Feelings of nursing professionals after the occurrence of medication errors

Abstracts

OBJETIVO: Conhecer os sentimentos dos profissionais de enfermagem que cometeram erro de medicação. MÉTODOS: Estudo descritivo, qualitativo, realizado com 15 profissionais de enfermagem de um hospital universitário de Goiânia. Os dados foram coletados através de entrevistas semi-estruturadas, gravadas e analisadas segundo os pressupostos de Bardin. RESULTADOS: Os resultados mostraram que os sentimentos mais comuns são pânico, desespero, medo, culpa, vergonha, entre outros. Adotam, como estratégias de enfretamento buscar alguém para compartilhar o problema, realizar comunicação formal do erro e buscar informação e conhecimento. CONCLUSÃO: Os hospitais não devem negligenciar a falha do ser humano, mas fazer disso um motivo para a implementação de estratégias sistêmicas como a revisão dos processos de medicação, condições ideais de trabalho, apoio psicológico e investimento em educação continuada.

Erros de medicação; Enfermeiras; Sentimentos; Conduta

ORIGINAL ARTICLE

Feelings of nursing professionals after the occurrence of medication errors^*

Sentimientos de profesionales de enfermería después de la ocurrencia de errores en la medicación

Jânia Oliveira Santos^I; Ana Elisa Bauer de Camargo Silva^II; Denize Bouttelet Munari^III; Adriana Inocenti Miasso^IV

^INurse. Goiânia Urgency Hospital - Goiânia (GO), Brazil

^IIMaster, Assistant Professor at the Federal University of Goiás College of Nursing UFG – Goiânia (GO), Brazil. Student of the Inter-units Doctorate Program offered by the University of São Paulo (USP) at Ribeirão Preto College of Nursing – Ribeirão Preto (SP), Brazil

^IIIPhD, Full Professor at the Federal University of Goiás College of Nursing - UFG - Goiânia (GO), Brazil

^IVPhD, Professor of the Department of Psychiatric Nursing and Human Sciences at the University of São Paulo (USP) at Ribeirão Preto College of Nursing Ribeirão Preto (SP), Brazil

^{Corresponding Author}

ABSTRACT

OBJECTIVE: To understand the feelings of nursing professionals who have committed medication errors.

METHODS: Descriptive and exploratory study with a qualitative approach. The subjects were 15 nursing professionals from a university hospital in Goiânia. Data were collected by interviews guided by a semi-structured instrument, which were recorded and analyzed according to the premises of Bardin.

RESULTS: The results showed that the most common feelings are panic, despair, fear, guilt and shame, among others. The coping strategies they adopt include looking for someone to share the problem, formally communicating the error and looking for information and knowledge.

CONCLUSION: Hospitals should not ignore that human beings can err, but turn this into a motive to implement systemic strategies, such as the review of medication processes, ideal work conditions, psychological support and investment in continuing education.

Keywords: Medication errors/psychology; Nurses/psychology; Feelings; Behavior.

RESUMEN

OBJETIVO: Conocer los sentimientos de los profesionales de enfermería que cometieron error en la medicación.

MÉTODOS: Se trata de un estudio descriptivo, cualitativo, realizado con 15 profesionales de enfermería de un hospital universitario de Goiânia. Los datos fueron recolectados a través de entrevistas semi-estructuradas, grabadas y analizadas según las premisas de Bardin.

RESULTADOS: Los resultados mostraron que los sentimientos más comunes son pánico, desesperación, miedo, culpa, vergüenza, entre otros. Adoptan, como estrategias de enfretamiento buscar a alguien para compartir el problema, realizar comunicación formal del error y buscar información y conocimiento.

CONCLUSIÓN: Los hospitales no deben descuidar la falla del ser humano, sino hacer de ello un motivo para la implementación de estrategias sistémicas como la revisión de los procesos de medicación, condiciones ideales de trabajo, apoyo psicológico e inversión en educación continuada.

Descriptores: Errores de medicación/psicología; Enfermeras/psicología; Sentimientos; Conducta.

INTRODUCTION

In the last few years, scientific journals and the media have detected errors regarding health professionals. The United States Medicine Institute report "To err is human: building a safer health system", states that around 7,000 Americans die annually by medication errors⁽¹⁾.

This fact brings up a major problem seen in hospitals, because such errors jeopardize the client/user's physical integrity and the quality of services offered by the institutions^(2-3). For the clients, these errors may generate longer hospitalizations, higher hospitalization costs, need for further treatment, extra exams and procedures such as pain, suffering, sequelae that may take them to death. For the institutions, the errors compromise the quality of service, the institutional image, generate distrust and increase costs and expenses⁽¹⁾.

The health professionals involved in errors suffer consequences that can be administrative, oral or written punishments, civil, legal and ethical trials. Trials can impede the legal exercise of the profession and cause emotional damage because, when facing a error, undesirable feelings are common^(3-5). These professionals feel guilty and show emotional reactions that can lead them to voluntary demission for having their professional image tarnished⁽⁶⁾.

The nursing team is the edge of the medication system, which increases its responsibility when exposed to an error. It appoints the transition from a predictable to an actual error, causing great mental suffering to the professional ⁽⁶⁾. An aggravating factor in this process is that, when medication errors occur, the emphasis is not on the education but on the punishment, leading to underreporting and lost of knowledge about the risk factors permitting the repetition of the error⁽⁷⁾.

In view of this matter, it is very important to comprehend the feelings of the professionals when making an error, so as to act preventively and, especially, offer adequate help to the professional, trying to diminish the event for both parts (professional and client). The study by Padilha et al.⁽³⁾, performed with this intent, shows a list of possible feelings. However, they use the quantitative perspective and do not allow for the comprehension of how the professionals face this situation.

Considering the importance of knowing what happens in these cases, this study aims to investigate the feelings of the professionals who experienced medication errors and how they face this matter. It is believed that the analysis of this process from a qualitative perspective may offer ideas of where actions are possible in order to diminish the situation of suffering for the professional and also for the client who, in most cases, is aware of the event.

OBJECTIVES

Identify the feelings of nursing professionals when they make a medication error and how to face this situation.

METHODS

A descriptive research was carried out, aiming at obtaining knowledge through the description of human experience, based on the way it is felt and defined by its individuals⁽⁸⁾. The investigation was performed with professionals who work at the Intensive Therapy (clinical and surgical) Medical Clinic and Emergency Room at a hospital in Goiânia – GO, Brazil. The Institution trains human resources in health and is a member of the sentinel hospital network of the Brazilian National Health Surveillance Agency.

This research was presented to the professionals at the units, informing that those who had made any medication errors during their professional career and wanted to collaborate would be heard. The number of professionals was defined throughout the gathering, considering the criterion of data saturation⁽⁹⁾. Thus, 12 nursing technicians and three nurses formed the study group. Data collection took place after approval by the Research Ethics Committee of the Federal University of Goiás and signing of the free and informed consent term.

Data collection occurred from March to June 2006 through interviews, with a semi-structured guide, previously scheduled at the professionals' workplace, in a private environment. The guide consisted of two parts: the first looked at the study participants and the second identified the feelings of the nursing professionals when making the medication error. Their anonymity was preserved, replacing their names by the letter (I), followed by the interview number.

The interviews were recorded and fully copied and their content was submitted to thematic content analysis⁽⁸⁾, including pre-analysis, material exploration, data treatment and interpretation. The data analysis, organized by meaning units, permitted the identification of the following categories: Feelings experienced after the error and strategic actions to face these feelings.

RESULTS

Fifteen professionals between 22 and 49 years old participated in this study, most of them female. They had worked in the nursing area from one to twenty years. All of them were also employed in other institutions. It is important to say that the participant did not have to identify the institution where the error happened, because the discussion was about the identification of the feelings when making an error and not the time or place where it had happened. The results and discussion will be presented below.

Category I – Feelings experienced after the error

This category reveals the emotions the individuals expressed under the influence of the error. The feelings are expressed by the way we notice our reactions to the world around us^(10-11). The professionals' testimonies show the feelings about the discovery of the error situation and their consequences for the client and for the environment where it happened.

Discourse analysis shows that the feelings are strictly related to the individual who makes the error and to the person subject to the error. In both directions, we identified: panic, despair, preoccupation, guilt, shame, fear and insecurity. When making a medication error, the professional's first experience tends to be panic and despair about the event:

I was terrified, and trying to discover what had happened, it was me and the patient being sick, then I decided to check what medication I had given and I got really scared (I11)

The feelings of guilt and concern were also common and they appear when the professionals are aware of causing damage to the client, due to lack of attention during their action.

I felt guilty and uncomfortable about being the main origin of this discomfort for the patient. (I12)

I went home and I called over and over asking for news, I spend the night with remorse, bad, disturbed. I went cold when it happened. I was thinking the other day, it was an elderly, I couldn't sleep at night, and I was worried. (I15)

I was worried about her, you know? What if she dies? So each and every minute you pass by and look, she's alive. (I9)

Another common feeling about committing an error was shame and the need to reveal to the client that you made an error, including the possibility of some colleagues knowing about it. Statements related to the feeling of shame express the situation for the professional, the client and the institution.

Ashamed, I was ashamed of the staff, myself, of not paying attention (I13)

I was very ashamed because I had prepared it and didn't have the guts to tell the patient that I had prepared it, you know? I was the supervisor and I had made the error, you know? (I14)

...that silly idea that other people may know what had happened. (I2)

The professionals also reported feelings of insecurity and fear that something serious may happen to the client. The data show that these feelings pass the idea to the professional that the client should be protected and that he/she put him at risk. This generates the fear of the client's death, as the testimonies show.

My thought was the fear of losing that patient. our biggest asset is the patient, so, when the patient is at stake we get shocked, right? (I5)

I feared that my patient would die. He had got out of a severe moment and I would be the responsible for that and I didn't want to. (I11)

The feeling was of fear, I get scared until today. I pray to God every day when I come to work so that he can help me not to commit an error. (E9)

I got insecure for, let's say, a couple of months, but, you know, until today when I prepare a medication I feel it. (E10)

Category II. Actions and Strategies to face feelings caused by errors

The second category reveals two basic movements of the professionals when facing the error and the search for strategies to overcome the event. From the perspective of the study group, the first way to face the unpleasant feeling was to look for help or share the problem with someone who could help him/her to take a decision at this moment of stress and insecurity.

I wanted someone to help me. (I11)

At that very moment! I was like, I didn't know what to do...(I8)

We feel incapable of doing things at the time, incapable. (I2)

The search made some professionals formally communicate the error, generating a feeling of tranquility. The professionals' testimonies express the feeling of tranquility they had after communicating the event to someone and of being supported. The feeling of relief, finally, is common when realizing that they did not cause serious harm.

The decision I took soothed me because I did the right thing. I called my boss and communicated the event to her (I3)

But then I talked to the resident, to my supervisor and they soothed me. (I8)

Oh, I think that my biggest misery was when I was trying to find the doctor to say what had happened, after that I relaxed because she soothed me. (I7)

The second movement of facing this situation is about being aware of the experienced fact. This established a moment of personal learning, generating strategies for the transitory living with feelings of tension and disability. In this sense, the error was marked as a fact not to be forgotten.

I have never forgotten. In fact, whenever I'm injecting I remember this error, you know. You can see how it marks us, can't you? (I10)

It marked me and since then I'm very careful with this matter of medication dosage, right route and right time (I15)

I learned from it, so that I never made this error again. (I03)

I learned that life is a greater thing and I don't have to be in a hurry. (I5)

I learned the lesson that it's not a thing to play with, that you don't play with medication, that you don't play with life. (I5)

Another learning aspect is related to the positive dimension that may be involved in this episode. From the interviewees' perspective, the unpleasant feelings generate a state of alert, which is triggered whenever the person is involved in the same activity.

For me it was positive because, from this moment on, I'm more alert. (I10)

Now I ask the name, I'm more alert to the patient's name. I don't call the patient, I ask his/her name. (I06)

I did the labeling and still I go there and look if it is really from that patient, I see if that medication that I unlabeled in the morning was not suspended in the afternoon (I9)

Take a good look at the prescription, look in how much time it is going to run, the time, I started to observe it more carefully (I11)

The search for information and more knowledge about their work was another strategy some professionals adopted.

Read, if you're in doubt read again, still in doubt?... ask (I13)

I started studying more about pharmacology. (I4)

DISCUSSION

Errors negatively affect nursing professionals with ethical and moral principles to do good and never harm the client. These episodes may cause psychological and emotional traumas that may be oppressive and harmful^(4,12).

Health professionals are not prepared to deal with errors and with unpleasant feelings resulting from errors, such as shame, incapability, guilt, doubt about their knowledge^(4,10-13), as seen in testimonies in the first category.

Padilha et al.⁽³⁾, in a quantitative study about this theme, shows anxiety, disability and anger as the most mentioned feelings. These lead to a loss of confidence in one's abilities and practice, which are common events for the professional who, in many cases, feels unsettled, guilty and terrified about committing a medication error^(12,14).

Shame appears as a feeling that diminishes the professional image, even when considering that all human beings can make an error. They are hard to accept and comprehend and they expose the individual to embarrassing situations and evil judgments about his/her professional responsibility and proficiency⁽¹¹⁾. In the same sense, it is easy to understand fear of error, since it can put the client's life, the professional's technical proficiency and even his/her professional career at stake^(15-16).

The professional is supposed to feel relieved after noticing that he/she did not harm the client, in view of the seriousness of medication errors and the risk context eminent to the parties involved: client, professional and institution. In our daily life, as well as in work, emotion is present and it is impossible to separate work from our emotional state^(10-11). This is clearer in the hospital work environment, especially when direct contact with pain, suffering, misery and clients' death may result from an action we did and, despite strong efforts, these facts affect our emotions⁽¹¹⁾.

Besides psychological consequences, emotions may also trigger physical alterations. They alter immunological responses and exert great influence on the autonomous nervous system. Disturbing emotions may be particularly harmful to the body and should be considered a threat to health⁽¹⁰⁾. Feelings like anger, rage, hostility, tension, anxiety and depression are associated with heart, gastrointestinal, contagious, immunological diseases, among others⁽¹⁰⁾. Therein, emotional support is needed for professional who are experiencing this and is useful not only to prevent illness, but also to help the persons to face this situation⁽¹¹⁾.

The second category that deals with strategies the professionals adopted to overcome difficulties related to the error show that facing the situation leads to personal and professional maturation. The statements show that, when the professional has the opportunity to be heard about the happening, his/her suffering is relieved and the situation is better elaborated. The space to share the event seems beneficial, so that the person who made the error can review his/her way of dealing with unpleasant feelings⁽¹¹⁾.

This movement seems to facilitate the registration of the error and not its omission, which can be lethal in some cases. Thus, awareness and assumption of what caused the error marks the professional's life and avoids that the error is identified as an accident.

It was observed in some testimonies that the error produced a more conscious, attentive professional, responsible for his/her acts, as well as awakening to follow security rules, such as labeling and dose checking. It seemed to turn the medication moment into an interaction space among professional, staff and client, instead of a mere mechanical act^(4,14-16).

Exploring psychological mechanisms that are hidden by the error makes sense when we look for a way to overcome them, turning the error into a lesson for anyone trying to prevent it, considering that, if you know something, you can control it⁽¹⁵⁾.

CONCLUSION

This study tried to identify feelings of nursing professionals when they make a medication error and how to face it. The results show that panic, despair, concern, guilt, shame, fear, and insecurity are common feelings experienced by the professionals, causing personal and professional instability.

These feelings also interfere when helping the client and stays in the professionals' memories, associated with the fear of committing an error again. However, the professionals seem to acknowledge the value of this experience for their learning and the importance of producing personal strategies to prevent new errors.

Inside the organizations, near the activities and influencing actions to reach determined objectives, the professionals are subject to faults. Therefore, they need ideal work environments, psychological support, investment in continued education, systemic strategy implementation to support them and prevent medication errors.

Like in every capitalist and globalized organization, hospitals seek productivity and quality, investing in high technologies to improve care. However, they should not ignore the importance of investing in human capital.

By not neglecting feelings and emotions that come from errors, the institutions start to establish an important partnership with professionals because they feel supported, secure and assisted to register the errors and, thus, to search fast and effective solutions. Nursing, as the legal responsible for managing medications, should be engaged in this task force, promoting actions and behaviors that are in compliance with practices of non punishment, supporting, consolidating the continued education culture in services and security for professionals and clients, thus minimizing the suffering for all parties involved.

REFERENCES

Received article 11/06/2007 and accepted 01/09/2007

• 1. Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.
• 2. Bulhões I. Os anjos também erram: mecanismos e prevenção da falha humana no trabalho hospitalar. Rio de Janeiro: Atheneu; 2001.
• 3. Padilha KG, Kitahara PH, Gonçalves CCS, Sanches ALC. Ocorrências iatrogênicas com medicação em unidade de terapia intensiva: condutas adotadas e sentimentos expressos pelos enfermeiros. Rev Esc Enferm USP. 2002; 36(1): 50-7.
• 4. Carlton G, Blegen MA. Medication-related errors: a literature review of incidence and antecedents. Annu Rev Nurs Res. 2006; 24:19-38.
• 5. Santos AE, Padilha KG. Eventos adversos com medicações em serviços de emergências: condutas profissionais e sentimentos vivenciados por enfermeiros. Rev Bras Enferm. 2005; 58(4):429-33.
• 6. Chiericato C, Cassiani SHB, Carvalho VT. Instrumento de registro dos erros nas medicações segundo a revisão da literatura. Acta Paul Enferm. 2001; 14(2): 79-90.
• 7. Carvalho VT, Cassiani SHB. Erros de medicação e conseqüências para profissionais de enfermagem e clientes: um estudo exploratório. Rev Latinoam Enferm. 2002; 10(4): 523-9.
• 8. Polit DF, Beck CT, Hungler BP. Fundamentos de pesquisa em enfermagem: métodos, avaliação e utilização. 5a ed. Porto Alegre: Artmed; 2004.
• 9. Bardin L. Análise de conteúdo. 3a ed. Lisboa: Edições 70; 2004.
• 10. Goleman D. Mente e medicina. In: Goleman D. Inteligência emocional: a teoria revolucionária que redefine o que é ser inteligente. Rio de Janeiro: Objetiva; 1996. p.179-200.
• 11. Remen RN. Carinho cooperativo. In: Remen RN. O paciente como ser humano. São Paulo: Summus; 1993. p.179-217.
• 12. Mayo AM, Duncan D. Nurse perceptions of medication errors: what we need to know for patient safety. J Nurs Care Qual. 2004; 19(3):209-17.
• 13. Barreto MNCB, Kuramoto JB. A Bioética e o erro humano. In: Harada MJCS, Pedreira MLG, Pereira SR, Peterlini MAS, organizadores. O erro humano e a segurança do paciente. São Paulo: Atheneu; 2006. p. 61-8.
• 14. Kazaoka T, Ohtsuka K, Ueno K, Mori M. Why nurses make medication errors: a simulation study. Nurse Educ Today. 2007; 27(4):312-7.
• 15. Lacasa P. Errores, conocimiento y emoción en el personal sanitario. In: Lacasa C, Humet C, Cot R. Errores de medicación. Prevención, diagnóstico y tratamiento. Barcelona: EASO; 2001. p. 23-38.
• 16. Bohomol E, Ramos LH. Perceptions about medication errors: analysis of answers by the nursing team. Rev Latinoam Enferm. 2006; 14(6): 887-92.

*

This study was performed at the Internal Medicine Unit, Intensive Care (clinical and surgical) and Emergency Room of a Hospital in the city of Goiânia Goiás State.

Publication Dates

• Publication in this collection
  18 Jan 2008
• Date of issue
  Dec 2007

History

• Received
  11 June 2007
• Accepted
  01 Sept 2007