Int J Pharm Pract 2000:8:128-34

Pharmacy Department, Kingston Hospital, Galsworthy Road, Surrey, England KT2 7QB
Katy J. Hand, MSc, MRPharmS, paediatric pharmacist

Centre for Practice and Policy, School of Pharmacy, London
Nick Barber, PhD, MRPharmS, professor of the practice of pharmacy

Correspondence: Mrs Hand katy.hand@kh-tr.sthames.nhs.uk

Original Papers

Nurses' attitudes and beliefs about medication errors in a UK hospital

KATY HAND and NICK BARBER

Objective -To investigate nurses' attitudes and beliefs about medication administration and medication system errors, and to determine the impact of these attitudes and beliefs at ward level.
Method - Semi-structured interviews with a purposive sample of nurses who had been selected initially by ward specialty and then by grade.
Setting - A teaching hospital in London, United Kingdom.
Key findings - Seventeen nurses were interviewed and their attitudes and beliefs about types of medication errors, causes of medication errors, reporting of medication errors and the responsibility for medication errors were explored. The types of errors mentioned by the nurses were consistent with those cited in the literature. Nurses believed both doctors and pharmacy staff to be sources of errors but by far the most common source of error was said to be the nurses themselves. Few of the nurses interviewed believed all errors were reported and almost all believed they were responsible for any errors which occurred when they were administering drugs. As well as blaming themselves, some also blamed the pharmacist and the doctor, if they had been involved. The nurses thought the fear of disciplinary action and having to admit to making a "silly" mistake stopped a nurse from reporting an error if it had no ill effects on the patient. They hoped anything that could harm the patient would be reported, as would any errors involving intravenous drugs, Controlled Drugs and drugs with serious side effects. They believed errors should be reported to the nurse in charge of the ward, the doctor and sometimes the ward manager, if necessary. Generally the nurses felt the patient should be informed if they might suffer any ill effects due to the error; if the error was not going to harm the patient, the nurses were divided as to whether the patient should even be told an error had occurred.
Conclusion - It was felt that medication errors should be a learning experience which could allow the nurse to reflect on her own practice. The emphasis of errors should be shifted from the nurse to the situation in which it occurred as blaming the nurse was not considered to be very constructive.