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When an error is not really an error?

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, too.

·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 carried out.

·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 not remember.

·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 error.

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.

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