When an error is not really
From the November 19, 1997 issue
The reasons why nurses report or do not report medication
errors may surprise you. Some literature supports the idea
that more experienced nurses make fewer errors, while other
researchers believe that more experienced nurses report fewer
errors. Recent research1 identifies tacitly shared rules that
nurses apply to clinical situations to determine if a "real"
medication error occurred. The rules frequently involve reading
between the lines of medication orders or modifying organizational
regulations. Even though this research involved nurses, we
suspect that physicians and pharmacists have their own rules,
·If it's not my fault, it is not an error.
If the nurse cannot avoid the error, it is not an error. Examples
include late drug administration or omission when the patient
is off the unit or when the prescribed drug is not available
on the unit.
·If everyone knows, it is not an error.
When everyone is aware that actual practice differs from policy
and procedure, it is not an error. Applying transdermal patch
medications at 0600 instead of the prescribed time of 0800
is an example. Since 0800 is not a routine time for medication
administration, and the patch would likely be applied later
than the prescribed time because of busy schedules, the nurses
change the time of patch application. The physicians know
and approve of this practice.
·If you can make it right, it is not an error.
More experienced nurses become innovative about making things
right when an error has occurred. If a dose is omitted, the
nurse may change the subsequent drug administration schedule
to "get back on track." This mind-set may also include documentation.
When a discrepancy is noted, the nurse involved may be asked
later to document a procedure that may or may not have been
·If a patient's needs are more urgent than accurate
medication administration, it is not an error. If,
in the nurse's clinical judgment, other patient needs take
priority, any irregularity in drug administration is not considered
an error. Examples include dealing with emergencies, which
often delay or otherwise alter drug administration.
·A clerical error is not an error. Nurses
frequently assume there is no "real" error when faced with
an apparent error in documentation. When a nurse on a previous
shift fails to document drug administration or documents a
dose in the wrong section of an MAR, often no one investigates
because the nurse may already be at home sleeping or would
·If it prevents something worse, it is not an
error. If a nurse knows that she will be busy later
due to planned admissions, discharges and procedures, she
may administer medications early rather than risk omitting
doses. Technically, early administration is an error, but
it is preferable to omission.
Medication errors should be reported regardless of the circumstances
surrounding them. Institutions may have official organizational
policies and procedures on medication administration and error
reporting, but when faced with real clinical situations, this
study shows that nurses develop alternative tactics. Some
of these tactics evolved because many managers look for individuals
to blame instead of fixing the systems that failed. Fearful
of punishment, nurses try to protect their colleagues and
independently change practice when they feel it is in their
patients' best interests. As a result, a lot of important
information about errors is lost. With this in mind, promote
an atmosphere that encourages honest inquiry, and stimulate
discussion about your organization's medication use problems
and possible solutions. This is one rule ISMP hopes is never
used: it was a blessing in disguise, so it's not an
1. Baker H. Rules outside the rules for administration
of medication: a study in New South Wales, Australia. Jour
of Nursing Scholarship. 1997; 29(2): 155-58.