Cent Eur J Nurs Midw 2019;10(2):1059–1067
doi: 10.15452/CEJNM.2019.10.0014
REVIEW
MEASURES TO PREVENT MEDICATION ERRORS IN INTENSIVE CARE UNITS
Zuzana Plutínská1, Ilona Plevová2
Pediatric Intensive Care Unit, Hospital Frýdek-Místek, Czech Republic
Department of Nursing and Midwifery, Faculty of Medicine, University of Ostrava, Czech Republic
1
2
Received December 12, 2018; Accepted May 10, 2019. Copyright: This is an open access article distributed under the terms of the Creative
Commons Attribution International License (CC BY). http://creativecommons.org/licenses/by/4.0/
Abstract
Aim: The aims were to summarize studies on the effectiveness of interventions to reduce adverse events of the medication error
type and, based on the studies, to identify recommendations for preventing medication errors in intensive care units (ICUs).
Design: A descriptive review. Methods: To find relevant resources, the SCOPUS and EBSCO electronic databases were searched
using the following search words: prevention, medication errors, intensive care unit. Both primary and secondary studies
on prevention of medication errors in ICUs were selected. Results: A total of eight primary studies and three systematic reviews
were included. The studies showed considerable variability and differed in methods, numbers of monitored events or ways of data
collection. The assessed interventions were pharmacist involvement, automated infusion devices, reporting medication errors,
strategies to limit interruptions during drug administration, electronic health records together with support systems for clinical
decision making, nurse education in drug administration and creating checklists. Conclusion: The assessment of selected studies
suggests that to a certain extent, all of them showed certain medication error reduction. Due to numerous limitations, however,
it is impossible to select and recommend a single approach.
Keywords: adverse event, intensive care, medication error, nursing, patient safety, prevention.
Introduction
Medication errors in intensive care units (ICUs) have
far greater risk potential than those in general wards,
particularly in pediatric patients. Generally, many risk
factors and circumstances play a role, such as the
patient’s
critical
condition,
comorbidities,
physiological
dysfunction,
more
frequent
interventions or more complex drug therapy. The latter
mainly includes higher amounts of drugs taken,
weight-based dosing and continuous administration
of drugs requiring precise dosing. Last but not least,
workload and rapidly changing health conditions
necessitating a rapid response are also involved. In the
Czech health care system, no major changes to the
drug administration process have been made over a
long period of time, even though numerous strategies
and technologies are used globally to reduce
medication errors. One example may be a positive
effect of clinical pharmacists on the incidence of
incorrect doses or selection of better drug
combinations. A medication error is defined as an
adverse event in which a patient’s/ healthcare worker’s
Corresponding author: Ilona Plevová, Department of Nursing
and Midwifery, Faculty of Medicine, University of Ostrava,
Syllabova
19,
Ostrava,
Czech
Republic;
email:
[email protected]
© 2019 Central European Journal of Nursing and Midwifery
health was or may have been threatened or damaged
during healthcare provision (Machaczek, Whitfield,
2012). The Agency for Healthcare Research and
Quality (AHRQ) defined a medication error as
potential harm to a patient’s health resulting from
exposure to an inappropriate drug (AHRQ, 2018). The
National Coordinating Council for Medication Error
Reporting and Prevention (NCCMERP) states that
medication errors are preventable and may occur at
any time during drug handling (About Medication
Errors). In the Czech Republic, medication errors fall
under the responsibility of the State Institute for Drug
Control and its surveillance activities. They are
addressed by Act No. 387/2007 Coll., on
pharmaceuticals, as amended, including the related
Decree No. 84/2008 Coll., on good pharmaceutical
practice, as amended.
According to the AHRQ, the composition of
therapeutics, and thus patients’ health status, continue
to improve, but these benefits are also associated with
higher risks. In the sense that 5% of hospitalized
patients experience adverse drug events (ADEs) due
to the use/application of drugs. These, however, not
necessarily mean poor quality of care. Medication
errors, on the other hand, refer to errors throughout the
entire process of drug administration, from
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prescription to when the patient actually receives the
drug. It is generally estimated that approximately half
of ADEs may be prevented. In some cases, however,
ADEs occur even though drugs are prescribed and
administered appropriately (AHRQ, 2018).
The general risk factors for ADEs, as stated by the
AHRQ, mainly include polypharmacy; older patient
age associated with taking more drugs being more
vulnerable to adverse effects; pediatric patients and
weight-based dosing; limited computer literacy when
searching information; and high-alert drugs – those
potentially harming patients if used in error, having
similar appearance or names but different effects
(AHRQ, 2018).
The AHRQ (2018) recommends the following
strategies to prevent ADEs: 1) prescribing – avoiding
unnecessary drugs by adhering to conservative
prescribing principles; computerized provider order
entry, particularly when paired with clinical decision
support systems; drug reconciliation at times
of transitions in care; 2) transcribing – computerized
provider order entry to eliminate handwriting errors;
3) dispensing – pharmacists overseeing the dispensing
process; using tallman lettering and other strategies to
minimize confusion between drugs with similar
appearance or names; and 4) administration – adhering
to “five rights” (i.e. the right medication, dose, time,
route and patient); barcode medication administration
to ensure drugs are given to the right patients;
minimizing interruptions during drug preparation and
administration by nurses; using smart infusion pumps
for intravenous administration; patient education and
revised drug labels to improve patient comprehension
of administration instructions.
Drug administration is an integral part of the nursing
process; a therapeutic may be applied or administered
by a competent healthcare worker only when ordered
by a doctor (Mikšová et al., 2006), in accordance with
regulations and standards governing healthcare
delivery and procedures (Vondráček, Vondráček,
2006). Richards and Edwards (2004) state that a nurse
should never administer a drug without knowing its
effects. Additionally, she must fully identify the
patient and know their treatment plan and diagnosis.
Doctor’s orders must be clear and legible; in case
of any doubt, a nurse should contact the doctor.
Generally, the above five rights should be adhered to.
Safe patient identification belongs to safety objectives
as defined by the Czech Ministry of Health. A hospital
must develop a regulation defining the process of
patient identification; the main requirement is that
there are at least two forms of patient identification
(e.g. name and date of birth). A patient’s identification
must always be verified prior to administration of
© 2019 Central European Journal of Nursing and Midwifery
Cent Eur J Nurs Midw 2019;10(2):1059–1067
therapeutics/transfusions, laboratory tests and
diagnostic or therapeutic procedures (MZČR, 2015).
At the 1996 congress of the Massachusetts Nurses
Association, Cook (1999) presented the following Six
Rights for Nurses Administering Medications: 1) right
to a complete and clearly written order; 2) right to have
the correct drug route and dose dispensed; 3) right to
have access to information; 4) right to have policies on
medication administration; 5) right to administer
medications safely and to identify problems in the
system; and 6) right to stop, think, and be vigilant
when administering medications.
To increase patient safety and involvement in
processes related to healthcare provision, the Czech
Ministry of Health issued the Patient Guide in 2016.
One of the chapters, Drugs in the Hospital,
recommends that patients: make a list of chronically
used drugs; take them to the hospital and hand them in
to the hospital staff; do not use their drugs without the
staff’s knowledge; are aware that drugs must be
administered from original packaging in their rooms;
have the right to be informed about the prescribed
drugs and their adverse effects; know that this
information may be obtained from their attending
physicians (MZČR, 2016).
Aim
The aims were to summarize studies on the
effectiveness of interventions to reduce adverse events
of the medication error type and, based on the studies,
to identify recommendations for preventing
medication errors in ICUs.
Methods
Design
A descriptive review.
Eligibility criteria
Both primary and secondary studies published
in 2008–2018 were included, with the exception
of theoretical reviews. The studies had to focus
on preventive strategies and measures to reduce risks
associated with drug administration in ICUs. Another
criterion was availability of a full text.
Sources
To find relevant resources, the SCOPUS and EBSCO
electronic databases were searched.
Search
Using the PICOT format, the following search words
were identified: prevention, medication errors,
intensive care unit. The research question was: “Are
there evidence-based recommendations or expert
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Cent Eur J Nurs Midw 2019;10(2):1059–1067
recommendations for preventing medication errors in
ICUs related to nursing interventions?”
Data analysis
The search strategy yielded a total of 189 records
of which 11 studies were retrieved that were key for
the review. Studies were gradually excluded using the
PRISMA recommendations (Figure 1).
For the final analysis, both primary and secondary
studies assessing the effect of reducing medication
errors were selected. These included three systematic
reviews, one study with a Plan-Do-Study-Act design,
one direct observational study, two retrospective
studies, three prospective studies and one quantitative
survey.
Study selection
To increase search effectiveness, synonyms were
added and for all terms, asterisks or quotation marks
were used (Table 1). For advanced search in electronic
databases, the Boolean operators AND and OR were
used.
Table 1 Working with search words
Identification
Search words
prevention
medication errors
intensive care unit
Synonyms
protection, safe, patient safety, reduction
adverse drugs event
critical care
Records identified through
database searching
(n = 185)
Truncation and quotations
prevent*, protect*, saf*, “patient safety”, reduct*
medic* error*, advers* drug* event*
intensiv* car* unit*, critic*car*
Additional records identified
through other sources
(n = 4)
Included
Eligibility
Screening
Records after duplicates removed
(n = 161)
Records screened
(n = 161)
Full-text articles assessed
for eligibility
(n = 40)
Records excluded
(n = 121)
Full-text articles excluded,
with reasons
(n = 29)
Studies included in quantitative
synthesis
(n = 11)
Studies included in qualitative synthesis
(n = 0)
Figure 1 Flow diagram – PRISMA recommendations
© 2019 Central European Journal of Nursing and Midwifery
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Results
The outcomes of relevant studies are presented
in Table 2.
Kaushal et al. (2008) conducted a prospective cohort
study in a pediatric hospital to assess medication error
rates prior to and after pharmacist intervention in two
ICUs. Full-time presence of a clinical pharmacist in an
ICU was associated with a decrease in serious
medication errors from 29/1000 to 6/1000 patient days
(p < 0.01). There was no significant difference in preintervention serious medication error rates between
the two ICUs. On the other hand, the rate
of intercepted near misses increased from 32/1000 to
57/1000 (p = 0.08) during the intervention period.
Although errors were intercepted by clinical
pharmacists at all stages of the medication process, the
highest rate (79%) was at a physician ordering stage.
The authors concluded that the introduction of fulltime clinical pharmacists was beneficial while there
was no reduction of medication errors with part-time
presence.
In their retrospective study, Hennings et al. (2010)
focused on automated infusion device (AID)
technology used to prevent medication errors. At an
academic medical center in Tucson (Arizona, USA),
AID technology (smart pumps with computer
processors combining drug delivery, monitoring and
data management functions) was implemented in 2003
as the only type of infusion pumps, with nurses
undergoing two-hour training to learn to use the
technology. Only events involving high-risk drugs
were assessed. According to the authors, the
technology, when properly used, leads to reduction
in medication error rates and is particularly useful
in critically ill pediatric patients receiving high-risk
drugs. Moreover, these patients are administered
weight-, age- or body surface area-based dosages
of drugs and solutions. The results also showed that
adult patients received high-risk drugs more
frequently but children were 1.68 times more likely to
need pump reprogramming events.
Manias, Williams and Liew (2012) sought the
effectiveness of interventions to reduce medication
errors during intensive care. They identified eight
types of interventions: computerized physician order
entry (CPOE), changes in work schedules (CWS),
intravenous systems, modules of education (ME),
medication
reconciliation
(MR),
pharmacist
involvement, protocols and guidelines (PG) and
support systems for clinical decision making (SSCD).
Of those, only four (CWS, ME, MR and PG)
demonstrated reduction of medication errors. The
authors added, however, that there were concerns
regarding the level of evidence and quality of studies
© 2019 Central European Journal of Nursing and Midwifery
Cent Eur J Nurs Midw 2019;10(2):1059–1067
on these interventions. The main limitations were the
facts that most studies had no control groups and only
assessed
interventions
before
and
after
implementation.
Breeding et al. (2013) proved that the Medication
Error Minimization Scheme (MEMS), their project
based on multidisciplinary and multifaceted
improvement of quality in an adult tertiary level ICU
was able to increase the rate of reported medication
errors and thus to reduce the number of errors affecting
patients. According to the results, the reporting rate
increased by more than 50% (from 6.2/1,000 to
13.65/1,000 patient days). The project also showed
that although nurses agreed on the importance of
reporting medication errors, nearly half of them (43%
and 66% in the pre- and post-intervention periods,
respectively) stated that they had failed to report such
errors, fearing that it might be personally or
professionally damaging. Interestingly, respondents
were encouraged to administer drugs safely but more
frequently, they were pressured to be quicker rather
than check things thoroughly. Nevertheless, audits of
intravenous infusions revealed a reduced medication
error rate.
Santesteban, Arenas and Campino (2015) conducted
a systematic review to identify the most common
interventions and their activities in neonatal ICUs.
The most frequently reported techniques reducing
medication errors, or the risk thereof, were CPOE, barcoded medication administration (BCMA), AID
technology, incident reporting systems and
comprehensive educational strategies. Additionally,
the
authors
recommended
implementation
of multidisciplinary
evidence-based
measures
in collaboration with pharmacists and supported
changes to safety culture in healthcare facilities and
medication error reporting.
A study by Durham et al. (2016) monitored the effect
of a medication safety pilot program, assessed
strategies promoting reporting and aimed to increase
nurse sensitivity to errors and teach mindfulness. The
authors suggested that interprofessional risk analysis
teams were created and preventive measures
recommended by them were used. The study showed
that 49% of nurses agreed that their awareness of error
risk increased and intended to change their practice.
Moreover, the rate of reported medication errors
increased.
Connor et al. (2016) aimed to assess the effectiveness
of implementing a “red zone” as a strategy to prevent
distraction during preparation and administration of
drugs. The distraction-free practice was improved
using a General Electric’s model and the Six Sigma
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Table 2 Characteristics of studies included in the analysis
Author (year)
Kaushal et al.
(2008)
Hennings et al.
(2010)
Manias, Williams,
Liew (2012)
Intervention/measures
PI
Methods
prospective cohort study
AID
retrospective study
CPOE
CWS
IS
ME
MR
PI
PG
SSCD*
MEMS, a QI project
systematic review
Santesteban,
Arenas, Campino
(2015)
BCMA
CPOE
AID
incident report systems
educational strategies
pharmacist-led educational
programs
systematic review
Durham et al.
(2016)
medication error reporting
checklist
mindfulness
prospective observational study
Connor et al.
(2016)
Flynn et al. (2016)
“red zone” (distraction-free
practice)
strategies limiting interruptions:
hourly patient rounds
protected time
outlining a no interruption zone
limiting phone calls by triage
visible wear
patient/family education
materials
nurses’ knowledge
retrospective analysis
Breeding et al.
(2013)
Di Simone et al.
(2016)
Liao et al. (2017)
Nguyen, Mosel,
Grzeskowiak
(2018)
PDSA-based research project
Study conclusion
full-time PI reduces medication
error rates
AID technology leads to
reductions in medication errors
little evidence
increased medication error
reporting rate, reduction of
incidents
changes to safety culture,
systems for reporting and
auditing errors, a
multidisciplinary evidencebased approach in collaboration
with pharmacists
creating interprofessional risk
analysis teams and using
preventive strategies
recommended by them
the “red zone” is effective
direct observational study with
a control group
strategies limiting interruptions
improve patient safety but their
effect on medication errors is
unclear
quantitative survey
pharmacological knowledge
EHR
CPOE
BCMA
prospective observational study
technology,
organizational, guidelines,
policies
personnel (education)
pharmacy services
risk analysis
combinations of the above
systematic review
reduction in medication error
after implementation of EHR
together with CPOE and
BCMA
no single intervention to reduce
medication errors in neonatal
care was clearly superior; the
use of technology was a
priority
AID – automated infusion device; CPOE – computerized physician order entry; CWS – changes in work schedules; IS – intravenous systems; ME – modules of
education; MR – medication reconciliation; PI – pharmacist intervention/involvement; PG – protocols and guidelines; SSCD – support systems for clinical
decision-making; EHR – electronic health records; BCMA – bar-coded medication administration; MEMS – Medication Error Minimization Scheme; QI –
quality improvement; PDSA – Plan-Do-Study-Act
© 2019 Central European Journal of Nursing and Midwifery
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tool involving a five-step approach: define, measure,
analyze, improve and control. The General Electric’s
model was used to accelerate changes in each of the
five steps. A badge was designed to be worn and
visible, a red zone decal was placed on the floor, and
staff members, patients and families were informed
about the strategy and asked to adhere to the rules.
This resulted in a 79.2% reduction in medication
errors. A rather important limitation of the study was
that during the strategy assessment, a medication
barcode scanning process was introduced in the
hospital, potentially distorting the results.
A direct observational prospective study by Flynn et
al. (2016) aimed to assess the effectiveness of
strategies to limit interruptions during medical
administration in ICUs. The implemented
interventions whose effectiveness was evaluated were
regular patient assessment; protected time (no
interruption drug administration times: 5 am – 7 am, 8
am – 10 am, 8 pm – 10 pm); hourly rounds (regular
patient assessment, e.g. every two hours); nurses
wearing a yellow safety sash to signify that they are
not to be disturbed; establishment of no interruption
zones; limitation of phone calls (triage of phone calls);
distribution of patient/family education materials.
Direct observations were retrospectively analyzed
from adapted standardized records (Medication
Administration Accuracy Observation Code Sheet;
Medication Administration Accuracy Record Review
Worksheet) developed by the California Nursing
Outcomes Coalition. The results showed that the most
common sources of interruptions were patient-related,
phone calls, face-to-face interaction and unavailability
of resources during preparation/administration
(sufficient fluids to facilitate drug swallowing).
According to the authors, limiting nurse interruptions
improves drug safety but the effect on medication
error rates is unclear.
Di Simone et al. (2016) reported elements of nurses’
knowledge, training, behavior and attitude potentially
preventing medication errors in ICUs during
administration of intravenous drugs. They concluded
that the prerequisite for proper administration of drugs
and evaluation of their effects is pharmacological
knowledge.
Due to doubts about the effectiveness of electronic
health records (EHR) in preventing medication errors,
Liao et al. (2017) studied interventions including
CPOE and BCMA. After EHR implementation, the
types and severity of medication errors changed. More
specifically, medication administration record
discrepancies, incomplete orders and missed doses
changed to missed doses and wrong time
of administration in the postimplementation period.
© 2019 Central European Journal of Nursing and Midwifery
Cent Eur J Nurs Midw 2019;10(2):1059–1067
Moreover, the rate of near-misses increased.
The authors claim that in the short-term, EHR
implementation did not lead to reduction
in medication errors. There was a significant decrease
after as long as two years. The authors also explain that
unawareness of these technologies could initially
cause new adverse events.
Nguyen, Mosel and Grzeskowiak (2018) conducted
a systematic review to study the effectiveness of
interventions to reduce medication errors in neonatal
care. In the identified studies, interventions were
classified
into
five
themes:
technology,
organizational, personnel, pharmacy, hazard and risk
analysis. A qualitative synthesis of comparative
studies showed that the greatest median reduction
(73%) in overall medication errors was seen when
technology-based interventions were used. The
authors promote technologies such as CPOE with
automated dose checking, E-calculators, AID, BCMA,
preparation of prediluted drugs for administration, etc.
Discussion
A possible solution to reduce medication errors is to
employ full-time pharmacists, particularly in pediatric
ICUs (Kaushal et al., 2008). For successful
involvement of pharmacists and other professionals
in addressing ADEs, it is necessary to implement
an accessible system for reporting adverse events so
that staff members do not face barriers that discourage
them from reporting such events. It is also important
to create an environment that supports error reporting
and repeated meetings allowing bilateral exchange of
information and experiences (Breeding et al., 2013;
Durham et al., 2016). One of the reasons for errors to
happen may be interruptions during drug preparation
and administration. This, however, was not confirmed
by an identified study (Flynn et al., 2016). Yet this
strategy is perceived as suitable with regard to patient
safety and is also recommended by the AHRQ
(AHRQ, 2018). The importance of this aspect was also
shown in a survey by Di Simone et al. (2016).
Respondents perceived training of new colleagues as
a high-risk area. These situations undoubtedly place
high demands on attention. Distraction-free practices
were also recommended by Connor et al. (2016) who
used various methods to significantly reduce
medication errors by 79.2% (p = 0.00184). However,
there were certain limitations: the results were based
on self-reporting of errors and a BCMA system was
introduced at the same time.
The AID technology is mainly recommended in
pediatric units where patients are at a higher risk of
inadequately ordered/set care (Hennings et al., 2010).
Nicholas and Agius (2005) explain that smart pumps
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Plutínská Z, Plevová I.
may warn nurses of errors in the process (not the right
patient, amount, drug, time or route). These pumps
have their own libraries of drugs with protocols
in software to compare the set parameters with the
limits. Other pump parameters may be set such as
clinical condition, age or drug compatibility
information. The authors conclude that administration
of IV drugs is a complex issue and errors may be
reduced by using AID and other risk reduction
strategies such as CPOE and BCMA and improving
nurse education in drug administration.
Using EHR, CPOE and BMCA may reduce
medication errors by as much as 24% (p = 0.0008)
over a long period of time (Liao et al., 2017).
According to Cima and Clarke (2012) and Plischke
(2015), each healthcare provider should establish
a multidisciplinary team for drug management
(physicians, IT specialists, pharmacists, specialist
nurses) and introduce BCMA to try to prevent human
errors. This strategy is also supported by the European
Association of Hospital Pharmacists claiming that
errors may be reduced by approximately one third.
In the Czech Republic, the system is used, for
example, when cytostatic drugs are administered in the
Masaryk Memorial Cancer Institute in Brno. It is
based on central preparation and interlinked processes
from prescription to administration. Prior to
administration, the nurse clearly identifies the
centrally prepared cytostatic drug and the patient by
reading a barcode, including the technique to be used
and her own identity (Oldřichová, 2010). Yet BCMA
is not a one-size-fits-all solution as it is always
dependent on the proportions of particular errors. The
technology does reduce certain types of errors but also
introduces novel errors in the form of work-arounds
(Keers et al., 2013).
A systematic review by Santesteban, Arenas and
Campino (2015) showed that all interventions (CPOE,
BCMA, AID, medication error reporting, education)
had reduced the incidence or risk of medication errors
in neonatal care and recommended changes in the
culture of error reporting and auditing as well as
implementation of any evidence-based interventions
in collaboration with pharmacists. To a certain extent,
however, this was not confirmed by other systematic
reviews which showed a reduced incidence of errors
but their authors had doubts about the quality of such
evidence. A review by Nguyen, Mosel and
Grzeskowiak (2018) found the greatest median
reduction in medication errors (73%) with the use of
technologies (e.g. CPOE, BCMA, AID and
E-calculators). Other strategies such as organizational
changes, risk analysis, pharmacy services were also
associated with error reduction but the median was
lower (50–60%). The authors recommended further
© 2019 Central European Journal of Nursing and Midwifery
Cent Eur J Nurs Midw 2019;10(2):1059–1067
research to evaluate the cost-effectiveness of various
interventions. According to Manias, Williams and
Liew (2012), medication errors in adult intensive care
were reduced following implementation of education
strategies, promotion of medication error reporting,
changes in work schedules and the use of protocols
and guidelines. Similar results were shown by another
study focusing not only on ICUs but inpatient settings
in general. In their systematic review and metaanalysis, Berdot et al. (2016) found that high-quality
studies to evaluate the effectiveness of interventions
reducing medication errors were lacking. The authors
identified a total of 26 studies evaluating such
interventions based on direct observations, of which
only seven met the criteria for inclusion in the
analysis. Those comprised five randomized controlled
trials and two non-randomized controlled studies.
Three of them focused on CPOE or automated
dispensing systems; four studies were concerned with
nurse education. However, all the studies were
susceptible to bias. There were no differences in
overall administration error rates between the
intervention and control groups. Potential biases were
likely to be greater for non-randomized studies.
According to the authors, results from before and after
studies should be interpreted with caution (Berdot et
al., 2016).
All the above strategies, however, may not lead to
effects they actually offer. Additional literature search
for resources in Czech language yielded a 2015
diploma thesis called Identification of medication
errors by nurses during simulated scenarios by
Kelblová (2015). A qualitative analysis of interviews
with nurses (n = 13) selected at a single ICU showed
that although they did not know the exact definition of
medication errors their awareness of those was
relatively good. In simulated scenarios, none of the
nurses was able to detect all errors. One example of
a rarely identified error was wrongly prescribed
insulin (a lack of detailed descriptions of units, time
and route of administration); the least frequently
detected error was wrong prescription of infusions. By
contrast, incomplete opioid orders (no route of
administration stated) were most commonly
recognized. The author concluded that the interviewed
nurses were aware of medication errors and their
ability to detect them during simulated scenarios was
related to the number of years of experience and level
of education (Kelblová, 2015).
Limitations of study
The main limitations of the search strategy were the
availability of full texts and choosing English as the
only possible language. Another limitation may be
looking for studies conducted in ICUs only. Surely
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a considerable proportion of studies were performed
in general wards so other methods could have been
found, potentially applicable in the intensive care
setting.
Conclusion
The assessment of selected studies suggests that to
a certain extent, all of them showed certain medication
error reduction. Due to numerous limitations of either
the selected studies or our search strategy, however, it
is impossible to select and recommend a single
approach. Such selection mainly depends on
healthcare providers’ financial resources and types
of medication errors that occur.
Therefore, the selected recommendations for practice
are mainly based on interventions recommended by
the AHRQ, with regard to conclusions of the identified
studies.
Although the evidence failed to provide a particular
instrument or method, it may be assumed that any
combination of technologies together with education
and a good system for reporting medication errors
seem to be a good strategy. According to the AHRQ,
during prescription certain principles should be
adhered to such as avoiding unnecessary medications,
using the CPOE technology and medication
reconciliation at times of patient transition. For
transcription, they recommend computerized/printed
orders, clinical pharmacists overseeing drug
dispensation and the use of tallman lettering. In the
process of administration itself, the “five rights”
should be adhered to, the BCMA and AID
technologies should be used, interruptions minimized
and patients educated (AHRQ, 2018).
Based on results of the studies, we may recommend
electronic health records together with clinical
decision support systems, zero tolerance to
handwritten orders, with the exception of situations
requiring immediate help, a policy of not interrupting
nurses during drug administration, implementation
of AID technology, particularly in pediatric ICUs,
better educational strategies to promote knowledge
about drugs administered and awareness of adverse
events occurring in particular departments (drugs
suitable for nasogastric tubes, high-risk drugs,
intravenous drugs, discussion on adverse drug
reactions that have occurred, including near-errors),
creating checklists tailor-made to suit the needs
of departments and, last but not least, involvement
of pharmacists in medication processes.
© 2019 Central European Journal of Nursing and Midwifery
Cent Eur J Nurs Midw 2019;10(2):1059–1067
Ethical aspects and conflict of interest
The authors solemnly declare that the manuscript has
not yet been published or submitted for publication by
another journal, they have no conflict of interest
regarding the topic, creation and publication of this
article and that it has not been supported by
a commercial organization.
Author contributions
Conception and design (IP, ZP), data analysis and
interpretation (ZP), manuscript draft (IP, ZP), critical
revision of the manuscript (IP, ZP), final approval of
the manuscript (IP).
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1
Fostering Therapeutic
Communication
Division of Nursing, Allied Health, Life and Physical Science
Student Name:
“Fostering Therapeutic Communication While Inputting Data into the
Electronic Health Record”
NURS-115C Foundations of Nursing Theory/Practicum
Dr. Stella Ayika
University of the District of Columbia – Community College
13 October 2021
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Fostering Therapeutic
Communication
Introduction
Effective communication between patient and provider is an important part of building a
connection between the two parties. It is crucial that this relationship is built on trust in order to
optimize the transfer of information between individuals. Applying therapeutic communication
techniques during client visits is key to achieving successful communication between patient and
provider.
Summary of Article
The use of computerized technology in health care settings is continuing to expand in the
United States. For example, most health care settings are implementing the use of the Electronic
Health Record (EHR) as required by the Meaningful Use Incentives of 2016 (Curran, 2016). Use
of the Electronic Health Record has many benefits over paper charting for both the provider and
the patient. For example, the EHR helps to reduce charting errors, makes for easier monitoring
and transfer of patient data, and can be accessed remotely. The EHR can be used to aid patients
in creating and maintaining their health care goals, thereby allowing them more control over
their own health. The positive aspects of the correct use of the EHR are evident; however, what
are the effects of the EHR on patient-provider communication?
This study analyzes how use of the EHR can negatively impact patient-provider
communication by disrupting traditionally used therapeutic communication techniques. This
study was conducted by reviewing literature, surveys and questionnaires from 2010 through
2015 relating to the topic of the EHR and patient-provider communication. The literature,
3
Fostering Therapeutic
Communication
surveys and questionnaires reviewed by the author incorporated a broad section of the general
population (adults) as well as physicians and health care workers. The goal of this study is to
encourage the use of strategies that incorporate effective therapeutic communication techniques
while utilizing the EHR in order to enhance the relationship between the patient and the provider.
Knowledge and Lessons Learned
The successful use of the EHR is closely linked to how effectively and efficiently the
provider can utilize its functions. Lack of proper training in the use of the EHR negatively
impacts client care. Providers who are not well versed in the use of the EHR may take too long
charting thus reducing therapeutic interactions with the patient. According to one videotaped
study, 71.2% of the provider’s time was spent on the EHR (Curran, 2016). Providers indicate
that better support from managers and EHR vendors would help them better use the EHR. The
data gathered from this study also indicates that, although 81% of patients are content with the
care they receive from providers utilizing the EHR, therapeutic communication techniques
should not be overlooked. This study demonstrates that patients most prefer the therapeutic
communication techniques of eye contact, comforting touch and focused attention from the
provider (Curran, 2016). The study also suggests that implementation of these most desired
therapeutic communication techniques by the provider will increase patient satisfaction with the
EHR in the exam room (Curran, 2016).
Application
In practice, it is important that all providers are familiar with all functions of the EHR
and able to use them properly before using them with a patient. This will lower the chances of
the provider spending too much time on the EHR and not enough focused time with the patient.
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Fostering Therapeutic
Communication
It is also important for the provider to face the patient and maintain eye contact when not
imputing information into the EHR. The provider should use comforting touch during the
appointment to enhance patient satisfaction and trust. The provider should also make sure the
patient is familiar with the aspects of the EHR that they are able to access. This will enable the
patient to feel more engaged in their own health care decisions. It will also lessen their worry
over the possibility of any incorrect information being included in their chart.
Conclusion
Advances in technology can have an array of very positive impacts on client care.
However, it is important to analyze and have an awareness of any negative implications of the
use of newer technologies. With this awareness, providers are better able to adjust systems in
order to create better outcomes for patients. The increasingly widespread use of the EHR is a
good example. The positive effects of this tool were evident to providers and patients alike.
However, using the EHR, disrupts the use of many therapeutic communication techniques that
enhance the patient-provider relationship. This study highlights the importance of blending
therapeutic communication techniques and new technology such as the EHR.
5
Fostering Therapeutic
Communication
References
Curran, H. J. (2016). Fostering Therapeutic Communication While Inputting
Data into the Electronic Health Record. Nursing Informatics Today, 2016 1st
Quarter; 31(1): 4-16.

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