An observational study of medicationadministration errors in.docx

An observational study of medication
administration errors in old-age
psychiatric inpatients
CAMILLA HAW, JEAN STUBBS AND GEOFF DICKENS
St. Andrew’s Hospital, Billing Road, Northampton, NN1 5DG,
United Kingdom.
Abstract
Background. Relatively little is known about medication
administration errors in mental health settings.
Objective. To investigate the frequency and nature of
medication administration errors in old-age psychiatry. To
assess the
acceptability of the observational technique to nurse
participants.
Method. Cross-sectional study technique using (i) direct
observation, (ii) medication chart review and (iii) incident
reports.
Setting. Two elderly long-stay wards in an independent UK
psychiatric hospital.
Participants. Nine nurses administering medication at routine
medication rounds.
Main outcome measures. Frequency, type and severity of
directly observed medication administration errors compared
with

errors detected by retrospective chart review and incident
reports.
Results. Using direct observation 369 errors in 1423
opportunities for errors (25.9%) were detected vs. chart review
detected
148 errors and incident reports none. Most errors were of
doubtful or minor severity. The pharmacist intervened on four
occasions to prevent an error causing patient harm. The
commonest errors observed were unauthorized tablet crushing
or
capsule opening (111/369, 30.1%), omission without a valid
reason (100/369, 27.1%) and failure to record administration
(87/369, 23.6%). Among the nurses observed, the error rate
varied widely from no errors to one error in every two doses
administered. Of the seven nurses who completed the post-
observation questionnaire, all said they would be willing to be
observed again.
Conclusion. Medication administration errors are common and
mostly minor. Direct observation is a useful, sensitive
method for detecting medication administration errors in
psychiatry and detects many more errors than chart review or
inci-
dent reports. The technique appeared to be acceptable to most of
the nursing staff that were observed.
Keywords: administration, adverse drug events, elderly,
medication errors, mental health, observation, psychiatry
Medication errors (prescribing, transcribing, dispensing and
administration errors) are an important cause of patient mor-
bidity and mortality [1]. Medication administration errors are
a common sub-type of medication errors and accounted for
34% of errors in one large USA study conducted in medical
and surgical units [2]. Observational studies in general hospi-

tals have yielded error rates varying between 3.5 and 27% of
doses [3–8]. Direct observation detects medication adminis-
tration errors at a much higher rate than chart review or inci-
dent report review [9]. The observational method has been
demonstrated to be valid and reliable [10].
Less research on medication errors has been conducted
in mental health settings, and little is known about the
incidence of medication administration errors in psychiatry
[11]. Medication administration to psychiatric inpatients
presents different challenges from that to patients in
general hospitals. Psychiatric settings might be expected to
pose fewer risks to patients, as parenteral drug adminis-
tration is uncommon and mainly limited to depot antipsy-
chotics used to treat schizophrenia, intravenous vitamin B
for patients with alcohol dependence and intra-muscular
antipsychotics and benzodiazepines for rapid tranquilliza-
tion. Intravenous fluids and blood products are not admi-
nistered. On the other hand, many psychiatric patients are
extremely vulnerable. They may lack mental capacity to
give informed consent to medication, may be non-
compliant and even violent. The elderly mentally ill are
particularly vulnerable as they may be confused, resist
Address reprint requests to: Dr. Camilla Haw, St. Andrew’s
Hospital, Billing Road, Northampton, NN1 5DG,
United Kingdom. E-mail: [email protected]
International Journal for Quality in Health Care vol. 19 no. 4
# The Author 2007. Published by Oxford University Press on
behalf of International Society for Quality in Health Care; all
rights reserved 210
International Journal for Quality in Health Care;Volume 19,
Number 4: pp. 210 – 216 10.1093/intqhc/mzm019
Advance Access Publication: 10 June 2007

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medication administration, be physically frail and require
complex medication regimes.
Review of the literature (by searching Medline, PsycINFO,
CINAHL, BNID and AMED from 1966 onwards) revealed
only a handful of studies on medication administration errors
in psychiatry, with most based on retrospective chart review
or official incident reports [12–14]. We were unable to
identify any reports of observational studies in psychiatry,
apart from a very small study conducted in a learning disabil-
ity group home [15], a study of tablet crushing in residential
homes for the elderly [16] and an observational study of
medication administration to psychiatric inpatients but this
did not report on the frequency of errors [17]. Concerning
studies of older persons conducted in general hospitals, we
identified an observational study partly conducted in a geria-
tric unit [6] and another conducted in an elderly female ward
with acute admissions [4].
The aims of the current study were to use the observa-
tional technique in two long-stay old-age psychiatry wards to
determine the frequency and nature of medication adminis-

tration errors, to study factors associated with errors and to
compare observed errors with those detected by chart review
and incident report. We also wanted to assess if the observa-
tional technique was acceptable to participating nurses.
Methods
Study setting
The study was approved by the Local Research Ethics
Committee. It was conducted at St. Andrew’s Hospital,
Northampton, a 450-bedded independent charitable hospital
providing psychiatric care for patients with a wide range of
mental health problems. We studied medication adminis-
tration on two long-stay wards for elderly mentally ill
patients, a 13-bedded unit for patients with dementia and
challenging behaviour (Ward A) and a 21-bedded unit for
frail elderly patients with dementia (some patients also had
schizophrenia) offering nursing home type care (Ward B). We
carried out a semi-structured interview with each patient’s
consultant psychiatrist to obtain an ICD-10 clinical diagnosis
[18] and details of the patient’s disabilities.
Medication administration
Prescriptions are written on a paper medication chart. It is
hospital policy that each time a medication is administered
the administering nurse signs the medication chart. If the
nurse is not able to administer the medication, they should
record an omission code e.g. ‘A’ if the patient is absent, ‘R’ if
the patient refuses the medication. Medication administration
on Wards A and B is undertaken by one nurse, with the
assistance of ‘runners’ who may be nurses or healthcare
assistants. The runners take medication to patients who are
unable to walk to the medicines trolley. Runners are required
to ensure that medication is taken by the patient, i.e. tablets

are swallowed.
Details of how participants were recruited
Nursing staff were given information about the aims of the
study and invited to participate. Participants were required to
give written consent. At the end of the study, participants were
invited to complete a questionnaire on how acceptable or
otherwise they had found the experience of being observed.
Definition and classification of medication
administration errors
We defined a medication administration error as ‘a deviation
from a prescriber’s valid prescription or the hospital’s policy in
relation to drug administration, including failure to correctly
record the administration of a medication’. This definition was
derived and adapted from the literature [7, 19, 20] and is one
that we have used previously [14]. Omission of a drug for
valid clinical reason was not counted as an administration
error, provided the nurse recorded an appropriate code on the
medication chart indicating that the drug was not given.
Administration errors were categorized using the National
Coordinating Council for Medication Error Reporting and
Prevention (NCC MERP) taxonomy [21]. Errors were cate-
gorized at consensus meetings attended by all three
researchers.
Severity of errors
Error severity was rated on the following five-point scale that
two of the researchers had previously used in medication
error research [22]:
Grade 1—errors or omissions of doubtful or negligible
importance.

Grade 2—errors or omissions likely to result in minor
adverse effects or worsening condition.
Grade 3—errors or omissions likely to result in serious
effects or relapse.
Grade 4—errors or omissions likely to result in fatality.
Grade X—unratable (due to lack of clinical and other
information).
Error severity was agreed by the three researchers at consen-
sus meetings.
Method of observing medication administration
J.S. (Head Pharmacist) observed medication administration of
regular and as required (prn) drugs given at each of the four
routine daily drug rounds. Administration of ‘prn’ drugs and
depot preparations given at other times of the day or night
was not observed. Details of medications that were adminis-
tered were recorded on a standard pro-forma data collection
sheet. It was agreed beforehand that if the observer witnessed
a ‘near miss’ incident whereby an error was about to be made
that was likely to cause patient harm, then she would intervene
prior to the medication being administered. For the purposes
of the study, such ‘near miss’ events were counted as errors.
After the medication round, J.S. examined each patient’s medi-
cation chart to check that the correct medication had been
Medication administration errors
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given, to see if any medication had been omitted in error and
if any clerical errors had been made.
Administration errors detected by chart review
A second pharmacist (see Acknowledgement) blind to the
results of the observational study carried out a retrospective
chart review of the recording of medication administration
for those drug rounds that were included in the observa-
tional study. She recorded the number and type of errors that
she was able to detect by chart review.
Administration errors reported using the
Hospital’s medication error reporting system
The Hospital policy is that all medication errors should be
reported on an incident form that is sent to and collated by
the responsible senior nurse manager. We requested details
of the number of administration errors reported for Wards A
and B for the 3 months before and the 3 months after the
study as well as for the study period.
Statistical analysis
Data were analysed using SPSS version 14.0 [23]. The x2 test

was used to compare differences between variables and
whether or not an error had occurred.
Results
Patient details
Medication administration to 32 patients was observed. Of
these, 20 (63%) had organic brain disease and 12 (38%)
schizophrenia. Nineteen (59%) patients had more than one
diagnosis. Twenty-one (66%) were unable to give informed
consent with respect to medication. Thirteen (41%) had
swallowing difficulties, 13 (41%) sometimes refused or spat
out medication and 15 (47%) had a history of aggression
towards nursing staff.
Participants and details of medication
rounds observed
Nine out of 12 (75%) nurses approached consented to take
part in the study. Observations were conducted over a
2-week period in March 2006 on Ward A and in June and
July 2006 on the Ward B. On Ward A five medication
rounds at 08.00, 12.00, 18.00 and 22.00 h were observed,
giving a total of 20 rounds observed, whereas on Ward B,
four rounds each at these times were observed, giving a total
of 16 rounds.
Details of medication administered
A total of 1423 opportunities for error were studied (1313
doses were administered, 10 doses were not/could not be
administered for valid clinical reasons and there were 100
omission errors). Most doses were oral (1306; 91.8%). The
rest were: topical 59 (4.1%), inhaled 47 (3.3%), ophthalmic 9

(0.6%) and subcutaneous 2 (0.1%).
Details of error numbers, types and severity
detected by direct observation
A total of 369 errors were made out of 1423 doses (25.9%).
For 20 (1.4%) doses, two errors were made. The types of
error observed are given in Table 1. The commonest error
types encountered were crushing tablets without the author-
ization of the prescriber (28.7%), omission without a valid
clinical reason (27.1%), failing to sign the medication chart
to record that a drug had been administered (23.6%) and
wrong quantity (8.7%). Other types of error were compara-
tively rare. Concerning the 111 instances where tablets were
crushed or capsules opened without authorization, this was
specifically contra-indicated by the drugs’ manufacturers in
seven instances (esomeprazole three doses, digoxin two
doses, aminophylline modified release one dose and lanso-
prazole orodispersible one dose).
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Table 1 Types of medication administration error detected
by observation (N ¼ 369)
Error type Frequency Percent
of total
number
of
errors
Percent
of total
number
of doses

Crushing tablets
without
authorization
106 28.7 7.4
Omission without
valid reason
100 27.1 7.0
Not signing for an
administered
medication
87 23.6 6.1
Wrong quantity 32 8.7 2.2
Wrong
formulation
14 3.8 1.0
Administration of
a prescribing
error
9 2.4 0.6
Wrong time 7 1.9 0.5
Wrong drug 6 1.6 0.4
Opening capsules
without
authorization

5 1.4 0.4
Mixing drug with
food without
authorization
2 0.5 0.1
Unauthorized
extra dose
1 0.3 0.1
Total 369 100 25.9
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The severity ratings of the errors detected are given in
Table 2. More than two-thirds of errors were of doubtful or
negligible significance (Grade 1). Only one error was rated as
likely to result in serious effects or relapse. For nearly a

quarter of errors, potential severity could not be rated. This
was mainly because a nurse had been observed to have cor-
rectly administered a dose of medication but had then failed
to sign the medication chart. It was therefore possible, but
not certain, that another nurse might then have administered
a duplicate dose. The pharmacist observer intervened on
four occasions to prevent patient harm (two wrong drug
errors, one wrong dose error and one omission error).
Analysis of the more severe errors (Grade 2 and 3) showed
the commonest error types were omission (N ¼ 13) (e.g.
insulin, sodium valproate and carbamazepine), wrong drug
(N ¼ 6) (e.g. propranolol given instead of trazodone, que-
tiapine given instead of olanzapine) and unauthorized crush-
ing (N ¼ 5) (e.g. aminophylline modified-release).
Factors associated with errors
Proportionally fewer errors were made at the 22.00 h medi-
cation round than at other rounds (08.00 h 215 errors out of
694 doses, 31.0%; 12.00 h 50/157, 31.8%; 18.00 h 81/345,
23.5%; 22.00 h 23/227, 10.1%, P , 0.0001).
A greater proportion of errors involved non-psychotropic
drugs (non-psychotropic errors 258 out of 893 doses
(28.9%) vs. psychotropics 111 errors out of 530 doses
(20.9%), P ¼ 0.001). A greater proportion of errors involved
drugs administered by non-oral routes (non-oral routes, 70
errors in 118 doses (59.3%) vs. oral route, 299 errors in
1305 doses (22.9%), P , 0.0001). Of the 59 doses of topical
preparations prescribed, there were 58 errors. In 57 instances,
the error involved was omission of a topical preparation
without a valid clinical reason. When topical creams and
lotions were excluded from the analysis, the difference
between errors involving the oral and non-oral routes
disappeared.

Errors were more often associated with patients with a
diagnosis of organic brain disease than those with functional
mental illnesses (253/829, 30.5% vs. 116/594, 19.5%; P ,
0.0001) and with those who lacked capacity to consent to
medication administration than those with capacity (272/913,
29.8% vs. 97/510, 19.0%; P , 0.0001). Medication errors
were also more often associated with patients with swallow-
ing difficulties than those without (179/480, 37.3% vs. 190/
943, 20.1%; P , 0.0001) and with those who were known to
regularly spit out or refuse medication than with those who
did not (169/540, 31.3% vs. 200/883, 22.7%; P , 0.0001).
After excluding those doses of medication where tablets were
crushed or capsules opened, errors were still more often
associated with patients with swallowing difficulties (110/
377, 29.2% vs. 117/780, 15%; P , 0.0001) but not with the
other patient characteristics.
Among the nurses observed, the error ratio (number of
errors made per total doses observed) varied widely from no
errors made to one error in every 2.0 doses administered
(P , 0.0001). The median error rate was one error in every
6.4 doses administered.
Errors detected by chart review
The independent pharmacist who reviewed the medication
charts detected 148 administration errors. The types of
errors detected were as follows: 133 omissions, 9 unauthor-
ized extra doses, 5 wrong times and 1 administration of a
discontinued item. All errors detected by chart review were
detected by direct observation but of the 133 omissions
detected by chart review, direct observation demonstrated
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Table 2 Severity ratings of medication administration errors
(N ¼ 369)
Severity grade of
error
Examples Medication
administration
errors N (%)
Grade 1: Errors
or omissions of
doubtful or
negligible
importance
Lactulose 20 ml
administered—
30 ml
prescribed.
Pericyazine
2.5 mg
administered at
the wrong time.
255 (69.1)
Grade 2: Errors
or omissions
likely to result
in minor
adverse effects
or worsening of
condition

Sinemet 110
administered at
the wrong time.
Carbamazepine
200 mg
administered—
400 mg
prescribed
27 (7.3)
Grade 3: Errors
or omissions
likely to result
in serious
effects or
relapse
Insulin omitted
but the nurse
recorded
administration
on the
medication
chart.
1 (0.3)
Grade 4: Errors
or omissions
likely to result
in fatality
0 (0)
Grade X:

Unrateable
Medication was
observed to be
correctly
administered
but the nurse
failed to record
administration
on the
medication
chart.
86 (23.3)
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that 33 of the 133 omissions were in fact clerical errors (the
nurse had correctly administered the medication but then
failed to record administration on the medication chart).

Errors reported using the Hospital’s medication
error reporting system
During the period of the observational study no adminis-
tration errors on Wards A or B were reported using the
Hospital’s medication error reporting system. No errors were
reported in the 3 months before and only one error in the 3
months after the study.
Acceptability of the observational technique
reported by participants
Seven (78%) of the nine participants completed the post-
observation questionnaire. Five out of seven (71%) thought
the observational procedure was well explained prior to com-
mencement. None rated the experience of being observed as
unpleasant. Two (29%) reported that they felt being observed
made it more likely for them to make an error. All seven
said they would be willing to be observed while administering
medication in the future.
Discussion
In this observational study of medication administration to
elderly long-stay psychiatric inpatients, errors were very
common, occurring in one in four doses. Most errors were
not serious and no patient suffered observable harm as a
result of errors, although the pharmacist intervened on four
occasions to prevent patient harm. The commonest types of
error were unauthorized crushing of tablets or opening cap-
sules, omission of medication and failing to sign for medi-
cation. More errors were associated with patients with
swallowing difficulties, even after crushed doses of medi-
cation were excluded from the analysis. The reason for this
association is not clear. The error rate varied widely between
the nine nurse participants. The observational study detected

two and a half times the number of errors than did retro-
spective review of the medication charts, whereas none of
the errors detected during the observational study were
reported using the hospital’s incident report system. In
addition, some errors misclassified as unauthorized omis-
sions by chart review were shown by the observational study
to be failures to sign for administered doses.
The observational technique appeared acceptable to most
of the participating nurses. All who completed the post-
observation questionnaire stated they would be willing to be
observed administering medication in the future, although
two reported they felt that being observed made them more
prone to make errors. The pharmacist observer had to stand
very close to the administering nurse in order to accurately
record medicines administration and some nurses commen-
ted that this was intrusive. However, an observational study
conducted in a general hospital reported no evidence that
the technique made nurses more or less likely to make errors
[10]. The participating nurses were aware of the aims of the
study and it is possible that this knowledge may have affected
their behaviour. The fact that observation was not disguised
could have resulted in greater vigilance. Equally, it could have
made some nurses anxious and inattentive and thus more
prone to make errors.
Compared with observational studies conducted in general
hospital settings, our study detected a similar proportion of
errors but fewer potentially serious errors [6, 7]. In psychia-
try, few drugs are administered parenterally. However, many
of the patients in our study were physically frail requiring
medication for physical conditions and all were elderly.
Serious and fatal medication administration errors are more
common in elderly patients [1]. Medicines administration to
our patients was particularly difficult as some were confused

and uncooperative, could be aggressive and had swallowing
difficulties. On the other hand, the patients in our study
were long stay and there was a low turnover of nursing staff.
Patients’ medication changed little during the study period
and yet despite this errors were very common. It would be
expected that the error rate on a psychiatric admission ward
would be much higher because of the greater turnover of
patients and nursing staff and frequent changes to prescrip-
tions. There are a number of possible reasons for the large
number of process errors detected in our study. The phar-
macist observer noted that medication administration fre-
quently occurred at patients’ meal times in noisy and
sometimes cramped conditions. Thus, the administering
nurse had to contend with many potential distractions as well
as being under pressure to complete the medication round as
swiftly as possible. The ward atmosphere during the night-
time medication round was, by contrast, much quieter and
less pressured. At the time the study was conducted, there
was no standardized refresher training in safe medication
practice for nursing staff.
In our study, the commonest error type was the unauthor-
ized crushing of tablets (and a few instances of opening cap-
sules). Although beyond the scope of this researcher study,
the pharmacist observer found no evidence that unauthor-
ized tablet crushing was being used to covertly administer
medication to patients. In some instances, the crushed medi-
cation was then mixed with food. However, we could not
find reports of this type of error in other observational
studies, apart from one conducted in two units in France,
one of which was a geriatric unit [6] and another conducted
in an elderly acute admission ward [4]. Tablet crushing and
capsule opening were observed to be common in an
Australian study of units for the elderly [16]. In our study,
crushing was done for two main reasons: for patients with
swallowing difficulties and for uncooperative patients, but

there were also instances of tablets being crushed for no
obvious reason. Surveys of nursing and care staff have
reported that tablet crushing is common in residential and
nursing homes [24], as is the practice of concealing drugs in
food and beverages [25]. Crushing tablets alters the bioavail-
ability of some drugs and may have serious consequences
for the patient. It may be appropriate but should be
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authorized by the prescriber. A pharmacist may be able to
recommend a more appropriate dosage form. Since this
study was conducted, staff on one of the wards concerned
have set up a multidisciplinary medication administration
group to review all patients’ medication regarding adminis-
tration problems such as swallowing difficulties. The team
includes a pharmacist and a speech and language therapist
and aims to ensure medicines are administered in a safe and
effective way.
The other common error types we encountered were

omission of a medication without a valid clinical reason and
failing to sign the medication chart after a medication had
been administered. In our study, most of the prescriptions
for topical preparations were not being administered.
Omission errors have been reported as the commonest type
of administration error in observational studies conducted in
general hospitals [3–5].
Six wrong drug errors were detected in our study, all rated
as being of grade 2 severity (likely to results in minor adverse
effects or worsening of the condition). None of these errors
involved drugs of similar sounding names or similar packa-
ging. One wrong dose error concerned confusion between
two liquid preparations held in bottles of approximately the
same size though with different coloured labels. Thus, given
that no clear cause for these wrong drug errors was evident,
it was not possible to develop strategies to prevent their
re-occurrence. Wrong drug errors are an important cause of
morbidity and mortality in general hospitals, and in one large
USA study, they were the second most common cause of
fatal medication errors [1].
Our study has a number of limitations. It took place on
two wards of an independent sector hospital, and thus the
findings may not apply to the National Health Service or
community settings. However, the patients studied were not
atypical of those found in nursing homes for the elderly
mentally ill, although some exhibited particularly challenging
behaviour and had been referred from NHS hospitals for
this reason. We studied medicines administration by a rela-
tively small number of nurses and not all nurses approached
agreed to participate. These are important limitations, and
because of the small number of nurses observed, we were
unable to report on whether errors were associated with par-
ticular nurse characteristics. A study conducted in a paedia-
tric hospital reported that error rates were higher for student

nurses and nurses who did not regularly work on the unit
[8]. All the nurses in our study were permanent staff on the
wards concerned.
Conclusion
The observational technique can usefully be applied in psy-
chiatry, although informed consent must be obtained from
nurse participants. Medication administration errors in our
study were very common, although fortunately most were
not serious. The fact that the error rate varied widely
between nurses and also the absence of annual refresher
courses in medicines administration at our hospital suggests
some form of regular standardized training might impact on
the error rate. We plan to repeat the study at a later date
once training has taken place to see if practice has
improved. However, a recent systematic review found little
research on the efficacy of nursing educational interventions
in reducing medication administration errors [26]. In a ran-
domized controlled trial, the use of dedicated medication
nurses who had undergone brief review training in safe
medication use did not result in a reduction in medication
administration errors compared with the control group [27].
The reporting of errors using incident reports needs to
be encouraged, although several authors have highlighted
the many reasons why staff are reluctant to report errors
[28, 29].
Acknowledgement
Our thanks to Caroline Cahill for reporting on medication
errors detected by chart review.
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17. Haglund K, Von Essen L, Von Knorring L et al.
Medication administration in inpatient psychiatric care – get
control and leave control. J Psychiatr Ment Health Nurs
2004;11:
229–34.
18. World Health Organisation. The ICD-10 Classification of
Mental
and Behavioural Disorders. Clinical Descriptions and
Diagnostic
Guidelines. Geneva: World Health Organisation, 1992.
19. O’Shea E. Factors contributing to medication errors: a
literature
review. J Clin Nurs 1999;8:496–504.
20. Taxis K, Barber N. Ethnographic study of incidence and
sever-
ity of intravenous drug errors. BMJ 2003;326:684–7.
21. National Coordinating Council for Medication Error
Reporting
and Prevention: Taxonomy of Medication Errors, 1998. www.
nccmerp.org/pdf/taxo2001-07-31.pdf

22. Stubbs J, Haw C, Taylor D. Prescribing errors in psychiatry
– a
multi-centre study. J Psychopharm 2006;20:553–61.
23. SPSS Inc. (2006) SPSS Base 14.0 User’s Guide. New
Jersey:
Prentice Hall.
24. Wright D. Medication administration in nursing homes.
Nurs
Stand 2002;16:33–8.
25. Kirkevold Ø, Engedal K. Concealment of drugs and food in
beverages in nursing homes: cross sectional study. BMJ
2005;330:20–2.
26. Hodgkinson B, Koch S, Nay S et al. Strategies to reduce
medi-
cation errors with reference to older adults. Int J Evid Based
Healthc 2006;4:2–41.
27. Greengold NL, Shane R, Schneider P et al. The impact of
dedi-
cated medication nurses on the medication administration error
rate. Arch Intern Med 2003;163:2359–67.
28. Wakefield DS, Wakefield BJ, Uden-Holman T et al.
Perceived
barriers in reporting medication administration errors. Best
Pract
Benchmark Healthc 1996;1:191–7.
29. McBride-Henry K, Foureur M. Medication administration
errors:
understanding the issues. Aust J Adv Nurs 2006;23:33–40.

Accepted for publication 13 April 2007
Haw et al.
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3/15/20, 1)56 PMThe medication process in a psychiatric
hospital: are errors a potential threat to patient safety?
Page 1 of
17https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3775703/
Risk Manag Healthc Policy. 2013; 6: 23–31.
Published online 2013 Sep 9. doi: 10.2147/RMHP.S47723
PMCID: PMC3775703
PMID: 24049464
The medication process in a psychiatric hospital: are errors a
potential

threat to patient safety?
Ann Lykkegaard Soerensen, Marianne Lisby, Lars Peter
Nielsen, Birgitte Klindt Poulsen, and Jan Mainz
Faculty of Social Sciences and of Health Sciences, Aalborg
University, Aalborg, Denmark
Department of Nursing, University College of Northern
Denmark, Aalborg, Denmark
Research Centre of Emergency Medicine, Aarhus University
Hospital, Aarhus, Denmark
Department of Clinical Pharmacology, Aarhus University
Hospital, Aarhus, Denmark
Aalborg Psychiatric University Hospital, Aalborg, Denmark
Department for Health Services Research, University of
Southern Denmark, Denmark
Correspondence: Ann Lykkegaard Soerensen, Aalborg
University, Danish Center for Healthcare Improvements,
Fibigerstraede 11, 9220 Aalborg Oest, Denmark, Tel +45 99 40
27 22, Email [email protected]
Copyright © 2013 Soerensen et al, publisher and licensee Dove
Medical Press Ltd
The full terms of the License are available at
http://creativecommons.org/licenses/by-nc/3.0/. Non-
commercial uses of
the work are permitted without any further permission from
Dove Medical Press Ltd, provided the work is properly

attributed.
Abstract
Purpose
To investigate the frequency, type, and potential severity of
errors in several stages of the medication
process in an inpatient psychiatric setting.
Methods
A cross-sectional study using three methods for detecting
errors: (1) direct observation; (2)
unannounced control visits in the wards collecting dispensed
drugs; and (3) chart reviews. All errors,
except errors in discharge summaries, were assessed for
potential consequences by two clinical
pharmacologists.
Setting
Three psychiatric wards with adult patients at Aalborg
University Hospital, Denmark, from January
2010–April 2010.
1,2 3 4 4 5,6
1
2
3
4

5
6
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3775703/#
https://dx.doi.org/10.2147%2FRMHP.S47723
https://www.ncbi.nlm.nih.gov/pubmed/24049464
https://www.ncbi.nlm.nih.gov/pubmed/?term=Soerensen%20AL
%5BAuthor%5D&cauthor=true&cauthor_uid=24049464
https://www.ncbi.nlm.nih.gov/pubmed/?term=Lisby%20M%5BA
uthor%5D&cauthor=true&cauthor_uid=24049464
https://www.ncbi.nlm.nih.gov/pubmed/?term=Nielsen%20LP%5
BAuthor%5D&cauthor=true&cauthor_uid=24049464
https://www.ncbi.nlm.nih.gov/pubmed/?term=Poulsen%20BK%5
BAuthor%5D&cauthor=true&cauthor_uid=24049464
https://www.ncbi.nlm.nih.gov/pubmed/?term=Mainz%20J%5BA
uthor%5D&cauthor=true&cauthor_uid=24049464
mailto:[email protected]
https://www.ncbi.nlm.nih.gov/pmc/about/copyright/
http://creativecommons.org/licenses/by-nc/3.0/
Page 2 of
The observational unit
The individual handling of medication (prescribing, dispensing,
and administering).
Results
In total, 189 errors were detected in 1,082 opportunities for

error (17%) of which 84/998 (8%) were
assessed as potentially harmful. The frequency of errors was:
prescribing, 10/189 (5%); dispensing,
18/189 (10%); administration, 142/189 (75%); and discharge
summaries, 19/189 (10%). The most
common errors were omission of pro re nata dosing regime in
computerized physician order entry,
omission of dose, lack of identity control, and omission of drug.
Conclusion
Errors throughout the medication process are common in
psychiatric wards to an extent which
resembles error rates in somatic care. Despite a substantial
proportion of errors with potential to harm
patients, very few errors were considered potentially fatal.
Medical staff needs greater awareness of
medication safety and guidelines related to the medication
process. Many errors in this study might
potentially be prevented by nursing staff when handling
medication and observing patients for effect
and side effects of medication. The nurses’ role in psychiatric
medication safety should be further
explored as nurses appear to be in the unique position to
intercept errors before they reach the patient.
Keywords: medication safety, mental health disorders,
medication errors, psychiatry
Introduction
Adverse drug events (ADEs) and medication errors (MEs) are
recognized as an important quality and
patient safety problem in modern hospital settings, causing
harm as well as avoidable morbidity and
mortality.1–5

There is limited evidence about these issues in psychiatric
settings. Only a few studies on ADEs and
MEs in psychiatric hospital settings exist. Four of these studies
addressed prescribing errors and two
studies addressed administration errors.6–11
Results from three of the studies investigating prescribing
errors displayed a rate of decision-making
errors which ranged from 12.5%–23.7% and a rate of
documentation (clerical) errors, which ranged
from 76.3%–84.5%.7–9 The fourth study, aimed at describing
errors in the prescribing phase, was
based on reports about pharmacists’ interventions.6 In the two
studies which focused on administration
errors, one study was based on self-reporting by nurses and did
not report any rate of error. The other
study was an observational study of administration errors in
elderly psychiatric inpatients where
administration errors were detected in 25.9% of all
opportunities for error.10,11 Some studies have
investigated several stages in the medication process, but these
studies were primarily based on data
collected from self-reporting of medication errors and chart
reviews.12–15 These studies measured
their outcomes using different methods and denominators which
makes it difficult to conduct
comparisons. However, it is recognized that direct observation
is the most valid method when
Page 3 of

collecting data in the dispensing stage and the administration
stage.16 It is highly important to apply
reliable methods when investigating frequency and character of
errors in the medication process to
produce valid and precise information.16,17
To our knowledge, there are no studies in psychiatric hospital
settings which focus on errors in more
stages of the medication process, including discharge
summaries, by applying the most sensitive
methods of detection. A precise estimate of frequency, type, and
potential severity of errors is needed
to choose relevant interventions to reduce errors in the
medication process. Therefore, the objective of
this study was to investigate the frequency, type, and potential
severity of errors in several stages of the
medication process in an inpatient psychiatric setting.
Materials and methods
The medication process can be divided into prescribing,
dispensing, administering, and monitoring.18
Furthermore, the prescription stage of the medication process
can be divided into a decision-making
process and a clerical process. The decision-making process
concerns the physician’s choice of drug,
dose, and form of administration.18 The stage of monitoring the
patient for effects and side effects was
not included in the study.
An error was defined as “a planned action which failed to
achieve the desired consequences.”19 This
means that all deviations from guidelines were considered

errors; subsequently, two clinical
pharmacologists evaluated all errors for potential severity,
thereby separating harmless errors from
errors with the potential to harm patients.
Describing proportions of errors requires a defined
denominator.20
“Opportunities for error”, defined as opportunities for active
errors (omissions, mistakes, and/or
conscious or unconscious rule violations), was the denominator
used to calculate the proportion of
errors in this study. The denominator is established by
multiplying the number of handled medications
with the number of requirements in the guidelines to be
followed. The proportion of errors was the sum
of actual errors divided by the total number of opportunities for
errors.
Design
The study was designed as a descriptive, cross-sectional study
of errors in the medication process and
potential harm. Data was collected using three methods: direct
observation; unannounced visits to the
wards to collect dispensed drugs for identification; and chart
review. The study population included in-
hospital patients aged 18 or above (n = 67), nurses and nurses’
assistants dispensing and administering
drugs, and physicians prescribing drugs, but the observational
unit was the individual handling of
medication (prescribing, dispensing, and administering). It is
common in Denmark that each ward has
its own stock ward system where nurses dispense drugs. The
term “dispensing” refers to nurses
identifying the drugs prescribed and dispensing it to medication

cups. Subsequently, the nurses will
administer the medications to patients. The hospital pharmacy
staff undertakes monitoring the use,
needs, and reordering of drugs as well as giving advice for the
individual wards. In this study, regular
and pro re nata (PRN) prescriptions were included, apart from
discharge summaries in which PRN
prescriptions were excluded. The choice of excluding PRN
prescriptions in discharge summaries was
Page 4 of
made because physicians often forget or are not aware that a
PRN drug deliberately not prescribed in
the discharge summary must be discontinued in the
computerized physician order entry (CPOE).
Including this as an error type would give a distorted
impression of the prevalence of errors in
discharge summaries. PRN prescriptions are prescriptions not
scheduled to be administered at
predetermined times of the day but to be used “when needed.”
Errors in discharge summaries were not
evaluated for potential severity, due to practical reasons.
Included drug forms were tablets, capsules,
mixture, suppositories, and injections.
Study site
This study was conducted in three psychiatric wards at Aalborg
University Hospital, Denmark, from

January 2010 to April 2010. Physicians were responsible for
prescribing drugs and nurses or nurses’
assistants were responsible for dispensing and administering
medication. There was no administration
of drugs scheduled in the night shift. Drug prescriptions were
documented in a CPOE system.
Methods for collecting data
All comparisons of observations to the CPOE were conducted
by one of the authors (ALS).
Observational method
Data were collected on the wards using direct observation. The
observer spent two day shifts (8 hours)
and one evening shift (8 hours) on each ward, observing the
nurse or nursing assistant responsible for
dispensing and administering drugs. The observations covered
six rounds of dispensing and
administering drugs in each of the three wards. The caregiver
responsible for the entire medication
administration in the ward was aware of the study purpose but
had no knowledge about which actions
were observed and registered. The observations of dispensed
and administered drugs were registered
on a structured paper form and subsequently compared with
prescriptions in the CPOE. Due to the
tradition and rules of observing the patients’ consumption of
medication in psychiatric nursing, it was
possible to register all administered medication. Any
discrepancies between the observed and the
prescribed medication in the CPOE were classified as errors,
according to the criteria outlined in Table
S1.

Unannounced visit to the ward
The unannounced visit to the ward was conducted
approximately 3 weeks after the observational study.
The dispensed medication was collected from the medication
storage room before administration. The
medicine collected from the medication storage room was
subsequently compared to the CPOE. Any
discrepancies between the identified drugs and the prescriptions
in the CPOE were classified as errors,
according to the criteria outlined in Table S1.
Chart review
The CPOE and discharge summaries were retrospectively
screened for errors. It was assessed whether
drug prescriptions were in accordance with the criteria outlined
in Table S1. If a patient was sampled
more than once, only new or altered prescriptions were screened
for errors. Discharge summaries were
Page 5 of
also screened to identify errors, ie, discrepancies between
eligible prescriptions in the CPOE and the
discharge summaries, according to the criteria outlined in Table
S1.
Potential clinical consequences

All registered errors in the observational study, screening of the
CPOE (errors in discharge summaries
excluded), and the unannounced visits to the wards to collect
dispensed drugs were assessed for
potential clinical consequences. The assessment was conducted
independently by two senior clinical
pharmacologists using a four-scale system: potentially fatal;
potentially serious; potentially significant;
and potentially nonsignificant.5 The four-scale classification
system can be found in Table S2.
Statistics
All data were analyzed using Stata/IC 10.0 (StataCorp, College
Station, TX, USA). Frequencies were
described as percentages. The kappa test was used to evaluate
the interrater variation in the clinical
pharmacologists’ assessment of potential clinical consequences
where appropriate. The statistical
significance level was set at 0.05.
Ethics
Approval of the study was obtained from the Danish Data
Protection Agency. The investigator was
ethically obliged to intervene in the case of observing an error.
If the investigator had to intervene, it
was registered as an error.
Results
Patients
The study included 67 eligible patients (24 men [36%] and 43
women [64%]) with a mean age of 46
years (20–79 years). The most common reason for admission

was schizophrenia and other psychotic
disorders (22/67;33%), followed by bipolar disorders
(11/67;16%).
Frequency of errors
A total of 189 errors were detected in 1,082 (17%) opportunities
for errors. The frequency of errors in
the different stages of the medication process is shown in Table
1. The majority of errors were detected
in the administration stage with errors in 142/340 (42%)
opportunities for error. This was followed by
discharge summaries with errors in 19/84 (23%) opportunities
for error. Nine (47%) errors in discharge
summaries were due to eligible prescriptions in the CPOE,
which were not prescribed in the discharge
summary.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3775703/table/t
1-rmhp-6-023/
Page 6 of
Table 1
Frequency of errors in the different stages of the medication
process
Prescribing,
CPOE n/N
(%)

Dispensing,
observational study
n/N (%)
Dispensing,
unannounced visit
n/N (%)
Administration
n/N (%)
Discharge
summaries
n/N (%)
10/267 (4) 9/324 (3) 9/67 (13) 142/340 (42) 19/84 (23)
Notes: N , the total number of opportunities of errors in each
stage (prescription and doses); n, the total
number of detected errors in each stage of the medication
process. The difference in number of dispensed
medications and number of administered medications in the
observational study was due to incidents where
staff had administered medicine without the investigators’
presence.
Abbreviation: CPOE, computerized physician order entry.
The intention behind investigating the dispensing stage using
two methods was to examine the validity
of the results obtained in the observational study. There were
errors in 9/324 (3%) opportunities for
error of the dispensed drugs in the observational study and in
(9/67) 13% of the dispensed drugs in the
unannounced control visit of which the majority was associated

with one nurse assistant. Fewest errors
were detected in the prescribing stage.
Frequency of error types
The identified errors were distributed by error types which are
shown in Table 2. The most frequent
error types were lack of identity control (135/142; 95%) and
concordance with drug prescription
(10/142; 7%). The error type lack of identity control occurs
when the patients’ identity is not
established before administering drugs. The clinical guideline
states that the person administering the
drugs must identify the patient by having the patient say his full
name and Social Security number, or
by using the obligatory wristband to identify the patient. The
error type concordance with drug
prescription occurs if already-dispensed drugs are delegated to
another staff member; this person must
compare the drugs to be administered with the prescriptions in
the CPOE. Error types in the
administration stage could be mutually dependent. This
occurred with the following error types: “lack
of identity control;” “wrong time;” and “lack of correct
labeling.” The dependency arises because each
of the aforementioned error types affects all doses which were
delivered to the patient in that particular
incidence. Analysis of these error types showed that “lack of
identity control” occurred in 49 of 137
(36%) deliveries. “Wrong time” occurred in four of 137 (3%)
deliveries. Finally, “Lack of correct
labeling” occurred in three of 137 (3%) deliveries.
total
total total

total
total
total
2-rmhp-6-023/
Page 7 of
Table 2
Frequency of error types in the different stages of the
medication process
Stage in
medication
process
Total number of doses or prescriptions affected with at
least one error in each stage of the medication process
(N)
Total number of
error types in each
stage (n/N)
Prescribing,
CPOE
N = 10

Drug name 0
Drug
prescription
2/10
Omission of
PRN dosing in
CPOE
8/10
Dispensing,
observational
study
N = 9
Drug
prescription
0
Omission of
dose
3/9
Wrong dose 1/9
Unordered dose 0
Contamination 1/9

Lack of correct
labeling
4/9
Dispensing,
unannounced
control visit
N = 9
Drug
prescription
0
Omission of
dose
6/9
Wrong dose 2/9
Unordered dose 1/9
Administration N = 142
Omission of
dose
0
a
b

c
Page 8 of
Open in a separate window
Notes:
One dose or prescription affected by an error could be
associated with more than one error type;
drug prescription: means one or more errors (including
omissions) in strength per unit, route of
administration, form of administration, dose, frequency of
administration, signature, date, duration of
treatment (only antibiotics was included in this study);
omission of PRN dosing regime in CPOE: means one or more
errors (including omissions) in strength per
unit, route of administration, form of administration, dose,
frequency of administration, signature, date,
duration of treatment;
lack of correct labeling: means that all drugs administered to
patients must be marked with the patient’s full
identity;
wrong time: means the drugs were administered ±60 minutes off
the scheduled time;
lack of identity control: means that the patient’s identity has not
been established by having the patient state

full name and Social Security number or using the obligatory
wristband;
concordance with drug prescription: means that when dispensed
drugs are delegated to another staff member,
this person must compare the drugs to be administered with the
prescriptions in the CPOE.
Abbreviations: CPOE, computerized physician order entry;
PRN, pro re nata.
Assessment of potential clinical consequences
The assessment of the potential clinical consequences was
carried out in a worse-case scenario,
meaning that whenever the clinical pharmacologists disagreed
on the severity of an error, the most
severe assessment was included in the analysis. Results from
the assessment are displayed in Table 3;
definitions are outlined in Table S2. The inter-rater agreement
(measured by the test statistic kappa) for
errors in prescribing, dispensing, and administration varied
from good to perfect (0.54; 0.75; 0.82; and
1.0, respectively).21
a
b
c
d
e

f
g
3-rmhp-6-023/
2-rmhp-6-023/?report=objectonly
Page 9 of
Table 3
Categories of potential clinical consequences of errors in the
medication process
Nonsignificant
n (%)
Significant n
(%)
Serious n
(%)
Fatal n
(%)
Interrater
variation

Prescribing, CPOE 0 4 (40) 4 (40) 2 (20) κ = 1,0
Dispensing, observational
study, n (%)
0 6 (66) 3 (33) 0 κ = 0.82
Dispensing, unannounced
visit, n (%)
4 (44) 5 (56) 0 0 κ = 0.75
Administration, n (%) 29 (20) 38 (27) 73 (51) 2 (1) κ = 0.54
Notes:
Kappa test for interrater agreement; the highlighted areas
represent errors with the potential to harm patients.
The pharmacologists assessed 84/998 (8%) errors as potentially
serious or potentially fatal. The
number of opportunities for error in this part of the study was
reduced to 998 because assessment of
potential clinical consequences did not include errors in
discharge summaries. The four potentially fatal
errors were related to the error types: “omission of PRN dosing
regime” (n = 2) and “lack of identity
control” (n = 2). There were errors in 142/340 (42%) of all
opportunities for errors in the
administration stage, and it was assessed that 75/142 (53%) of
these errors had the potential to harm
patients.
Drug categories and errors

Errors with the potential to harm patients were most often
associated with drugs related to the patients’
psychiatric condition (Table 4). The drug category most often
associated with these errors was
psycholeptics. The type of drug most often involved in potential
harmful errors was atypical
antipsychotics, followed by anxiolytic-sedative drugs and mood
stabilizers. The errors assessed to be
potentially fatal were related to prescribing and administration
of medication and were associated with
analgesics (opioids) (n = 2) and psycholeptics (atypical
antipsychotics) (n = 2). Nonpsychiatric drugs
associated with potential harmful errors constituted 7/77 (9%).
The majority of these errors were anti-
inflammatory and antirheumatic drugs, including nonsteroidal
anti-inflammatory drugs (NSAIDs).
a
a
a
a
a
4-rmhp-6-023/
Page 10 of

Table 4
Categories of drugs involved in errors with potential to harm
patients
Drug category Prescribing Dispensing (observational and
unannounced control visit)
Administration
N Nervous system
N02 Analgesics 2 0 0
N03 Antiepileptics 0 0 9
N05 Psycholeptics
– Atypical antipsychotics 3 3 20
– Typical antipsychotics 0 1 9
– Anxiolytic-sedative 1 0 17
– Other 0 0 3
N06 Psychoanaleptics
– Mood stabilizers 0 0 9
N07 Other nervous system drug 0 1
M Musculoskeletal system

M01 Anti-inflammatory and
antirheumatic products
6
H Systemic hormonal preparations, excluding sex hormones and
insulins
H03 Thyroid therapy 1
Notes: Drugs are categorized according to the Anatomic
Therapeutic Chemical (ATC) Classification System
(World Health Organization Collaborating Centre for Drugs
Statistics Methodology [WHOCC]).
In this table, the observational and unannounced control visit in
the dispensing stage have been collapsed.
Discussion
There were errors in almost one-fifth of all handlings of
medication of which the vast majority
occurred in the administration stage. The main type of errors
was lack of identity control. The
prevalence of potentially harmful errors was 8%, of which 0.3%
errors were considered potentially
fatal. The potentially fatal errors involved drugs from the
categories of analgesics and psycholeptics. A
few other studies in psychiatry have examined administration
errors and identified the error types
mismatching between medication and patient and wrong patient.
One study found mismatching
a
a

Page 11 of
between medication and patient to occur with the second highest
frequency; whereas, the second study
found wrong patient to constitute 4/108 (3.7%) of all
administration errors.10,14 These results
emphasize the importance of systematically identifying patients
to secure the right medication for the
right patient. We found that administration errors constituted
142/340 (42%) of all errors, which is in
contrast to a USA study of several stages in the medication
process, which demonstrated that 10% of
all medication errors were identified in the administration
stage.15 This disparity is most likely due to
variation in error types. In an observational study of
administration errors in elderly psychiatric
patients, errors were identified in 369/1423 (25.9%) of
opportunities for error. However, this result is
not entirely comparable, because the aforementioned study did
not include the error type lack of
identity control or any of the related error types, such as wrong
patient or mismatching between
medication and patient.
The severity of administration errors in psychiatric settings has
been assessed less severe when
compared to administration errors in somatic hospital
settings.11,15 However, this study assessed more
than one-half of all administration errors to be potentially

serious. Many hospitals have introduced
wristbands as a means to control patients’ identity, including
the psychiatric hospital where our study
was carried out. In a study of how and whether nurses identify
patients in a psychiatric hospital setting,
it was found that the use of wristbands was erratic and
influenced by a psychiatric nursing culture
rooted in the belief that (good) nurses know who the patients
are.22 The inconsistency in using the
patient’s wristband for identification has also been addressed in
somatic settings, and it has been shown
in simulation tests that as many as 61% of nurses do not
discover an unexpected identity error.23,24
This raises a question about how and when nursing culture plays
a role in patient safety and whether
this brings advantages or barriers. Nurses are involved in many
errors, but nurses also prevent many
errors from happening.25 It needs to be considered that nurses
are the professionals spending most time
with the patients and, therefore, function as gatekeepers, where
they can prevent errors and harm from
reaching the patient. Nurses are coordinating several aspects of
care to patients, including the care
delivered by other health care professionals, and this is a major
contribution to patient safety.26
Errors in discharge summaries constituted 10% (19/189) of all
errors detected in the study. It is not
possible to compare these results directly to other studies due to
definitions and categorizations;
however, earlier studies of errors in discharge summaries in
general hospital settings have found
discrepancies in 2%–76% of the prescribed drugs.5,27,28
It has been asserted that surgery and psychiatry are associated
with the highest rate of dispensing errors

and, therefore, it appears reasonable to consider psychiatry a
high-risk specialty, in regards to
dispensing errors.29 We investigated dispensing errors using
observation and unannounced control
visit, which showed a difference in results. When using
observation and unannounced control visit to
identify dispensing errors the rate of errors was 9/324 (3%) and
9/67 (13%), respectively. The
difference in identified errors is caused by dependency in data,
which arises due to the few nurses and
nurses’ assistants involved in dispensing and administering
medication. When pooling the results from
the dispensing stage, the error rate was 18/391 (5%). This result
is supported by other studies not
depending on unit dose systems which found error rates <1%
and up to 5%.5,29,30 The most common
error type in the dispensing stage was omitted dose, which is in
accordance with a previous study using
similar methods of error detecting but in a general hospital
setting.5
Page 12 of
In this present study, the clinical pharmacologists assessed
three errors in the dispensing stage to be
potentially serious, and no errors were assessed as potentially
fatal. To our knowledge, there are no
other studies in psychiatry where observed dispensing errors
have been assessed for severity.

There were few prescription errors, but the prescription stage
represented one-half of the potential fatal
errors. Most of the prescribing errors were of the type “lack of
PRN regime,” which is a type of
prescription error that nurses are capable of intercepting. On the
other hand, it also places nurses in a
situation where they possibly make independent decisions as to
whether a PRN medication is
appropriate. The use of PRN medication is often solely the
nurses’ decision and, perhaps, due to a lack
of research into the use of PRN medication as an intervention in
mental health care, the practice varies
considerably.31
Strengths and weaknesses in the study
The majority of studies on medication errors and
psychopharmacotherapy have been conducted in
general hospital settings, and very few studies include a
psychiatric population. Thus, this study is an
important contribution to the current knowledge, as it focuses
on errors in several stages of the
medication process by applying the most sensitive method to
each stage in a psychiatric hospital
setting. There were 67 patients included in the study, which is a
relatively small sample and a potential
weakness in the study. Observation as a method of detecting
errors is considered a valid and well-tested
method; in this study, we sought to substantiate the validity of
observing for errors with the
unannounced control visit.17,32 The difference in errors
identified by observation and the
unannounced control visit is solely due to the dependency in
data caused by the few nurses and nurses’
assistants participating in the study. In this study, dispensing of
drugs was done by nurses and nurses’

assistants, which might complicate comparisons with other
hospitals and settings where hospital
pharmacies undertake the dispensing of drugs. It appears the
study has a good internal validity, but the
study was carried out in a single university hospital, thus
producing a limited external validity.
However, it is evident that psychiatric university hospitals – in
comparison with somatic hospitals – are
equally challenged in improving the quality of the medication
process.
Conclusion
Errors were found in almost one-fifth of all handlings of
medication, and a proportion of these errors
had the potential to harm patients. In this study, the majority of
errors involved psycholeptics, but
potential fatal errors also involved analgesics. Most errors were
found in the administration stage, and
studies suggest that both nursing culture as well as an irregular
practice regarding the patient’s identity
wristband could be a risk factor for not checking the patient’s
identity. This could lead to the error type
“wrong patient.” It might be beneficial to address nursing
culture as well as awareness of existing
clinical guidelines. Further studies are needed to investigate
how and whether nurses influence
medication safety for in-hospital psychiatric patients and how
nurses can improve the quality of
medication and medication safety for psychiatric patients.
Supplementary tables

Page 13 of
Table S1
Criteria and definitions for error types
Stage in
medication
process
Definition Error types
Prescribing Unambiguous
prescription
Omission of drug name, drug formulation, route, dose,
dosing regime, date, signature, length of treatment time
where required
Dispensing Dispensed
medication is
concordant with
prescribed drug in
electronic
medication chart
Wrong drug, unordered dose, omission of dose, wrong dose,
wrong drug formulation, contamination (ie, touching tablets
without gloves), control of prescription (ie, controlling that
only prescribed drugs are dispensed), ambiguous labeling of
medication
Administering The right

medication to the
right patient in the
right way and at the
right time
Wrong: dose, administration technique, route, time (±60
minutes), unordered drug, unordered dose, omission of dose,
lack of identity control, wrong patient (one or more
medications administered to the wrong patient),
contamination, concordance with drug prescription
Discharge
summaries
Eligible
prescriptions in
medical record are
identical to
prescriptions in
discharge
summaries
Discrepancy in: drug name, drug formulation, route, dose,
regime, omission of drug, unordered drug
Note: Adapted with permission from Lisby M, Nielsen LP,
Mainz J. Errors in the medication process:
frequency, type, and potential clinical consequences. Int J Qual
Health Care. 2005.
Table S2

Page 14 of
Definition of potential clinical consequences
Category Definition Definition of keywords
Potentially
fatal
Errors judged to imply a
potential clinical risk for
causing the death of the
patient
Fatal refers to errors that could lead to the death of
the patient
Potentially
serious
potential clinical risk of
injuring the patient
Injury includes errors that would require active
treatment to restore the health of the patient. A
potentially serious error would lead to either
permanent or temporary disability
Potentially
significant

potential clinical risk of
being “inconvenient” for
the patient – without
causing any harm or injury
“Inconvenient” refers to unpleasant consequences of
wrong dose/drug omission of dose/drug that could
lead to pain, dizziness. It also refers to any
monitoring of the patient, such as extra blood test,
measurement of blood pressure
Potentially
nonsignificant
Errors judged to be without
any potential clinical risk
for the patient
Without clinical risk refers to errors that did not lead
to any injury or inconvenience for the patient
Notes: The highlighted areas represent errors with the potential
to harm patients. Adapted with
permission from Lisby M, Nielsen LP, Mainz J. Errors in the
medication process: frequency, type,
and potential clinical consequences. Int J Qual Health Care.
2005.
Reference
1. Lisby M, Nielsen LP, Mainz J. Errors in the medication
process: frequency, type, and potential
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Footnotes
Disclosure
The authors report no conflicts of interest in this work.
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Page 17 of
Articles from Risk Management and Healthcare Policy are
provided here courtesy of Dove Press
...‫ریثات‬ ‫شزومآ‬ ‫هداوناخ‬ ‫روحم‬ ‫رب‬ ‫ناسیم‬ ‫تیعبت‬
Preventive Care in Nursing & Midwifery Journal
2018; 8(2): 1-8
Factors associated with medication errors in the psychiatric
ward of Razi Hospital in
Tabriz: Perspectives of nurses
Abdi M1 , Piri Sh2 , Mohammadian R2 , Asadi Aghajeri M2 ,
khademi E3 *
1Department of Intensive Care, School of Nursing and
Midwifery, Zanjan University of Medical Sciences, Zanjan, Iran
2MSc. Department of Nursing, Maragheh Branch, Islamic Azad
University, Maragheh, Iran
3MSc. Dept. Nursing, Maragheh Branch, Islamic Azad
University, Maragheh, Iran

*Corresponding Author: Dept. Nursing, Maragheh Branch,
Islamic Azad University, Maragheh, Iran
Email: [email protected]
Received: 7 Jan 2019 Accepted: 11 Aug 2019
Abstract
Background: Medication errors are considered to be the most
significant safety threatening factors for the
patients in hospital, to which many factors contribute.
Objectives: This study was conducted to determine the role of
associated factors in the incidence of
medication errors in the psychiatric ward of Razi Hospital in
Tabriz from the perspectives of nurses in 2017.
Methods: In this descriptive cross-sectional study, we selected
150 nurses working in the psychiatric ward of
Razi Hospital in Tabriz through random sampling method. The
data collection instrument included a
demographic and researcher-made questionnaire to assess the
effective factors in the incidence of medication
errors according to the perspectives of nurses. The data were
imported into SPSS version 20 and analyzed
via ANOVA and Chi-square tests.
Results: In this study, 95(63.3%) women and 55(36.7%) men
with the mean age of 34.4±0.66 participated.
The highest mean score for the causes of medication errors was
related to the professional errors made by
nurses (33.93±2.61) and the structure of the psychiatric ward
(27.96±5.8). The change in Kardex during the
transfer of the patient to other wards was the most significant

cause of errors with a mean of 4.35±5.53. The
mean score of medication errors was significantly different with
that of the level of education, age, work
experience, and employment types. However, it was not
significantly different with that of gender, marital
status, nurse job position, and shift work rotation.
Conclusion: Considering the incidence of the most common
medication errors in the field of nursing careers
and structure of psychiatric ward, we recommend that nurse
managers increase the skills of medication
administration through holding training courses and improve the
physical conditions of the ward.
Keywords: medication errors, nurses, psychiatric ward
Introduction
Providing patient safety is one of the most
important tasks of healthcare -medical complexes.
Today, patient safety in the delivery service
system is a key concept and is regarded as one of
the important indicators of control quality of
health services [1]. Factors such as wrong
injection, falls, burns, and errors in invasive
procedures threaten patients’ safety, among which
medication errors are the most important factors
[2]. Medication errors are defined as deviations
from the proper conduct of the treatment process,
which may occur in administration, preparation,
delivery, use, or distribution of drugs.
Administering drugs to patients is one of the main
tasks of nurses and the most important part of care
processes. Proper administration of drugs to
patients requires high level of knowledge and

https://orcid.org/0000-0002-5694-6888
https://orcid.org/0000-0002-0534-8060
https://orcid.org/0000-0002-2407-9986
https://orcid.org/0000-0001-5980-0385
https://orcid.org/0000-0003-0807-2319
2 Factors associated with medication errors in the ….
Preventive Care in Nursing & Midwifery Journal (PCNM) 2018;
8(2)
accuracy on the part of nurses [3]. Today, various
types of medicine are used in the field of health
and treatment of patients, all of which may have
harmful effects on the health of individuals
despite their beneficial effects. Thus, nurses
should be aware of the importance of correctly
recognizing and administering drugs to prevent
possible complications due to medication errors
[4].
According to a survey conducted in England in
2018, more than 2 million people are injured each
year due to medication errors, and of which about
100,000 die in hospitals [5]. According to
previous studies, the cost of medication side
effects was estimated to be nearly $ 300 million in
2018 [6]. However, it is difficult to estimate
accurate statistics in the third world and
developing countries due to the lack of proper
registration and reports [7]. Watanabe et al.
showed that 30% of the injured patients due to
medication errors are impaired for more than 6
months or even lose their lives [8]. In this regard,
psychiatric drugs are very sensitive, and if

administered incorrectly, they poison the patient
very early. A majority of medicines for patients
with psychological problems are taken orally, and
due to drug similarities, the risk of wrong
administration is high [10]. The structure of the
psychiatric ward, the lack of co-operation of
mental patients in treatments, the poisoning dose
close with the therapeutic dose in mood-
stabilizing, antipsychotic, and depression drugs
necessitate nurses' attention when administering
the drug [11,12]. Ferrera et al. mentioned that
more than half of the medication errors could be
prevented, and observing the precise principles of
drugs medication could reduce the incidence of
errors [13].
The reason for the incidence of medication errors
is not limited to one aspect and must be controlled
in all aspects [14]. There are several factors
involved in the incidence of medication errors;
however, in previous studies, the cause of
medication errors has been differently reported.
For instance, Jones et al. have reported that the
most common cause of medication errors made by
nurses is the lack of compliance with the five
rights of medication administration (the right
patient, the right drug, the right dose, the right
route, and the right time) [15]. However,
Sarvadikar et al. (2010) stated that most of the
errors occurred in the process of administering
drugs to the patients [16]. A study by Cottney et
al in 2014 suggested that medication errors of the
psychiatric ward is more likely to occur due to
insufficient knowledge and skills of nurses in
terms of the right dose, time, and medication [12].
Yakubi et al. and Mashhala et al. reported factors

such as the burden on nurses, the lack of
readability of drug orders in patient's file or
medication card, doctors’ bad handwriting, the
similarity in the form and packages of drugs,
fatigue due to overwork, anxiety and stress
resulted from work, noise of the ward settings,
and nurses’ dissatisfaction with the amount of
salary and benefits as the most important causes
of medication errors [17,18]. In summary, the
main causes of the incidence of nurses’
medication errors are workplaces, drug
companies, and nurse management. Each study
has presented a cause for the error in a different
way, and the number of studies that
comprehensively examine these factors is small. It
seems that there has not been a study in Iran to
examine the medication errors of the psychiatric
ward.
In the present study, considering the
complications of drugs for patients, heavy
economic costs for individuals and society due to
medication errors, the role of each member in the
drug supply chain in the incidence of medication
errors, and the sensitivity of drugs in the
psychiatric ward, we aim to determine the
associated factors in the incidence of medication
errors in the psychiatric ward of Razi Hospital in
Tabriz from the perspective of nurses. We hope
that the results of this study can help identify the
causes of the incidence of medication errors and
provide a solution to reduce their incidence and
complications in patients and decrease the cost of
treatment and the duration of hospitalization.
Methods
This descriptive cross-sectional study was carried

out using random sampling method based on a
random table of numbers in the first half of 2017.
One hundred fifty nurses working in the
psychiatric ward of Razi psychiatric hospital
participated in the present study. The main
population of the study included 280 nurses. To
estimate the minimum sample size at 95%
confidence level, with a 90% test power and the
Abdi M, Piri Sh, Mohammadian R, Asadi Aghajeri M, khademi
E…… 3
Preventive Care in Nursing & Midwifery Journal (PCNM) 2018;
8(2)
mean incidence of medication errors as at least
=0.18 using the formula
(d=1/96), the final sample size included 141
participants. To prevent sample loss, 165 people
were invited to participate in the study. During the
research, 15 people refused to continue, and the
study was done using 150 people.
The data was collected in morning, noon, and
night shifts. The inclusion criteria in this study
were having more than one year of work
experience in hospital, undergraduate and
postgraduate studies, and lack of mental and
physical illness. Nurses who had less than one
year of work experience or were reluctant to
participate in the study were excluded. In order to
ensure the confidentiality of information, it was
announced to the participants that writing name
and surname is optional.

This study was approved by the Ethics Committee
of Maragheh University of Medical Sciences with
number 5/13/15/12378 and Iranian code of
IR.MARAGHEHPHC.REC.1396.26. After
obtaining informed consent from the patients,
compliance with the ethical issues according to
the Helsinki Treaty, and compliance with the
conditions of inclusion criteria, the questionnaires
were completed.
A demographic and researcher-made questionnaire
was used to assess the factors affecting the
incidence of medication errors according to the
perspective of nurses, which were designed after
studying different texts [19,20]. The questionnaire
consists of 31 questions and five areas in which
questions 1 to 10 are related to nursing
professional errors, 11 to 18 to the conditions of
the ward and the attendance of patients, 19 to 22
to doctors’ errors, 23 to 24 to the errors of drug
companies, and 25 to 31 to the management
process errors. The scoring procedure of the
questionnaire was considered as a 5-point Likert
spectrum that included very low, low, moderate,
high, and very high with the scores of 1 to 5. The
least acquired score is 31, and the maximum is
155. Higher scores in one area indicate the
importance of that area. The face and content
validity of this questionnaire was verified by ten
faculty members and nursing experts. To
determine the reliability, split-half method and the
correlation coefficient calculation were used in
two parts of the questionnaire, for which
correlation coefficient was found to be 81%.
The data were imported into SPSS version 21
software, and then the data normalization was

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