Running head: fatigue and medication error 1

Fatigue and Medication Error

Hope Hindmarch
University of South Florida, College of Nursing

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Fatigue and Medication Error

Medication administration is arguably the highest risk procedure that a nurse preforms.
Medication errors result in 7,000 inpatient deaths annually in the United states alone (Flynn,
Liang, Dickson, Xie, & Suh, 2012). Medication errors can occur when there is a breakdown in
any step of the medication administration process, or the lack of procedural steps to ensure
patient safety. There are a multitude of ways a breakdown in medication administration
procedures can occur- from lack of knowledge, to setting a pump incorrectly, to forgetting to
check a lab value. All of these are preventable errors that can result in patient harm. This paper
will explore the effects of fatigue on nurses and how it relates to medication errors.
Fatigue & Error: A Real Life Example
It was 12am on the medical/surgical telemetry unit and vital signs were being taken as
ordered. A patient who was being treated for elevated ammonia levels was found to have a blood
pressure of 145/80. The patient reported over whelming anxiety, and requested her as needed
anti-anxiety medication. The patient care technician reported the elevated blood pressure and
request for anti-anxiety medication to the patients nurse, who was dosing off while charting on
her computer. The nurse hastily reviewed the patients medication orders and obtained an antihypertensive and anxiolytic medication. Upon the nurse entering the room the patient informed
her that she never takes her blood pressure medication at the same time as her anxiety
medication. The nurse told the patient that it was ok and tonight she would take them together.
The nurse proceeded to administer the medication as the patient continued to say she did not
think it was a good idea for her to take them together. Two hours later the patient reported not
feeling right and the patient care technician obtained a set of vital signs. The patients blood

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pressure was now 70/30. The patient care technician reported the value to the nurse who was
found asleep in the staff lounge.
The nurse confessed that she failed to re-check the patients blood pressure after giving
the medication because she was exhausted and wanted to rest, and that she administered the two
medications simultaneously for the same reason. Upon further evaluation the nurse realized that
she administered the incorrect blood pressure medication. According to the patients blood
pressure protocol she was supposed to receive a different, lower dose medication. She attributed
these two over sights to the patients drastic fall in blood pressure. This was the nurses third
night shift in a row and she was there the previous night for 14 hours.
In this example the nurses fatigue resulted in her overlooking established patient safety
guidelines, the six patient medication administration rights, and failing to perform vital post
medication administration assessments. Studies have found that nurses are twice as likely to
commit a medication error when they work shifts of 12.5 hours or longer, and are even more
likely when they experience fatigue (Lockley, Barger, Ayas, Rothschild, Czeisler, & Landrigan,
2007). Many hospitals standard nursing shifts are 12.5 hours not accounting for extra time they
may spend after their shift to chart. In a recent study, 65% of nurses reported working shifts of
12 hours or more (Maust Martin, 2015). This means that a large proportion of nurses are twice
as likely to commit a medication error every day they work.
Interventions to Reduce Nursing Fatigue and Error
In 2011 the Joint Commission released a Sentinel Event Alert noting the relationship
between health care worker fatigue and adverse events (Maust Martin, 2015). This alert makes it
clear that there are improvements that need to be made to decrease nursing fatigue in order to
ensure patient safety, and potentially decrease medication error. Recent data suggests that

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moving from 12 hour shifts to 8 hour shifts may improve patient safety in regards to nursing
fatigue (Maust Martin, 2015). When discussing night shift fatigue in particular, nurse
management should take extra care when interviewing prospective employees. To ensure patient
safety, nursing management should ask potential employees lifestyle questions in order to find
out if their lifestyle is compatible with night shift work. Candidates that have extensive day time
obligations that may prevent them from getting the sleep they need to be effective clear minded
nurses may not be the best fit for night shift work. Nursing units could also establish
interventions in which if a nurse works beyond 12.5 hours they are taken off the schedule for the
following day. With the developing statistics pointing towards the dangers related with long
nursing shifts and medication errors it is evident that interventions need to be seriously
considered.
Medication Administration Fears
As a new nurse I fear my inexperience will cause me to commit a medication error. A
study from 2009 indicated that a nurses inexperience was correlated with an increase in
medication administration errors (Parry, Barriball, & While, 2015). I know I will learn an
extraordinary amount my first year as a nurse and fear my lack of experience will be a threat to
patient safety. It seems to me that every clinical day the nurse I am with has to call the provider
to verify that an order is correct because it appears off to the nurse. Sometimes the order is
correct and no change needs to be made, but frequently the provider made a mistake and an
adjustment must be made. I fear that I will not be able to recognize an incorrect order as I first
begin my nursing career. To prevent this fear from becoming a reality I will ensure that I
religiously look up my medications. As a student I will familiarize myself with common
medication orders so that I will be able to spot an order that appears to be incorrect.

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References
Flynn, L., Liang, Y., Dickson, G., Xie, M., & Suh, D. (2012). Nurses practice environments,
error interception practices, and inpatient medication errors. Journal Of Nursing
Scholarship, 44(2), 180-186. doi:10.1111/j.1547-5069.2012.01443.x
Lockley, S., Barger, L., Ayas, N., Rothschild, J., Czeisler, C., & Landrigan, C. (2007). Effects of
health care provider work hours and sleep deprivation on safety and performance. The
Joint Commission Journal on Quality and Patient Safety, 33(11). Retrieved September
11, 2015, from http://www.jointcommission.org/assets/1/18/S2-JQPS-11-07S-lockley.pdf
Maust Martin, D. (2015). Nurse fatigue and shift length: a pilot study. Nursing Economic$,
33(2), 81-87. Retrieved September 12, 2015, from
http://eds.b.ebscohost.com.ezproxy.lib.usf.edu/eds/pdfviewer/pdfviewer?
vid=8&sid=b1b6eb80-f192-4546-8b2c-c9c478617265@sessionmgr112&hid=119
Parry, A., Barriball, K., & While, A. (2015). Factors contributing to registered nurse medication
administration error: A narrative review. International Journal of Nursing Studies, 403420. doi:10.1016/j.ijnurstu.2014.07.003