The current “blame culture” around drug errors made by nurses must be addressed to allow for learning opportunities and help improve patient safety, a global nursing leader has urged.
Chief executive of the International Council of Nurses Howard Catton has used this year’s World Patient Safety Day, which carries the theme of “medication safety”, to call for changes to the way health providers manage drug errors involving nurses.
“What is required is shift from a criminalising and a disciplinary mindset to communication and dialogue that will lead to learning”
He stressed that while nurses have “vital responsibilities” in this field, the negative impact of overstretched services and worsening staff shortages must not be ignored.
The annual awareness day, spearheaded every 17 September by the World Health Organization, brings together patients, families, caregivers, communities, health workers, leaders and policymakers to show their commitment to patient safety.
This year centres on medication safety and involves the slogan: “Medication Without Harm”.
The campaign aims to raise global awareness of the “high burden of medication-related harm due to medication errors and unsafe practices” and “advocate urgent action to improve medication safety”, according to the WHO.
The international organisation recognised that drug errors occur because of “systemic issues and/or human factors such as fatigue, poor environmental conditions or staff shortages which affect prescribing, transcribing, dispensing, administration and monitoring practices”.
It added that evidence suggested “more than half of all medication harm occurs at the stage when medicines are prescribed and when they are being taken by patients due to inadequate monitoring”.
Antibiotics were the “highest risk” category for medication-related harm, according to the WHO, but medicines such as sedatives, anti-inflammatories and heart and blood pressure medication also “pose significant risks”, it added.
“Medicines are powerful tools for protecting health,” said Dr Tedros Adhanom Ghebreyesus, the WHO director-general.
“But medicines that are wrongly prescribed, taken incorrectly or are of poor quality, can cause serious harm. Nobody should be harmed while seeking care.”
While the ICN welcomed the focus on medication as this year’s theme, it has also called for a culture change in the way drug errors made by nurses are managed and addressed.
Speaking at a WHO virtual event ahead of the awareness day, Mr Catton described the “current blame culture around medicine errors made by nurses” as the “enemy of patient safety”.
“We’re not talking about gross negligence, but honest mistakes often linked to system failure in organisations,” he said.
“Neither are we seeking to exonerate nurses from their responsibilities, but when errors happen, open reporting can lead to learning, not only for the individual concerned, but also for the organisation they work in.”
Mr Catton stressed it was “important to have a ‘just culture’, rather than one in which there is an immediate move to impose sanctions, refer the nurse to the national nursing regulator and take disciplinary action”.
“What is required is shift from a criminalising and a disciplinary mindset to communication and dialogue that will lead to learning and improvement and vitally improved patient safety,” he added.
The ICN chief executive highlighted the recent case of nurse RaDonda Vaught in the US who made a fatal drug error and was prosecuted “despite evidence of a system failure”.
He went on to warn of the negative impact of strained health services and nurse shortages on patient safety.
“Nurses have vital responsibilities in the administration of medicines, but we know that they are working in environments where they are often overstretched, short staffed and too busy to be able to always give the high quality of care that they want to,” said Mr Catton.
“We know that all 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 up to 13 million, nor that this fact alone has a very real impact on their everyday practice.
“And of course, medication safety is an example of the type of errors that can have very serious implications for the wellbeing of patients.”
It was recently revealed that the NHS in England is facing a record high shortage of almost 47,000 nurses.
Also speaking ahead of World Patient Safety Day, the Royal College of Nursing’s director for England, Patricia Marquis, echoed concerns about nurse shortages impacting patient care and medication safety.
“Keeping patients safe is at the heart of everything nurses and nursing support workers do and this year’s theme, medication safety, is about precisely that,” said Ms Marquis.
“But with a record one in eight nursing posts in England vacant – and a similar picture across the rest of the UK – the workforce crisis means care is being left undone and patients put at risk.
“Medication errors become far more likely when staff are overstretched and unable to give their patients the attention they deserve.”
She added: “Nursing staff take enormous pride in their work and are distraught that they can’t provide the care they want to give.
“We know the best way to improve patient safety is to have the right number of staff on shift.”