Nurses relate the contributing factors involved in medication errors


  • Fu-In Tang PhD, RN,

  • Shuh-Jen Sheu PhD, RN,

  • Shu Yu RN,

  • Ien-Lan Wei PhD,

  • Ching-Huey Chen PhD, RN

Fu-In Tang
School of Nursing
National Yang-Ming University
155, Section 2, Li-Nong Street
Shih-Pai, Taipei 112
Telephone: 886 2 28267297


Aims and objectives.  Understanding the processes by which nurses administer medication is critical to the minimization of medication errors. This study investigates nurses’ views on the factors contributing to medication errors in the hope of facilitating improvements to medication administration processes.

Design and methods.  A focus group of nine Registered Nurses discussed medication errors with which they were familiar as a result of both their own experiences and of literature review. The group, along with other researchers, then developed a semi-structured questionnaire consisting of three parts: narrative description of the error, the nurse's background and contributing factors. After the contributing factors had been elicited and verified with eight categories and 34 conditions, additional Registered Nurses were invited to participate by recalling one of the most significant medication errors that they had experienced and identifying contributing factors from those listed on the questionnaire. Identities of the hospital, patient and participants involved in the study remain confidential.

Results.  Of the 72 female nurses who responded, 55 (76·4%) believed more than one factor contributed to medication errors. ‘Personal neglect’ (86·1%), ‘heavy workload’ (37·5%) and ‘new staff’ (37·5%) were the three main factors in the eight categories. ‘Need to solve other problems while administering drugs,’‘advanced drug preparation without rechecking,’ and ‘new graduate’ were the top three of the 34 conditions. Medical wards (36·1%) and intensive care units (33·3%) were the two most error-prone places. The errors common to the two were ‘wrong dose’ (36·1%) and ‘wrong drug’ (26·4%). Antibiotics (38·9%) were the most commonly misadministered drugs.

Conclusions.  Although the majority of respondents considered nurse's personal neglect as the leading factor in medication errors, analysis indicated that additional factors involving the health care system, patients’ conditions and doctors’ prescriptions all contributed to administration errors.

Relevance to clinical practice.  Identification of the main factors and conditions contributing to medication errors allows clinical nurses and administration systems to eliminate situations that promote errors and to incorporate changes that minimize them, creating a safer patient environment.