37 percent of the nurses stated that they had stopped themselves from making between two and seven errors. Errors were made due to giving the wrong drug (17 percent), omitting a medication (15 percent), or giving the medication at the wrong time (34 percent), at the wrong dose (24 percent), to the wrong patient (8 percent), or via the wrong route (2 percent).

See "The prevalence and nature of errors and near errors reported by hospital staff nurses," by Michele C. Balas, M.S., R.N., C.C.R.N., C.R.N.P., Linda D. Scott, Ph.D., R.N., and Dr. Rogers, in the November 2004 Applied Nursing Research 17(4), pp. 224-230.

Editor's Note: Another AHRQ-funded study on a related topic provides an overview of what is known about errors in medication administration, barriers to implementing safer practices, and current and potential mechanisms to improve medication administration. For more details, see Hughes, R.G., and Ortiz, E. (2005, March). "Medication errors: Why they happen, and how they can be prevented." American Journal of Nursing Suppl, pp. 14-24. Reprints (AHRQ Publication No. 05-R044) are available from the AHRQ Publications Clearinghouse.

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