Nursing Management of Medication Errors

Luk, Leung Andrew; Ng, Wai I; Ko, Kam Ki Stanley; Ung, Vai Ha

doi:10.1177/0969733007083932

Cited by 20 publications

(31 citation statements)

References 32 publications

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“…Another important finding of this study was that only 13.5% of participants disclosed the medication error to the patients and their family. Unless there is a serious harm involved to the patient, nurses tend not to disclose medication errors because of fear of breaking the established relationship and trust with the patients (Luk et al 2008). Recent recommendations of the IOM placed emphasis on empowering and strengthening patients in medication safety.…”

Section: Discussionmentioning

confidence: 99%

Nurses’ perceptions of medication errors and their contributing factors in South Korea

Kim¹,

Kwon²,

Kim³

et al. 2011

Journal of Nursing Management

110

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Section: Discussionmentioning

confidence: 99%

Nurses’ perceptions of medication errors and their contributing factors in South Korea

Kim¹,

Kwon²,

Kim³

et al. 2011

Journal of Nursing Management

110

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show abstract

“…The second interview allowed the participants to elaborate on their thoughts, feelings, actions, and coping mechanisms after the event. Similar interview guides have been used in several studies that investigated medical errors committed by physicians, residents, and nurses (Courvoisier, Agoritsas, Perneger, Schmidt, & Cullati, 2011;Crigger & Meek, 2007;Engel et al, 2006;Fischer et al, 2006;Kroll et al, 2008;Luk, Ng, Ko, & Ung, 2008;Scott et al, 2009;Stetina, Groves, & Pafford, 2005).…”

Section: Data Collectionmentioning

confidence: 99%

Exploring the experience of nurse practitioners who have committed medical errors

Delacroix

2017

Journal of the American Association of Nurse Practitioners

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Background and purpose To explore the experience of committing medical error from the perspective of nurse practitioners (NPs). Overall, the purpose of the study is to discern NPs’ behaviors, perceptions, and coping mechanisms in response to having made a medical error. Methods Qualitative research based on two face‐to‐face audio‐recorded semistructured interviews with 10 NPs who had made medical errors in practice. The analysis was guided by concepts in phenomenology. Conclusions During iterative analyses, four overarching themes were identified: (a) The paradox of error victimization, (b) primacy of responsibility and mindfulness, (c) yearning for forgiveness and a supportive other, and (d) coping with a new reality is context dependent. The narratives strongly suggest that NPs who err experience “second victim” phenomena. Implications for practice Reminiscing about the experience of living through an error, NPs shared meaningful insights into their need for a safe environment in which they could candidly share feelings, reflect on the experience, and ascertain the etiology of the mistake. Debriefing in a formal manner might prevent the development of permanent psychological injuries. Hence, inherent to the care of “second victims” is the notion of co‐workers’ fairness, compassion, and recognition of appropriate caring responses that contribute to effective coping and healing.

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“…This may create additional dilemmas for nurses when faced with the responsibility of disclosure and has been identified as posing challenges when continuing to provide day-to-day care. 100,168,169 Though a small number of papers make comment on the potential role of the nurse, 170,171 empirical literature exploring nurse disclosure is limited. The literature suggests that while nurses are confident in reporting safety incidents through organisational mechanisms, feelings about the contribution of nurses to disclosing those incidents are more varied.…”

Section: Individual/multidisciplinary Team Responsibilitymentioning

confidence: 99%

An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review and qualitative exploration

Birks

Harrison

Bosanquet

et al. 2014

Health Services and Delivery Research

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BackgroundIn 2009 the UK National Patient Safety Agency relaunched its Being Open framework to facilitate the open disclosure of adverse events to patients in the NHS. The implementation of the framework has been, and remains, challenging in practice.AimThe aim of this work was to both critically evaluate and extend the current evidence base relating to open disclosure, with a view to supporting the implementation of a policy of open disclosure of adverse events in the NHS.MethodsThis work was conducted in three phases. The first phase comprised two focused systematic literature reviews, one summarising empirical research on the effectiveness of interventions to enhance open disclosure, and a second, broader scoping review, looking at reports of current opinion and practice and wider knowledge. The second phase involved primary qualitative research with the objective of generating new knowledge about UK-based stakeholders’ views on their role in and experiences of open disclosure. Stakeholder interviews were analysed using the framework approach. The third phase synthesised the findings from the first two phases to inform and develop a set of short pragmatic suggestions for NHS trust management, to facilitate the implementation and evaluation of open disclosure.ResultsA total of 610 papers met the inclusion criteria for the broad review. A large body of literature discussed open disclosure from a number of related, but sometimes conflicted, perspectives. Evidential gaps persist and current practice is based largely on expert consensus rather than evidence. There appears to be a tension between the existing pragmatic guidance and the more in-depth critiques of what being consistent and transparent in health care really means. Eleven papers met the inclusion criteria for the more focused review. There was little evidence for the effectiveness of disclosure alone on organisational or individual outcomes or of interventions to promote and support open disclosure. Interviews with stakeholders identified strong support for the basic principle of being honest with patients or relatives when someone was seriously harmed by health care. In practice however, the issues are complex and there is confusion about a number of issues relating to disclosure policies in the UK. The interviews generated insights into the difficulties perceived within health care at individual and institutional levels, in relation to fully implementing the Being Open guidance.ConclusionsThere are several clear strategies that the NHS could learn from to implement and sustain a policy of openness. Literature reviews and stakeholder accounts both identified the potential benefits of a culture that was generally more open (not just retrospectively open about serious harm). Future work could usefully evaluate the impact of disclosure on legal challenges within the NHS, best practice in models of support and training for open disclosure, embedding disclosure conversations in critical incident analysis and disclosure of less serious events.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Nursing Management of Medication Errors

Cited by 20 publications

References 32 publications

Nurses’ perceptions of medication errors and their contributing factors in South Korea

Nurses’ perceptions of medication errors and their contributing factors in South Korea

Exploring the experience of nurse practitioners who have committed medical errors

An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review and qualitative exploration

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