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Running head: MEDICATION ERRORS IN THE NURSING WORLD

Medication Errors in the Nursing World

Nathan Eppich

Brigham Young University – Idaho

Nursing 420 section 02

Dr. Bennion

December 8, 2018
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Medication Errors In the Nursing World

Background

Decreased cognitive function from long working hours increases risks of medication

errors. Night shifts as well as long working hours can cause overtired nurses, leading to a

decrease in cognitive function (Unver, Tastan, & Akbayrak, 2012). Medication administration is

a multidisciplinary process and is a critical responsibility of the nurse. According to research in

the American Journal of Critical Care 27% of the nurses in the study made at least one error, and

38% reported making at least one near error, as a result, a total of 224 errors, and 350 near errors

were made during the study period from decreased cognitive function and long shift hours (Scott,

Rogers, Hwang & Zhang, 2006). Medications, when administered improperly, may have lasting

effects on patient health.

Environmental interruptions and distractions is another reason that medication errors

occur in a hospital setting. During medication administration, the social interaction,

environmental noise, and medication room layout and size are likely to cause errors in

medications preparation (Mahmood, Chaudury, Gaumont, & Rust, 2012). In the citation

referenced above there was a research conducted in which the staff had to divide their attention

between moving safely around the small medication room, environmental noise, and preparing

the medication. Due to the division of attention, the nurses prepared the medication incorrectly

and gave a patient the wrong dosage. In a research conducted by the UNAC/UHCP, 983 nurses

were asked what they believed was the biggest reason for medication errors (Duncan & Mayo,

2004). 65.6% of the 983 nurses said they believed the errors were due to environmental

surroundings. These two studies show that medication errors can happen because of the

environment in which nurses prepare medication.


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Lack of pharmacological knowledge is a contributing factor of medication errors among

nursing personal. Most medication errors occur because of abbreviations in prescriptions and

similarities in the drug names (Cheragi, Manoocheri, Mohammadnejad, & Ehsani, 2013).

Although medication errors can occur in all aspects of the medical world, nursing medication

errors are by far the most common. About 40% of a nurse’s day consists of dealing with

medication. With the large amount of time nurses deal with medication it is easy to see how

errors can occur, especially with how similar their names can be.

Significance

Medication errors are compromising patient’s safety in the hospital. This is a very real

problem in the nursing world that decreases the safety in the hospital setting (Unver et al., 2012).

According to Gladstone’s Scale of Medication’s research, the most common type of medication

errors that result in harm to patients is wrong dose (40.9 %), wrong drug (16 %), and wrong

route (9.5 %). This study also reports that only 41.6% of nurses believe that medication errors

are reported (Unver et al.,2012). Based on the information above, patients’ safety is being

compromised and the causative agents are decreasing the safety among patients in the hospital.

Medication errors are increasing cost for patients and hospitals. It is estimated that

medication errors have costs hospitals in the United States on average 76.6 billion dollars

annually (Samp, Touchette, Marinac, & Kuo, 2013). According to a study down by American

College of Clinical Pharmacy, a local hospital had to pay an excess of $4685 per person for

medication errors. This resulted in an increase cost of 2.8 million per year for this single

hospital. Another study done by the NCBI shows that medication errors increased costs of

hospital stays by $2000 – $2500 per patient (Cheragi et al., 2013). All of these medication errors

significantly contribute to the increase costs for patients as well as the hospitals.
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Medication errors are increasing mortality rates in the hospital setting. It has been

reported that medication errors have accounted for as many as 251,000 deaths annually in the

United States (Anderson & Abrahamson, 2017). According to a study done by the NCBU,

medication errors account for 9% of all deaths in the United States. This statistic makes

medication errors the third leading cause of death in the United States behind heart disease and

cancer. This exact same study shows that death by medication error increase from 22% to 48%

when four or more physicians are involved in patient care. These statistics show that death by

medication errors are very common and should not be taken lightly. Medication errors are

decreasing patient’s safety, increasing cost for patients and hospitals, and increasing mortality

rates.

Nightingale’s Environmental Theory

Florence Nightingale’s theory focuses on creating the perfect atmosphere around her

patients to promote a positive health environment. During the Crimean war, Nightingale first

implemented this theory to improve the environment around her patients in promoting healing

(Hegge, 2013). She understood that an unfavorable environment could compromise the health of

her patients, resulting in an increase in mortalities. By focusing on cleanliness, nourishing foods,

ventilation, light & noise, observation, and hope, she was able to empower the nature of health

and healing. Nightingale knew that the high mortality rates were not because of the disease

alone, but also the environment that they were put in to recover (Sher & Akhtar, 2018). She

knew that in order to provide the best outcome for the patient, all aspects needed to be in

complete balance. This can only be done by making the patient the main focus, which is exactly

how the environmental theory works.


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Nightingales theory provides an environment that can transform how patients are being

cared for. In this theory, the nurse’s duty is to balance the patient’s environment, which in return

helps the patients conserve energy to properly heal from disease (Medeiros, Enders, & Lira,

2015). For example, during the Crimean war Nightingale was able to balance the environment

of the 2,000 solders through observation, decreasing the noise and light, giving hope, and face to

face communication (Hegge, 2013). Through observation and decreasing environmentally

stimulations, she was able decrease the stress put on patients during their time at the hospital.

This goes right along with a major goal in the nursing field, which is to provide assistance for

patients in maintaining their capacity as well as satisfying their needs.

Florence Nightingale clearly had an understanding of the complexity that the

environment plays on a patient’s health. This theory of Nightingales can be viewed as a system

in which the patient is in the center, surrounded by all aspects of the environment all in balance

(Zborowsky, 2014). If that environment becomes unbalanced it puts stress on the patient

resulting in an unfavorable atmosphere for patients to regain their full health. Similar to

Florence Nightingale, nurses today understand the role the environment plays on the ability to

heal. Having this knowledge has allowed nurses to contribute greatly to the continuation of

increased patients’ health that was started by Nightingale many years ago.

Link Between Nightingales Environmental Theory and Medication Errors

The issue of medication errors in the work place can be linked to Florence Nightingale’s

environmental theory of light and noise. The environment around nurses can greatly deter

concentration during medication preparation (Mahmood et al., 2012). During medication

administration, social interaction, noise, and medication room layout are likely to cause errors in

medication preparation. For example, if a co-worker is talking to a nurse during medication


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preparation and incorrectly prepares the proper amount of medication it could potentially kill the

patient or cause adverse effects. Nightingale’s environmental theory focuses on controlling the

noise and distractions in order to provide a safer environment for the patient (Zborowsky, 2014).

If this environment is not controlled it becomes unbalanced causing stress and an unfavorable

atmosphere for health promotion. Nightingale’s environmental theory eliminates the

environmental noise allowing for a more favorable atmosphere for the patient.

Medication errors can be linked to Nightingales environmental theory through

observation. Long shifts and long working hours can cause overtired nurses, leading to a

decrease in cognitive function (Unver et al., 2012). A main focus of Nightingales theory is

observing the patient for any signs of decreased health. For example, during the Crimean War,

Nightingale cared for 2,000 soldiers observing each one’s health, hoping to improve their

surrounding to establish balance in their recovery (Hegge, 2013). She was only able to properly

balance the environment through proper observation, which requires full attention and cognitive

function in the observer. As we can see from the research by the American Journal of Critical

Care, 224 of the 393 nurses made at least one error because of decreased cognitive function

(Scott et al., 2006). This research shows that there was improper observation of the patients

because of decreased cognitive function. Proper observation of the surrounds and safe care is

provided for patients when cognitive function is not diminished because of long shift hours.

The concept of medication errors can also be linked to Nightingales theory of

observation. The goal of a nurse is to place the patient in the best conditions for nature to act

(Selanders, 2010). This can only be done through observing the environment and altering it in a

way to improve or maintain health of the patient. Observation of the surroundings includes

proper understanding in the similarities and abbreviations of medications given. About 40% of a
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nurse’s day consists of dealing with medications (Cheragi et al., 2015). For this it is important

that nurses develop proper observational skills to prevent errors in preparation of medication.

Many errors occur because of abbreviations in prescriptions and similarities in the drug names.

For example, chlorpropamide and chlorpromazine are very similar in spelling and are easily

mistaken for each other. Without proper observation of the surroundings, one medication can be

easily mistaken for another.

Research Methods

How do environmental distractions (noise, light, other co-works) affect medication

errors? The Florence Nightingale environmental theory determines that an unfavorable

environment can compromise the health of patients, resulting in an increase in mortality rate

(Zborowsky, 2014). By focusing on controlling the noise and distractions around patients, a

safer atmosphere can be provided. That same focus can be implemented into the environment

surrounding nurses while preparing and administering medications to help keep patient safe.

Research Design

This research will use a qualitative grounded theory method. Qualitative research is a

method of observation to gather non-numerical data (Grove, Gray, & Burns, 2015). This

research provides meaning, characteristics, definitions, and descriptions that help understand the

individual experience that the participant is going through. Grounded theory is a type of research

that involves observation, analyzing, and interviewing subjects to gather a deeper understanding

of their experience (Grove et al., 2015). Subtle messages and meanings derived from the

subjects can give further understanding of their experience to help formulate themes and

establish a theory of the research topic. Qualitative grounded theory is the best research for

medication errors because it allows for observational analysis of nurses on the ICU/medical
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surgical unit as well as interviews of the participants (nurses). The information obtained from

observing and interviewing nurses will help formulate a theory on how environmental

distractions affect medications errors.

Research Population

This research will study nurses administering medication within a hospital setting. There

will be 15-20 participants involved in the research. The inclusion criteria for this study will be

nurses in southern Idaho, ICU/medical surgical floor, and working a 12-hour shift. Including

nurses in southern Idaho will provide a larger population of nurses that work in acute care in

comparison with southeast Idaho. With this larger population, there will be more ICU nurses

dealing with multiple medications and distractions. There will also be more medical-surgical

nurses dealing with a larger load of patients. Lastly, medication errors are more likely to occur

during long shift hours. This research will exclude nurse managers, nurses in orientation, and

nurses not taking full patient loads. The reasons for excluding these individuals is because nurse

managers do not have a lot of patient interaction, orientation nurse provide a second nurse to

catch errors, and nurses without full patient loads are exposed to less medication administration

opportunities. This information will provide the research with a plethora of valuable information

to help direct the research on medication errors.

Methods and Measurements

Recruitment will first be done by contacting the IRB (Institution Review Board) of four

different hospitals in southeast Idaho with a level two ICU and a medical surgical unit that is full

20 out of 30 days of the month. Having data from four different hospitals in southeast Idaho will

give pertinent research data to better understand the effect the environment has on medication

errors. After attaining permission from the IRB, the directors of nursing will then be contacted
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and asked to send out an email for recruitment. The email will only be sent out to those that

meet the inclusion criteria mentioned in the research population sections above. Of those that are

willing to participate, eight to 10 will be chosen from the ICU and eight to 10 from the medical

surgical unit. Once the research is over the participant will be rewarded 20 dollars for his or her

services.

Participants in the research will be observed and then interviewed over their experience

during medication administration. Observation will take place on the ICU/medical surgical

units. Medication errors and environmental distractions affecting medication preparation will be

observed throughout the day. Semi-structured interviews will be used for data collection, which

allows participants to provide thoughts, ideas, and perceptions of medication errors (Grove et al.,

2015). Open-ended questions will be used in the interview to allow participants to elaborate on

their own experience. Connections can then be made between the environment and medication

errors. All participants will be asked questions like “discuss the distractions experienced during

medication preparation/administration and how those distractions affected your ability to prepare

medications appropriately.” And “what environmental distraction do you feel have the biggest

impact on medication preparation, and why.” The information received from these open-ended

questions will be observed and coded to gather themes to help develop a theory of the

relationship between medication errors and the environment (Grove et al., 2015). After coding

has taken place, observational and interviewed data will be examined to see how distractions

affect medication errors.


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Ethical consideration

In this research, nurses participating do not want to be stated by name. This ethical

consideration is called right to anonymity and confidentiality (Grove et al., 2015). To insure

protection and confidentiality, informed consent will be signed in order to participate. De-

identification will be applied after interviews are conducted by removing any personal

information that can be traced back to participants such as names and specific details in

experiences. Each participant will be assigned a number to ensure all information is safe.

Lastly all interview and observational data gathered in the research will be intensively examined

for any potential breach of confidentiality.

In this research participants will be able to choose whether or not to participate, and to

withdraw when they wish. This ethical consideration is called right to self-determination (Grove

et al., 2015). All participants will be informed of the research and will not be coerced into doing

anything against their own will. A packet of information will be handed out to each participant

prior to observation to inform them of all that will be observed. Participants being interviewed

will have a full understanding on exactly what type of questions are being asked and can pass on

any question if they decide not to answer. Those being interviewed can decide if they no longer

want to participate and can withdraw from the interview at anytime with no repercussion of

decision.

In this research, participants will be treated equally and receive the same respect as others

being observed. This ethical consideration is called the right to fair selection and treatment

(Grove et al., 2015). All participants in the research will be chosen at random to prevent any

possibility of favoritism. Once participant have been chosen they will be required to sign a

consent form regarding the roles pertaining to the research. If any changes need to be made to
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the rules, they will not be done without consent from the subject and IRB’s permission. All

subjects will be respected and treated the same no matter the race, age, or socioeconomic level

and be provided the benefits used to recruit participants.

Annotated Bibliography

McLeod, M., Barber, N., & Franklin, B. D. (2015) Facilitators and barriers to safe medication

administration to hospital inpatients: A mixed methods study of nurses’ medication

administration processes and systems (the MAPS Study). PLoS ONE, 10(6): e0128958.

These three authors are colleagues in the Pharmacy and Medical Department at the

Imperial College Healthcare NHS Trust in London. They have received their Doctorate

in Medicine or Pharmaceutical practice. They collaborated together in a qualitative

ethnographic approach involving observational framework. Their focus in this article

was to identify factors that hinder successful medication administration. One of the

greatest strengths to this research was the ethnographic approach. This allowed the

researchers to gather observational data on real world practice and see what really caused

errors in medication administration. One of the weaknesses in the literature is that they

failed to categorize the nurses used in the study (age and qualification), and only a few

environmental factors were included. For example, there was no research done on noise,

light, and co-workers. The quality of this study was moderate because the research was

organized very well and there were a lot of charts and facts to support the finding,

however, there was not enough research done on environmental distractions causing

medication errors. This research is best utilized by nurses to help enhance the safety of

patients during medication preparation and administration in the hospital setting. The

intended audience for this research study is nurse managers and nurses in the hospital
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setting. This literature is relevant to the research problem because they both focus on the

cause of medication errors (intervention) and decreasing medication errors (outcome).

Özkan, S., Kocaman, G., & Öztürk, C. (2016). Interruptions during pediatric medication

reparation and administration. Journal of Pediatric Research, 3(2), 104-108.

The authors in this study have received their Doctorate in Nursing and are professors at

Sifa University in Izmir, Turkey. In addition, each of the authors has contributed in

multiple research studies, many of which were focused on medication errors. The type of

study conducted in this literature was a quantitative descriptive study. One of the greatest

strengths to this study was the pre-test that was performed on the usability of the form to

document the data. This form allowed for easy and proper documentation of the start and

finish times of medication preparation and administration. It also takes into account the

frequency and reason for interruption. One of the biggest weaknesses in the study is the

interruption periods were not calculated. For example, when a nurse was interrupted, the

duration of the interruption was not documented. This data would have allowed the

researchers to make a connection between the duration of the distraction and medication

errors. Overall the quality of this research was high because the form that was used was

very thorough and a pre-test was done to make sure it was adequate for the research.

Also, the charts and graphs showed in great detail the various distractions and cause that

contributed to medication errors. This research is useful for nurse managers and nurses

to help pinpoint the distractions on the floor that are causing medication errors. The

intended audience is nurse managers and nurses trying to pinpoint what distractions make

the most medications errors. This article was chosen because it links to the research
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problem through nurses with 12-hour shifts (population), and medication errors

(intervention).

Vazin, A., & Delfani, S. (2012). Medication errors in an internal intensive care unit of a large

teaching hospital: A direct observation study. Acta Medica Iranica, 50(6), 425-32.

The researchers in this article have received their PhD in Pharmaceutical practice and are

professors at the University of Medical Science of the Pharmacy and Pharmaceutical

Research in Shiraz, Iran. This research includes a quantitative direct observational study.

The researchers conducted this study to determine the frequency, type, and consequences

of medication errors in the ICU. One of the greatest strengths from this research study is

the researchers provided a variety of specific causes of medication errors. For example,

in the charts that were created, it provides a number of different categories in which the

reader can see the exact cause of medication errors. A weakness in this study is of ethical

consideration. For example, individuals that were being observed in the study did not

know they were being observed for medication errors. The quality of this study is strong

because the data was clear and precise. This study also provided adequate data, graphs,

and charts from their observation of each nurse that backed up the reasons for medication

errors in the ICU. The data collected in this research would be useful to nurse managers

in the ICU unit looking to decrease the occurrence of medication errors and for those

looking for ways to improve quality of care. The intended audience in this research is

nurse managers, and nurses looking to decrease medication errors and improve quality of

care in the ICU. A link can be made between this literature and the research problem

through ICU (population) and medication errors (intervention).


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Keers, R. N., Madalena, P., Bennett, K., Clayton, K., Brown, P., & Ashcroft, D. M. (2018). What

causes medication administration errors in a mental health hospital? A qualitative study

with nursing staff. PLoS ONE, 13(10)

Researchers from this study have received their PhD in Pharmaceutical practice and are

professors at the University of Manchester in the United Kingdom. This research study

includes a qualitative grounded theory approach. The researchers are conducting this

study in aim to pinpoint the causes of medication errors in mental health. A strength

found in this literature is that semi structured interviews were used to gather information

from participants. This aloud researchers to gather experiences from participants to help

focus the research towards a specific theory. A weakness found in this research study is

participants were asked to recall experiences up to six months back. The data collected

from these experiences could have been inaccurate, causing falsified date. Overall

strength of this study was high because researches broke up causes of medication errors

into multiple categories allowing the reader to distinguish exactly what caused each error.

Also, there are charts and graphs provided braking down each category into specific facts

and percentages. This article is useful for nurses in all practices striving to decrease

medication errors and improve patient safety and outcomes. It will allow nurse managers

to pinpoint exactly what to focus on to decrease medication errors. The audience that this

research is directed to is nurse managers and nurse’s working in mental initiations. This

study is relevant to the stated research problem because they are addressing the

medication errors (intervention) and environmental distractions (intervention).


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Implications

Nursing Knowledge

After this research study is concluded, nurses will have a greater knowledge of how

environmental distractions and decreased cognitive function can effect medication preparation.

This study will allow nurses to have a proper understanding of the most common distractions

during medication preparation so they can be removed from their surroundings. For example,

social interaction during medication preparation, and high volume workflow at the medication

station are some of the most common reasons for medication errors. Knowledge gained from

this study will warn nurses of these distractions and allow them to prepare medications properly.

Nurses will also have a greater knowledge on how diminished cognitive function can increase

medication errors. For instance, medication errors are most likely to occur in the last three hours

of the shift when cognitive function is at its lowest. The knowledge gained from this research

study on medication errors will supply nurses with the proper information needed to provide a

safer atmosphere for all patients.

Nursing Theory

Despite all the technical advances in the medical field that help reduce errors when

administrating medication, errors inevitably still occur. By implementing Nightingales

environmental theory into practice, medications errors can be decreased and patient safety

increased. Nightingale understood that an unfavorable environment could compromise the

health of her patients, resulting in an increase in mortalities (Hegge, 2013). By focusing on

cleanliness, nourishing foods, ventilation, light & noise, observation, and hope, she was able to

empower the nature of health and healing in her patients. Nightingales environmental theory

supports this research study because properly observing the surroundings to decrease distractions
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allows for proper medication preparation, resulting in a favorable environment for patient

recovery.

Nursing Practice

After the completion of this research, nurses will implement changes into their practice.

Things nurses will do differently is make sure that they remove themselves from distracting

coworkers and patients, loud noises, and heavily trafficked areas before preparing and

administering medications. By doing this, medications will be properly prepared and patients

will be given the best chance of reaching their optimal health. Another change that nurses will

make after completion of this study is strive to maintain cognition function during the last few

hours of their shift. By acknowledging that cognitive function decreases during this time, nurses

can take measures to prevent this from occurring. Prior to this study nurses were advised to

check medication twice, do six rights, and only prepare one patient’s medications at a time but

did not always follow through with these stipulations. After reviewing this research nurses will

make an extra emphasis on following through with these three guidelines. By implementing

these changes into practice nurses will provide patients with an environment that promotes

optimal recovery and patient safety.

Improved Patient Care

This research study will improve patient care in the hospital setting by improving patient

safety. Every year medication errors account for as many as 251,000 deaths annually (Anderson

& Abrahamson, 2017). Although several strides have been made to reduce the amount of

medication errors that occur, they continue to happen. These improperly prepared and

administered medications can potentially cause damage and harm to the patients. For example,

gentamicin can cause kidney problems, and morphine can cause respiratory depression. This
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research will help further the progress and decrease the amount of errors that happen because of

environmental distractions and in turn, provide a safer environment. With this new knowledge

provided there will be a decrease in medication administration errors and ultimately, patient care

and safety will improve.

This research study will improve patient care by saving hospitals and patient’s money.

As stated previously in this research, there are multiple medication errors every year and these

errors cost patients and hospitals thousands of dollars. For example, these errors on average cost

patients anywhere between $2,000-$2,500 per stay and hospitals around 2.8 million per year

(Cheragi et al., 2013). Many of these errors that occur are related to environmental distractions

deterring the focus of nurses. By reviewing this study and adding to the knowledge that

hospitals already have, a focus can be put on reducing the most common distractions in the

hospital. Decreasing these environmental distraction will minimize medication errors and money

spent by patients and hospitals.

This research study will improve patient care and in turn provide the best possible

outcome for patients. Proper medication administration is very important and can be altered

through distractions like co-works, patients, and other environmental surroundings. With the

knowledge that will be gained from this study, nurses will be able to prevent these errors and

alter their surroundings in a way that will provide patients with an environment that promotes

healing and a better patient outcome. Applying the techniques found in this research study will

reduce the number of medication errors. As a result, with a reduction in the mistakes occurring,

patient outcomes will improve and patients will be given the best chance of reaching their

optimal health.
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Recommendations

Nursing administration can use this study to cut down on the amount of medication errors

occurring in hospitals. By reviewing this study they will find that environmental distractions are

a very prevalent reason for medication errors. For example, increased noise, patient loads, and

conversations with coworkers at the medication station are a common reason for medication

errors. Once this data is reviewed, nursing administration can come up with strategies on how to

prevent these environmental distractions from causing medication errors. By implementing the

information gained from this research study, patient care and safety in the hospital settings will

continue to improve.

This research study can be transferred to cardiac floors and emergency centers. Because

semi-structured interviews were used to gather information for this research, this form of data

collection can easily be transferred to the emergency department and cardiac floor to gather

statistical data in those departments. Also, with cardiac floors and emergency centers having a

higher intensity of care with multiple patients and a large amount of distractions, the information

from this study can easily be implemented into their practice to help reduce medication errors.

By applying the techniques found in this research study the amount of errors caused by

environmental distraction will be reduced and patient satisfaction will be met. As a result, the

patients experience and safety will be improved while in the emergency center and cardiac floor.

A future study that can be done on medication errors is a quantitative descriptive study.

This type of study takes a large group of participants in a situation as it naturally happens and

identifies theories or problems with the practice to gather statistical data on a specific topic

(Grove et al., 2015). This type of research can be used in a future study because it will allow the

researcher to incorporate a larger sample size. By including a larger sample the data gathered
MEDICATION ERRORS IN THE NURSING WORLD 19

will be more accurate and reliable information. Also, a ratio level measurement will be included

in this future study to help separate the most common environmental distractions into different

categories allowing readers to gather precise information on medication errors.


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