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Nurse medication errors and the role of packaging

Sixty percent of nurses polled identified look-a-like drugs and packaging as the sixth-leading cause of medication errors.

The results of this poll of 202 nurses will be published in the July/September issue of Journal of Nursing Care Quality .
The study, scholarly research by 2 nurses, intended to address the working conditions which may contribute to nurse medication errors.

Other reasons for medication errors included illegible or unclear handwriting from a physician (86%), high patient-nurse ratio (71%), unclear verbal orders (68%), insufficient staffing (68%), nurse incompetence (66%), and poor training (56%).

The study drives home the fact that, “in clinical settings, nurses function in fast-paced, complex, unpredictable settings with high-stakes patient care situations.”

According to the study, many errors are not reported, even when no harm has come to the patient, and most certainly nurses feel bad when it happens. An interesting side note, even though they may complain about exhaustion, poor training, long shifts, etc., nurses still feel personally responsible for their mistakes, and have low self-esteem and a strong sense of failure when an error occurs.

A publisher’s packaging perspective:

I don’t know how to address the communication issues between doctors and nurses (probably volumes exist exploring this dynamic), but I know a little about packaging.

I do not think I am naïve enough to believe we can get drug companies to change their packaging even if 2 of their own drugs look alike, let alone tackle identification problems between competitors. I’m sure as incidents are reported these national records could be compiled to discover which drugs are most commonly confused.

How about one extra yellow label per package--Most Commonly Confused With: _____________________.

At least the nursing community would be given an extra chance to stop and think they might be about to administer a look-a-like.

Maybe any drug marked with this sticker needs a second set of eyes or written sign off?

Yes there will be extra red tape to follow to make sure no one gets the wrong drug. But if the package needs to work to keep the medicine dry and safe and at full strength during transportation and storage right up through use and disposal, it could also be called on to warn: “Nurses report this particular drug is commonly confused with another.”

Better track and trace from the hospital pharmacy, where the wrong drug would be caught while swiping the bar code before administering to patient, is another, more high tech, more sophisticated and more expensive approach.

With drug dispensing and authentication, errors would be easier to report because inventory would be affected and could even be traced back to the shift and the nurse.

Not sure this addresses the crisis situations described in the study where typically a variety of factors contribute to a dosing or wrong medication error.

Its one thing to say the doctor’s handwriting was questionable, but combine that with fatigue, similar packages and other distractions, and you can see how easy it would be to make a mistake.

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