Abstract

The critical incident technique was used to study medication errors in a 1100-bed hospital during a 7 month period. An attempt was made to catalogue and describe the common kinds of errors and to analyze their causes. The ultimate study objective was to suggest ways of making the medication system safer and more efficient. The critical incident technique is a procedure for collecting direct observations of human behavior and is aimed at the solution of practical problems. In final form the questionnaire to be completed by nursing personnel listed the 7 categories or types of incidents which had been found to include all the medication errors previously reported. Over the 7 month period 178 medication incidents were reported and these are the raw data which form the substance of this study. 75% of the incidents were obtained from the questionnaire and the remaining 45 by the usual incident form sent to the director of nursing. Of the total number 80% were medication errors and 20% were near errors. Most of the incidents were reported by student nurses. 170 of the 178 incidents were classified according to the time of day at which they occurred. Several peaks were evident with the most pronounced at 10 a.m. and other smaller peaks at 8 a.m. 12 noon 2 p.m. 4 p.m. 5 p.m. and 10 p.m. These results can probably be explained by 1 or more of the following factors: preferred times for scheduling medications; stress periods; meal times; and change of shift. The greatest number of incidents was reported when a nurse administered medication to only 1 patient. Single-patient assignments almost invariably represent unscheduled orders which are to be carried out immediately. The 2 major kinds of orders are stat medication and a preoperative order. Either type of order interrupts the nurse with the result that she is more likely to forget to follow procedures and so commit an error.

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