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Self-reported violations during medication administration in two paediatric hospitals
  1. Samuel J Alper1,
  2. Richard J Holden2,
  3. Matthew C Scanlon3,
  4. Neal Patel4,
  5. Rainu Kaushal5,
  6. Kathleen Skibinski6,
  7. Roger L Brown7,
  8. Ben-Tzion Karsh8
  1. 1Human Factors Practice, Exponent Failure Analysis Associates, Chicago, IL USA (work completed while a PhD student in the Department of Industrial and Systems Engineering of the University of Wisconsin)
  2. 2Departments of Medicine and Biomedical Informatics, Vanderbilt University, Nashville, TN, USA (work completed while a Postdoctoral Fellow at the School of Medicine and Public Health at the University of Wisconsin)
  3. 3Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI USA
  4. 4Department of Pediatrics, Vanderbilt University, Nashville, TN, USA
  5. 5Departments of Pediatrics, Public Health, and Medicine, Weill Cornell Medical College, New York, New York, USA
  6. 6Department of Pharmacy, St Mary's Hospital, Madison, Wisconsin, USA
  7. 7School of Nursing and Department of Family Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
  8. 8Department of Industrial and Systems Engineering and Systems Engineering Initiative for Patient Safety, University of Wisconsin, Madison, WI USA
  1. Correspondence to Dr Ben-Tzion Karsh, Industrial and Systems Engineering, University of Wisconsin-Madison, 1513 University Avenue, Madison, WI 53706-1572, USA; bkarsh{at}


Content Violations of safety protocols are paths to adverse outcomes that have been poorly addressed by existing safety efforts. This study reports on nurses' self-reported violations in the medication administration process.

Objective To assess the extent of violations in the medication administration process among nurses.

Design, setting and participants Participants were 199 nurses from two US urban, academic, tertiary care, free-standing paediatric hospitals who worked in a paediatric intensive care unit (PICU), a haematology-oncology-transplant (HOT) unit or a medical-surgical (Med/Surg) unit. In a cross-sectional survey, nurses were asked about violations in routine or emergency situations in three steps of the medication administration process.

Main outcome measure Self-reported violations of three medication administration protocols were made using a seven-point 0–6 scale from ‘not at all’ to ‘a great deal’.

Results Analysis of variance identified that violation reports were highest for emergency situations, rather than for routine operations, highest by HOT unit nurses, followed by PICU nurses and then Med/Surg unit nurses, and highest during patient identification checking, followed by matching a medication to a medication administration record, and then documenting an administration. There was also a significant three-way interaction among violation situation, step in the process, and unit.

Conclusions Protocol violations occur throughout the medication administration process and their prevalence varies as a function of hospital unit, step in the process, and violation situation. Further research is required to determine whether these violations improve or worsen safety, and for those that worsen safety, how to redesign the system of administration to reduce the need to violate protocol to accomplish job tasks.

  • Patient safety
  • compliance
  • medication administration
  • violation
  • human error
  • human factors
  • implementation science
  • information technology

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  • Funding This study was funded in part by a grant from the Agency for Healthcare Research and Quality (R01 HS013610, Karsh PI). RJH was supported by a pre-doctoral training grant from the National Institutes of Health (1 TL1 RR025013-01) and a post-doctoral training grant from the Agency for Healthcare Research and Quality (5 T32 HS000083-11).

  • Competing interests None.

  • Ethics approval Ethics approval was provided by University of Wisconsin-Madison, Children's Hospital of Wisconsin, Vanderbilt Children's Hospital.

  • Provenance and peer review Not commissioned; externally peer reviewed.