In Part 1 of this study into the Causes of Medication Errors, an anonymous questionnaire, was circulated to all wards and departments in Barts and The London NHS Trust. Respondents were asked to provide details of any error or near miss that they had witnessed and also to identify what in his/her opinion contributed to nurses making medication errors. The main reasons the respondents felt that medication errors occurred were:

• interruptions during administration,
• loss of concentration because of tiredness,
• lack of clarity in prescription charts and the busyness of the ward,
• lack of knowledge,
• and the number and quality of nursing staff on duty.

Survey respondents were invited to provide their name and contact number when returning the questionnaire (under separate cover to preserve anonymity) if they would like to take part in further research into the topic. These volunteers were contacted and invited to attend with other nurses known to be interested. The focus groups began with brief introductions and then participants were asked to suggest what might cause drug errors they came up with a long list without any difficulty whatsoever Inevitably, many of the reasons suggested were the same as those identified in the survey (see above). However, the following suggestions had not been previously identified. These were mostly related to patients not receiving their medications, which is often not regarded as an error and so frequently goes unreported. The main reasons cited were:

• On night duty, patients falling asleep without taking their medication.
• Not wanting to wake patients when doing the early morning medicine round. Medicines are left on the locker and may be forgotten or possibly taken by the wrong patient.
• Nurses recording 'Code 4' on the Prescription Chart to indicate that the medicine is not available, but failing to make sure that it is obtained as soon as possible. Some patients miss several doses before the medicine is obtained.
• If the doctor changes the dose or route of the medicine but does not cross out the previous dose/route, the nurses may not realise that it has been changed and give the wrong one.
• Confusion when lines or boxes are used on the chart to indicate when doses should/should not be given or discontinued. An example given related to the doctor wanting a serum level prior to administration of the antibiotic but the confusion led to the dose being missed.
• Another issue raised by all groups was the packaging used by manufacturers, which means that entirely different medications may be packaged in almost identical boxes. Increasingly, tablets are being dispensed in bubble strips that come in boxes. Similar packaging is one problem, but so too is the fact that most medicine trolleys are designed for bottles, and not boxes. This makes it more difficult to identify the contents of a box at a glance, and increases the likelihood of picking up the wrong box by mistake.

Having identified some of the reasons why errors can happen, the groups were asked to think of possible solutions. There were several suggestions aimed at improving concentration and reducing distractions and interruptions. For example:

Putting a 'Do Not Disturb' sign on the medicine trolley to discourage people from approaching the nurse unless really important. Wearing a coloured tabard to signify that the nurse was doing medicines and should not be interrupted had been tried in some wards. The experience of most nurses was that it was effective for a short time, but staff soon got used to it and failed to respond to the request not to interrupt.

The increasing use of small, lockable cupboards at the bedside was felt to be a good idea. Patients have their own supply of medicines (except some stock medications) and there is less room for error as only the correct medicines are in the patient's box. However, a number of problems were raised. Getting access to the box is difficult if patients have belongings (cards, bottles of drink, etc.) on the locker as the box opens outwards. This is a design issue that needs to be addressed. Some wards have individual boxes affixed to the wall, rather than the locker; but this can be a problem if the patient is moved - their medicines may be forgotten. The locker usually moves with the patient and so this design is thought to be safer. Some nurses suggested preparing the medicines for individual patients in the treatment room, away from distractions, and then taking them to the patient. This was only felt to be practical where each nurse had a small number of patients. Several nurses felt that there was a high risk of distractions to or from the treatment room.

Checking procedures were discussed. Most participants did not get routine medications checked by another nurse, unless they were unfamiliar with that medication. Some commented on the low incidence of errors involving controlled drugs, suggesting that this was because two nurses check them. However, others felt that if two nurses checked all medicines it would become routine. There is a danger that both nurses merely 'go through the motions' of checking, but in fact neither concentrates on the task. It could be argued that there is a lower incidence of errors with CDs because it is unusual to have two people checking and so both take it seriously.

The problems of administering medicines on night duty when tired, particularly at the end of a 10 or 12 hour shift was felt to be a real cause for concern. This was also highlighted in the survey, which showed a higher incidence of errors on night duty. This may simply reflect the fact that there are often two medicine rounds during that shift if the night staff do the early morning medicines before they go off duty. There are numerous reasons why it is considered necessary for the night staff rather than the day staff to administer these but the fact remains that nurses at the end of a 10 or 12 hour shift are often required to concentrate and possibly calculate doses. The risk of error is likely to be increased.

The routine nature of administering medicines was recognised as a problem. All those involved in the focus groups and those who have recently attended updates on administration of medicines feel that their awareness is heightened and their practice is positively affected immediately afterwards. However; this positive effect is short lived and administration of medicines quickly becomes routine and ritualised again. It was felt that a way to reduce the risk of medication errors would be to heighten awareness on a regular basis.

To explore how this might be achieved, Medication Nurses Forum has been established. It meets at Bart's and The London on alternate sites every month, and is an open forum that anyone can attend. Ward Sisters and Charge Nurses are informed of the date and time, and invited to send a member of staff. All those who attend are automatically added to the Mailing List for future meetings. The aim is to provide a forum where nurses who are involved in the administration of medicines on a daily basis, can come together to discuss problems. The two authors facilitate the group, which now also includes a senior pharmacist. The intention is to raise issues that are known to be problematic but the focus is very much on trying to find solutions. The groups explore ways of working that, given the realities of healthcare with the current pressures and staff shortages, attempt to make errors less likely to happen. These meetings have raised some really interesting issues and shared ideas and good practice in different wards.

The forum has met six times thus far; three times on each site. Each time lively discussion has taken place and several of the issues raised have been taken further. Some of the issues raised are outlined below.

The risk inherent in buying different medicines from the same manufacturer as they are dispensed in identical packaging. An example is Lignocaine Hydrocholoride, which was mistakenly replaced in a box of Sodium Chloride Ampoules. Only very careful checking prevented an error. The pharmacist informed the group that for financial reasons it is not possible to avoid buying different drugs from the same manufacturers. The manufacturers have been approached but they want to establish their brand image by having all their products in the same packaging. There are also cost implications for them if they were to have a variety of packaging types. It was stressed that there is no substitute for careful checking of the ampoule itself.

The use of medicines that have been dispensed by pharmacy as part of a bubble-strip because the patient does not require a full strip. This leads to problems because there may be no identification on the strip itself, only on the box. Nurses are rightly reluctant to administer medicines from a strip which they are unable to identify as the prescribed medication, and in addition, the expiry date is often absent as this usually appears only once on the strip. The pharmacist pointed out the costs involved if these medications, which are often very expensive, could not be used in this way. The nurses voiced their concerns about being unable to check the medication that they were about to administer. A small working party is being established to try to resolve this issue and manufacturers are being asked to identify the medication more than once on the bubble strip. This should be resolved in the future when all patients receive original packs of their medicines in readiness for their discharge home.

2.  Bloodworth C, Lea A, Lane S,  Ginn R. Challenging the myth of the 12-hour shift: a pilot evaluation Nursing Standard 2001: 15.29; 33—6.

3.  Gladstone J. Drug administration errors: a study into factors underlying the occurrence and reporting of drug errors in a district general hospital. Journal of Advanced Nursing 1995: 22: 628—37.

Nursing Progress: Issue 10: June  2001.