A systems approach to the reduction of medication error on the hospital ward

Aims. To discuss a potentially powerful approach to safer medication admini stration on the hospital ward, based on principles of safety developed in o ther high-risk industries, and consistent with recent national reports on s afety in health care released in the United Kingdom (UK) and United States of America (USA). To discuss why punitive approaches to safety on the hospi tal ward and in the nursing literature do not work. Background. Drug administration error on the hospital ward is an ever-prese nt problem and its occurrence is too frequent. Administering medication is probably the highest-risk task a nurse can perform, and accidents can lead to devastating consequences for the patient and for the nurse's career. Dru g errors in nursing are often dealt with by unsystematic, punitive, and ine ffective means, with little knowledge of the factors influencing error gene ration. Typically, individual nurses are simply blamed for their carelessne ss. By focusing on the individual, the complete set of contributing factors cannot be known. Instead, vain attempts will be made to change human behav iour - one of the most change-resistant aspects of any system. A punitive, person-centred approach therefore, severely hampers effective improvements in safety. By contrast, in other high-risk industries, such as aviation and nuclear power, the systems-centred approach to error reduction is routine. Conclusions. Accidents or errors are only the tip of the incident iceberg. Through effective, nonpunitive incident reporting, which includes reports o f near-misses and system problems in addition to actual accidents, the syst ems-approach allows the complete set of contributing factors underlying an accident to be understood and addressed. Feedback to participants and targe ted improvement in the workplace is also important to demonstrate that inci dent data are being used appropriately, and to maintain high levels of on-g oing reporting and enthusiasm for the scheme. Drug administration error is a serious problem, which warrants a well-reasoned approach to its improveme nt.