By Debra Wood, RN, contributor
September 4, 2012 - Adding to a growing body of evidence about the importance of supportive nursing environments, a new study has found that a positive practice setting allows nurses to catch many medication errors before they occur, increasing patient safety.
“A better environment was associated with better medication safety practices, and nurses’ better medication safety practices were associated with fewer errors,” said lead author Linda Flynn, PhD, RN, FAAN, associate professor at the University of Colorado College of Nursing in Denver, and formerly at Rutgers University College of Nursing, Newark, N.J., where she conducted the research. The study was funded by the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative.
Flynn and colleagues surveyed 686 staff nurses working on 82 medical–surgical units at 14 acute care teaching hospitals in New Jersey about their practice environment, using the Practice Environment Scale of Nursing Work Index. They then compared practice environment and staffing levels with prescribing, transcribing, dispensing and administration errors based on administrative data.
The research team found a significant association between practice environment and error interception practices, as they reported in Journal of Nursing Scholarship.
Flynn explained that positive environments include a supportive manager, collegial relationships with physicians, enough resources to do the job, staff development and opportunities to be involved in the decision-making process.
“They are intangible, but so important,” said Flynn, adding that the traits of a supportive practice environment are modifiable and can be improved.
Mary A. Dolansky, RN, PhD, emphasized the importance of teamwork as part of a supportive environment that facilitates safer medication administration.
“A lot has to do with a culture of safety,” commented Mary A. Dolansky, RN, PhD, associate professor at the Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland, Ohio. She added that interdisciplinary teamwork and a reliance on each other to ensure care is delivered safely and effectively is important to culture.
Deborah A. Boyle, RN, MSN, AOCNS, FAAN, a clinical nurse specialist at the University of California Irvine Medical Center’s Chao Family Comprehensive Cancer Center and contributor to TheONC (theonc.org), an online community for oncology nurses, called inter- and intra-disciplinary communication particularly important, along with evidence-based care and following best practices.
“The other piece is if nurses have a better work environment and are not in chaos or short on time, they have a moment to critically think. That helps to reduce errors,” Dolansky said.
Interestingly, staffing levels did not make a difference in error reduction in this study. Flynn did not have an explanation; however, she added that units must staff with enough nurses to provide quality care, but staffing alone will not deliver the positive results of a supportive environment.
“When it comes to staffing and work environment, work environment trumps,” Flynn said.
Dolansky added that nursing culture--an environment where nurses are able to practice to the full extent of their education and expertise--was an important factor in association with reducing errors, something recommended in the Institute of Medicine (IOM) Future of Nursing Report.
Prior research has shown that nurses intercept more errors than any other profession, with 83 percent of errors caught before reaching the patient, Flynn said. To find out what the nurses do to prevent errors, the investigators also interviewed 50 registered nurses, five from 10 hospitals, about their error-interception strategies, including night-shift nurses verifying the order matches the medication record.
Linda Flynn, PhD, RN, FAAN, found a supportive practice environment associated with nurses’ ability to intercept medication errors before they reach the patient.
“These nurses said that’s great, but they don’t rely on that,” Flynn said. “At the beginning of their shift, they carve out the time to look at the medication list and go back to the record and look at the original order.”
Other tactics the nurses used include speaking up and clarifying orders with physicians, determining the rationale for every medication and considering if it is still needed.
“In nursing practice environments that don’t encourage critical thinking, and just want the nurse to do the task, [the nurse] won’t feel empowered to stop, pause and question,” Dolansky said.
“It stands to reason that the more they engage in these practices, the lower the medication error rate would be,” Flynn said.
Other lines of defense
Dolansky suggested following evidence-based practices for safe medication administration, such as “no-interruption” zones.
Karen Curtiss, author of Safe & Sound in the Hospital: Must-Have Checklists and Tools for Your Loved One’s Care in Lake Forest, Ill., advises family caregivers to never interrupt a nurse during medication administration, unless they sense a mistake, and then they should speak up and ask the nurse to verify the prescription.
The nurses interviewed for the Rutgers study did not consider themselves the last line of defense, saying that’s the patient. They welcomed patient inquiries about unfamiliar medications.
Dolansky called such patient and family involvement “huge.”
“The consumer movement of speaking up is big,” Dolansky said. “Family members can be advocates for patients.”
Flynn hopes other nurses will adopt the interception safety practices the nurses in the study use.
“It’s not just making sure it’s the right patient; it’s doing all of these critical reasoning things and asking doctors for clarification,” Flynn said. “What nurses do makes a difference. When nurses are vigilant about patient safety, errors are decreased.”
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