Consequences of Fatal Medication Errors for Health Care Providers: A Secondary Analysis Study

Consequences of Fatal Medication Errors for Health Care Providers: A Secondary Analysis Study

Joanne Farley Serembus

For all health care providers involved in the process of administering medications, the potential for error exists (Hunt & Rapp, 1996; Potts & Phelan, 1996; Rolfe & Harper, 1995). Serious errors may occur in approximately 2 per 1,000 prescriptions (Lesar et al., 1990). The rate of adverse drug events (ADEs), including medication errors, are estimated at approximately 1%, with 12% to 30% of them classified as serious or life threatening (Lindquist & Gersema, 1998). Approximately 1,000 medication errors yearly are estimated to be associated with the deaths of patients.

For many health care professionals, making a medication error is antithetical to the personal goals of alleviating suffering, restoring and promoting health, and preventing illness (Arndt, 1994). Medication errors are equated with failure and a breach of the implicit trust between nurses, physicians, pharmacists, and patients (Wolf, 1994). The prospect of making a medication error invokes anxiety on the part of some health care providers (Cheek, 1997).

The Premier Health Alliance (1995), accounting for 25 hospitals, indicated that 91% of the more than 9,000 errors voluntarily reported caused patients no harm (Business World, 1995). However, when a medication error results in a patient death, the worst outcome is realized. According to one study, the number of Americans who died from medication errors increased sharply between 1983 and 1993 (Phillips, Christenfeld, & Glynn, 1998).

Some claim that clinical errors made by nurses are attributable to downsizing, restructuring, and reorganization (Blegen, Goode, & Reed, 1998; Laughlin, 1998). Moreover, public dissatisfaction is growing since health professionals are not credited with policing themselves effectively (Grunsven, 1996). Betrayal of trust is part of the motivation of patients and their dependents when malpractice claims are made (Kraman & Hamm, 1999). Additionally, a trend is developing in which it is apparent that criminal charges are being brought against health care providers for errors in clinical practice (Laughlin, 1998; Smetzer, 1998; Smetzer & Cohen, 1998).

Nurses, pharmacists, and physicians involved in a fatal medication error suffer as a result. The memory of the error stays with providers for many years (Cardinale, 1999; Christensen, Levinson, & Dunn, 1992; Hilfiker, 1984; “The Mistake,” 1990; Wolf, 1994). To understand the effects of a fatal error on health care providers, descriptions of these events must be elicited. Therefore, the purpose of this secondary analysis of a previous study (McArt & McDougal, 1985; Miller, 1982; Sobal, 1982) was to describe the consequences of making a fatal medication error for health care providers. Fatal medication error was defined as a serious mistake involving drugs or intravenous (IV) solutions that resulted in patient death. In this study, consequence was defined as an effect experienced because of the error. A case study design was used; data were re-analyzed from that obtained during a descriptive study (Wolf, Serembus, Smetzer, Cohen, & Cohen, 2000) using a subsample of 11 respondents involved in medication errors in which death was the outcome.

The literature on medication errors emphasizes procedures to prevent them. In contrast, the investigators sought “new knowledge and insights” (Abel & Sherman, 1991, p. 795) gained from the analysis of respondents’ surveys. They also intended to sensitize (Knafl & Howard, 1984) nurses to the impact on health care providers involved in such a damaging event. Understanding the consequences of fatal errors could help health care professionals to appreciate the fear and guilt associated with reporting medication errors and ultimately assist in reporting errors.

Background

Nurses, pharmacists, and physicians are educated to be proficient professionals. They have a great deal of difficulty dealing with human error. This difficulty is attributable to their socialization, according to Leape (1994), and as supported by others (Bosk, 1979; Wolf, 1994). The assertion of health care providers that mistakes at work are unacceptable has most likely limited interdisciplinary collaboration. A culture of blame, visited upon individual health care providers following an error, has pervaded the health care industry for decades. The emphasis on continuous quality improvement, process improvement initiatives, and systems analysis has redirected efforts toward medication error prevention (Bechtel, Vertrees, & Swartzberg, 1993). In order for necessary change to take place across health care systems, cultural modifications must occur regarding health care mistakes. Errors are inevitable and must be addressed as evidence of systems flaws before error rates are substantially reduced (Leape, 1994).

Many medication errors are not reported orally or in writing. This can be explained by the fear of nurses and other health care professionals of lawsuits and public humiliation as well as by the economic costs associated with such events. For example, Osborne, Blais, and Hayes (1999) investigated nurses’ (n=57) perceptions of medication errors and appropriate reporting. The investigators found that nurses did not report medication errors because they were afraid. Subjects failed to report a medication error because they feared repercussions; they were fearful of the reactions from nurse managers and co-workers.

Additionally, Meurier, Vincent, and Parmar (1998) investigated the attributions nurses made following errors with serious outcomes (n=30) as compared to those with non-serious outcomes (n=30). They presented nurses with an instrument containing a scenario in which a written instruction was not carried out for a patient following a prostatectomy. A set of nine causal dimensions, including semantic differential rating subscales of locus of causation, stability, and controllability, was used. When the cause was perceived as internal, nurses involved in serious errors tended to take responsibility for their mistakes as compared to the other group. More nurses in the serious outcome group blamed themselves for the error. Meurier and colleagues noted that when internal attributions were made, nurses might fail to take necessary actions to correct systems problems.

Christensen et al. (1992) described 11 physicians’ recollections and feelings about their mistakes, prior beliefs that influenced emotional responses to mistakes, and ways of coping with these emotions. Each subject defined the mistake. Some physicians indicated that the error demonstrated overall incompetence while others viewed the mistake as an isolated event. Coping strategies were either problem focused or emotion focused. Problem-focused strategies included finding out what happened and learning from the mistake. Emotion-focused coping encompassed disclosure of the mistake with spouses or close friends. Many physicians incorporated changes in practice following the mistake. Some taught others about the experience of making and dealing with the mistakes.

Lawsuits are being brought against nurses for medication errors. For example, a wrongful death claim resulted in a visiting nurse being ruled negligent in a patient’s death when she failed to intervene to effect medication compliance. The patient did not take an anti-seizure medication, and died during a seizure from a myocardial infarction (Ohio Court of Claims, 1996). In another case, three registered nurses in Colorado were indicted for criminally negligent homicide in a medication error associated with a newborn infant’s death (American Nurse, 1997; Smetzer, 1998; Smetzer & Cohen, 1998). The state board of nursing sanctioned two of the nurses and a county prosecuting attorney obtained a grand jury ruling that the error was criminally negligent. Smetzer and Cohen (1998), reporting on a systems analysis of the error on behalf of the trial defense team, pointed out 50 failures leading to the error. The authors specified prescribing, order-processing, drug-dispensing, and drug-administration problems. The nurse on trial was acquitted. Smetzer (1998) described the tragedy and encouraged providers to look beyond blaming one individual and to change the systems under which medication errors occur.

Pharmacists who make medication errors that result in the death of patients are very hurt by these events. Cardinale (1999) reported on drug errors in which pharmacists were implicated. Each incident was covered extensively by the media, sometimes inaccurately. Pharmacists were reprimanded at work and were sued. One admitted that difficult memories persisted. Another pharmacist who stabbed his wife to death and injured his daughter with a knife was sentenced to prison for manslaughter, assault, and two counts of using a weapon to commit a felony (Williams, 2000). His crime was attributed to depression linked to a medication error that ended in the death of two patients. It is noteworthy that the effect of fatal errors for health care providers is not well understood.

When patients die as a result of medication errors, the public may or may not learn of the mistake. It is more likely that the public will be familiar with it when a well-known person’s death is linked to an adverse drug event. The publicity associated with such cases exposes the role that health care professionals played when the medication error was made. The exposure brings many consequences. For example, in the death of Betsy Lehman a wrongful death lawsuit was brought by the patient’s family against the hospital and professionals who cared for her (Fetter, 1995). Dana-Farber Cancer Institute investigated the error and improved the patient care system. The administrators and clinicians also shared their experience with the health care community. Although the nurses were not fired, they have lived with the consequences of this error (Grant, 1999).

Kowalski, Hayden, and Burck (1996) suggested that when a serious medication error is made, punishment and blame should not be meted out to the health care provider. Instead, the experience should be used as an opportunity to learn how to avoid future errors. The authors emphasized that the errors that kill patients also undermine the confidence of practitioners to continue their work. Kowalski et al. encouraged clinicians to support each other and share the responsibility as well as the disappointment engendered by medication errors.

The suffering resulting from medication errors is not confined to patients, families, and health care agencies (Lindquist & Gersema, 1998; Wolf et al., 2000). Nurses, physicians, pharmacists, and other health care providers blame themselves for drug misadventures. They are worried and guilty; they fear for the safety of the patient and fear disciplinary action (O’Neil et al., 1993; Wolf et al., 2000).

Framework

The theory about mistakes at work by Hughes (1951) oriented this study. According to Hughes, the most proficient as well as the least proficient individuals make mistakes, a common theme in the work of all occupations. Workers provide a collective rationale to build and maintain “collective defenses against the lay world” (p. 321) regarding mistakes. For health care providers, mistakes are often more fateful than those of other occupations. Hughes proposed that workers believe that outsiders may not understand the risk of mistakes, such as medication errors, and fear public knowledge.

Methods

This secondary analysis (McArt & McDougal, 1985; Sobal, 1982) used a case study design to describe the latent and manifest meanings in the survey accounts of 11 health care providers who made fatal medication errors. The unique attribute (Kennedy, 1979) of the 11 special cases was that each medication error resulted in a patient death. The subgroup for the analysis was selected from a descriptive, correlational design investigation focusing on the responses and concerns of health care providers regarding serious medication errors (Wolf et al., 2000).

Sample and Setting

Eleven cases were analyzed in which the death of patients was reported. The respondents were selected from a systematic random sample of health care professionals (n=402) of nurses (n=208), pharmacists (n=112), and physicians (n=82) that was generated from a target population. The target population was obtained from a complete list of licensed professional nurses (n=161,387), physicians (MDs) (n=30,111), and pharmacists (n=12,582) provided by the State Boards of Medicine, Nursing, and Pharmacy of the Bureau of Professional Affairs of the Commonwealth of Pennsylvania. Every 50th registered professional nurse, 10th physician, and 4th registered pharmacist was asked to complete a survey that focused on a medication error that they judged to be serious. Three thousand health care providers from each category were invited to participate in the study. Six hundred thirty-one surveys were returned and 402 were completed; 52 retired health care providers did not complete the survey; 115 indicated that they had never made a medication error; and 62 were returned as incorrect address, change of address, or no forwarding address. The response rate was 6.36%.

Ethical Considerations

A university institutional review board reviewed the study for human subjects’ considerations and approved the study. Consent to participate in the study was established when subjects returned completed instruments. The anonymity of the subjects was guaranteed.

Instrumentation

Section I of the self-report survey uses open-ended questions to elicit a description of the most serious drug errors made by respondents. Two of the investigators reviewed the transcribed descriptions of the medication errors and achieved agreement with the classification of indicators. The survey includes a checklist of interventions performed as a result of the drug error. Also, the National Coordinating Council’s Medication Error Index (Hartwig, Denger, & Schneider, 1991) was employed to determine the harm ranking of the error. A nine-point scale ranging from “0=No Error, Circumstances or events that have the capacity to cause error” to “8=Error, Death, An error occurred that resulted in patient death” evokes respondents’ judgments. Another harm scale is located in this section. The scale is “0=no harmful effect (improvement in symptoms, condition; no change in symptoms or condition); 1 =moderately harmful effect (morbidity: symptoms, illness); 2=severely harmful effect (morbidity: severe symptoms, permanent disability); and 3=maximally harmful effect (mortality: death).” The scores on the two scales were correlated to determine convergent validity of the harm ranking (Allen & Yen, 1979). The validity of the four-point scale was established in previous studies (Flynn et al., 1996; Wolf, McGoldrick, Jablonski, & Haakenson, 1995). The correlation between the MEI scale and the four-point harm scale was moderately strong (Kendall’s tau=0.66, p=.01). Section I also contains a checklist of people involved in and notified of the error.

Section II addresses health care providers’ responses to (55 items) and concerns (16 items) about making the medication error. A six-point scale (0=did not experience to 5=definitely experienced) is used to elicit ranks on a listing of responses and concerns. Examples of responses are “guilty, anguished, shocked” and examples of concerns are “fear of punishment” and “fear of lawsuit.” Open-ended questions follow in which respondents detail the circumstances surrounding the reporting of the error. Section II also contains a checklist in which individuals who supported health care professionals after the error are identified along with a seven-point scale, “0=not supportive at all” to “6=very supportive” and a “don’t know” category.

The theoretical validity of close-ended items in Section II was established by agreement with medication error literature and a content analysis of medication error literature on providers’ responses and concerns (Wolf & Cohen, 1999). Also, two doctorally prepared nurses, two doctorally prepared pharmacists, and two physicians established expert validity. Revisions were made based on expert review.

An attempt was made to establish test-retest reliability, 1 week apart, by paired t-tests on the responses (t= -4.77, p= [is less than] .0001), concerns (t=-4.82, p=.0003) subscales, and by a two sample t-test on the support subscale (t= -3.03, p=.009) with graduate nursing students (n=14). The groups were different. Perhaps subjects changed their responses in order for their answers to be more socially desirable than the first testing. Internal consistency reliability was also calculated. Cronbach’s alpha coefficients for responses and concerns were .96 and .92 respectively on the pretest, pilot study, and .94 and .91 in the primary study (Wolf et al., 2000).

Procedures for Data Collection

The investigators mailed the instrument to health care professionals. Subjects self-administered the instrument and a demographic profile. An addressed, stamped envelope was included to increase response rates and ensure respondent anonymity. Data collection continued for 3 months. After the primary study ended, the investigators culled from the set 11 surveys in which respondents reported the death of a patient from a medication error.

Data Analysis

Statistical analyses were accomplished using SPSS-PC. The numeric data from the subsample constituted a separate data set; descriptive statistics for close-ended items were reviewed for themes. Themes of the meaning of the experience for subjects were also sought (van Manen, 1990, p. 87) in the textual responses to open-ended questions that were gleaned from the larger data set. Textual responses were read, reread, and analyzed for consequences of the error. Each investigator initially coded the material independently. They next compared results and achieved agreement in interpretation. The investigators searched for latent and manifest meanings, seeking to discover essential themes.

Results

Respondent characteristics and medication error profiles are found in Table 1. The mean years elapsed since the error occurred was 22.7 (SD=14.4, Range 2-50). Table 2 includes the medications associated with the error and accounts of the events. Patient symptoms prior to death reported by respondents included unconsciousness, seizure, anaphylaxis, respiratory arrest, hypoglycemia, bradycardia, blindness, deafness, encephalopathy, and neutropenia.

Table 1.

Respondent Characteristics and Medication Error Profile

Age at Years in Highest Location of

Subject Error Sex Practice Degree Error

0008 23 F 1 MD Patient unit

0016 58 M 35 MD Pharmacy

0019 45 M 13 MD Pharmacy

0057 35 M 5 MD Home

0128 No M 14 Pharmacist; Pharmacy

Response BS

0199 26 M <1 yr MD/MBA Emergency

department

0266 36 M 5 Pharmacist; Patient unit

PharmD

0276 36 M 6 MD Home

0286 21 F 2 Registered Intensive care

nurse; unit

diploma

0287 20 F 2 Nursing Medical-

student Surgical unit

0391 25 M Intern MD Emergency

department

Phase of

Subject Administration Intervention

0008 Drug prescribing Additional drug

Order processing administered and

lab study

Radiology studies

0016 Drug prescribing Additional drug

Drug dispensing administered

Drug monitoring

0019 Order processing Hospitalized

Drug dispensing Additional time

monitoring and

time in treatment

Resuscitated

0057 Drug prescribing Resuscitated

0128 Drug prescribing Additional time

Order processing monitoring

Drug dispensing

Drug

administration

0199 Drug prescribing

Drug

administration

Drug monitoring

0266 Drug prescribing Additional lab

Order processing study, time

Drug dispensing monitoring, and

Drug time in treatment

administration Radiology studies

Drug monitoring Patient transferred

0276 Drug monitoring Additional drug

administered and

lab study

Radiology studies

Hospitalized

Additional time

monitoring and

time in treatment

0286 Drug Additional drug

administration administered, lab

study, and time in

treatment

Resuscitated

0287 Drug prescribing Additional drug

Order processing administered, lab

Drug study, time

administration monitoring, and

time in

treatment

0391 Drug Additional drug

administration

Table 2.

Description of Medication Error

Subject Medication Subject’s Description of Error

0008 Digitalis Miscalculation of injected dose using

oral medication. Concentration was made.

Dose in milligrams. Correct but in volume

incorrect. Discrepancy not observed by

nurse. Child’s clinical course worsened

and child died.

0016 Darvocet Patient continued to renew Darvocet

prescription; only one refill prescribed,

but druggist refilled 5-6 times. Patient

overdosed and died. Criminal prosecution,

went to trial; poor lawyer protection.

Found guilty when I was completely

innocent.

0019 Diamox Patient given Glucotrol instead of

Diamox.

0057 Indocin Patient with aspirin allergy given

Indocin and developed respiratory arrest.

0128 Inderal MD wanted Decadron 4 mg IV q6h but he

wrote Medrol 4 mg IV. Order was faxed to

Central Pharmacy. Pharmacy technician

entered Inderal 4 mg IV q6h. I checked

label with order and dispensed Inderal

IV. Patient terminally ill with a brain

tumor.

0199 Sulfa/Gantrisin ER visit by infant appearing mildly

infected with upper respiratory

infection, no high fever, no cough. DOA

days later in ER. Medication apparently

insufficient; error of judgement. No

autopsy done.

0266 Cisplatin MD wrote for combination chemotherapy.

Given cisplatin at a dose of 25

mg/[m.sup.2] over a total of 4 days. I

knew what she meant and interpreted it

correctly and passed it on. Subsequent

pharmacists and RNs misinterpreted it as

meaning cisplatin 25 mg/[m.sup.2]/day X

4 days. Patient got 4 times as much

cisplatin as intended. Error discovered

on day 4 of hospitalization. Patient died

of toxicities several days later. MD took

full responsibility for error, viewed as

system defect. Hospital-wide process

instituted to identify sources of error

and prevent their occurrence. Family

sued; damages awarded.

0276 Vitamin D Led to calcification of cerebral arteries

leading to CVA.

0286 Lidocaine Another staff nurse took my lidocaine

drip off the pump to give a patient a

bolus of the drip for his PVCs. I was

present and did not see harm in it. He

had a seizure and died. We told the

cardiologist. At first he also saw no

error in it but did discuss it with the

head nurse.

0287 Chemotherapy drug As a nursing student, I transcribed

medication incorrectly because I didn’t

know how drug was used. Placed on 3

times/day not daily X 3.

0391 Sodium amytal Police brought man to the emergency room

convulsing. I gave usual IV dose of

sodium amytal to stop convulsions. In 3

minutes respirations ceased. The coroner

found a high alcohol level.

For subjects, the highest-ranked responses after making the medication error, arranged from highest to lowest means, were: wished to make amends, immobilized, nervous, fearful, insomnia, denial, cried, lost confidence in ability to perform job, humiliated, embarrassed, worried, and guilty. Highest-ranked concerns, ordered from highest to lowest, were: fear for the patient, fear of license suspension, judged as incompetent by co-workers, loss of respect by coworkers, judged as incompetent by patient, fear of rejection, held responsible by other, and fear of disciplinary action.

Some of the subjects were unaware of the error as it occurred, only having been informed of the incident after the patient’s death. Those who knew a medication error was made feared that the patient was harmed and reacted by initiating resuscitation or by informing peers, attending physicians, and other co-workers. Some managers and administrators did not intervene after the error; those who did treated the patient, discussed the mistake with the respondent, filed an incident report, initiated an investigation, or shared the responsibility of the mistake with the subject. Two subjects were fired and never worked again in the agency in which the error took place. Eight of the respondents experienced no legal action; one was found guilty after criminal prosecution and two others were sued. Damages were awarded in one situation.

Medication errors were noted verbally; some were formally investigated. The errors became public because of details on incident reports and legal prosecution. While some respondents denied that the mistake affected them at all, most acknowledged its impact at a moderate level. It was difficult on an implicit level for some respondents to take ownership of the medication error. Rather, they deflected the blame onto individuals and situations associated with the error. Six out of the seven physicians in this study had no punitive action taken as a result of their error.

Additionally, respondents admitted the likelihood that errors would continue to take place despite every effort to do a perfect job and were disturbed by the error up to the present. They had insomnia; hid their guilt from family members or distanced themselves from supporters; lost a part-time job and as a result felt strained finances; were worried; developed a heightened sense of responsibility; became more kind with co-workers; and attempted to make amends.

The medication error was engraved indelibly in memory with details easily recalled by respondents. They were guilty and sad, although the episode was not thought of frequently. Their hypervigilance and heightened sense of responsibility about medication administration persisted. They reported that they did not hesitate to question orders or to change their practice to prevent another such occurrence. Respondents appreciated safety checks instituted to increase the safety of medication administration systems. One adamantly gave advice about finding a good lawyer in malpractice cases. Another continued to resent the fact that a physician denied writing an order for the wrong drug.

Individuals who supported respondents included other colleagues, physicians, managers, family members, friends, and members of the patient’s family. Some peers were sympathetic and very upset about the error. In some cases, reactions from peers were not observed. Only one respondent sought professional psychological counseling.

Respondents described the following impact on their clinical practice: acted hypervigilant, particularly when dispensing powerful drugs; felt loss of confidence; refused to delegate the responsibility to administer medications to co-workers; and questioned orders more often.

Essential Themes

The experiential consequences of making fatal medication errors revealed essential themes. These included being responsible for a patient’s death, noting failure, fearing punishment, hoping to correct the wrong, denying personal culpability, feeling guilty and depressed about the death, discerning public humiliation, needing support, coping with the error, and being fatalistic and feeling threatened about the likelihood of future errors.

Discussion

Subjects reported various emotional responses upon making a medication error. For many, these responses returned when reminded of the error. Emotions were consistent with those found in other investigations. Health care providers were shamed, worried, and guilty; they feared for the safety of the patient and feared disciplinary action as a consequence of making a medication error (Arndt, 1994; O’Neil et al., 1993; Wolf et al., 2000). Symptoms of depression were evident, such as disturbances in appetite, sleep, and concentration, along with fear for the patient’s welfare, concerns about litigation, as well as colleagues’ discovery of their incompetence.

That six of seven physicians involved in the study had no punitive action taken against them as a result of their medication errors is not unusual. In medical education, role models reinforce the concept of infallibility. The need to be perfect creates an atmosphere of intellectual dishonesty, to cover up mistakes rather than admit them (McIntyre & Popper, 1989). The standard of perfection is also evident in nurses who make medication errors (Wolf, 1994). Also, it could be that fear of humiliation, litigation, or punishment prevents health care providers from discussing mistakes. For nurses and pharmacists there may exist, such as for physicians, “a climate of competition … fostered initially in medical school, that may present a further barrier to professional self-disclosure” (Christensen et al., 1992, p. 429).

Some of the respondents in the study attempted to shift the blame for the error to other individuals. Leape (1994) asserted that physicians typically felt that admission of an error will lead to criticism, increased supervision, or that colleagues will judge them incompetent. When weighing the alternatives, respondents shifted the blame to another, including the patient, in an attempt to conceal their part in the error. On the other hand, subjects may have been in denial regarding errors, feared losing their anonymity, or feared being prosecuted.

As noted in this investigation, some medication errors have been made public in a variety of ways. Blame was cast on an individual and in some cases punishment was meted out in the form of peer/administrative disapproval and litigation (Leape, 1994). The impact of the verbal disclosures of medication errors, incident reports, and formal investigations on respondents is not known. Perhaps the fact that the error was known to others was punishment enough. However, three medication errors resulted in litigation. Only one resulted in a systemic investigation of the root cause. It is possible that in such a case the respondent’s morale was not attacked as the error had been identified as a system defect. That this approach to error prevention would have this effect is congruent with the assertions of Leape (1994), Smetzer (1998), and Smetzer and Cohen (1998).

Respondents accepted the notion that the likelihood existed of future errors despite their best efforts to avoid mistakes. This was also encountered in Christensen et al.’s (1992) investigation. It is a contradiction that the standard of professional practice is perfection, while at the same time health care providers admit that mistakes are inevitable.

Respondents attempted to cope with their mistakes in several ways. Christensen and colleagues (1992) detected two major types of coping strategies: problem-focused and emotion-focused. Respondents sought to process and learn from the mistake (problem-focused coping strategies). They discussed the details of the error with a health care provider, systematically investigated the error, and put safety checks in place. Emotion-focused coping strategies addressed respondents’ feelings. These included hiding errors from family members, distancing themselves from supporters, being more benevolent with co-workers, and attempting to make atonement with the patient’s family.

Respondents received little support from peers (Christensen et al., 1992; Hilfiker, 1984; Wu, Folkman, McPhee, & Lo, 1991). In an atmosphere of isolation, sharing what went wrong so that others may learn does not occur. In this case study of 11 health care providers, the three that were involved in legal action as a result of their medication error only gives credence to the belief that it is safer to hide errors than to report them.

Changes in practice following the error ranged from being fired from part time positions and losing self-confidence to developing a heightened sense of responsibility and hypervigilance with respect to medication administration. Again, these results support Christensen et al.’s (1992) findings. Health care providers who make medication errors may be riding in the wake of the expectation of professional perfection years later.

The findings of this investigation support the theory of Hughes (1951) about mistakes at work. As Hughes suggested, health care providers fear public scrutiny of their errors and build and maintain defenses against the lay world. Respondents defended themselves by hiding the error. This protected them from the derision of peers, employment consequences, as well from the risk of litigation.

The study findings can not be generalized to the target population. Rather they may serve to sensitize others to the consequences of fatal errors for health care providers. Medication errors have emotional consequences and occasionally financial and legal consequences for those who commit them. Health care professionals strive never to err; however, such a standard is impossible to meet. Given the repercussions for mistakes and lack of peer or administrative support, health care professionals often ,decide to hide errors. The outcome of this action is that when the mistake is not shared, others will not learn from it nor will medication administration systems improve.

Smetzer (1998) and Smetzer and Cohen (1998) recommended an approach to reducing medication errors in which blame is not placed on an individual and that the system where mistakes occur is reformed. Medication errors would thus be seen as failures in the system, rather than with the competency and vigilance of individual health care professionals (Leape, 1994; Smetzer & Cohen, 1998). Health care professionals may feel safe to report errors to administrators. Errors could be investigated using a failure mode and effects analysis (FMEA), a systemic process in which failures in mechanical, material, and production processes are evaluated and systems are put into place to prevent such errors (Cohen, 1999).

Future investigations could address health care providers’ experience of making a fatal medication error. Perhaps separate studies should focus on each of the groups of health care professionals represented in this investigation. Differences could be ascertained. Furthermore, the effect of systematic investigations following a medication error on the health care provider could be studied.

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Additional Readings

Cohen, M.R. (1991). Cooperative approaches to medication error management. Topics in Hospital Pharmacy Management, 11(1), 53-65.

Escovitz, A., Pathak, D.S., & Schneider, P.J. (Eds.). (1998). Improving the quality of the medication use process. New York: Pharmaceutical Products Press.

Farahmand, J.M. (1984). Factors associated with medication errors made by professional nurses. Philadelphia: Abstracts of Health Care Management Studies, University of Pennsylvania.

Murphy, M.D. (1992). Individual characteristics of nurses who committed medication administration errors. Issues, 13(1), 11-13.

Roseman, C., & Booker, J.M. (1995). Workload and environmental factors in hospital medication errors. Nursing Research, 44(4), 226-230.

Joanne Farley Serembus, MSN, RN, CCRN, is Assistant Professor, and Director, Undergraduate Nursing Programs, La Salle University School of Nursing, Philadelphia, PA.

Zane Robinson Wolf, PhD, RN, FAAN, is Dean and Professor, La Salle University School of Nursing, Philadelphia, PA.

Nancy Youngblood, PhD, RN, CRNP, is Coordinator, Nurse Practitioner Programs, and Assistant Professor, La Salle University School of Nursing, Philadelphia, PA.

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