Home International organisation A “culture shift” is needed in managing nurse medication errors

A “culture shift” is needed in managing nurse medication errors


The current ‘blame culture’ around medication errors made by nurses must be addressed to enable learning opportunities and help improve patient safety, a global nursing leader has urged.

International Council of Nurses chief executive Howard Catton has used this year’s World Patient Safety Day, which has the theme ‘medication safety’, to call for changes in the way providers health care manage medication errors involving nurses.

“What is needed is to move from a criminalizing and disciplinary mindset to communication and dialogue that will lead to learning”

Howard Catton

He stressed that while nurses have “vital responsibilities” in this area, the negative impact of overburdened wards and worsening staff shortages should not be ignored.

The annual Awareness Day, held each September 17 by the World Health Organization, brings together patients, families, caregivers, communities, health workers, leaders and decision-makers to show their commitment to the patient safety.

This year is centered on drug safety and carries the slogan: “Medications without danger”.

The campaign aims to raise global awareness of the “heavy burden of drug-related harm due to medication errors and unsafe practices” and to “advocate for urgent action to improve drug safety”, according to the WHO.

The international organization has recognized that medication errors occur due to “systemic issues and/or human factors such as fatigue, poor environmental conditions or staff shortages that affect prescribing, transcribing, dispensing practices , administration and supervision”.

Dr Tedros Adhanom Ghebreyesus

He added that the evidence suggests that “more than half of all drug-induced harm occurs at the stage when drugs are prescribed and when they are taken by patients due to inadequate monitoring”.

Antibiotics were the “highest risk” category for drug-related harm, according to the WHO, but drugs such as sedatives, anti-inflammatories, and heart and blood pressure medications “also have risks.” significant risks,” she added.

“Medicines are powerful tools to protect health,” said Dr Tedros Adhanom Ghebreyesus, Director General of WHO.

“But drugs that are badly prescribed, badly taken or of poor quality can cause serious harm. No one should be harmed while seeking care.

While ICN welcomed the focus on medications as this year’s theme, it also called for a culture change in how medication errors by nurses are managed and addressed.

Speaking at a virtual WHO event ahead of the awareness day, Mr Catton described the ‘current blame culture around medical errors made by nurses’ as the ‘enemy of patient safety’ .

International Council of Nurses

Howard Catton

“We’re not talking about gross negligence, but about honest mistakes often linked to system failure in organizations,” he said.

“Nor are we trying to absolve nurses of their responsibilities, but when errors do occur, open reporting can lead to learning, not only for the individual concerned, but also for the organization in which they work.”

Mr Catton stressed that it was “important to have a ‘just culture’, rather than one in which there is an immediate movement to impose sanctions, refer the nurse to the national nursing regulator and take disciplinary measures”.

“What is needed is a shift from a criminalizing and disciplinary mindset to communication and dialogue that will lead to learning and improvement and vital improvement in patient safety,” he added.

The ICN CEO highlighted the recent case of nurse RaDonda Vaught in the US who made a fatal medication error and was prosecuted “despite evidence of system failure”.

He then warned of the negative impact of strained health services and nursing shortages on patient safety.

“Nurses have vital responsibilities in administering medication, but we know they work in environments where they are often overstretched, short-staffed and too busy to consistently deliver the high-quality care they want. “said Mr. Caton.

“We know that all of these factors can lead to errors, including potentially serious medication errors.

“We cannot ignore the fact that the world is short of many millions of nurses, perhaps as many as 13 million, nor that this fact alone has a very real impact on their daily practice.

“And of course, drug safety is an example of the type of errors that can have very serious implications for patient well-being.”

It was recently revealed that the NHS in England is facing a record shortage of nearly 47,000 nurses.

Also speaking ahead of World Patient Safety Day, Royal College of Nursing Director for England, Patricia Marquis, echoed concerns about nursing shortages impacting patient care and drug safety.

“Ensuring patient safety is at the heart of everything nurses and nursing support staff do and this year’s theme, Medication Safety, is about exactly that,” said Marquis.

Patricia Marquis

“But with a record one in eight nursing vacancies in England – and a similar picture across the rest of the UK – the workforce crisis means care is left on hold and patients are put at risk.

“Medication errors become much more likely when staff are overwhelmed and unable to give their patients the attention they deserve.”

She added: “The nursing staff are extremely proud of their work and are distraught that they cannot provide the care they wish to provide.

“We know that the best way to improve patient safety is to have the right number of employees in place.”