Factors contributing to registered nurse medication administration error: a narrative review

February 20, 2015

Source:  International Journal of Nursing Studies 52/1 pp. 403-20

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Date of publication:  January 2015

Publication type:  Journal article

In a nutshell: The authors explored the factors contributing to medication administration incidents amongst registered nurses. A number of factors, including the environment and characteristics of the nurse, were found to influence medication administration incidents. In terms of environment, clinical workload and work setting were important. In terms of nurse characteristics, nurses’ lived experience of work and their demographics were significant. More studies have focused on environmental issues than on how personal characteristics may contribute to incidents. Any inter-relationship between factors was not explored.

Length of Publication:  17 pages

Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library

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A simple flashcard: big impact for junior doctors!

November 26, 2014

Source:  The Clinical Teacher 11/6 pp. 454-60.

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Date of publication:  October 2014

Publication type:  Journal article

In a nutshell:  Reducing prescribing errors is crucial for ensuring patient safety. Many studies have reported that foundation-year doctors (FYs) have been found to be major contributors to prescribing errors; however, few studies have introduced meaningful interventions. Questionnaires were sent to FY2s to find the 15 most commonly prescribed medications on call. The medications and instructions were incorporated into a flashcard that was disseminated to new FY1s at a hospital in the UK. The FY1s were asked to complete a pre- and post-flashcard questionnaire, giving instructions for 10 medications and their confidence in prescribing these medications. A control group at another hospital were given the same questionnaires, but not the flashcard. No significant difference in confidence was seen in FY1s at either hospital before the flashcard was issued. At week 4, 93% of FY1s still used the flashcard 2.2 times per day, claiming that it saved time on call. The authors say they have introduced an inexpensive and simple prescribing aid, which has been statistically shown to improve prescribing confidence in FY1s.

Length of Publication:  7 pages

Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library


Patient safety alert on non-Luer spinal (intrathecal) devices for chemotherapy

March 26, 2014

Source:  NHS England

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Date of publication:  February 2014

Publication type:  News item

In a nutshell: An NHS England patient safety alert to all hospitals in England administering spinal (intrathecal) chemotherapy has been issued to minimise the risk of wrong route administration. Connection with intravenous devices is not permitted, so the alert instructs hospitals to only use syringes and needles, and other devices, with non-Luer connectors when delivering this type of chemotherapy. No incidents of this kind have been reported in England since 2001, but they have happened in Europe and worldwide.

Length of Publication:  1 web page


Causes of Medication Administration Errors in Hospitals: a Systematic Review of Quantitative and Qualitative Evidence

December 18, 2013

Source:  Drug Safety vol/iss 36/11 pp. 1045-1067

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Date of publication:  November 2013

Publication type:  Journal article

In a nutshell:  The causes of medication administration errors in hospital were examined in this article. Medication lapses were the most commonly reported medication administration errors, followed by mistakes-based on inaccurate knowledge or deliberate violations. Factors potentially leading to medication administration errors included inadequate written communication, problems with medicines supply and storage such as pharmacy dispensing errors and ward stock management, perceived high workload, problems with access to or functioning of ward equipment, patient availability or acuity, fatigue or stress amongst professionals and distractions during drug administration. Medication administration errors are influenced by multiple systems factors so managers and clinicians need to take a system-wide approach to minimise errors.

Length of Publication:  23 pages


Safety in numbers: an introduction to the Nurse Education in Practice series

May 29, 2013

Source:  Nurse Educ Pract. Vol/iss 13/2 pp. e4-e10

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Date of publication:  March  2013

Publication type:  Journal article

In a nutshell:  This paper introduces this Nurse Education in Practice ‘Safety in Numbers’ series. The background is discussed and the papers provided in the journal that explore the outcomes of a 20-year programme of healthcare education translation research and education action research that focuses on medication dosage calculation problem-solving (MDC-PS) education.

Length of Publication:  7 pages

Some important notes:  Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library.


Administration of medicines – the nurse role in ensuring patient safety.

March 27, 2013

Source:  Br J Nurs. Vol/iss 22/1 pp. 32-5

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Date of publication:  January 2013

Publication type:  Journal article

In a nutshell:  The importance of drug administration and some of the key legislation that relates to it is explored in this paper. The responsibility of qualified nurses and student nurses in this area is discussed. The authors look at the concept of informed consent and what that means in the health care setting. The importance of the safe administration of medicines to patients is emphasised.

Length of Publication:  4 pages

Some important notes:  Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library.


Medication administration technologies and patient safety : a mixed-method systematic review

September 28, 2011

Source:  Journal of Advanced Nursing   Vol 67

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Date of publication: September 2011

Publication type:  Journal article

In a nutshell:   This article explores the links between patient safety and medicine administration including preventable adverse drug events.

Length of publication:  15 pages

Some important notes: Please contact your local NHS Library for the full text of the article. Follow this link to find your local NHS Library.

Acknowledgements:   NELM