Sei sulla pagina 1di 6

International Journal of Africa Nursing Sciences 3 (2015) 18–23

Contents lists available at ScienceDirect

International Journal of Africa Nursing Sciences


journal homepage: www.elsevier.com/locate/ijans

The role of nursing education in preventing medication errors


in Botswana
Wananani B. Tshiamo ⇑, Mabedi Kgositau, Esther Ntsayagae, Motshedisi B. Sabone
University of Botswana, Private Bag UB 00712, Gaborone, Botswana

a r t i c l e i n f o a b s t r a c t

Article history: Medication errors frequently feature in research world-wide. Although medication errors are also a
Received 18 August 2014 concern in medicine and anesthesia, they have become a regular topic in nursing. In Botswana, a country
Received in revised form 29 May 2015 challenged by shortage of both medications and professionals qualified to process and administer med-
Accepted 2 June 2015
ications, as well as low levels of health literacy, the risk of medications errors should be even higher.
Available online 20 June 2015
In Botswana nurses are deployed in both acute and primary care settings taking an active part in
prescription, transcription, dispensing and administration of medications. Pre-service nursing education
Keywords:
must therefore ensure that students are equipped with knowledge and skills on medication management
Medication
Error
and prevention of medication errors to prepare them for safe practice.
Prevention In this paper, the authors take stock of the extent to which nursing curricula address the prevention of
Nursing education medication errors, highlighting strengths and pinpointing weaknesses yet to be addressed. The exercise
Curriculum involved review of curricula at various levels of nursing education as well as nursing regulatory docu-
ments. Findings from the review were corroborated with published work on the subject.
Recommendations for strengthening basic nursing curricula at both diploma and undergraduate levels’
coverage of medications errors are proposed. Also recommended are measures to improve the system
in the practice arena as well as research to establish the magnitude of medication errors and their related
risk factors in Botswana. The exercise is envisaged to improve patients’ safety and reduce the risk of lit-
igation for nurses.
Ó 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2. Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3. Literature review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.1. Findings of the review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.1.1. Strengths . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.1.2. Weaknesses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.2. Discussion of findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.2.1. Implications for nursing curricula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.2.2. Implications for the practice environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
3.2.3. Implications for research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4. Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

⇑ Corresponding author. Tel.: +267 3555088 (O), +267 71799462 (mobile); fax: +267 397 4538.
E-mail addresses: tshiamowb@mopipi.ub.bw (W.B. Tshiamo), kgositaum@mopipi.ub.bw (M. Kgositau), esther.ntsayagae@mopipi.ub.bw (E. Ntsayagae), sabonemb@
mopipi.ub.bw (M.B. Sabone).

http://dx.doi.org/10.1016/j.ijans.2015.06.001
2214-1391/Ó 2015 The Authors. Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
W.B. Tshiamo et al. / International Journal of Africa Nursing Sciences 3 (2015) 18–23 19

1. Introduction basic nursing curricula and health care regulatory statutes in the
country. It was hoped that the review would provide documenta-
Medication errors are a serious scenario that is not only costly tion on the risk of medication errors in practice settings. The resul-
in financial terms but also that can cost a patient’s life (Glavin, tant documentation will guide curriculum review and research.
2010). In a study done in the USA, it was reported that medication
errors were responsible for 7000 deaths in a year (Phillips,
Christenfeld, & Glynn, 1998). Although medication errors are 3. Literature review
prevalent in health care fields such as medicine and anaesthesia,
they are more commonly reported in nursing (Aronson, 2009; Definitions of medication errors are numerous with some
Zakharov, Tomas, & Pelclova, 2012). The negative consequences restricted to a defined area while some have a much wider appli-
of medication errors are not limited to the patient for whom the cation. Variations of the definition of medication errors, together
medication is intended; but may affect as well, the health profes- with variations in methodological approaches in researching the
sionals who are involved in committing such errors. Professionals concept make it difficult to compare medication error rates across
may suffer psychological distress especially if the error is associ- studies (Quality (US), 2008). It is therefore important that efforts to
ated with high risk of harm. They may have to appear for address medication errors should be accompanied by a clarifica-
disciplinary hearings, or may be charged with malpractice. For tion of what is referred to as medication error. Medication error
instance, a doctor was sentenced for manslaughter following an has been defined as an act or omission involving medications with
intra-spinal administration of a medication that must have been potential or actual negative consequences for a patient that, based
administered intravenously (Holbrook, 2003). on standard of care, is considered to be an incorrect course of
Because no empirical work on medication errors has been done action (Cheung, Bouvy, & De Smet, 2009). It was noted that a med-
in Botswana, the exact magnitude of the problem is unknown. ication error may occur at any point of medication processing con-
However, in the work context that is challenged by shortage of pro- tinuum; and that such points may be prescribing, dispensing,
fessionals qualified to process and administer medications as is the administering or recording (Miller, Clark, & Lehman, 2006).
situation in Botswana and in other developing countries, the risk of Elsewhere, a medication error is defined as any preventable event
medications errors should be even higher. Although the Botswana that may cause or lead to inappropriate medication use or patient
Nurses Act assigns significant responsibility of medication man- harm while the medication is in the control of the health care
agement to nurses, the curriculum does not reflect sufficient professional, patient, or consumer (United Kingdom National
breadth and depth of medication management to enable nurses’ Coordinating Council, 2005). For purposes of this paper, medication
competency in managing medications. Faced with the obligation errors are defined as any preventable and unintentional event
to provide quality and safe care within a resource constrained occurring at any point in the chain of medication handling or deci-
environment as well as the increasingly litigating society, nursing sion making that has a potential to compromise the intended pur-
curricula in Botswana must therefore pay serious attention to pose of the medication or to cause harm to the person taking the
equipping students with knowledge and skills on the prevention medication. This definition does not include adverse reactions to
of medication errors. Although there have been no studies to appropriately administered medication or events of deliberate
establish the magnitude of medication errors in Botswana, the intention to cause harm or to cheat or exploit a person or the
deficiencies noted in nursing curricula and constraints of system.
practice environment such as shortage of staff pose a risk for Conditions that prevail at any given point of medication pro-
medication errors. Given the significant role that nurses play cessing will determine the risk of error at that particular point in
in medication management and the isolated anecdotal reports of time. In USA, it has been noted that paediatric population may be
medication errors in the clinical environment, the authors of this at a greater risk for medication errors (Scott, Engum, & Breckler,
paper found it imperative to critically interrogate literature on 2008). In a study done in Canada, it has been shown that seemingly
medication management and examine the country’s basic nursing benign errors in calculation of stock solution volumes for children
curricula at diploma and undergraduate levels for coverage of may have serious unanticipated consequences (Koren, 2002).
competencies necessary for the prevention and management Medication errors have also been found to be common in patients
of medication errors. For purposes of this paper, medication with limited cognitive abilities. A study examining medication
management emphasises the processes of prescribing, transcribing, errors in two academic paediatric hospitals in USA reported that
dispensing and administering medications in which nurses in the rate of potential adverse drug events was three times higher
Botswana play an active part. The Drug and Related Substances than previously reported in studies involving adults (Kaushal
Regulation of 1992, provides a guide to which medications nurses et al., 2001). The risk of medication errors is also high in intensive
may prescribe and which ones can only be prescribed by doctors care units because of the high incidence of multi-system disorders
(Ministry of Health, 1992). The purpose of the paper is to examine requiring multi-drug therapy (Camire, Moyen, & Stelfox, 2009). In a
the extent to which basic/pre-service and training programme for study done in ICU in Ethiopia among nurses out of 1200 medica-
nurses in Botswana address prevention of medication errors. tion administration interventions, 621/51.8% had errors. Common
errors were wrong timing, dose omission due to drug unavailabil-
ity, missed doses and inaccurate dose calculations (Agalu, Ayele,
2. Materials and methods Bedada, & Woldie, 2012).
Other conditions that have been found to present high risks of
The exercise involved the authors’ review of literature on med- medication errors include (a) high workloads for health profession-
ication errors and on nursing education and medication errors als, (b) lack of requisite training, (c) poor intra and inter-
globally, regionally and locally. The specific question addressed professional communication (d) patient’s compromised ability to
was: What are the strengths and weaknesses of the basic nursing comprehend medication information, (e) loopholes in the market-
curricula in addressing medication errors when considered against ing and distribution of pharmaceutical products, and (f) absence
what should prevail as revealed in the reviewed literature? The of an effective system for the prevention and management of
review was not limited to any time frame but priority was given medication errors (Dornan et al., 2009).
to the most recent work between April and August of 2013. In High workloads for those who handle medications or who make
addition to empirical work, local literature review also covered decisions on medications may lead to fatigue and burnout
20 W.B. Tshiamo et al. / International Journal of Africa Nursing Sciences 3 (2015) 18–23

resulting in memory lapses which are believed to play a part in the cannot read the medication label may administer medication to a
mechanism of error (Dornan et al., 2009). Wards with high patient child when it is meant for an adult or may administer the medica-
acuity often require complex care and management hence more tion through a wrong route. Patients who are able to read and com-
physical and psychological demands for nurses (Tang, Sheu, Yu, prehend information provided with the medication can be able to
Wei, & Chen, 2007). Tasks such as prescribing, dispensing and ask for clarification of contradicting information and to alert health
administering medications demand a sound mind to enable one care providers if they notice some errors in prescribing, dispensing,
to pay attention to details. In addition, health care professionals or administration of the medication. Patients with poor judgment
need requisite training for managing medications. An untrained or those with an unstable mind may not benefit from instructions
prescriber may not be aware of the drug–drug interaction. provided with the medications and may use such medication
Similarly, an untrained dispenser may fail to provide the patient inappropriately.
with adequate or accurate instructions about the medication. Marketing may provide misleading information about the ben-
Medication errors have been found to be associated with poor efits and potential risks of the medication to consumers. Packaging
training and inexperience on the part of nursing personnel (Singh and presentation that are similar for two pharmaceutical agents
et al., 2012). may cause confusion and lead to medication errors. Other condi-
In a study done in the US, it was found that nursing students tions in the treatment environment may also present risks for
frequently made medication errors and that was attributed to defi- medication errors. Absence of a deliberate system for the preven-
ciency of medication error coverage in their curriculum (Wolf, tion and detection of medication errors presents a false perception
Hicks & Serembus, 2006). Page and McKinney (2007) noted that of a medication error free environment and may make medication
nurse education should equip nurses with awareness of diverse errors to go unnoticed. Victimization of those who commit errors
factors contributing to medication errors. They reported an educa- prevents reporting of such errors and denies the institution an
tional initiative called ‘‘Medication Safety Day’’ which is devoted to opportunity to learn from the errors and to build safety nets
cultivating medication error prevention competencies among against the recurrence of such errors. Lack of patients’ involvement
nursing students. in the care process denies the institution the checks and balances
The review on medication errors and nursing curricula suggests that patients can input into the treatment plan (Smith, 2003).
the need for a holistic approach to the health care system in Nurses in Botswana play the roles of acute care provider and
addressing medication errors. A multi-site study on the establish- primary health care provider and are deployed at all levels of the
ment of medication error reporting systems involving 16 countries health care delivery system hierarchy. The levels comprise of com-
in both the developing and developed countries indicated that ele- plex high-tech medical care provided in referral hospitals (highest)
ven countries had national or local systems of reporting medica- and simple low-tech health promotive services provided in mobile
tion errors (Terzibanjan, Laaksonen, Weiss, Airaksonen, & Wuliji, stops (lowest). At the higher levels of the health care delivery sys-
2008). Of the eleven countries that had a medication error report- tem, nurses’ responsibility in medication mainly covers adminis-
ing system, only two were in Africa while ten were in the devel- tration and transcription while at the lower levels, it includes
oped world. dispensing and prescription. It is therefore important that basic
Medication administration is a multi-stage process that nursing curricula provide students with competencies in not only
involves members from different disciplines. The management of pharmacodynamics and pharmacotherapeutics as they currently
medications must therefore be a joint effort of those who prescribe, do, but also in aspects such as prescription, transcription and dis-
those who dispense, and those who administer medications. pensing (Ministry of Health, 1992).
Well-coordinated communication across disciplines at each step The role of Botswana nurses in medication management is sup-
is critical for safe medication management (Manojlovich & ported by the Drug Act (1992) that stipulates the list of medica-
DeCicco, 2007). Any communication gap in the chain of medication tions that nurses may prescribe, from among those listed in the
decision or handling will therefore increase the risk of medication Botswana National Drug Formulary. The Act further makes provi-
error. Similarly, failure of communication between any two people sion for dispensing of drugs by nurses (Ministry of Health, 1992).
who are responsible for prescribing, dispensing, or administering The Nurses and Midwives Act (1995) makes provision for a nurse
medication will increase the risk of error. For instance, if a nurse to administer hypodermic, intramuscular and intravenous injec-
who hands over to another at the end of a shift gives medication tions and infusions on a written and verbal order of a medical prac-
and fails to document, the in-coming nurse may repeat the medi- titioner or dentist (Ministry of Health, 1995). Registered nurses
cation and overdose the patient. The risk of medication errors may dispense medications at all levels of health care facilities
has been found to be associated with failure to provide all neces- in both private and public sectors (Ministry of Health, 1995).
sary information when transferring patients across units as well The legal provisions therefore legitimize the need for requisite
as failure to share information about changes in the medication resources for equipping nurses with appropriate competencies in
charts (Hughes & Blegen, 2008). Clear communication should be medication management. For instance, nurses must be conversant
provided to patients as they need appropriate information about with the principles and precautions for transcribing and instituting
their medications. verbal medication orders.
A prospective study that examined the incidence of medication Whereas literature from elsewhere shows that most medication
administration errors by anaesthetists at three South African ter- errors are related to prescription (Balas, Scott, & Rogers, 2004), this
tiary hospitals indicated that the combined incidence of medica- is unfortunately one area of deficiency in the basic nursing curric-
tion errors and near-misses for anaesthetist were 1:274 out of a ula of Botswana. In Botswana medication prescription is common
total of 30,412 anaesthetics given in a seven months period. practice for nurses especially in primary health care settings.
Errors that were found to be common were related to substitution Prescribing is a complex and challenging task that requires diag-
of medications by anaesthetists. Almost 37% of the errors involved nostic skills, knowledge of medicines, and communications skills
drug ampoule misidentification; while the majority (64.4%) were (Ministry of Health, 1995). The authors of the paper reviewed cur-
attributed to the similarities of ampoules (Llewellyn et al., 2009). ricula for both the basic nursing diploma and basic nursing degree
Medication errors may be committed by patients themselves in Botswana to determine how much of medication prescription is
especially if they are not able to comprehend the information pro- covered. Authors of this paper are convinced that rates of medica-
vided by health care professionals or if they cannot read the label- tion errors could be reduced through a robust curriculum that
ling and the medication leaflet because of illiteracy. A parent who reflects the context in which its graduates function.
W.B. Tshiamo et al. / International Journal of Africa Nursing Sciences 3 (2015) 18–23 21

3.1. Findings of the review prevention of medication errors. Even though curricula may be
credited for the presence of tools for assessing medication admin-
In a nut shell, the reviewed literature revealed that medication istration, such tools make no provision for testing proficiency in
errors can be better minimized by building student competency in calculation of medication dosage. Therefore, this means that a
medication management including prescription, transcription, student may graduate from the program without having mastered
dose calculation, administration and dispending. In addition the calculation of medication dosage; a skill that is critical in the pre-
clinical learning environment such as high workloads for staff, poor vention of medication errors (Elliot & Joyce, 2005).
inter professional communication and lack of medication error The high workloads for nurse educators and nurse clinicians in
prevention protocol also compromised quality learning. The find- Botswana pose a risk for medication errors on the part of both
ings provided a guide for curricula review. practitioners and students (Gennaro, 2005). Especially in the
The authors’ reflection on existing literature and Botswana’s absence of formalized preceptorship, there may be situations in
basic nursing curricula reveals both strengths and weaknesses which students dispense and administer medications without
with regards to the prevention of medication errors. We could cap- supervision. The situation poses challenges for both educators
italize on the strengths and sell our good practices to colleagues and clinicians because whereas we can argue that hands-on expe-
especially those in contexts that closely resemble ours. Also, we rience is important, if that will occur at the expense of patients’
could take advantage of what is available in the literature by safety and learning the right medication management, then we
benchmarking practices that have been associated with reduction are faced with a dilemma.
of medication errors. Nursing education can play a significant role
in improving medication management in Botswana through 3.2. Discussion of findings
strengthening the basic nursing curricula at diploma and degree
levels such that nurse graduates are equipped with competencies The review on medication errors and nursing curricula suggests
for preventing medication errors. Educators can also support the the need for a holist approach to the health care system in address-
Ministry of Health to improve system loopholes that present a risk ing medication errors. It is evident that nursing curricula needs
for medication errors. strengthening such that its graduates are sufficiently equipped
with competencies for preventing medication errors. It is therefore
3.1.1. Strengths incumbent upon nurse educators in Botswana to provide leader-
Curricula have stand-alone pharmacology courses that intro- ship in the prevention of medication errors, not only at curriculum
duce future nurses to pharmaceutical agents commonly used in level but also in practice and in research.
the health care delivery system. The course content includes Botswana is yet to establish an explicit system for monitoring,
pharmacokinetics and pharmacodynamics and is offered by phar- reporting and dealing with medication errors. This leaves the
macists and clinical pharmacologists with emphasis on common health care system with no information on the magnitude of med-
medications used in the health care system. Pharmacists and clin- ication errors. The situation poses challenges for researching med-
ical pharmacologists are better placed to teach pharmacology as ication errors in that an established system could provide some
they are the masters of the subject. The stand-alone course is data for use as baseline for measuring change, particularly when
followed by theory and skill-based foundation courses offered in new practices are adopted. Finding health care practitioners will-
the classroom, nursing art laboratory and the clinical area. The ing to serve as informants in researching medication errors could
courses provide the application aspect of oral and parenteral med- also be difficult in a system where people do not know what is safe
ication management that includes the five rights of medication to report and what is unsafe. In 2009, the Ministry of Health’s Drug
administration, dose calculation and the necessary precautions. Regulatory Unit developed guidelines that aim at improving
The courses are offered by nurse educators. Tools for medication patient care and safety with regard the use of medicines. The
administration that provide important steps of the process have guidelines also ensure effective assessment of benefits, harm and
been developed and are in use. risks associated with medications (Ministry of Health, Drug
Some prevailing conditions of the nursing curricula are Regulatory Unit, & Botswana, 2009). Botswana has adopted the
considered strengths because they provide students with knowl- global best practices guidelines on pharmacovigilance that encour-
edge and skills that can help reduce medication errors. For ages reporting of adverse drug reactions and medication errors
instance, blocked-time practical courses (internship) in the acute (Pal, 2006). The best practices that have been adopted may not
medical-surgical units with patient care objectives addressing be adequate in addressing Botswana’s unique concerns regarding
medications provide students with an opportunity for hands-on medication errors. In order to address these concerns, implications
medication management. The blocked-time practical courses are drawn from the work reviewed for this paper are discussed and
followed by courses on specialized areas of nursing including they cover undergraduate nursing curricula, practice environment
medical, surgical, orthopedic, gynecological and pediatric care with and research.
medication management incorporated in each course. At the final
level of training, students are exposed to complex patient condi- 3.2.1. Implications for nursing curricula
tions and medication management in adult health, critical care, The literature reviewed indicates that whereas there are
obstetric, psychiatric and community nursing areas. strengths in the basic nursing curricula with regard to teaching
the management of medication, there are areas that need improve-
3.1.2. Weaknesses ment. Nursing curricula can benefit from the incorporation of the
Stand-alone pharmacology courses do not provide students WHO Guide to Good Prescribing in the basic curriculum.
with real-life situations whereby they can apply skills such as Although WHO recommends the guide for medical students, it
medication calculation. There is no deliberate effort to address can be applied to nursing students as long as it is contextualized
medication errors in the course content which may include to the role of nurses in medication prescription in the country.
prescription, transcription, dispensing and administration. The guide is good in that it provides essential information for
Curricula do not have formalized students’ preceptorship rational prescription such as the efficacy, safety, cost, and conve-
arrangement whereby students could be attached to dedicated nience of any drug that is prescribed (Shakib, Buckley, & Misan,
clinicians (Gennaro, 2005; Sabone, 2011) to support their 2001). Not only should nursing students learn safe prescription
skill development including medication management and the but they should also be able to critically appraise the prescription
22 W.B. Tshiamo et al. / International Journal of Africa Nursing Sciences 3 (2015) 18–23

of others (Likic & Maxwell, 2009; Page & McKinney, 2007). Nurses changes in drug policy and staff training (Stratton, Blegen,
must be aware that they are accountable for the errors of medica- Pepper, & Vaughn, 2004).
tions they administered even if those medications may be Establishing medication error information and incident man-
prescribed by others. agement system could allow for learning from the incidents and
Education on managing medications must be an on-going reducing their recurrence. Sharing institutional efforts to prevent
process because the field is continuously changing. Students must medication errors may enhance the public’s input in preventing
be assisted to understand that they need to continue learning even medication errors. It could also facilitate sharing of good practices
after graduation (Likic & Maxwell, 2009). We are living in the across institutions and across countries (Glavin, 2010). The use of
cyberspace era and students could take advantages of the computer assisted diagnosis and treatment can enhance quality
Internet for their continuing professional development. However, through improved dosing calculation and medication scheduling
caution must be exercised to ensure that the websites that inform and through eliminating the error in hand-written prescriptions
students’ learning are trusted ones and that the trade names of (Glavin, 2010).
medications are used. Educators must support the students’ con- Lack of clear instructions may lead to the patient taking the
tinuing learning by encouraging research on any medication that medication through the wrong route. Long queues that character-
the student encounters and by providing them with feedback. ize low resourced settings may compromise the nurse’s ability to
Whereas students may work through the medication dosage devote meaningful time to each patient. It has been observed that
calculations in a theory course, there is need to bring in the mate- nurses in developing countries were disinclined to spending time
rial used to the classroom so as to provide students with an with patients and to respond to their concerns (Smith, 2003) and
approximation of the real world. In appreciation of the construc- that the average dispensing counselling time in Botswana was
tivist theory of learning, special sessions must be created for 25 s (Boonstra, Lindbaek, Ngome, Tshukudu, & Fugelli, 2003). The
students to play with such materials as drug order forms medica- curriculum must as well pay attention to packaging and labelling
tion ampules, syringes and drawing needles, and manikins so that dispensed medications because those also pose a risk for errors
they can calculate and administer appropriate dosages to simu- (Smith, 2003).
lated patients (Weeks, Lyne, & Torrance, 2000). It is also important
for educators to set a proficiency level for student’s ability to
3.2.3. Implications for research
calculate correct medication dosages and to put in place a plan
It is evident that the field of medication errors has not been
to ensure that all students can accurately calculate dosages
studied in Botswana. At the same time, the country is yet to put
(Cleary-Holdforth & Leufer, 2013; Elliot & Joyce, 2005). During
in place a plan for detecting and reporting medication errors.
the final year of the training, curriculum can provide the students
However, anecdotal reports provide evidence that medication
with hands-on practice in calculating medications dosage for
errors do occur; and that those that become known are those that
in-patients and in prescribing medications for out-patients.
are raised up by patients seeking re-dress. There is therefore a need
Errors in dispensing may have even more serious consequences
for research on the magnitude of medication errors and factors
because it is usually done at out-patient departments at a single
related to their occurrence. There is a need to break the conspiracy
encounter with patients that the nurse knows very little about.
of silence that surrounds medication errors so as to allow those
The nurse may over-estimate the patient’s ability to understand
who have been involved to pent-up. Acknowledging the existence
the instructions given with the medications. Sometimes the person
of medication errors could sensitize the patients and the public at
showing at the dispensing counter is not the consumer of the med-
large to work collaboratively with nurses and doctors to curb the
ications. The instructions may therefore be distorted as they are
problem. It could be ideal to start with qualitative approaches to
relayed from one person to another. It is therefore crucial that
explore salient issues around the problem and to facilitate devel-
nursing students learn the art of effective communication as well
opment of appropriate research instruments. It must be acknowl-
as culturally appropriate communication.
edged that particularly at the beginning, finding clinicians who
may be willing to serve as informants for research on medication
3.2.2. Implications for the practice environment
errors may be a challenge. Creative ways that researchers else-
In order that they can be motivated to support the students’
where have used to circumvent the sensitivity surrounding report-
learning, nurses in the clinical practice must be continuously kept
ing of medication errors can be adapted and used in Botswana
abreast with recent developments in the treatment of common
(Tang, Sheu, Yu, Wei, & Chen, 2007).
medical conditions. Particular attention must be given to those
Even more relevant could be an investigation into the learning
who have just qualified. Case study seminars supported with
needs of students regarding pharmacology in general and preven-
published work on a given area or a given medication can be made
tion medication errors in particular. We could tap from the input of
routine for those who manage medications such as nurses and doc-
nursing program graduates to enhance our understanding of how
tors. Reviewing cases together and deciding on the best approach
we are seen to be performing in our effort to prepare graduates
to treatment can enhance nurse-doctor communication for the
for the world of work and the prevention of medication errors, in
reduction of medication errors. For instance, errors related to
particular. Although research literature from elsewhere could give
poorly written prescriptions can be reduced through open commu-
us some plausible insights, locally generated data could provide
nication between those who prescribe and those who administer
information that is closer to reality; and could guide us toward
medications. eLearning resources can also be created and used to
instituting effective teaching strategies for cultivating clinical
enhance safe management of medications.
reasoning in medication management.
A non-punitive atmosphere that encourages reporting of medi-
cation errors must be encouraged. Reporting of medication errors
along with their contributing factors can sensitize clinical author- 4. Conclusions
ities to attend to risk factors such as heavy workloads and insuffi-
cient training. As it been observed, medication errors frequently The problem of medication errors has been well documented
stem from the system itself rather than any single person’s actions especially in developed countries. Some of the countries have put
or omissions (Tang, Sheu, Yu, Wei, & Chen, 2007). A multidisci- in place mechanisms such as care standards and computerized
plinary and non-punitive approach to tackling medication errors information management systems; with the aim of improving
has increased staff vigilance for errors and facilitated positive quality patient care including the reduction of medication errors.
W.B. Tshiamo et al. / International Journal of Africa Nursing Sciences 3 (2015) 18–23 23

In Botswana, not much is known about the magnitude of the prob- Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.
Chapter 37. Available from: <http://www.ncbi.nlm.nih.gov/books/NBK2656/>.
lem even though anecdotal reports suggest that medication errors
Kaushal, R., Bates, D. W., Landrigan, C., McKenna, K. J., Clapp, M. D., Federico, F., &
do occur. Neither has there been a deliberate effort in education Goldmann, D. A. (2001). Medication errors and adverse drug events in pediatric
and practice to establish explicit mechanisms for preventing med- hospitals. JAMA, 285(16), 2114–2120.
ication errors. Motivated by the belief that nursing curricula can be Koren, G. (2002). Trends of medication errors in hospitalized children. Journal of
Clinical Pharmacology, 42(7), 707–710.
instrumental in preventing medication errors, the authors Likic, R., & Maxwell, S. R. (2009). Prevention of medication errors: Teaching and
reviewed literature and pointed out the strengths and weaknesses training. British Journal of Clinical Pharmacology, 67(6), 656–661.
of the nursing education programs, based on curricula’s attention Llewellyn, R. L., Gordon, P. C., Wheatcroft, D., Lines, D., Reed, A., Butt, D., & Lundgren,
A. C. (2009). Drug administration errors: A prospective survey from three South
to medication errors. African teaching hospitals. Anaesthesia and Intensive Care, 37(1), 93–98.
The authors make recommendations for curricula, policy/ Manojlovich, M., & DeCicco, B. (2007). Health work environments, nurse–physcian
program and research. Nursing education can play important role communication and patients’ outcomes. American Journal of Critical Care, 16(6),
536–543.
in improving medication management in Botswana through Miller, M. R., Clark, J. S., & Lehman, C. U. (2006). Computer based medication error
strengthening the basic nursing curricula. Educators can also pro- reporting: Insights and implications. Nurse Education Today, 27, 219–224. http://
vide leadership in the improvement of conditions that pose a risk dx.doi.org/10.1016/j.nedt.2006.05.002.
Ministry of Health (1992). Drugs and Related Substances Act. Botswana: Government
for medication errors in the clinical settings as well as in research- Printer Gaborone.
ing medication errors. The review has a potential to stimulate dis- Ministry of Health (1995). Nurse and midwives act. Gaborone, Botswana:
course, research and new practices toward the prevention of Government Printers.
Ministry of Health, Drug Regulatory Unit, Botswana (2009). Pharmacovigilance
medication errors including strengthening the curriculum.
guidelines (2nd ed.). Gaborone: Government Printers.
Page, K., & McKinney, A. A. (2007). Addressing medication errors – The role of
undergraduate nurse education. Nurse Education Today, 27, 219–224. http://
Conflict of interest dx.doi.org/10.1016/j.nedt.2006.05.002.
Pal, S. (2006). Pharmacovigilance, edgeways and edgewise. UR33 April 2006.
Retrieved from <www.who umc.org> Accessed: 5 July 2013.
None.
Phillips, D., Christenfeld, N., & Glynn, L. M. (1998). Increase in US medication error
deaths between 1983 and 1993. Lancet, 351, 643–644.
Sabone, M. B. (2011). Graduates’ evaluations of the Master of Nursing Science
References degree programme offered by the University of Botswana. Africa Journal of
Nursing and Midwifery, 13(1), 105–116.
Agalu, A., Ayele, Y., Bedada W., & Woldie, M. (2012). Medication administration Scott, L. D., Engum, S. A., & Breckler, F. D. (2008). An evaluation of medication errors
errors in an intensive care unit in Ethiopia. International Archives of Medicine. – The pediatric surgical service experience. Journal of Pediatric Surgery, 43,
515 <http://www.intarchmed.com/content/5/1/15> Accessed 14 May, 2015. 348–352.
Aronson, J. K. (2009). Medication errors: emerging solutions. British Journal of Shakib, S., Buckley, N., & Misan, G. (2001). The easy guide to good prescribing.
Clinical Pharmacology, 676, 589–591. National Prescribing Service (NPC) Limited. NPC Pty Ltd (Australia). Retrieved
Balas, M. C., Scott, L. D., & Rogers, A. G. (2004). The prevalence and nature of from <http://nswhealth.moodle.com.au/DOH/Child_Prescribing/EasyGuide.
medication errors and near errors reported by hospital staff nurses. Applied pdf> Accessed 6 October 2013.
Nursing Research, 17(4), 224–230. Singh, S. D., Vohora, S. I., Chokski, K. S., Solanki, A. J., Chaudhary, D. R., & Patel, S. D.
Boonstra, E., Lindbaek, M., Ngome, E., Tshukudu, K., & Fugelli, P. (2003). Labelling (2012). Medication errors in relation to education and medication errors in
and patient knowledge of dispensed drugs as quality indicators in primary care relation to years of nursing experience. International Journal for Pharmaceutical
in Botswana. Quality and Safety in Health Care, 12(3), 168–175. Research Scholars, ISSN No: 2277-7873.
Camire, E., Moyen, E., & Stelfox, H. T. (2009). Medication errors in critical care: risk Smith, F. (2003). Drug use in sub-Saharan Africa: Quality in processes–safety in use
factors prevention and disclosure. Canadian Medical Assocition Journal, 180(9), (Commentaries). Quality in Safety and Health Care, 12(3), 164–165.
936–943. http://dx.doi.org/10.1503/cmaj.080869. Stratton, K. M., Blegen, M. A., Pepper, G., & Vaughn, T. (2004). Reporting of
Cheung, K. C., Bouvy, M. L., & De Smet, P. A. G. M. (2009). Medication errors: the medication errors by pediatric nurses. Journal of Pediatric Nursing, 19(6),
importance of safe dispensing. British Journal of Clinical Pharmacology, 67(67), 385–392.
678–680. http://dx.doi.org/10.1111/j.1365-2125.2009.03428.x. Tang, F. L., Sheu, S. J., Yu, S., Wei, I. L., & Chen, C. H. (2007). Nurses relate the
Cleary-Holdforth, J., & Leufer, T. (2013). The strategic role of education in the contributing factors involved in medication errors. Journal of Clinical Nursing,
prevention of medication errors in nursing: Part 2. Nurse Education in Practice, 16(3), 447–457.
13(3), 217–220. http://dx.doi.org/10.1016/j.nepr.2013.01.12. Terzibanjan, A., Laaksonen, R., Weiss, M., Airaksonen, M., & Wuliji, T. (2008).
Dornan, T., Ashcroft, D., Heathfield, H., Lewis, P., Miles, J., Taylor, D., et al. (2009). An Medication error reporting systems-lessons learnt2008pdf. Retrieved from
investigation into causes of prescribing errors by foundation trainees in relation <https://www.fip.org/files> Accessed 25 August 2013.
to their medical education. EQUIP study. (Final report). Retrieved from <http:// Weeks, K. W., Lyne, P., & Torrance, C. (2000). Written dosage errors made by
www.badmed.net/docs/Final_Report.pdf> Accessed 12 July 2013. students: The threat to clinical effectiveness and the need for a new approach.
Elliot, M., & Joyce, J. (2005). Mapping drug calculation skills in an undergraduate Clinical Effectiveness in Nursing, 4, 20–29.
curriculum (Editor’s view). Nurse Education in Practice, 5, 225–229. Zakharov, S., Tomas, N., & Pelclova, D. D. (2012). Medication errors – An enduring
Gennaro, S. (2005). External Review of Nursing Programs: University of Botswana problem for children and elderly patients. Upsala Journal of Medical Sciences,
University of Pennsylvania, School of Nursing (Unpublished Report). 117(3), 309–317.
Glavin, R. J. (2010). Drug errors: Consequences, mechanisms, and avoidance. British
Journal of Anaesthesia, 105(1), 76–82.
Holbrook, J. (2003). The criminalization of fatal medical mistakes. British Medical Further reading
Journal, 327. http://dx.doi.org/10.1136/bmj.327.7424.1118.
Hughes R. G., & Blegen M. A., Medication Administration Safety. In: R. G. Hughes Allan, E. L., & Barker, K. N. (1990). Fundamentals of medication error research.
(Ed.), Patient safety and quality: an evidence-based handbook for nurses. American Journal of Health Systems Pharmacy, 47, S555–S571.