5 Ways to Become the Head Nurse

By: Steve Berman

October 10, 2014
SOURCE: http://nursinglink.monster.com/benefits/articles/471-5-ways-to-becomethe-head-nurse
If you care about your job, you probably want to move up to the highest level possible. Thats how you
make more money, tackle more challenges, and, in many cases, gain more respect. For nurses, the
position of head nurse is the ultimate goal. Head nurse is an importantleadership role that can put you
in the position to control many facets of the nursing experience, not just for yourself, but for all the nurses
you
oversee.
How do you become a head nurse? If youre serious about becoming one, its best to have a plan in place
years in advance. However, even if you just decided after years of nursing that youd like to make the leap
to the top of the nursing pile, there are still steps you can take. Here are a few tips to get you started.

1. Get an Advanced Degree

You probably arent going to be considered for the head of nursing or any high-ranking administrative
position within a hospital without becoming an RN, and most hospitals will want someone with at least a
bachelors degree from an accredited school. Some nurses even earn amaster of science in
nursing as part of an MBA or a master of health care administration, which can also increase your
chances of someday becoming a head nurse.

2. Take Extra Responsibilities Whenever Possible

The head nurse is someone who has to put in his or her time beforehand. If extra shifts are available and
the current head nurse is in a pinch, dont hesitate to offer your services if youre free. Get a wide variety
of experience by working in different departments. Apply for higher positions, like a charge nurse. Be
enthusiastic while working, whether its training new nurses or working with the most difficult patients.
One thing to keep in mind is that a head nurse should always lead by example.

3. Shadow the Head Nurse

During your free time (if you can find any), ask the current head nurse if you can shadow her to learn what
she does. Youll need to learn how to manage people, create schedules, put out fires, work closely with
physicians, maintain patients records, and monitor training, equipment, and supplies. A head nurse wears
many hats shadowing a head nurse will mentally prepare you for all the work you would be facing.

4. Stay Professional
No one is going to want their boss to be someone they cant trust. For that reason, while you should keep
a high profile with a good attitude and work ethic, you should stay away from drama whenever possible.
Dont get involved with gossip, dont complain about other staff members behind their backs, and dont
ever be seen as lazy, incompetent, or too tired to do the job. And most of all: dont date any of your
coworkers. While hospital romances arent exactly rare, its rare that someone in a leadership role got
there after a dalliance with one of the other nurses or doctors on staff.

5. Be Patient
It can take several years to become a head nurse, even if you take care of the first four things on this list.
Generally speaking, becoming a head nurse takes a combination of skill and tenure. You need to be good
at your job and show that youre in it for the long haul. So if you want to get promoted to the top spot, but
the only option available is a much smaller promotion or a transfer to another department, take the
smaller promotion or the transfer in stride. Persistence is key to becoming a head nurse, because its one
of the great qualities that those selecting head nurses are looking for.
To be a head nurse, it isnt enough to just be a good nurse. You have to show that you command the
respect of others. You have to be able to give honest assessments of your fellow nurses without fear of
hurt feelings or losing friendships. You have to have a strict eye for detail, because if anything goes
wrong, the head nurse is the person who gets the blame. Thats the price that comes with the money,
power, and respect that head nurses achieve.

Responsibilities of a Head Nurse

Assumes the responsibility for the delivery of quality patient care to patients
within the unit.
1. Provide nursing standards and policies regarding patient care to guide the staff
nurses.
2. They have the responsibility of orienting and updating the staff of the systems
and standard of patient care.
3. Responsible for the implementation of the health care programs, and standards
of patient care.
4. Assumes the role of patient advocate.
5. Assumes the role of staff members advocate.
6. Acts as liaison with the medical staff to coordinate medical and nursing
management of patient care.
7. Serves as resource person to nursing personnel under him in assessing,
planning, implementation and evaluating nursing care provided.
8. Coordinates the patient care with the other members of the health care team.
9. Keeps superior informed regarding problems or issues in patient care.
10. Evaluates the quality of patient care through frequent rounds.
11. Evaluates the nursing standard cyclically to provide development of the new
standards of patient care.

STAFF NURSE
By: nursesource.org
April 19, 2013
SOURCE: http://www.nursesource.org/staff.html

Background:
Although there are many health care professions, none offers the range of opportunities or the ability to
focus specifically on ones interests and skills than registered nursing. Currently, registered nurses are the
largest segment of the nations health care professionals. Numbering nearly 2.7 million, the majority work
as staff nurses providing direct patient care at our nations hospitals. Wherever there is a need for health
care, there is a need for registered nurses (RNs).
Nursing is an art and a science. RNs need expertise in both to practice effectively. With a solid
educational background in anatomy and physiology, microbiology and other sciences, nurses understand
the way diseases and chronic conditions progress so they can implement nursing interventions that help
patients improve. A background in psychology, educational techniques, and communication, allows them
to work with a variety of patients and develop specific strategies known as care plans to help
patients get better faster.
While the practice of medicine focuses on disease, the practice of nursing focuses on health. RNs not
only want to help patients overcome their immediate health problem, they want to assist patients in
preventing a recurrence through lifestyle and other changes. To accomplish this, registered nurses take a
holistic approach to patient care; they look at the total person, including physical, emotional, psychosocial
and spiritual needs.
Roles:
RNs who hold staff nurse positions in hospitals have the opportunity to work as generalists or specialists.
For example, they can choose to practice in fast-paced, high-tech areas like cardiac intensive care units
or newborn intensive care units, or they can work in general medical-surgical units, where they provide
care to patients who have just undergone surgery or who are suffering from any number of complex
medical conditions. They also can choose to work with any age group, from newborns to the elderly.
No matter where nurses practice, they always perform two important roles: patient advocate and
interdisciplinary team member. As a patient advocate, nurses play a key role in ensuring that patients
needs and desires are met. As part of the health care team, nurses work with other professionals, from
physicians to physical therapists, to keep patients on track toward their recovery.
Depending on their experience, advanced education, and special certification, nurses can serve in an
even wider range of roles, including case manager, patient educator, nurse researcher, nurse practitioner,
and clinical nurse specialist.
Qualifications:

Staff nurses must have strong critical thinking, decision-making, communications, and interpersonal skills.
Nurses must be able to accurately assess a patients condition and needs, develop a solid strategy to
care for that patient, and competently perform a wide range of high-level skills. They also must be able to
provide non-judgmental care to people of varied cultural backgrounds and be committed to practicing in a
safe and ethical manner.
Practice Settings:
Registered nurses can use their expertise in traditional settings, such as hospitals, nursing homes,
schools, ambulatory care, and community and public health agencies. They also can be employed in nontraditional settings, such as childrens camps, homeless shelters, and community-based centers, like
elder day care programs.
Within the hospital, staff nurses can work in:

Emergency Department

Intensive Care Units

Labor and Delivery

Medical-Surgical Units

Operating Room/Recovery Room

Outpatient Services

Pediatrics

Salary Range:
The average annual earnings of RNs employed full time in 2013 was $68,910 per annum, according to
the National Sample Survey of Registered Nurses - March 2013.
Education:
To become a registered nurse, an individual must graduate from a state-approved school of nursing
either a four-year university program, a two-year associate degree program, or a three-year diploma
program and pass a licensing exam.
To earn a bachelors degree in nursing, students take coursework in nursing theory, science, humanities
and behavioral science, as well as gain clinical experience in a variety of settings. Students enrolled in
associate degree programs receive classroom and clinical instruction over two years; those in hospitalbased diploma programs generally over three years.

REACTION

As a 4th year nursing student I can say that I am quite nervous on the transition
from being a student nurse to staff nurse. A few months or a year from now I cant stop
thinking that school is over, the NCLEX is passed and hopefully, my first job landed. But
then am I prepared to be an RN?
The student nurse to staff nurse transition is challenging. One minute youre a
student nurse with one patient, and the next minute, youre a staff nurse with
accountability for six patients or more. Its overwhelming. Here are a few things I am
worried about.
The reality can be shocking. Being a student nurse on a floor and a staff nurse
on the same floor are two entirely different experiences. Once becoming an RN you
have to start all over, you have to prove yourself to your new coworkers and doctors.
Life style changes, as a student nurse we lived in an 8 hour shift but once we become
RNs, in most hospitals, RNs work twelve-hour shifts, days, nights, weekends, holidays.
You simply cant underestimate what shift work does to your being. And lastly, Critical
thinking is one of the most important skills. Most newly graduated nurses are thrust into
the workplace with critical thinking skills that are not fully developed. The real world is
frustrating because situations dont go by the book.

RESPONSIBILITIES OF THE STAFF NURSE

The staff nurse initiate and perform nursing care and services to meet the needs patient
in assigned areas utilizing the nursing process.
1. Assesses the individual needs for nursing care based on patients history, results
of physical, diagnostic, and laboratory examinations.
2. Infers correct nursing diagnosis.
3. Plans and prioritizes nursing care activities considering overall health needs of
the patient.
4. Institute nursing intervention consistent with the overall plan of care with special
consideration of the patients safety and comfort.
5. Provides health teaching to patient, his family and significant others so that they
may understand this illness and participate actively in his care.

6. Coordinates patient care services with members of the health team.

7. Evaluates or modifies of nursing care by means of:

Effectiveness and efficiency of nursing measures rendered.

Feedback from patient/family and significant others.

8. Documents accurately the observation and services rendered to the patient.

Becoming a Charge Nurse

By: Barbara Durham, DNP, RN, CNE
September 18, 2014
SOURCE: http://nursewithoutborders.org/charge-nurse/
Every healthcare facility, office, unit and ward needs some sort of leadership. Without it, nothing would run
smoothly and utter chaos would ensue.
Medical facilities face this problem by appointing leaders for each of their departments. These leaders
are responsible for making sure everyone is doing their job and everything runs smoothly.

Earning a BSN is the recommended level of education for this career.

What is a Charge Nurse?

Traditionally referred to as a nursing sister, a charge nurse is basically a nurse that is, well, in charge. These nurses
are often supervisors in specific areas of a healthcare facility. They are often in charge of specific shifts, and they
might also be referred to as shift supervisors.
Charge nurses typically work to ensure that everything goes as its supposed to under their watch. They will also
often act as links between staff nurses and higher supervisors, and well as patients and medical staff on their shifts.

Being a charge nurse requires a great deal of ambition and responsibility, and it is not a career to be taken lightly. In
order to become a charge nurse, you should have a few basic skills and characteristics, including leadership skills
and effective communication skills. You should also be extremely organized, yet slightly flexible and able to roll
with the punches, so to speak. If youre looking to become a charge nurse, you should also be able and willing to
tackle problems head-on and efficient in finding ways to solve them. Successful charge nurses must truly enjoy
working with other people and be able to act as a teacher and disciplinarian, if necessary.

What do Charge Nurses Do?

Charge nurses typically have a number of different responsibilities and duties, and none of these should be taken
lightly. They must take on several roles, including those of nurses, organizers, supervisors, disciplinarians, teachers,
and patient advocates.
First of all, they have many of the same duties as traditional nurses. This involves caring for patients and
maintaining a clean, safe, and sanitary work environment. As a charge nurse, you can expect to assist with
monitoring and caring for patients, including recording vital signs and administering medications. Many charge
nurses also work closely with care managers and physicians in an effort to create or update patient care plans.
One of the best traits for charge nurses to have is organizational skills. These nursing professionals are often
responsible for making sure that the healthcare professionals in their areas or on their shifts have access to the
necessary supplies and equipment. In order to do this, charge nurses must usually directly order necessary supplies
or confer with their facilitys administration department. Charge nurses might also be responsible for overseeing the
schedules of the nursing staff as well as the admissions, discharges, and transfers of patients to and from their areas.
Charge nurses are also responsible for a number of supervisory tasks as well. For instance, they may be responsible
for meeting and conferring with their healthcare facilitys administrators or managers, and relaying any changes in
protocol to the rest of the nursing staff. They might also need to evaluate and document the performance of the
nursing staff, and sometimes deal with unsatisfactory behavior or performance.
Charge nurses should also act as role models and may be required to provide any necessary training and orientation
for new nursing staff members. They are typically expected to assist and teach the nurses under their supervision.
Finally, charge nurses are expected to assist other nurses in dealing with difficult patients. They may be called upon
to act as mediators between patients and members of the nursing staff, and they may also need to look into
complaints from patients as well.

Where do Charge Nurses Work?

Nearly all healthcare facilities that employ nurses have charge nurse positions. These nursing professionals can often
be found in hospitals, clinics, and private physician offices.

How do I Become a Charge Nurse?

Becoming a charge nurse is typically less about education and training, and more about experience, ambition,
personality, and performance. Of course, in order to become a charge nurse, you must first become a licensed
nursing professional. This usually involves becoming and RN by earning your nursing degree and passing the
National Council Licensure Examination for Registered Nurses (NCLEX-RN).
Below is a common education path associated with a charge nurse

Educational Track

School
Programs

Average Education
Length

Choosing Online or
Campus

Earn a Bachelors Degree

View Programs

4 Years

Online or Campus

Earn a MSN Degree

View Programs

2 Additional Years

Online or Campus

Earn a PHD or DNP

View Programs

2-4 Additional Years

Online or Campus

Experience is also often a must before becoming a charge nurse. Generally, charge nurses are often required to have
at least three years of nursing experience under their belts before they can assume this role. Some charge nurse
positions may require additional experience, particularly if the position is for a specialty field.
Your performance working as a member of the nursing staff should be exemplary if youre looking to eventually
become a charge nurse. Youre more likely to be promoted to these types of supervisory positions if you demonstrate
excellent leadership, communication, and problem-solving skills.

Common Duties

Provide leadership and structure for the nursing staff

Improve overall care for patients through implementation of nursing research and new techniques

Maintain safety guidelines for nurse staff

Manage and control nursing assignments,

schedules, quality control, and staffing needs

REACTION

I have some views as a student nurse on how it is like to become a charge nurse.
I honestly want to be one someday, but am I capable of being a charge nurse? Here are
some of my views on how is it like being a charge nurse.
You cant be everyones friend. The people you thought were on your side start to
look at you sidewise. Lets face it: sometimes you make decisions that piss people off.
You cant please everyone. No matter what you do, or how carefully you consider
each decision, there will be someone, somewhere second-guessing you and then loudly
speaking about how they would have done things differently. Managing sick calls can
be stressful as you have to look for replacements which adds up to your daily duties and
responsibilities as a charge nurse. Your colleagues have no idea what you do. They
probably think it mostly involves sitting around and directing traffic.
But then, aside from all the negativity I can think of there are also some positive sides.
Aside from a bit higher salary, and gaining more experience in your resume, some of
your colleagues or physicians will start treating you with respect.

RESPONSIBILITIES OF THE CHARGE NURSE

1. Completes charge nurse checklist on daily assignment sheet and ensures the
tech checklist is completed.
2. Monitoring patient care activities by the staff and ensuring completion
3. Troubleshooting problems that may arise on the unit
4. Assuring orders are followed through by the staff
5. Informing unit management of potential problems in the unit
6. Resolving staffing issues for current and oncoming shift.
7. Assist nurses with discharges, admits, and patient care as needed
8. Complete charge nurse report sheet and give shift report to oncoming charge
nurse
9. Assures completion of daily patient call backs and culture board
10. Surveys unit/all treatment rooms for equipment and safety issues

The Impact of Dedicated

Medication Nurses on the
Medication Administration Error
RateA Randomized Controlled Trial
By: Nancy L. Greengold, MD, MBA; Rita Shane, PharmD; Philip Schneider, RPh;
Elizabeth Flynn, PhD; Janet Elashoff, PhD; Cheryl L. Hoying, PhD, RN; Kenneth
Barker, PhD, RPh; Linda Burnes Bolton, DrPH, RN
October 27, 2013
SOURCE: http://archinte.jamanetwork.com/article.aspx?articleid=216203

ABSTRACT
Background Concerns about hospital medication safety mount as the pace of new drug
releases accelerates.
Methods We performed a randomized study at 2 hospitals (A and B) to examine whether
the medication administration error rate could be decreased by having "dedicated" nurses
focus exclusively on administering drugs. "Medication nurses," after receiving a brief review
course on safe medication use, were responsible solely for drug delivery for up to 18
patients each. "General nurses," who did not attend the course, provided comprehensive
care, including drug delivery, for 6 patients each. A direct observation technique was used to
record drug errors, process-variation errors, and total errors.
Results At both hospitals combined, the total error rate was 15.7% for medication nurses
and 14.9% for general nurses (P<.84). Comparing hospitals, the total error rate for
medication nurses at hospital B was significantly higher than it was at hospital A (19.7% vs
11.2%; P<.04). At hospital A, there was a significantly lower error rate for medication nurses
than for general nurses in the surgical units (P<.01) but no significant differences in total
errors comparing nurse types in the medical units (P<.77).
Conclusions This trial suggests that use of dedicated medication nurses does not reduce
medication error rates. However, subgroup analysis indicates that medication nurses might
be useful in some settings. The differences in findings at the 2 hospitals and their differences
in medication-use processes reinforce the concept that medication errors are usually related
to systems design issues.

IN AN ERA in which pharmaceutical products are released at a rising rate and there is an increase in
reports of drug-related toxic effects and in the complexity of hospitalized patients, the medication-use
process has come under public, governmental, and health care industry scrutiny. In hospital settings,
where nurses have primary responsibility for medication administration as part of a disparate and
demanding set of patient care duties, the concern about medication safety is especially paramount. The
study reported herein used a direct observation process to examine the medication administration process
by registered nurses.
Medication administration is an activity that is prone to errors, in part because of the proliferation of new
devices and new drug products.1 Medications are administered through a variety of routes, dosages,
dosage forms, and dosing regimens, adding intricacy and variability. Moreover, medication orders are
changed frequently, as pharmacists and medical specialists provide input into patient care based on
changes in patient clinical status and the results of diagnostic tests.
The literature has corroborated the fact that errors are common in the process of prescribing,
transcribing, dispensing, and administering medications. In one study,2 prescribing errors represented
56% of preventable adverse drug events in a 700-bed hospital. Errors in medication administration were
the second most frequent type, accounting for 34% of preventable events. 2 Leape and colleagues3 found
that whereas 48% of prescribing errors, 33% of transcription and verification errors, and 34% of
dispensing errors were intercepted before they reached patients, only 2% of drug administration errors
were detected before they occurred.

In the Harvard Medical Practice Study, adverse events occurred in nearly 4% of hospitalizations, with 19%
of these being attributable to medication-related injuries. 4 In a similar Australian study,5 adverse drug
effects also accounted for 19% of adverse events. Despite the impressive statistics about adverse drug
events,2,6,7 it is believed that the percentages reported actually underestimate the problem because it is
known that most errors go unreported.8- 11 This contention is supported by a recent study12 that
compared the number of errors identified using incident reports with those identified via an independent
observation technique. It was found that more errors are detected by observation than by voluntary
reports by a factor of 457:1.12
The observation technique for studying medication administration errors was originally developed in
1962,11 and it has since been used in more than 40 studies. Research conducted since then has
consistently demonstrated that the observation technique is the most accurate in detecting drug
administration errors.8,12 Barker and colleagues,13 analyzing data from various studies, estimated that
errors (excluding wrong-time errors) occur at a rate of approximately 1 per hospitalized patient per day.
A variety of strategies have been developed to try to prevent medication errors, including computerized
physician order entry,14,15 bar coding,14,16- 18 unit dosing,19- 21 and use of the computerized
medication administration record.14,15,22 The first strategy does not focus on preventing administration
errors, and the other 3 interventions do not address the subtle issues involved in delivering the right
medication to the right patient using the right administration technique. Therefore, we undertook this
study to determine whether administration errors could be decreased by using a more focused human
approach to medication delivery.
We hypothesized that the drug administration error rate could be decreased by having "dedicated
medication nurses," who had received a brief review course on pharmacology and safe medication use,
focus exclusively on administering drugs during their nursing shifts without increasing the existing
complement of nursing staff.

METHODS
DESIGN AND STUDY PARTICIPANTS

This randomized study took place at 2 sites: an academic community hospital on the West Coast (hospital
A) and a university teaching hospital in the Midwest (hospital B). Study participants were registered
nurses who had at least 1 year of acute care nursing experience and a minimum of 6 months of full-time
employment at the hospital (Table 1). Study participants were informed that they would be participating
in a medication safety study designed to provide a greater understanding about the medication-use
process and that they would be observed as they prepared and administered medications. This study was
approved by the institutional review boards at the 2 participating hospitals, and all study participants
provided informed consent.
TIME FRAME AND CHARACTERISTICS OF STUDY HOSPITALS

The study was conducted simultaneously at the 2 academic hospitals in 2 contiguous 6-week blocks, 5
days per week (excluding weekends), for 12 weeks (July 9, 2001, through September 28, 2001). Four
separate nursing units were selected to participate at each institution, 2 participating during each 6-week
block. At hospital A, the nursing units are aggregated to focus on either medical or surgical patients. At
hospital B, all nursing units involved were mixed medical and surgical units. At hospital A, nurses worked
12-hour shifts generally 3 d/wk; at hospital B, nurses worked 8-hour shifts generally 5 d/wk.
MEDICATION-USE PROCESS

The medication-use processes at the 2 hospitals were different during the study. Figure 1 describes how
medications were ordered at each hospital, highlighting the differences.
RECRUITMENT AND RANDOMIZATION

Before the study began, 4 nursing units at each hospital selected to participate in the study recruited and
acquired consent from nurse volunteers from these units. Nurses were randomly assigned using a
random-number generator to 1 of 2 groups: medication nurses or general nurses. Eight medication nurses
and 8 general nurses were randomized to participate as principal study participants during the 12-week

study; an additional 7 medication nurses and 3 general nurses were randomized to participate as backup
study participants to fill in for the principal study participants if needed.
All nurses randomized to serve as medication nurses, including backup individuals, were trained in the
medication safety program described in the "Medication Nurse Responsibilities" subsection. These nurses
were assigned responsibility for medication administration 2 d/wk between 8 AM and 1 PM, during which
time they were observed. Study nurses randomized to serve as general nurses were observed between
8AM and 1 PM during the other 3 days of the week. The total number of nurses on a given study unit
remained the same, regardless of whether the medication nurse or the general nurse was being observed.
Of the 16 principal study participants, 2 medication nurses dropped out of the study (1 because of a family
death and another for administrative reasons) and were replaced by randomized backup medication
nurses. It was occasionally necessary to recruit nurses to serve in the general nurse role when the
randomized backup general nurses were unavailable. This occurred 12% of the time for total days worked
by general nurses. These nurses were not randomized.
MEDICATION NURSE RESPONSIBILITIES

Participants randomized to the medication nurse group attended a 1-day (8-hour) medication safety
program. The course, covering basic pharmacology and the principles of safe medication administration,
was taught by a multidisciplinary team of clinical pharmacists, nurse educators, and a physician,
including some of us (R.S., P.S., and N.L.G.). The content of the educational program was based on
information derived from the Institute for Safe Medication Practices, pharmacology texts, and the current
scientific literature. The course also covered the importance of adhering to safe medication practices,
described in the "Observers and Observation Design" subsection. Although each study site used faculty
from its own institution, both used the identical education syllabus, developed collaboratively. The
medication safety program was given on the first day of each study block in which the medication nurse
was participating.
On the 2 days each week that the medication nurses worked, they were responsible for administering
medications to assigned patients. At hospital A, medication nurses were assigned 16 to 18 patients each,
and at hospital B, medication nurses were assigned 15 patients each. (The difference in number of patients
assigned was a result of differences in the medication-use process between the 2 hospitals [Figure 1].)
Unit census varied during the study; therefore, the maximum number of patients was not always present
in a given unit each day. Nurses administered all scheduled medications with few exceptions, unless they
were unable to administer time-critical medications (eg, insulin and antibiotics), in which case they were
instructed to ask for assistance from the staff nurses on the unit. Medication nurses did not administer
STAT medicines, total parenteral nutrition, hydration, or bolus medications; these were handled by staff
nurses who were not followed by observers.
GENERAL NURSE RESPONSIBILITIES

Participants who served in the general nurse role provided nursing care in the usual manner, covering an
average of 6 patients each. They did not receive training in medication safety. They were observed only
when they administered medications, not when they were providing other patient care services.
MAIN OUTCOME MEASURES: ERROR RATES

For each individual error type, the error rate was determined by dividing the number of errors detected by
the total number of opportunities for error based on the established definition in the literature. 8,19Each
dose administered was considered to be a single opportunity for error, and total number of opportunities
for error represented the total number of doses administered plus those omitted. This method for
computing error rates enabled comparison of rates between medication nurses and general nurses by
correcting for the differences in the number of medications administered by each nurse group.
Using this definition, error rates were computed for the primary outcome measures: total errors (the sum
of medication errors and process-variation errors), medication errors, and process-variation errors. To
compute total errors, each dose was scored as having no errors or as having at least 1 error, and the
percentage of doses with an error of any type was computed. To compute medication errors, each dose
was scored as having no medication errors or as having at least 1 medication error, and the percentage of

doses with a medication error of any type was computed. To compute process-variation errors, each dose
was scored as having no process-variation errors or as having at least 1 process-variation error, and the
percentage of doses with a process-variation error of any type was computed.
Therefore, since a single opportunity for error could have had errors of varying types, for example, 2
medication errors and 1 process-variation error, the percentage of opportunities showing at least 1
medication error plus the percentage of opportunities showing at least 1 process-variation error will be
somewhat larger than the percentage of opportunities showing at least 1 total error.
STATISTICAL METHODS

Since individual opportunities for error (doses) are not independent of each other, standard statistical
methods, such as a 2 2 2 test, which are based on the assumption that each opportunity for error is
independent, would not be valid. Based on the complexities of the study design involving factors for
patient, nurse type, nurse, observer, site, day, week, and unit, a simple model for data analysis was used.
The error rate (as a percentage) was computed for each nursing unit for each hospital for each study week
for each nurse type (medication or general). At hospital A, error rates for medication and general nurses
were computed separately for the medical and surgical units for each week of the study (and then were
also pooled), whereas at hospital B, where all of the units were mixed medical and surgical, error rates for
the 2 different nurse types were computed only by pooling all of the units together for each week of the
study. Comparisons between error rates for medication and general nurses were based on the weekly
differences in error rates for the 2 nurse types for each of the 12 study weeks.
Statistical significance was assessed using the sign test, which is a test of the null hypothesis that the
probability of a positive difference is 50%; P values were computed based on the binomial distribution.
Thus, conclusions are based on the consistency of differences across the 12-week period. For example, if
medication nurses had a higher error rate than general nurses in 11 of 12 weeks, this would be strong
evidence that medication nurses made consistently more errors than general nurses (the sign test gives
aP<.01), whereas if medication nurses had a higher error rate than general nurses in only 6 of 12 weeks,
this would suggest that their error rates are similar (results are not consistent and the sign test would not
be significant).

RESULTS
TOTAL ERRORS

Total error rates, defined as the percentage of opportunities in which a medication error, a processvariation error, or both occurred, varied from a low of less than 1% per week to a high of 56% per
week.Table 3 displays total error rates by study site and nurse type. At both hospitals combined,
medication nurses had a 15.7% total error rate and general nurses had a 14.9% total error rate; this
difference was not significant (P<.84), as rates were higher for medication nurses in about half the weeks.
When analyzing results by unit type, we saw no significant differences in total errors between medication
and general nurses for hospital A medical units, whereas there was a significantly lower error rate for
medication nurses than for general nurses in hospital A surgical units and a nonsignificant tendency for a
higher error rate for medication nurses than for general nurses in the mixed medical and surgical units at
hospital B.
The total error rate for medication nurses was significantly higher at hospital B vs hospital A (19.7% vs
11.2%; P<.04). Rates for general nurses were essentially the same at each site (15.0% and 14.7%,
respectively).
MEDICATION ERRORS

Medication error rates (excluding wrong-time errors) varied from a low of less than 1% per week to a high
of 37% per week. Medication errors by study site and nurse type are given in Table 4. At both hospitals
combined, medication nurses had an 11.2% medication error rate and general nurses had a 6.9%
medication error rate; this difference was not statistically significant. Analyses of rates by unit type were
essentially the same as for total errors except that the higher rates for medication nurses at hospital B
were significant (P<.01). Comparisons between sites showed the same pattern as for total errors.

PROCESS-VARIATION ERRORS

Process-variation error rates varied from a low of 0% per week to a high of 53% per week. Processvariation errors by study site and nurse type are given in Table 6. At both hospitals combined, medication
nurses had a 4.9% process-variation error rate and general nurses had an 8.4% process-variation error
rate; this difference was not statistically significant using the sign test.
The overall pattern of results differed somewhat from that seen for total errors and medication errors. For
hospital A surgical units, medication nurses had a lower rate of process-variation errors than general
nurses, which did not reach statistical significance. At hospital B, in the mixed medical and surgical units,
medication nurses had a significantly lower rate of process-variation errors than general nurses (P<.01).
No statistically significant differences were found when comparing hospital A and hospital B processvariation error rates for medication nurses (4.4% and 5.2%, respectively) and general nurses (7.4% and
9.2%, respectively). The analysis of process-variation errors is limited by the relatively low number of
these errors recorded by the observers and the variation in recording these errors from one observer to
another. The most common process-variation errors were failure to check patient wristband identification
(4.0%) and unlabeled medication (1.8%).
PATIENT OUTCOME

There were no known cases in which observers intervened to prevent a serious error. Although this study
was not designed to measure patient outcome, there was no known association between the drug
administration errors recorded during the study observation periods and patient harm or death.

REACTION
Contrary to the results of the study, I still do believe that medication nurses
should have fewer errors because they have only one main focus as a functional
nursing and that is giving of medications than a staff nurse who is focused on total or
primary care nursing Results of this trial suggest that use of a dedicated medication
nurse does not reduce medication administration error rates. However, analysis
revealed some findings that suggest that a medication nurse might be useful in some
settings and with certain types of workloads. When I analyzed the study that was done I
figured that the differences in error rates between hospitals possibly may be attributed
to the fact that registered nurses at hospital A were, on average, more experienced than
those at hospital B.
Medication nurses had relatively little training for their roles. They received only a
1-day didactic course, and they did not have the opportunity to develop proficiency in
their roles on the nursing units before being observed based on this study. Thus, the
findings of this study should not be interpreted to apply to medication nurses who may
receive much more extensive training, perform this role full-time, and develop expertise
over time.
It is likely that more changes to the medication-use system and training are
required to reduce the rate of medication errors. Attempting to reduce the medication
error rate by providing a comprehensive educational program, which would train nurses
to become specialists in medication administration, requires further study.

RESPONSIBILITIES OF THE MEDICATION NURSE

The medication nurse should have the knowledge (indications, contraindications,

dose, interactions, adverse effects, route and knowledge of how to administer
drug safely) skill and judgement to assess the appropriateness of the medication
for particular patient. The medication nurse should also know patient drug
allergies.

1. Preparing the medication correctly

2. Ensuring the 8 Rights:
a. right PATIENT
b. right MEDICATION to be given
c. right REASON
d. right DOSE - what is the patient's weight
e. right ROUTE
f. right FREQUENCY
g. right TIME/ DAY of order
h. right SITE
3. Monitoring the patient while administering the medication
4. Appropriately intervening as necessary
5. Evaluating the outcome of the medication on the patients health status
6. Complete medication charts accurately and unambiguously in order to ensure
that patients receive safe and optimal drug therapy
7. Monitoring the effect of the drugs that are administered to the client
8. Safe and accurate administration of medication
9. Documentation of the process.