Ethical reflections and discussion of methods
We complied with the Helsinki Declaration’s guidelines on
anonymity and confidentiality. Since information about medication
error may be sensitive, it was vital to be aware of ethical aspects
in connection with the project (32). When researching patient
safety, a conflict of interests may arise. On the one hand,
confidentiality must be safeguarded and a relationship of trust
with the interviewees upheld. On the other hand, it is incumbent on
us to warn of any risk to patient safety or treatment that is not
professionally sound (32, 33). The interviews did not give rise to
any such ethical dilemmas.
Several nursing homes in the region were asked to participate
but only two of them found it possible to allow several nurses to
leave the ward at the same time to participate in an interview.
This restricted the breadth of the data. The students who took part
assumed responsibility for a nursing home ward for two weeks. They
had the same functional area as the nurses, apart from the handling
of drugs, which was always checked by a nurse. The students had
less experience than the nurses but their strength was their
critical external gaze and their attention to theory. When we read
through the body of material, it emerged that the nurses and
students had similar experiences. For this reason, the data
analysis does not distinguish between the nurses’ and the
students’ experiences. Both groups are defined as health
personnel, and in light of the principle of responsible conduct,
prior learning and work experience is decisive for what tasks they
can perform in connection with the handling of medication (33).
Experiences of how safety measures functioned with regard to
medication management in nursing homes were divided into three main
topics (table 2):
- Safety procedures
- Training and medication competence as safety measures
- Organisation of work and allocation of tasks
Incomplete safety procedures
Verification by two members of staff was a well-established
safety procedure. Two nurses checked the selection or preparation
of medicines. If only one nurse was on duty, a practitioner (for
example, a care worker or a nursing assistant) could help to check.
The medicines were placed in a pill dispenser one week in advance,
and were most often distributed by a nursing assistant. Two nurses
mixed the drugs used in the infusion pump, but only one changed the
pump. The informants said that after a near-accident, the staff had
discussed whether there should also be two present when changing
At one of the nursing homes, there was a computer-controlled
medicine cabinet with inbuilt control of the withdrawal and
selection of medication. Secure practice relied on there being no
interruptions to the work on preparing the medication. It was
pointed out that the cabinet was too cramped, it was difficult to
get a full overview and it quickly became very untidy.
Time pressure and interruptions characterised work on managing
Written regulations on medication management were well
implemented. However, according to the informants, there were many
examples of non-compliance with the safety procedures. Due to time
pressures, sometimes they skipped a step in the documentation
routine. For example, they might forget to sign for the medicines
administered, or they might sign for medicines that had not been
handed out. A detailed example of a forgotten signing-off of a
blood-thinning drug was described in a learning log. In the
evenings or at the weekends, the dispensing of medicine often took
place by telephone. Sometimes it took a long time to get the
doctor’s signature, or it might be forgotten. A nurse also
gave an example where a patient was given the wrong type of
antibiotics because no information was noted about the
patient’s allergy to this type of antibiotics.
A lack of case histories and non-conformance with
The informants spoke of many episodes where case histories were
lacking, or an outdated case history accompanied the patient when
he/she was discharged from hospital. The last-mentioned incident
was discovered when the nursing home ward received the new case
history in the post some days later. If the nursing home asked the
hospital about a missing case history, they might be told to use
the list of medications, but as one nurse said, ‘That’s
just a mess because it’s written by hand, so you don’t
understand a thing.’ Such inaccuracies may result in
deficient or incorrect treatment of patients. Nor did the nursing
documentation and the case history always correspond. Considerable
time was wasted in calling the hospital to try to obtain the case
history or calling the doctor who had written it.
A topic addressed in several learning logs was non-conformance
with procedures by failing to administer medicine at the correct
time, or forgetting to do so at all. Nurses in several focus groups
related that they were often too busy to write error reports. Time
pressure and a shortage of nurses meant that they had to prioritise
nursing tasks that involved giving immediate help. They also gave
lower priority to writing error reports because they felt it was a
waste of time. One nurse said ‘One summer I wrote all the
error reports I possibly could (not only those related to
medication) to map how much time I required to do this properly.
Sometimes I was there one or two hours longer than the ordinary day
shift on a completely voluntary basis and without being paid
overtime for it.’
Another nurse claimed that only serious and obvious errors were
documented. Even though it did not take long to describe the event,
answering the point ‘Suggested improvements’ was
time-consuming. The error reports were reviewed on a weekly basis
in all nursing home wards but practice differed regarding feedback
to the staff.
Training and medication competence as safety measures
The informants said that they were constantly being introduced
to new drugs, generic drugs and new ways of administering them.
Even experienced doctors expressed the view that there was a huge
number of new things. Two manufacturers might produce the same drug
but under different names. A less experienced nurse could easily
select the wrong drug. Although the chemist published lists of all
generic drugs, nurses did not always have time to consult the list.
In answer to questions about training related to new drugs, new
methods of administration and observation of the effects and side
effects, one group answered as follows:
‘I have never taken part in anything like that (training
in new medications).’
‘In connection with the use of a new pain-relieving nasal
spray, a nurse from the hospital came along to show us a smart way
to hold it. We have to read up on the effects and side effects of
medicines ourselves.’ Several of the others nodded in
agreement, saying things like:
‘… and we learn from each other…’
‘… so we read the package information leaflet
‘We have a duty to keep updated at all times.’
The informants stated that training in medication management was
‘ad hoc’ and poorly organised. The training consisted
of information sheets, package information leaflets, the app of the
Norwegian Pharmaceutical Products Compendium on private mobile
phones, self-study and exchange of experience. No one had been
offered any training by the pharmaceutical companies.
Work organisation and allocation of tasks
The organisation of work and allocation of tasks among health
personnel in connection with handling medication was part of the
safety measures. Patients were prescribed medication by various
actors such as their GP, the nursing home physician and doctors
from various hospital departments. At the nursing homes, there were
doctor’s visits once a week (twice a week in some short stay
wards) with a routine review of medicines. At one of the nursing
homes, the doctors had a strong focus on unnecessary
At the other nursing home, in contrast, both the nurses and the
doctors paid less attention to polypharmacy. A group of student
nurses discussed how easy it was to resort to laxatives and
tranquillisers to save time instead of focusing on diet and
activity. One student nurse wrote a detailed learning log about a
patient who appeared to be considerably overmedicated with
analgesics and psycho-pharmaceuticals. The patient was very
overweight, and the side effects of several of the medications
included drowsiness, an increased need for sleep and weight
increase. The patient was hospitalised for reasons of mobilisation,
but sat in the lounge and slept the whole day. The student
attempted several times to take this up during the pre-visit
consultation, but to no avail since it was said to be non-acute.
Two more learning logs also dealt with patients who were
There was a lack of systematic competence
In the short stay wards, the patients on occasion administered
their medicines themselves, often without having the necessary
overview. One nurse said ‘They come along with a whole box
filled with medicines that they’ve collected and saved up for
several years. They ask if they have to use it, because no one has
told them to stop.’ If attempts were made to gradually reduce
their medication, family members might protest because they wanted
active treatment for their loved ones. One of the nursing homes
arranged scheduled meetings with family members twice a year,
opening for a discussion of medication regimes.
In all nursing home wards, nurses usually prepared the
medication, but they were often administered by a nursing assistant
who had undergone a six to twelve-hour course of internal training.
Each shift had few nurses on duty. Several of the interviews and
learning logs provided examples showing that considerable time was
spent on tidying, washing and serving food – tasks that do
not require nursing competence. Many simultaneous, complicated
nursing tasks gave the nurses little opportunity to work in a
concentrated manner without interruption. At one of the nursing
homes, medication selection was allocated to different days of the
week in order to shield the nurses who handled
This study has revealed that documentation as a safety procedure
was a risk factor because it was unreliable. Weaknesses in patient
record systems have previously been documented at 56 Norwegian
nursing homes (8). Another study shows that errors in medication
information was one of the most common adverse events when patients
are transferred between different levels of the health service
(34). Nor do error reports function satisfactorily as safety
measures. The nursing homes employ error reports, double-checking
and documentation when there is enough time, but the participants
described many situations when time pressure made it impossible to
follow safety procedures. This finding concurs with international
research (17, 21, 22) and shows that there is a long way to go to
fulfil the principles of double loop learning (27). This study is
also in line with Lipsky (35), who as early as 1980 described how
‘street-level bureaucrats’ were forced ‘to take
short cuts’ in situations with difficult priorities.
Descriptions of inaccurate documentation and a lack of error
reports recurred during the data collection period of almost three
years. This indicates a failure to improve safety measures, which
in turn indicates poor follow-up of internal control (5). The
responsible manager has the formal responsibility for medication
management and risk assessment (36). A 2015 survey also described
time pressure as the reason that the writing of error reports was
not given priority, and that error reporting systems seldom
resulted in improvements (37). This is a grave situation since the
Coordination Reform entails greater and more complex medication
being administered by the primary health service (3, 9).
If safety procedures that cannot be realised in practice are
retained, this can undermine staff’s understanding of the
importance of routines for patient safety. Exact documentation of
prescribed drugs is essential to prevent medication errors. Since
substantial resources are used both for documentation and error
reports, we need further research to evaluate the use of resources
in order to improve patient safety in the nursing home.
Must build up competence systematically
Our study showed that time pressure and interruptions
characterised work on medication management, while at the same time
considerable time was spent on tasks that did not require nursing
skills. Other surveys and studies also point this out (10, 18, 38),
which can be interpreted as indicating that training and the
development of medication competence is not being taken
sufficiently seriously. Brenden et al. showed that updating
knowledge in nursing homes was carried out informally with a lack
of formal management strategies to map competence and competence
enhancement (14). This finding confirms that there is a lack of
systematic competence building. The attending doctor is responsible
for medication management but is reliant on nurses’ reports
on observations of the effects and side effects. Such reports
require that the nurses have time to write them and professional
The study presents examples in which student nurses point to
procedural errors and overmedication. This indicates that the
nurses have competence that can be exploited in improving the
medication regime in nursing homes, so that competence building can
be in line with the principles of double loop learning (27).
Further research is necessary to examine why nurses give less
priority to safety measures that can improve patient safety, and
instead are carrying out tasks with considerably lower risk and
need for competence such as serving food, tidying and cleaning.
Professional identity must be enhanced and the nurse’s
role shielded from tasks that do not require nursing skills.
The Coordination Reform entails that the municipality has a much
greater degree of responsibility for treatment and no longer merely
has responsibility for nursing and care. This change increases the
need to build up medication competence systematically. When new
health reforms are introduced, there is little assessment of what
the consequence will be for patient safety (39). Our study
indicated that an overly high risk is associated with medication
management in nursing homes. Nurses are present twenty-four hours a
day in nursing home wards and represent a professional group with
formal medication competence.
This study has shed light on the great need that nurses and
student nurses have for medication competence, but implies that
there must be realistic framework conditions to apply and develop
such competence. In addition, the study shows that patients
possibly need training. A high rate of polypharmacy has been
revealed as being an underlying cause of falls in connection with
patients hospitalised in the specialist health service (40). If
patients and their family members have better information and
knowledge about drugs, this can reduce unnecessary medication use.
Implications for education and practice
The education of nurses must emphasise organisational competence
in order to increase understanding of the correlation between
safety measures and patient safety (24–26, 41). Professional
identity must be boosted, and the role of the nurse shielded from
tasks that do not require nursing competence (6). Internal control
in nursing homes must be improved. Nursing home management must pay
more attention to risk in connection with medication use and make
provision for systematic training and development of medication
competence, which must take place in relation to double loop
learning, including reflection and time to assess underlying causes
(27). Management must also facilitate training for patients and
The survey is based on experiences from a limited number of
nursing home wards, and must be interpreted with care to avoid
generalisation. However, the results correlate well with Norwegian
and international studies on patient safety, medication use and
competence needs in nursing homes (6, 8, 11, 15, 16, 18,
The results of this study describe safety procedures that are
not always feasible or reliable in practice. The training was
deficient and there was poor correlation between medication
competence, work tasks and staffing.
The Coordination Reform has resulted in greater and more complex
medication use in nursing homes, increasing the need for a
systematic enhancement of medication competence. The results of
this study concur with several similar studies and therefore raise
the question of why nursing competence is not better utilised to
ensure patient safety. Considerable resources are used on
structural measures such as documentation and error reports without
this having the optimal impact. Further research should be carried
out on how increased nursing staff levels and the development of
medication competence can improve patient safety in nursing
1. Meld. St. 10.
God kvalitet – trygge tjenester. Kvalitet og pasientsikkerhet
i helse- og omsorgstjenesten. Oslo: Helse- og omsorgsdepartementet.
2. Meld. St. 11.
Kvalitet og pasientsikkerhet 2013. Oslo: Helse- og
3. Meld. St. 26.
Fremtidens primærhelsetjeneste – nærhet og helhet. Oslo:
Helse- og omsorgsdepartementet. 2014–2015.
4. NOU 2015:11.
Med åpne kort. Forebygging og oppfølging av alvorlige hendelser i
helse- og omsorgstjenesten. Oslo: Helse- og omsorgsdepartementet.
5. Helse- og
omsorgsdepartementet. Forskrift om internkontroll i helse- og
omsorgstjenesten. 1. januar 2003 (Internkontrollforskriften).
PC, Bjørk IT, Hofoss D, Kirkevoll M, Foss C. Competence in advanced
older people nursing: development of «Nursing older people
– competence evaluation tool». International Journal of
Older People Nursing 2015; 10:59–72.
7. Kirkevold M,
Brodtkorb K, Ranhoff AH. Geriatrisk sykepleie. God omsorg til den
gamle pasienten. 2 utgave. Oslo: Gyldendal Akademisk. 2014.
Helsetilsynet. Sårbare pasienter – utrygg tilrettelegging.
Funn ved tilsyn med legemiddelbehandling i sjukeheimar
2008–2010. Report from Helsetilsynet 7/2010. Oslo:
9. Gautun H,
Syse A. Samhandlingsreformen. Nova-report no. 8/2013. Oslo:
Norsk Institutt for forskning, oppvekst, velferd og aldring.
10. Hofstad E. Sluttet i
protest. Tidstyvene gjorde at jeg sa opp på sykehjemmet. Oslo:
Sykepleien 2014;12:24–31. Available at:
11. Wannebo W, Sagmo L.
Stort behov for mer kunnskap om legemidler blant sykepleiere i
sykehjem. Sykepleien Forskning 2013;8(1):26–34. Available at:
12. Alteren J. Å lære
legemiddelhåndtering i sykehjem. Sykepleiestudentenes utfordringer.
Vård i Norden 2012;32(4):34–8.
13. Blekken L, Medby AO,
Forbord T. Læringsutbytte i sykepleiefaglig ledelse etter praksis
der sykepleierstudenter overtok ansvaret for en avdeling.
Sykepleien Forskning 2013;4(8):344–52. Available at:
14. Brenden TK, Storhei AJ,
Grov EK, Ytrehus S. Kompetanseutvikling i sykehjem – ansattes
perspektiv. Nordisk Tidsskrift for Helseforskning
15. Lane SJ, Trover JL,
Dienemann JA, Laditka SB, Blanchette CM. Effects of skilled nursing
facility structure and process factors on medical errors during
nursing home admission. Health Care Management Review 2014;
16. Lim RHM, Anderson JE,
Buckle PW. Work domain analysis for understanding medication safety
in care homes in England: an exploratory study. Ergonomics 2016;
17. Holmstrom A, Airaksinen
M, Weiss M, Wuliji T, Chan X, Laaksonen R. National and local
medication error reporting systems. A survey of practices in 16
countries. Journal of Patient Safety 2012; 8(4):165–76.
18. Dilles T, Elseviers MM,
van Rompaey B, van Bortel LM, Vander Stichele RR. Barriers for
nurses to safe medication management in nursing homes. Health
Policy and Systems. 2011; 43(2):165–76.
19. Stavropoulou C, Doherty
C, Tosey P. How effective are incident-reporting systems for
improving patient safety? A systematic literature review. The
Milbank Quarterly 2015; 93(4):826–66.
20. Barber ND, Alldred DP,
Raynor DK, Dickinson R, Garfield S et al. Care homes’ use of
medicines study: Prevalence, causes and potential harm of
medication errors in care homes for older people. Quality and
Safety in Health Care 2009;18:341–6.
21. Handler SM, Perera S,
Olshansky EF, Studenski SA, Nace DA, Fridsma DB, Hanlon JT.
Identifying modifiable barriers to medication error reporting in
the nursing home setting. Journal of the American Medical Directors
22. Barnes L, Cheek J,
Nation RL, Gilbert A, Paradiso L, Ballantyne A. Making sure the
residents get their tablets: medication administration in care
administration in care homes for older people. Journal of Advanced
23. Donabedian A. The
definition of quality and approaches to its assessment. Michigan:
Health Administration Press. 1980.
24. Carayon P, Wetterneck
TB, Rivera-Rodriguez AJ, Hundt AS, Hoonakker P, Holden R, Ayse PG.
Human factors system approach to healthcare quality and patient
safety. Applied Ergonomics 2014;45:14–25.
25. Hjort PF. Uheldige
hendelser i helsetjenesten. Oslo: Sosial- og helsedirektoratet.
26. Aase K.
Pasientsikkerhet. Teori og praksis. 2. ed. Oslo:
27. Argyris C, Schön, D.
Organizational learning II. Michigan: Addison-Wesley Publishing
28. Morgan DL. Focus groups
as qualitative research. 2. ed. California: Thousand Oaks Sage
29. Klemp T. Med
praksisloggen som vandrestav. En kvalitativ studie av
lærerstudenters læringsprosess. (Doctoral dissertation). Trondheim:
30. Halkier B. Fokusgrupper.
Oslo: Gyldendal Norsk Forlag. 2010
31. Storli M.
Feilmedisinering i sykehus – organisasjonskulturens
påvirkning. Vård i Norden 2008;3(28):19–23.
32. Kvale S. Det kvalitative
forskningsintervju. Oslo: Ad Notam Gyldendal. 1997.
33. Molven O. Sykepleie
og jus, 4. ed. Oslo: Gyldendal. 2012
34. Mesteig M, Hellebostad
J, Sletvold O, Rosstad T, Saltvedt I. Unwanted incidents during
transition of geriatric patients from hospital to home: a
prospective observational study. BMC Health Services Research
35. Lipsky M. Street-level
bureaucracy. Dilemmas of the individual in public service. New
York: Russel Sage Foundation. 1980.
Legemiddelhåndtering for virksomheter og helsepersonell som yter
helsehjelp. Oslo: Helsedirektoratet. 2008.
37. Flatgård I. Avvik
stoppes og avvises. «Det er bukken som passer
havresekken». Oslo, Sykepleien 2015;3:32–8.
38. Allen D. Re-reading
nursing and re-writing practice: towards an empirically based
reformulation of the nursing mandate. Nursing Inquiry
39. Aase K.
Pasientsikkerhet. Teori og praksis i helsevesenet. Oslo:
40. Fylkesmannen i Møre og
Romsdal, Nord-Trøndelag, Sør-Trøndelag. Fallprosjekt i Helseregion
Midt-Norge, Samlerapport etter Pilotstudien 2010, Journalstudien
2011, Kommunestudien 2012.
41. Orvik A. Organisatorisk
kompetanse. Innføring i profesjonskunnskap og klinisk ledelse.
Oslo: Cappelen Damm Akademisk. 2015.