The Effect Of Ilumination On Medication Preparation Errors In A Long Term 
Care Facility 
 
by 
 
Ranjani Varadarajan 
 
 
 
A disertation submited to the Graduate Faculty of 
Auburn University 
in partial fulfilment of the 
requirements for the Degree of 
 Doctor of Philosophy  
 
Auburn, Alabama 
August 6, 2011 
 
 
 
 
Keywords: medication preparation errors, ilumination, visual performance,  
nursing homes 
 
 
Copyright  2011 by Ranjani Varadarajan 
 
 
Approved by 
 
Kenneth N. Barker, Chair, Profesor Emeritus of Pharmacy Care Systems 
Elizabeth A. Flynn, Afiliate Asociate Research Profesor of Pharmacy Care Systems 
Salisa C. Westrick, Asociate Profesor of Pharmacy Care Systems 
Kristen L. Helms, Asociate Clinical Profesor of Pharmacy Practice 
Robert E. Thomas, Profesor Emeritus of Industrial & Systems Engineering 
Nathan T. Dorris, Afiliate Profesor of Industrial & Systems Engineering 
 ii 
            
 
 
 
 
Abstract 
 
 
The main objectives of this study were to (1) measure the efect of increased 
ilumination levels on the medication preparation error rate in a long term care facility, 
and (2) measure the efect of increased ilumination levels on the medication preparation 
error types in the same facility. 
           The data collection proces was divided into two phases: 
1. Initial site visit to explore and operationaly define the variables of interest and 
collect demographic information about the subjects in the study. 
2. Explanatory phase to study the efect of the intervention variable (increased 
ilumination level) on the dependant variable (medication preparation errors).   
The sampling unit was the preparation of an oral prescription medication dose by the 
nurse-subject in the particular section of the study site and observed by the principal 
investigator, before administration to the resident, during the study period. 
The data were collected by direct, undisguised observation method during the 
morning and evening medication pas shifts (8 am and 5 pm) at the study site, during a 
period of 45 days. The doses observed were randomly asigned for ilumination at one of 
three levels of ilumination (baseline, 100 and 145 foot-candles). Each nurse was 
observed for doses at al three ilumination levels, thus each subject served as their own 
control. The ilumination was controlled by a supplemental lighting apparatus (OttLite 
 iii 
508 Illumination
TM
 rechargeable fluorescent task lamp), which was afixed to the study 
medication cart. 
Seven nurse-subjects prepared a total of 6,758 doses during the observation 
period, of which 467 doses were in error (error rate 6.7%). The most frequently observed 
medication preparation error was Omision (N = 190, 40%), followed by Wrong time (N 
= 146, 31%), Wrong form (N = 72, 15%), Wrong Dose (23, 5%) and Unauthorized Dose 
(4, 1%). A repeated - measures Analysis of Variance (ANOVA) was performed on the 
observation data for the study period. 
Significant treatment (ilumination) efect (F
2,5 
=17.116, p < 0.05) was found on 
the medication preparation error rate, with Illumination level 3 (145 foot-candles; error 
rate 4.3%) significantly asociated with lower medication preparation error rate as 
compared to the baseline ilumination level (30 foot-candles; error rate 8.5%).   
Chi Square Analysis revealed Wrong dose form errors (X
2 
=12.954, df =2, p < 
0.05) and Omision errors (X
2 
=180825, df =2, p < 0.05) to have significant relationship 
with the ilumination level.  
Linear regresion analysis revealed no significant linear relationship betwen 
medication preparation workload of the nurse-subjects and their medication preparation 
error rate for al three ilumination levels (Level 1: F
1,26
 = 0.196, p > 0.05, Level 2: F
1,26
 = 
0, Level 2: p > 0.05, Level 3: F
1,26
 = 0.122, p > 0.05). There were no significant 
diferences in the proportion of medication preparation errors for each nurse-subject for 
al three ilumination levels. 
It was concluded that adjustment of lighting from baseline level to 145 foot-
candles achieved significant reduction in medication preparation errors. An important 
 iv 
implication of this study is that the elevation of ilumination standards at long- term care 
facilities could reduce the rate of errors in the preparation of doses for administration on 
the order of 50%. The study directed atention to the need for seting higher ilumination 
standards at long-term care facilities, in order to facilitate optimum visual performance 
by the healthcare staf. 
 
  v 
 
 
 
 
 
  Acknowledgements 
 
 
First and foremost, I wish to thank Dr. Kenneth N. Barker, for being my advisor and 
mentor and guiding and motivating me through the entire proces of my disertation 
research. 
I would like to extend my heartfelt gratitude and appreciation to Dr. Elizabeth 
Flynn, Dr. Salisa Westrick, and Kristen Helms who agreed to be in my research 
commite and provided me with valuable fedback and insight, during the entire 
research proces.  
My heartfelt thanks to Dr. Robert Thomas and Dr. Nathan Dorris, for helping me 
understand and appreciate the engineering concepts applied in my research study. 
I am grateful to the faculty, staf and graduate students of the Department of 
Pharmacy Care Systems for their help, encouragement and kind words. 
Special thanks to al my dear friends for standing by me through the dificult 
phases, and providing me with encouragement and a sense of ?a home away from home?. 
A special heartfelt note of thanks to my family in India, for their unwavering 
support and trust in me. I couldn?t have pursued my dreams to reach where I am today, 
without their love, prayers, trust and support.  
 vi 
 
 
  Table of Contents 
 
Abstract................................................................................................................................ii 
Acknowledgments ...............................................................................................................v 
List of Tables.........?????????...?????????????????.xv 
List of Figures..........?????????????????????????...xvii 
I.  Introduction..........?????????????.??????.??????? 1 
General problem area???????????????????????. 1 
Purpose of the Study???????????????????????.. 2 
Significance ????????????????????????..?? 2 
Summary of methods ??????????????????????? 3 
II.  Literature Review............................??????.????????..??..?. 4 
Overview ???????????????????????...???? 4 
Human vision?????????????????????????. ?4 
Human error ?????????????????????????.. ...12 
Visual fatigue ??????????????????????????13 
Lighting and productivity????????????????????..... 14 
Medication errors??????????????????????..?? 16 
Observation method???????????????????????.. 18 
Medication error problems in nursing homes?????????????... 20 
Problems faced by the nursing facility ???????????...????.. 20 
 vii 
The problem of insufficient lighting in nursing facilities?????...???.. 24 
Efect of ilumination on work performance??????????...???. 27 
Efect of ilumination on medication errors...........................................................30 
Rationale for study proposed ????????????????.?...??31 
III.  Statement Of The Problem................ ??????????????.??. ?..33 
Main Research questions ????????????????????.?.33 
Research hypotheses ????..????????????????.?..... 35 
Hypothesis Testing ???????????????????.????.. 38 
Concepts???????????????????????????.?40 
Medication Preparation Error Categories??????????????..?43 
Operational definitions ????????????????????.?.... 44 
IV.  Methodology.......... ???????????????????...????? 46 
Population ???????????????????????????.46 
Sample?????????????????????????.??.?..46 
Study Subjects ????????????????????..????? 47 
Independent Variable ?????????????????????.?.. 48 
Supplemental Lighting Apparatus????????????????.??49 
Research Design ?????????????????????????49 
Design Structure ???????????????????.?????.. 50 
Controls ???????????????????????????? 50 
Data Collection ...............???????????????????..??52 
Initial Visits for Orientation to Study Site ???????????????52 
Site Selection??????????????????????????.52 
 vii 
Background Information about the facility???????????????54 
Trip 1?????????????????????????????..53 
Trip 2?????????????????????????????..55 
Trip 3?????????????????????????????..56 
Trip 4?????????????????????????????..58 
Trip 5?????????????????????????????..58 
Visit to Pharmacy??????????????????????...??62 
Trip 6?????????????????????????????..67 
Trip 7 ????????????????????????????.?70 
Explanatory Study Phase????????????????????...?73 
IRB Approval??????????????????????????.73 
Informed Consent Leter??????????????????????73 
Demographic Information?????????????????????..74 
Visual Test???????????????????????????.74 
Group Embedded Figures Test???????????????????..75 
Observation Pilot Study??????????????????????.75 
Explanatory level Study?????????????????????.....76 
Statistical Analysis????????????????????????.78 
Significance Level????????????????????????.79 
V.   Results...... ????????????????????????????..80 
Study Subjects description?????????????????????.81 
Pilot Study: General description and results ??????????????.83 
Main Observation Study????????...???????????.........89 
 ix 
Medication Preparation Errors for the Study Sample????????..?..?91 
Medication Preparation Errors, by study sections??????????..?...94 
Section X??????????????????????????..?.95 
Section Y??????????????????????????.?..98 
Section Z??????????????????????????........99 
Medication Preparation Errors, by nurse subjects???????????...101 
Statistical Hypothesis and Analysis????????????????....106 
Analysis of Medication Preparation Error Rate ???????????.....106 
Analysis of Medication Preparation Error Rate (w/o wrong time errors) ?......110 
Analysis of Medication Preparation Error Types??????????....?113 
Analysis of Medication Preparation Workload????????????...119 
Analysis of Observer Efect???????????????????.....122 
Analysis of Medication Preparation Errors by Sections???..???....??126 
Analysis of Medication Preparation Errors by Shifts?????...??...??128 
Observation of Medication related incidents???????????..??.130 
VI.  Conclusion, Discussion, Limitations and Implications..................................??..132 
Main Conclusions???????????????????.????...132 
Discussion??????????????????????????...137 
Exploratory finding regarding demographic variables????????..?..137 
Age????????????????....??????........??...137 
Employment Status???????????....??.???....?.??.138 
Educational Level?????????????.....??.?????...138 
Gender???????????????????....????..??139 
 x 
GEFT Scores????????????????.?....????.?..139 
Visual Test Scores??????????????..??....????..140 
Medication Preparation Workload???????????....??.......141 
Explanatory Study Findings????????????????????.142 
            Efect Of Illumination On Medication Preparation Error Rate....................142 
            Efect Of Illumination On Medication Preparation Error Types.................144 
            Efect Of The Observer On The Observed..................................................146 
            Significance Of Nursing Sections................................................................147 
            Significance of Medication Shifts................................................................147 
Limitations???????????????????...???????148 
Recommendations????????????????...???????.151 
Implications for Future Research??????????????...???..153 
References........?????????????????????........??...??155 
Appendices.......................................................................................................................165 
Appendix A: Memorandum of the project ????????????......???....166 
Appendix B: IRB Approval Forms..................................................................................168 
Appendix C: Medication schedule???????????????.......??..?..171 
Appendix D: Additional pictures from the nursing facility ???????..?.??.173 
Appendix E: Copy of the Incident report form???????????.....???.. 180 
Appendix F: Data Collection Forms................................................................................182 
Appendix G: Informed Consent Leter............................................................................186 
Appendix H: Renewal IRB Approval Forms...................................................................189 
Appendix I: Medication Preparation Error Description...................................................192 
 xi 
 
 
 
List Of Tables 
 
Table 1.      Factors afecting visual inspection acuracy ????????????.15 
Table 2.      Minimum average iluminance for diferent task areas???????..?27  
Table 3.      Demographic Information of the Study Subjects...........................................82 
 
Table 4.      Pilot Study.......................................................................................................84 
 
   Table 5.      Frequency of error types during pilot study....................................................85 
   Table 6.      Description of Each Error during the Pilot Study...........................................87 
Table 7.      Reasons for excluded doses............................................................................89 
 
Table 8.      Total observed doses for each nurse-subject for each  
                    Illumination level...........................................................................................90    
Table 9.      Medication Preparation Errors for the Study Site for three 
                      Illumination levels..........................................................................................92 
   Table 10.     Total Medication Preparation Errors, by Error Types...................................93 
   Table 11.     Medication Preparation Errors for Section X................................................94 
   Table 12.     Medication Preparation Errors for Section X, by Error Types......................95 
   Table 13.     Medication Preparation Errors for Section Y................................................96 
   Table 14.     Medication Preparation Errors for Section Y, by Error Types......................97 
   Table 15.     Medication Preparation Errors for Section Z.................................................99 
Table 16.     Medication Preparation Errors for Section Z, by Error Types....................100 
   Table 17.     Medication Preparation Errors by Nurse-subjects ......................................102 
 xii 
Table 18.    Medication Preparation Errors, by types for each nurse-subject..................104 
Table 19.    Descriptive Statistics ....................................................................................106 
Table 20.    Repeated Measures Univariate ANOVA .....................................................107 
Table 21.    Tests for Linear and Quadratic trends ..........................................................107 
Table 22.    Pairwise Comparisons of the Medication Preparation Error rate ................108 
Table 23.    Descriptive Statistics (excluding wrong time errors)...................................111 
Table 24.    Repeated Measures Univariate ANOVA .....................................................111 
Table 25.    Pairwise Comparisons (excluding wrong time errors).................................112 
Table 26.    Chi Square Analysis for Wrong Dose Preparation Errors............................114 
Table 27.    Wrong Dose Preparation error rate...............................................................114 
Table 28.    Chi Square Analysis for Wrong Form Preparation Errors............................115 
Table 29.    Wrong Form Preparation error rate..............................................................115 
Table 30.    Chi Square Analysis for Wrong Time Preparation Errors............................116 
Table 31.    Wrong Time Preparation error rate...............................................................116 
Table 32.    Chi Square Analysis for Omision Errors.....................................................117 
Table 33.    Omision error rate.......................................................................................117 
Table 34.    Chi Square Analysis for Unauthorized Dose Preparation Errors.................118 
Table 35.    Unauthorized Dose Preparation error rate....................................................118 
Table 36.    Analysis of Variance for Linear Regresion for Illumination level 1 ..........120 
Table 37.    Analysis of Variance for Linear Regresion for Illumination level 2...........120 
Table 38.    Analysis of Variance for Linear Regresion for Illumination level 3...........121 
Table 39.    Chi-Square Analysis for each nurse-subject by ilumination levels.............123 
Table 40.     Medication Preparation Errors by Sections.................................................127 
 xii 
   Table 41.     Medication Preparation Errors by medication shifts...................................129 
   Table 42.     Analysis of Variance with respect to med-pas shifts ................................129 
Table 43.     Observation of Medication-Related Incidents.............................................130 
Table 44.     Nurse-subjects? comments re. the ilumination and the observer................131 
Table 45.     Results and Conclusions of Hypothesis testing ..........................................132 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 xiv 
 
 
List Of Figures 
 
Figure 1.   Diagramatic horizontal section through the right eye ????????....5  
Figure 2.    Diagram of the visual system ?????????????????...?6  
Figure 3.    Relationship betwen candelas, foot-candles and lux  ????????? 7 
Figure 4.    Decrease of visual acuity with age  ????????????????10 
Figure 5.    Efect of light intensity on visual acuity ??????????????.12    
Figure 6.    Decrease in visual transmitance with age ?????????????..22 
Figure 7.     Visual performance and lighting levels for moderately dificult 
 and dificult tasks?????????????????????....... 23 
Figure 8.    Layout of the nursing study site ????????????????? 57 
   Figure 9.    Exit door ........................................................................................................58 
  Figure 10.   Section X Medication cart upper surface ......................................................59 
Figure 11.    Section Y light measurements.......................................................................60 
  Figure 12.    Dining /Activity room....................................................................................60 
  Figure 13.    Section Y Medication cart upper surface.......................................................61 
  Figure 14.    Window bars at the pharmacy site.................................................................63 
  Figure 15.    Light fixtures used in the pharmacy...............................................................63 
  Figure 16.    Blister packaging material for the medications..............................................64 
  Figure 17.    Medications stacked in the cabinet.................................................................64 
  Figure 18.    Hospice pharmacy cabinet..............................................................................65 
Figure 19.    Hospice pharmacy window.............................................................................65 
 xv 
 Figure 20.    Computer station 1........................................................................................66 
   Figure 21.    Workstation overlooking an open window ...................................................66 
Figure 22.    Workstation overlooking a window with blinds...........................................67 
   Figure 23.    Section X: Medication cart light measurement.............................................68 
   Figure 24.    Section Y Medication cart ............................................................................69 
   Figure 25.    Study site workflow diagram ........................................................................71 
 Figure 26.    Blister packaging at the pharmacy................................................................72 
   Figure 27.    Controlled substance form and label.............................................................72 
Figure 28.    Baseline measurement...................................................................................76 
Figure 29.    Experimental (Intervention) measurement....................................................77 
Figure 30.    Sample of Visual Stimuli...............................................................................77 
Figure 31.    Observation instruments used during the study.............................................78 
   Figure 32.    Medication Preparation Errors for three ilumination levels.........................84 
   Figure 33.    Frequency of error types for three ilumination levels..................................86 
   Figure 34.    Doses prepared by each Nurse-subject (LPN) ..............................................91 
   Figure 35.    Error rate for the study site for three ilumination levels..............................92 
   Figure 36.    Frequency of Medication Preparation Error Types.......................................94 
   Figure 37.    Medication Preparation Error rate for Section X..........................................95 
   Figure 38.    Medication Preparation Errors, by Error Types for Section X......................96 
   Figure 39.    Medication Preparation Error rate for Section Y..........................................97 
Figure 40.    Medication Preparation Errors, by Error Types for Section Y......................98 
Figure 41.    Medication Preparation Error rate for Section Z...........................................99 
Figure 42.    Medication Preparation Errors, by Error Types for Section Z....................100 
 xvi 
Figure 43.    Medication Preparation Error rate for each nurse-subject..............................101 
Figure 44.    Medication Preparation Error types, by nurse-subjects..................................105 
Figure 45.    Box Plot of Medication Preparation Error rates ............................................108 
Figure 46.    Trend-line of Medication Preparation Errors for Illumination Level 1 .........124 
Figure 47.    Trend-line of Medication Preparation Errors for Illumination Level 2 .........124 
Figure 48.    Trend-line of Medication Preparation Errors for Ilumination Level 3 .........125 
 
 
 
 
 
 
 
 
 
 
 
1 
 
 
 
I. Introduction 
 
 
  General Problem Area 
Patient safety is an important concern of current healthcare delivery systems. 
Medication errors are often used as an indicator of quality and patient safety in the 
healthcare environment. The Institute of Medicine published the Quality Chasm series 
(2007) wherein they estimated about 800,000 preventable medication errors to occur 
every year in long term care facilities, harming at least 1.5 milion people. One of the 
factors reported as contributing to the errors in the healthcare delivery system, is lack of 
proper lighting conditions (Santel, 2003; (MEDMARX Data Report, 2008) 
In the long-term care setings, the tasks performed during the medication delivery 
proces (transcription, verification, drug dispensing, preparation and administration) are 
highly visual in nature. The problem of performing these tasks gets compounded with 
factors such as ilegible prescriptions, look-alike/sound-alike drug names, high workload 
and visual fatigue. When such high visual demands must be met in unfavorable 
environmental conditions, the probability of making an error is higher. That the quantity 
and quality of light are of paramount importance for the medication distribution tasks that 
have a high visual component should not be surprising. 
Poor lighting environment can contribute to visual discomfort and eye strain 
(Boyce, 1981). Visual performance is the only performance outcome that changing the 
lighting conditions can afect directly (Alvarado, 2007). While proper lighting cannot 
 
 
2 
produce work itself, it can make details easier to discriminate and colors easier to judge, 
without producing discomfort or distraction (Sanders & McCormick, 1993) 
Although research in long term care setings for studying the efects of lighting 
conditions on medication errors has been minimal (non-existent), there has been evidence 
in other healthcare and human factors fields which has established that improved lighting 
conditions (such as increased ilumination and reduced glare) help in improving the 
visual performance of the subjects, and thus help in decreasing errors. 
 
Purpose Of The Study 
The purpose of this study was to investigate the efect of increased ilumination 
level on the medication preparation error rate in a nursing facility. 
 
Significance 
A survey of 53 nursing homes in four states found that the nursing home facilities were 
often dimly lit. The ilumination was rated as inadequate or barely adequate in 45 percent 
of halways, 17 percent of activity areas and 51 percent of the resident rooms (Sloane, 
Mitchel, Calkins, & Zimerman, 2000). There are no federal standards or regulations 
requiring the quality and quantity of light to met the visual needs of the older people in 
nursing homes. There is great variability among the nursing facilities in diferent states, 
regarding lighting regulations.  Lack of lighting standards and specific minimum target 
iluminance values coupled with the aging nursing population catering to the nursing 
home residents likely aggravate the problem of medication errors in these facilities. 
 
 
3 
The consequences that medication errors can have in terms of mortality, 
morbidity and financial loss to both the patients and the nursing facility is wel 
documented in literature (Bootman et.al, 1997). If environmental factors such as 
ilumination can be shown to be related to the error rate, then greater emphasis can be 
placed upon the factors by governmental and profesional grouups in the form of high 
standards in lighting regulations requiring adherence by architects and facility designers. 
The significance of this study in particular is that the adjustment of lighting can be a 
relatively low cost measure requiring litle or no change in nursing procedures. 
 
 
 Summary of Methods 
This was an explanatory level research study, where the data were collected by 
direct observation. The principal investigator was trained in the scientific observation 
techniques (Barker, 1980) and observed the nurse-subjects, in the study nursing home 
site. 
Data collection occupied 2 phases: 
1) Exploratory phase ? where the variables of interest were explored and 
operationaly defined. 
2) Explanatory phase ? where the efect of the intervention variable (increased 
ilumination level) was studied on the dependant variable (medication preparation error 
rate). 
 
 4 
 
 
 
   II. Literature Review 
 
 
Overview 
 This review spans the literature from the general topic of human vision to the 
specific topic of studying the efect of ilumination levels on work performance; in this 
case medication errors in the long term care seting. 
The purpose of this literature review is: 
1. To explain the need to conduct this study, 
2. To explain the significance of this study with respect to the existing theory, 
3. To explain the rationale for the study proposed. 
 
 
Human Vision 
The human eye, a very important receptor organ, senses the energy from the 
outside world in the form of light waves and converts these into a form of energy into 
nerve impulses.  
 
 
 
 
 
 5 
 
Figure 1: Diagrammatic horizontal section through the right eye (K. Kroemer & E. 
Grandjean, 1997) 
 
The complete visual system controls about 90 percent of al our everyday activities (K. 
Kroemer & E. Grandjean, 1997) 
 
 
 
 
 
 
 
 
 
 
 6 
 
Figure 2:  Diagram of the visual system (K. Kroemer & E. Grandjean, 1997) 
1 = cornea and lens; 2 = light received on the retina; 3= transmision of optical 
information along the optic nerve to the brain; 4 = synapses and fedback to the eye; 5 = 
visual perception of the external world in the conscious sphere of the brain. 
 
The human eye contains about 130 milion rods and 7 milion cones. Cones detect 
fine diferences in either color or shape but need high ilumination for this. Rods are more 
sensitive even in dim light, but conceive only shades of grey betwen black and white. 
They are the most important light-detecting organs in poor visibility and at night (K. 
Kroemer & E. Grandjean, 1997) 
Illumination is also caled as iluminance, and is the amount of light faling on to a 
surface (K. H. E. Kroemer & E. Grandjean, 1997; Niebel & Freivalds, 2003; Sanders & 
McCormick, 1993)  It is measure in terms of luminous flux per unit area. The units of 
measurement are: 
Lux (an SI unit) = 1 lumen per square meter, the lumen being the unit of luminous flux 
 7 
Foot-candle (USCS unit) = 1 lumen per square foot 
One foot-candle equals 10.76 lux, usualy rounded off to 10 lux for practical 
purposes.(Sanders & McCormick, 1993) 
 
 
Figure 3: Relationship betwen candelas, foot-candles and lux (Sanders & 
McCormick, 1993) 
 
The amount of ilumination striking a surface drops off as the square of the distance 
("White paper on Quality Pharmaceutical Care in Long Term Care,") in fet from the 
source of the surface (Niebel & Freivalds, 2003) :  Illuminance = luminous intensity / d
2
 
 8 
Luminance - It is the amount of light reflected or emited from a surface (K. H. E. 
Kroemer & E. Grandjean, 1997). Its unit of measurement is: Candela per m
2 
(SI unit) or 
mililambert and footlambert (USCS unit). One mililambert is the amount of light 
emited from a surface at the rate of 0.001 lm/cm
2
. A footlambert is the amount of 
brightnes of an idealy reflecting surface iluminated by one foot-candle (K. H. E. 
Kroemer & E. Grandjean, 1997).  It is determined by the reflective properties of the 
surface, luminance = iluminance x reflectance (Niebel & Freivalds, 2003). 
Reflectance is measured and compared by the ratio betwen reflected and incident 
amounts of light. It is expresed as the percentage of reflected to incident light (K. H. E. 
Kroemer & E. Grandjean, 1997). 
Acommodation means the ability of the eye to bring into ?sharp focus? objects at 
varying distances from infinity down to the nearest point of vision, caled the ?near point? 
(K. Kroemer & E. Grandjean, 1997).  The level of ilumination is a critical factor in 
acommodation. The beter the luminance contrast of visual targets against the 
background, the faster, easier and more precise the acommodation (K. Kroemer & E. 
Grandjean, 1997).  It has been shown that speed and precision of acommodation 
decrease with age, there is a marked decrease from about the age of 40 (K. Kroemer & E. 
Grandjean, 1997). 
Glare is a gross overloading of the adaptation proceses of the eye, brought about 
by overexposure of the retina to light (K. Kroemer & E. Grandjean, 1997). 
 
 
 
 9 
There are 3 types of glare: 
1) Reflective glare, caused by excesive brightnes contrast betwen diferent parts 
of the visual field. 
2) Absolute glare, when a source of light is so bright that the eye cannot possibly 
adapt to it (e.g. the sun) 
3) Adaptive glare, a temporary efect during the period of light adaptation (e.g. 
coming out of a dark room into bright daylight). This phenomenon is also caled 
?transient adaptation?. 
The most important visual capacities are: 
Visual acuity - It is the ability to detect smal details and to discriminate smal objects 
(K. Kroemer & E. Grandjean, 1997). Measurement of visual acuity commonly uses 
standardized black stimuli (e.g. Landolt rings or Snelen leters) on a white background. 
The influences on visual acuity are: (K. Kroemer & E. Grandjean, 1997) 
1) Visual acuity increases with the level of ilumination, reaching a maximum at 
ilumination levels about 100 foot-candles (1000 lux). 
2) It increases with the contrast betwen the test symbol and its imediate 
background, and with the sharpnes of signs or characters. 
3) It is greater for dark symbols on a light background than for the reverse. 
4) It decreases with age. 
 
 
 
 
 10 
 
 
Figure 4: Decrease of visual acuity with age (K. Kroemer & E. Grandjean, 1997) 
 
Contrast sensitivity  - It is the ability of the eye to perceive a smal diference in 
luminance.(K. Kroemer & E. Grandjean, 1997)  It plays a very important role in jobs 
which involve visual inspection and product control. To measure contrast sensitivity, a 
procedure is used in which the luminance of a standardized target is compared with its 
surroundings.  
The influences on contrast sensitivity are: (K. Kroemer & E. Grandjean, 1997) 
1) It is greater in large areas than for smal areas. 
2) It is greater when boundaries are sharp and decreases when the change is gradual 
or indefinite. 
 11 
3) It increases with the surrounding luminance and is greatest within the range of 70 
cd/m
2
 and 1000 cd/m
2
 
4) Within this luminance range, the background must be at least 2 per cent lighter or 
darker than the target. 
5) It is greater when the outer parts of the visual field are darker than the center and 
weaker in the reverse contrast. 
 
Luckiesh and Moss (1937) conducted a series of experiments and concluded that 
raising the ilumination level from approximately 10 lux to 1000 lux (around 100 foot-
candles) increases the visual acuity from 100 to 170 percent and contrast sensitivity up to 
450 percent.(Luckiesh & Moss, 1937) They also recorded a decrease in muscular tension 
and rate of blinking the eyelids, which was interpreted as a reduction in nervous tension 
as a result of beter lighting. 
 
 
 
 
 
 
 
 
 
 
 12 
 
Figure 5: Effect of light intensity on visual acuity(Luckiesh & Moss, 1937) 
 
Human Error 
Reason defined human error as the failure of a planned sequence of mental or physical 
activities to achieve its intended outcome, when these failures cannot be atributed to 
chance (Reason, 2003). 
Leape defined it as an unintended act (either of omision or commision) or one 
that does not achieve its intended outcome (Leape, 1994).    
 13 
Errors have been clasified as skil, rule and knowledge based models (Reason, 
2003). Skil-based errors are errors of action. Reason (2003) defined them as unintended 
acts, which occur when there is a break in the routine while the atention is diverted. 
Rule-based errors usualy occur during problem solving when a wrong decision is 
chosen- either because of a misperception of the situation and, thus, the application of a 
wrong rule or a misapplication of a right rule. Knowledge-based errors arise because of 
lack of knowledge or misinterpretation of the problem (Leape, 1994). Errors that occur 
during the prescribing, dispensing and administering stages are termed as Medication 
Errors (Bates, Boyle, Vliet, Schneider & Leape, 1995).   
 
 
Visual Fatigue 
Visual fatigue comprises al those symptoms that arise after excesive stres on 
any of the functions of the eye. One of the manifestations include reduced visual acuity, 
sensitivity to contrast and speed of perception (K. Kroemer & E. Grandjean, 1997). These 
symptoms are brought about in particular by strenuous fine work, poorly printed texts, 
inadequate lighting, and exposure to flickering light. Elderly people are more prone to 
visual fatigue (K. Kroemer & E. Grandjean, 1997). 
The efects of visual fatigue on a person?s occupation may include loss of 
productivity, lowering of quality, more mistakes and increased acident rate (K. Kroemer 
& E. Grandjean, 1997). 
 14 
Grandjean (1988) referred to a report wherein experts concluded that bad lighting 
was the cause of 5 % of al industrial acidents and together with optical fatigue, it 
contributed to as much as 20 % (Grandjean, 1988). 
They concluded that work that requires high visual acuity and contrast sensitivity 
needs high levels of ilumination. Fine and delicate work need to be iluminated at 1000 
(100 foot-candles) to 10,000 lux (1000 foot-candles) (Grandjean, 1988). 
 
 
Lighting and Productivity  
There are many studies that report increased productivity after the lighting was 
improved. These increases are partly a direct efect (through more rapid visual work 
asesment) and partly indirect (reduction in visual fatigue) (K. Kroemer & E. Grandjean, 
1997). 
McCormick and Sanders (1987) provided a table summarizing the results of 15 
industrial studies, al of which showed increases in output, ranging from 4 to 35 %, after 
increasing the ilumination level. But there were some reservations because of the 
existence of other uncontrollable factors that were present in such situations (Sanders & 
McCormick, 1993). 
 
 
 
 
 
 15 
Table 1: Factors afecting visual inspection acuracy: diferent studies (Megaw, 1979) 
 
 
 
 
 
 
 
 
 16 
Medication Errors 
Medication error was defined in 1962, as the ??administration of the wrong 
medication or dose of medication, drug, diagnostic agent, chemical, or treatment 
requiring the use of such agents, to the wrong patient or at the wrong time, or the failure 
to administer such agents at the specified time or in the manner prescribed or normaly 
considered as acepted practice??. (Kenneth N. Barker & McConnel, 1962). 
In hospitals, medication errors have been found to occur at the rate of about one 
per patient per day (Alan & Barker, 1990).  This error rate includes the errors occurring 
in the dispensing and administration stages. 
The American Society of Health-System Pharmacy (1998) defined medication 
errors as any preventable event that may lead to inappropriate medication use or patient 
harm while the medication is in control of healthcare profesional, patient or consumer.  
 Such events maybe related to profesional practice, healthcare products, procedures and 
systems, including prescribing, order communication, product labeling, packaging and 
nomenclature, compounding, dispensing, distribution, administration, education, 
monitoring and use?.  
The term ?opportunity for error? has been used as the basic unit of data for 
calculating the medication error rate. An opportunity for error includes any dose given 
plus any dose ordered but omited. The ?total opportunities for error? is the sum of al the 
doses ordered plus al the unordered doses given. The medication error rate is calculated 
as the number of doses in errors (incorrect in one or more ways) divided by the total 
opportunities for error (Kenneth N. Barker, Kimbrough, & Heler, 1966). 
 
 17 
 
Medication error rate =    Total number of actual errors 
                                         Total opportunities for error 
 
A medication error may or may not be labeled as an ?Adverse event?, depending 
upon whether the error caused the patient harm or discomfort. An Adverse drug event is 
defined as an injury resulting from medical interventions related to a drug.  Adverse 
event reports are the ?tip of the iceberg? of the problem of errors (sen as system failures), 
since most errors do not result in reported injuries (Bates et al, 1995). 
Medication errors have been categorized somewhat diferently depending upon the 
healthcare setings, inpatient or outpatient.  
 
Cohen (1999) defined the diferent types of medication errors as: 
Prescribing/Ordering errors - Mistakes made by the physician (prescriber) when ordering 
a medication.   
Transcription errors ? Deviations from the prescriber?s orders, made by the nursing staf 
or the pharmacist, when transcribing medication orders. 
Dispensing errors - Deviation from the prescriber?s order, made by pharmacy staf, when 
distributing medications to nursing units or to patient?s in an ambulatory seting. 
Administration errors ? The American society of hospital pharmacists & National League 
for Nursing liaison commite (1998) defined them as ?the administration of the wrong 
medication or dose of medication, drug, diagnostic agent, chemical, or treatment 
requiring the use of such agents, to the wrong patient or at the wrong time, or the failure 
 18 
to administer such agents at the specified time or in the manner prescribed or normaly 
considered as aceptable practice.? 
 Near Errors ? The Joint Commision on Acreditation and Healthcare Organizations 
(2001) defined near error as ?any proces variation which did not afect the outcome, but 
for which a recurrence carries a significant chance of a serious adverse outcome.?                                
The Agency of Healthcare Research and Quality (2011) defined near errors as 
?events in which the unwanted consequences were prevented because there was a 
recovery and correction of the failure.? 
Such errors show that the quality asurance system in the pharmacy is working, 
but they also maybe taken to reflect a weaknes exists in the dispensing system.  
Davis stated that near errors should be constantly analyzed in an efort to develop 
methods to systematicaly reduce their occurrence (N. M. Davis, 1990). 
 
Observation method 
The disguised observation study was developed by Barker and McConnel 
(Barker K. N & McConnel, 1962) for the detection of medication errors. The observation 
is disguised in the sense that the subject is unaware of the goal of the study.  
Some of the advantages of observation method are (Flynn, Barker, & Carnahan, 2003): 
? Knowledge of error by the person involved is not required. 
? Wilingnes to report the error is not a factor. 
? Remembering to report or ability to communicate errors is not required 
? Selective perception of the nurse or pharmacist is not involved. 
 19 
? Unsolicited comments collected through the observation proces can help identify or 
asociations betwen errors and possible causes (K. N Barker, 1980). 
 
The uses of observation data as suggested by Flynn et al (2002) are as follows: 
? Indicate and signal major system breakdowns 
? Evaluate expensive interventions 
? Internaly and externaly benchmark for quality improvement 
? Focus resource deployment for error correction and prevention 
? Provide a source of examples for problem solving, continuing education programs 
? Focus on root cause analysis. 
 
Observation tends to be tiresome, if conducted over a long period of time. Special 
training is required for the data collectors, and some personality types may be unsuited 
for the role of observer (Flynn, Barker, Pepper, Bates, & Mikeal, 2002). Direct 
observation might be more expensive per examined dose due to the normal delays 
involved in medication administration sesions. The efect of the observer on the 
observed is also a concern.  
Researchers have conducted various studies to detect any significant efect of the 
observer on the observed. The possible efect was studied by monitoring individual error 
rates for 5 consecutive days. The consistency of each subject?s medication error rate was 
interpreted to indicate that the observer did not afect the rate.(Kenneth N. Barker, et al., 
1966). It has been long known that when observation is unobtrusive and non judgmental, 
 20 
the subject(s) adapts quickly to an observer?s presence and act as they would usualy act 
(F.N Kerlinger & Le, 1999).  
Dean and Barber studied the efect of observer intervention on nurses. They found 
that tactful intervention by the observer does not have significant efect on the observed, 
and that an observation period of les than seven days by one observer had high observer 
reliability. They concluded that concerns about the validity and reliability of observational 
methods for identifying medication administration errors may be unfounded (Dean & 
Barber, 2001). 
 
 
Medication eror problem in nursing homes 
One of the earliest studies linking eyesight and medication errors in nursing 
students was conducted by Byrne (Byrne, 1953). Although the study did not specify 
environmental factors as causes of errors, it listed ?failure to acurately read the medicine 
card as one of the causes?. 
The observation study of medication administration errors in a 300-500 bed, non-
governmental, health care facility by Barker et. al (Kenneth N. Barker, et al., 1966) found 
that some of the nurses involved in the medication administration errors had poor 
eyesight; and the lighting in the area where they prepared medications was poor. The 
authors suggested the need to improve the lighting conditions in the facility. 
A prospective cohort medication error study (Barker, Flynn et. al, 2002) of a 
stratified random sample of 36 healthcare institutions was conducted in Colorado and 
Georgia. Of the 36 institutions, 12 of them were skiled nursing facilities (6 facilities each 
 21 
in Georgia and Colorado). The researchers found a medication error rate of 10.8% 
(Georgia) and 14.2 % (Colorado) at the skiled nursing facilities. 
A prospective observational study (Barber et. al, 2009) of residents at 55 UK 
nursing care homes found that 69.5% of the residents living there had encountered one or 
more errors; with each resident experiencing a mean of 1.9 medication errors. Main 
contributing factors for the errors were found to be staf?s high workload, interruptions 
during the drug rounds, insufficient nurse?s knowledge and inadequate information about 
the residents in the facility. 
 
Problems faced by the nursing facility 
The nursing population in the long term care facilities is aging (Joint Commision 
on Acreditation of Healthcare Organizations, August 2002). The average age of a 
working registered nurse today is 43.3 years, and that average age is increasing at a rate 
more than twice that of al other workforces in this country. Only 12 percent of registered 
nurses in the workforce are under the age of 30 years. By 2010, it is projected that the 
average age of the working registered nurse wil be 50.8 years.(Buerhaus, Staiger, & 
Auerbach, 2000; Joint Commision on Acreditation of Healthcare Organizations, 
August 2002) The performance of the human eye declines with age, with the efects 
beginning to be noticeable at 40 years of age. This leads to changes in the spectral light 
sensitivity that by 80 years of age causes loss of vision.(The IESNA Lighting for the 
Aged and Partialy Sighted Commite, 2007) Research has established that aging eyes 
require more light as compared to younger eyes, for optimal visual performance.(M. O. 
Blackwel & Blackwel, 1980; Boyce, 1973; Crouch, 1965; Cullinan, 1986; R. G. Davis 
 22 
& Garza, Winter 2002; Smith & Rea, 1978; The IESNA Commite for Healthcare 
Facilities, 2006; The IESNA Lighting for the Aged and Partialy Sighted Commite, 
2007).  
Thus special atention must be given to the good visual performance, (and hence 
improved lighting conditions) for the aging care provider.(Alvarado, 2007) 
The following figures show that older eyes require increased lighting levels for 
beter visual performance.  
 
 
Figure 6: Figure depicting a decrease in the transmittance of the human eye, with 
age.(The IESNA Lighting for the Aged and Partially Sighted Committee, 2007) 
 
 
 23 
     
 
Figure 7: Figures showing the relative visual performance (%) and lighting levels 
(lux) for moderately difficult and difficult tasks.(Bommel & Beld, 2004) 
Continuous line: young people, broken line: older people; EN ? European Norm 
 
 24 
The problem of insufficient lighting in nursing facilities 
The problem of insufficient lighting in nursing homes was highlighted when a 
group of researchers (Lepeleire, Bouwen, Conninck, & Buntinx, 2007) measured lighting 
levels in diferent areas of a nursing home and found the lighting levels to be insufficient 
as per the lighting standards (The IESNA Lighting for the Aged and Partialy Sighted 
Commite, 2007) for the nursing home residents. Although, this study was not 
conducted in a United States healthcare facility, it begs the question of whether this 
problem exists in American healthcare facilities. 
Visual display terminals in the healthcare seting (such as computers, automated 
dispensing machine- monitors) need diferent lighting conditions. It is a wel-known fact 
that too much lighting can cause reflected glare on the computer monitor (Henderson, 
Spring 1995; Sanders & McCormick, 1993; The IESNA Commite for Healthcare 
Facilities, 2006; The IESNA Lighting for the Aged and Partialy Sighted Commite, 
2007). 
In addition to recommending minimum iluminance levels, the IESNA commite 
also highlighted other lighting isues in the healthcare areas, like reducing reflected glare 
on the computer monitor in the automated delivery system, facility design changes to 
improve beter light distribution, use of beter quality luminaries (light instalations) etc 
(The IESNA Commite for Healthcare Facilities, 2006; The IESNA Lighting for the 
Aged and Partialy Sighted Commite, 2007). 
The Centers for Medicare and Medicaid (CMS) has included adequate lighting 
requirements in their surveyor guidelines for inspections in long term care facilities (The 
Centers for Medicare & Medicaid Services, December 2006 edition). Although this 
 25 
guideline is meant to be for resident comfort, it does highlight the fact that lighting 
conditions can be an indicator of good quality of care provided in the long term care 
facilities. 
One of the suggestions provided by Dr. Carolyn Clancy, the director for the 
Agency of Healthcare Research and Quality (AHRQ), to improve quality of care is to 
improve the lighting conditions in the American healthcare setings (Clancy, 2008). 
Special considerations should be given to the lighting conditions for health care staf that 
work during the night shifts. Lighting conditions have shown to have an efect on a 
person?s circadian rhythm (biological clock) and the level of alertnes, during work 
(Juslen, January 2005) A research study investigated the efects of light on alertnes and 
mood, under night shift conditions. The results concluded that although there is a decline 
in arousal over the night, the group with the increased ilumination level showed 
significantly increased arousal level, and thus beter alertnes and mood (Boulos Z, 
Campbel SS, Lewy JJ, & et.al., 1995). 
The Illuminating Engineering Society (IESNA) provides recommendations and 
guidelines for lighting conditions in healthcare facilities (The IESNA Commite for 
Healthcare Facilities, 2006; The IESNA Lighting for the Aged and Partialy Sighted 
Commite, 2007). IESNA formulates lighting standards using iluminance categories 
and weighting factors based upon the subjects? age, speed and acuracy required to 
complete the task, and reflectance of the task background (The IESNA Commite for 
Healthcare Facilities, 2006). 
The commite identified the areas requiring diferent iluminance categories, 
based on the complexity and demands on the healthcare visual performance. The 
 26 
following table suggests minimum average iluminance for environments in a general 
hospital (Alvarado, 2007; Sanders & McCormick, 1993; The IESNA Lighting for the 
Aged and Partialy Sighted Commite, 2007). 
 
Table 2: Minimum average iluminance recommended for diferent task areas (The 
IESNA Lighting for the Aged and Partialy Sighted Commite, 2007) 
Environment Ambient light 
Lux/Footcandles 
Task Lighting 
Lux/Footcandles 
Patient rooms 300/30 750/75 
Nursing station (day) 300/30 500/50 
Nursing station (night) 100/10 500/50 
Medication 
preparation 
300/30                1000/100 
 
 
 
 
 
 
 27 
Effect of ilumination on work performance 
The quantity and quality of light are of paramount importance for highly visual 
task components. Literature provides evidence demonstrating a positive relationship 
betwen ilumination and task performance. In fact, its been suggested that ilumination 
increases of up to 50 foot-candles results in the most dramatic increase in visual 
performance (Boyce, 1981). 
Speed and acuracy are the two objective measures of visual performance of a 
task. There are a number of features of the visual system that are likely to afect the 
relationship betwen ilumination and human performance:(Terry Le Buchanan, 1989) 
? Nature of the visual task; simple detection, recognition or color discrimination 
? Task characteristics; size, contrast and color details 
? Event predictability 
? Time for which the information wil be available 
? Whether the stimuli is moving or stationary 
? State of adaptation of the visual system 
 
Lyons estimates that at least 80% of the sensory data required by an average 
worker in the performance of his task is obtained through visual modality (Lyons, 1981). 
Two pioneers in the lighting field, H.C. Weston and H.R. Blackwel, developed 
visual performance models to beter describe the relationship betwen lighting and its 
efects on work performance. Weston?s model (Weston HC, 1945, 1949) concluded that 
performance increased with an increase in ilumination, but not linearly. Also significant, 
larger improvements in visual performance can be achieved by increasing the contrast 
 28 
and print size than by increasing the iluminance alone. Finaly, one cannot reach the 
same level of performance for a visualy dificult task (smal print size and contrast) as 
compared to a visualy easy task, by simply increasing the ilumination level. 
Blackwel?s research on visibility threshold culminated in a model which 
characterized both threshold and suprathreshold visual performance.(H. R. Blackwel, 
1961, 1964; R. H. Blackwel & Blackwel, 1968) He developed the Blackwel Visual 
Task Evaluator, which is a contrast-reducing meter. He used this meter to determine the 
visual task?s equivalent contrast. The visual task evaluator can be used to determine the 
ilumination levels required for a specific task. This system has been used for establishing 
recommendations of ilumination levels by the CIE (International Commision on 
Illumination) and the IESNA (Illuminating Engineering Society of North America). 
Faulkner (Faulkner & Murphy, 1973) suggested 2 basic approaches to improve 
task visibility: 
1) Change the task; 
2) Change the ilumination faling upon the task. The most obvious way of varying 
the ilumination level is by changing the intensity. 
 
 In 1978 Smith and Rea studied proofreading under diferent levels of 
ilumination (Smith & Rea, 1978). They found that task performance improved as 
ilumination increased to the highest level with rapid improvements at low levels and 
more gradual improvement at the higher levels. They also found that the subject?s age 
and print quality of the visual task afected the results; with older subjects performed 
poorer as compared to younger subjects on the lower quality print tasks.  
 29 
In 1982, Smith and Rea studied the performance of a reading test under diferent 
ilumination levels (Smith & Rea, October 1982). Two forms of tests (one with good 
print quality and another with poor print quality) were performed under four diferent 
levels of ilumination. The ilumination level had no significant efect on task 
performance, but print quality did show significant efect; with the poor quality resulting 
in poor performance. They conducted a similar study with a check number verification 
task under diferent ilumination levels, and found that handwriting quality and 
ilumination level had a significant efect on visual performance (Smith & Rea, Winter 
1987). Rea studied the efects of lighting conditions on reading, which indicated that for 
the same contrast level, visual performance of the subjects increased at higher 
ilumination levels (Rea, Summer 1986). 
Some of the factors afecting the visual inspection proces include visual acuity, 
color-vision, age, lighting, noise, inspection time, complexity, paced versus unpaced, and 
number of inspectors (Megaw, 1979). 
A study conducted by Lion (Lion, Richardson, & Browne, 1967, 1969) looked at 
the performance of industrial inspectors under two diferent lighting types (tungsten and 
fluorescent). The tasks involved inspecting links for surface flaws and buttons for off-
center holes on a moving conveyor belt. They found that there were fewer errors in the 
link inspection task under fluorescent lighting as compared to tungsten (this task required 
greater visual acuity), but there was no diference in performance for the button 
inspection task. 
 
 
 30 
The Effect of Ilumination on Medication Errors 
The study by Buchanan (T.L Buchanan, Barker, & et, 1991) was first of its kind 
where the relationship betwen  ilumination levels and the dispensing error rate in a high 
volume outpatient pharmacy was investigated. The study found a significantly lower 
error rate of 2.6% for an ilumination level of 146 foot-candles as compared to the error 
rate of 3.8% for the baseline ilumination level (45 foot-candles). Thus, this study 
provides a basis in fact for the belief that ilumination level is definitely asociated with 
the medication error rate in a healthcare facility. 
Poor lighting condition has been one of the important contributing factors to 
hospital medication errors, as reported by USP?s MEDMARX Program (MEDMARX 
Data Report, 2008). From the year 2002 -2006, hospitals have reported an average of 230 
errors per year were contributed to poor lighting conditions. 
There is considerable research done studying the efect of ilumination on visual 
performance, in both laboratory and field setings. Illumination?s positive relationship to 
visual performance is strongly established both analyticaly and empiricaly.(Terry Le 
Buchanan, 1989) Illumination remains one of the most flexible and adjustable 
components of the visual performance model.  
Thus, there is considerable theoretical basis to expect a positive relationship 
betwen ilumination and a visualy demanding task such as medication preparation in a 
nursing home seting. 
 
 
 
 31 
Rationale For Study Proposed 
The medication preparation proces is highly visual in nature. The nurse must be 
able to read the contents of the medication administration record (MAR), read the label of 
the drug prescribed, compare the label to the MAR record and read any distinguishing 
numbers or leters on the medication in order to identify it. 
Studies in human factors research have established that improving the quality and 
level of ilumination greatly improves the visual performance. Weston?s studies on the 
efect of light on visual tasks demonstrated that the visual performance increased with an 
increase in ilumination and contrast size (Weston HC, 1945). 
Blackwel developed the Blackwel Visual Task Evaluator (H. R. Blackwel, 
1961), which is used by the Illuminating Engineering Society of North American 
(IESNA) to determine the levels of ilumination for a specific task, for eg. Medication 
preparation, in diferent healthcare facilities (The IESNA Commite for Healthcare 
Facilities, 2006; The IESNA Lighting for the Aged and Partialy Sighted Commite, 
2007). In subsequent studies, it was shown that the quality of the visual performance is 
highly dependant on the quantity and quality of ilumination provided for the task 
(Belchambers & Philipson, 1962; R. H. Blackwel & Blackwel, 1968; R. G. Davis & 
Garza, Winter 2002; Dockhorn, Scholz, Vandahl, & Gal, 2005; Faulkner & Murphy, 
1973; Megaw, 1979; Smith & Rea, 1978; Wei & Konz, 16-19 October 1978). 
The problem of insufficient lighting in nursing homes was highlighted when a 
group of researchers (Lepeleire, et al., 2007) measured lighting levels in diferent areas of 
a nursing home and found the lighting levels to be insufficient as per the IESNA (2007) 
guidelines for the nursing home residents and staf. 
 32 
That increasing the ilumination can reduce the error rate was the finding of the 
study of dispensing errors by Buchanan (T.L Buchanan, et al., 1991). A significantly 
lower error rate was achieved by increasing the ilumination level from 45 to 146 foot-
candles. This increase in ilumination produced a reduction in error rate from 3.8% down 
to 2.6%. This study thus found that ilumination level is definitely asociated with the 
medication error rate in a healthcare facility. 
A prospective cohort medication error study (Barker, Flynn et. al, 2002) of a 
random sample of 12 skiled nursing facilities in Colorado and Georgia found a 
medication error rate of 10.8% (Georgia) and 14.2 % (Colorado) respectively. It can be 
speculated that one of the contributing factors to the errors can be the improper 
preparation of medications during the preparation phase. 
USP?s MEDMARX Error Reporting Program also highlights Poor lighting 
conditions as one of the important factors contributing to hospital medication errors 
(MEDMARX Data Report, 2008). Acording to the MEDMARX reports, hospitals 
reported an average of 230 errors per year (for the years 2002-2006) which they 
atributed to poor lighting conditions. 
Al the above research studies support the need and value of focusing attention on 
the lighting system in the healthcare facilities. As the visual component in the healthcare 
medication distribution system becomes increasingly complex and possibly more prone 
to error, it is important that the positive impact that a good lighting system can have on 
the quality of care provided by long term care facilities receive further atention and 
study, thus ensuring patient as wel as healthcare staf safety. 
 
33 
 
 
 
III.  Statement Of The Problem 
 
 
Problem Statement 
The main objective of the study was to measure the efect of increased ilumination levels 
on the medication preparation errors, by total error rate and error types, in a long-term 
care study site. 
 
 
Main Research Questions 
1) Will increased ilumination level at the long-term care facility result in decrease 
of the medication-preparation error rate? 
 
2) Will increased ilumination level at the long-term care facility have an efect on 
the medication-preparation errors, by error types? 
 
3) Is there an asociation betwen the total number of medications prepared by an 
individual nurse-subject each day and the medication preparation errors detected for that 
nurse-subject in the long-term care facility? 
 
 34 
4) Is there an asociation betwen the day of the ilumination period and the number 
of medication preparation errors made during that day, at the long-term care facility? 
 
5) Is the proportion of medication preparation errors constant over al the sections at 
the study facility? 
 
6) Is there an asociation betwen the medication shift (work shift) and the 
medication preparation errors for al three ilumination levels, at the study facility? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 35 
Research Hypotheses 
Null (H
0A
): An increased ilumination level at the long-term care facility will not have a 
significant efect on the medication-preparation error rate. 
Alternative (H
1A
): An increased ilumination level at the long-term care facility will 
result in decrease of the medication-preparation error rate. 
 
Null (H
0B1
): An increased ilumination level at the long-term care facility will not have 
a significant efect on the medication-preparation errors, by wrong dose error type. 
Alternative (H
1B1
): An increased ilumination level at the long-term care facility will 
have a significant efect on the medication-preparation errors, by wrong dose error 
type. 
 
Null (H
0B2
): An increased ilumination level at the long-term care facility will not have 
a significant efect on the medication-preparation errors, by wrong form error type. 
Alternative (H
1B2
): An increased ilumination level at the long-term care facility will 
have a significant efect on the medication-preparation errors, by wrong form error 
type. 
 
Null (H
0B3
): An increased ilumination level at the long-term care facility will not have 
a significant efect on the medication-preparation errors, by wrong time error type. 
Alternative (H
1B3
): An increased ilumination level at the long-term care facility will 
have a significant efect on the medication-preparation errors, by wrong time error type. 
 
 36 
Null (H
0B4
): An increased ilumination level at the long-term care facility will not have 
a significant efect on the medication-preparation errors, by omision error type. 
Alternative (H
1B4
): An increased ilumination level at the long-term care facility will have 
a significant efect on the medication-preparation errors, by omision error type. 
 
Null (H
0B5
): An increased ilumination level at the long-term care facility will not have a 
significant efect on the medication-preparation errors, by unauthorized dose error type. 
Alternative (H
1B5
): An increased ilumination level at the long-term care facility will have 
a significant efect on the medication-preparation errors, by unauthorized dose error type. 
 
Null (H
0C
): There is no asociation betwen the total number of medications prepared by 
an individual nurse-subject each day and the medication preparation errors detected for 
that nurse-subject in the long-term care facility. 
Alternative (H
1C
): There is a significant asociation betwen the total number of 
medications prepared by an individual nurse-subject each day and the medication 
preparation errors detected for that nurse-subject in the long-term care facility. 
Null (H
0D
): There is no asociation betwen the day of the ilumination period and the 
number of medication preparation errors made during that day, at the long-term care 
facility. 
Alternative (H
1D
): There is a significant asociation betwen the day of the ilumination 
period and the number of medication preparation errors made during that day, at the long-
term care facility. 
 
 37 
Null (H
0E
): The medication preparation errors detected at the three sections of the study 
site are not significantly diferent. 
Alternative (H
1E
): The medication preparation errors detected at the three sections of the 
study site are significantly diferent.!
 
Null (H
0F
): There is no asociation betwen the medication shift and the medication 
preparation errors for al three ilumination levels, at the study site. 
Alternative (H
1F
): There is significant asociation betwen the medication shift and the 
medication preparation errors for al three ilumination levels, at the study site. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 38 
Hypothesis Testing 
H
0A1
 : u1 = u2 = u3 
H
1A1
: one or more treatment means difer 
H
0A2 
: u1 = u2  
H
1A2 
: u1 ? u2  
H
0A3
 : u1 = u3 
H
1A3 
: u1 ? u3 
H
0A4
 : u2 = u3 
H
1A4 
: u2 ? u3  
H
0A5
 : T
linear
 = 0
 
H
1A5 
: T
linear
 ? 0 
H
0A6
 : T
quadratic
 = 0
 
H
1A6 
: T
quadratic
 ? 0 
H
0B1
: u1 = u2 = u3 
H
1B1
: one or more treatment means difer 
H
0B2
: u1 = u2 = u3 
H
1B2
: one or more treatment means difer 
H
0B3 
: u1 = u2 = u3 
H
1B3 
: one or more treatment means difer 
H
0B4 
: u1 = u2 = u3 
H
1B4
 : one or more treatment means difer 
H
0B5
 : u1 = u2 = u3 
H
1B5
 : one or more treatment means difer 
 39 
Illumination level 1 
H
0C1 
: M= 0 
H
1C1 
: M ? 0 
Illumination level 2 
H
0C2 
: M= 0 
H
1C2 
: M ? 0 
Illumination level 3 
H
0C3 
: M= 0 
H
1C3 
: M ? 0 
For each individual nurse-subjects 
H
0D
 : u1= u2 =u3
 
H
1D
 : Error proportions difer for each nurse-subject for al 3 ilumination levels 
Illumination level 1 
H
0E1 
: U
X
 = U
Y = 
U
Z 
H
1E1 
: Error proportions difer for one or more study-sections 
Illumination level 2 
H
0E2 
: U
X
 = U
Y = 
U
Z 
H
1E2 
: Error proportions difer for one or more study-sections 
Illumination level 3 
H
0E3 
: U
X
 = U
Y = 
U
Z 
H
1E3 
: Error proportions difer for one or more study-sections 
For al 3 Illumination levels 
H
0F
 : U
9 AM 
=  U
5 PM ;  
H
1F 
: U
9 AM
 ?  U
5 PM
 
 40 
Concepts 
The concepts addresed in this study are as follows: 
Error - Failure of a planned sequence of mental or physical activities to achieve its 
intended outcome, when these failures cannot be atributed to chance
.
(Reason, 2003) 
It has also been defined as an unintended act (either of omision or commision) or the 
one that does not achieve its intended outcome (Reason, 2000, 2003). 
 
Medication error ? Errors occurring at any stage in the proces of ordering or delivering a 
medication. Medication errors can occur at any stage in the drug ordering, dispensing and 
administration proces (Leape, 1994). 
 
Prescription ? A medication order which designates a specific medication and dosage to 
be administered to a particular patient, at a specified time and isued by a physician or 
other properly licensed medical practitioner (Bates, Boyle, Vliet, Schneider, & Leape, 
1995). 
 
Illumination level ? The ilumination level is defined as the rate of light energy emision 
faling on the unit area of the task surface as measured in foot-candles by a portable, 
calibrated photometer with an iluminance sensor (Buchanan & Barker, 1991). 
 
Nursing home ? A nursing home is a generic term used to describe non-hospital 
institutions which provide nursing and other health and social related supportive services 
to the chronicaly il and the elderly (Cheung & Vlases, 1985).    
 41 
The Congresional Discursive Dictionary of Health care (Cheung & Vlases, 1985) 
defines nursing homes as ?generaly, a wide range of institutions other than hospitals, 
which provide various levels of maintenance, and personal or nursing care to people who 
are unable to care for themselves and who may have health problems which range from 
minimal to very serious. The term includes freestanding institutions, or identifiable 
components of other health facilities, which provide nursing care and other related 
services, personal care and residential care. Nursing homes include skiled nursing 
facilities, intermediate care facilities and extended care facilities, but not boarding 
houses.? 
 
Medication preparation - The preparation proces is divided into 6 steps: (Barker & 
Heler, 1963) 
? Obtaining the ordered drug in the form available 
? Separation of the quantity of drug required for one unit dose 
? Physical or chemical alteration of the drug form as required 
? Maintenance of proper environment for dose-unit 
? Maintenance of proper identification and other required information with dose-
unit 
? Macroscopic inspection of dose-unit for signs of unsuitability of use. 
Ergonomics  - Ergonomics the study of the relationship betwen the work system (the 
person, the job, and the work place) and human performance (Alexander, 1986).    
 42 
Illumination - Also caled iluminance, is the amount of light faling on to a surface 
(Sanders & McCormick, 1993). It is measured in terms of luminous flux per unit area. 
The units of measurement are: 
Lux (an SI unit) = 1 lumen per square meter, the lumen being the unit of luminous flux. 
Foot-candle (USCS unit) = 1 lumen per square foot.  
One foot-candle equals 10.76 lux, usualy rounded off to 10 lux for practical purposes 
(Sanders & McCormick, 1993). 
 
Luminance - It is the amount of light reflected or emited from a surface (Kroemer & 
Grandjean, 1997).
 
Its unit of measurement is: Candela per m
2 
(SI unit) or mililambert and 
footlambert (USCS unit).  
 
Reflectance ? It is measured and compared by the ratio betwen reflected and incident 
amounts of light. It is expresed as the percentage of reflected to incident light.
 
(Kroemer 
& Grandjean, 1997) 
 
Acommodation means the ability of the eye to bring into ?sharp focus? objects at varying 
distances from infinity down to the nearest point of vision, caled the ?near point? 
(Sanders & McCormick, 1993) 
 
Glare is a gross overloading of the adaptation proceses of the eye, brought about by 
overexposure of the retina to light
 
(Sanders & McCormick, 1993) 
The most important visual capacities are (Sanders & McCormick, 1993): 
 43 
Visual acuity  - It is the ability to detect smal details and to discriminate smal objects.  
Contrast sensitivity  - It is the ability of the eye to perceive a smal diference in 
luminance 
 
 
Medication Preparation Error Categories 
The medication preparation error categories addresed in this study are as follows 
(Cohen, 1999; Flynn, Barker, Pepper, Bates, & Mikeal, 2002): 
 
Unauthorized drug error ? Preparation of a dose of medication that was never ordered for 
that resident. 
 
Extra dose error - Any dose prepared in exces of the total number of times ordered by 
the physician, as documented in the MAR, such as a dose given on the basis of an expired 
order, after a drug had been discontinued, or after a drug's administration had been put on 
hold.  
 
Wrong dose error - Any dose of preformed dosage units (such as tablets) that contained 
the wrong strength or number. 
 
Omision error - Failure to prepare an ordered dose. Omisions wil be detected by 
comparing the medications prepared at the given observation period, with doses that should 
have been prepared at that time based on the physician's writen order and protocols. 
 44 
 
Wrong form error ? The preparation of a dose in a diferent form than ordered by the 
physician when a form was specified. If enteric-coated aspirin is ordered, but plain aspirin is 
prepared, then a wrong form error wil be counted. 
 
 
Wrong time error - Preparation of a dose more than 60 minutes before or after the 
scheduled administration time. Routine administration times were obtained from study 
site, and times asigned on the MAR were used when no other policy was available. 
 
 
Operational Definitions 
The operational definitions addresed in this study are as follows: 
Increased ilumination level ? The ilumination level measured in foot-candles, by a 
portable, calibrated photometer with an iluminance sensor, when a supplemental task 
light fixture (of known and constant iluminance) is instaled in the study medication cart. 
This value/increased level (experimental/treatment measure) was kept constant for the 
entire study period.  
 
Medication preparation ?!It was defined as the proces where the nurse-subject reads the 
resident medication administration record, retrieves the oral medication from the task 
area medication cart and measures the medication (counts the number of pils in case of 
 45 
solids, measures the volume in case of liquids) and places it on a medication tray, before 
administering it to the particular resident. 
 
Medication preparation error - A deviation from the resident?s physician record filed in 
the study nursing home pharmacy, as made by the nurse when preparing medications to 
be administered to the nursing home residents. 
 
Total opportunities for error - The total number of medication doses prepared (and 
omited) by the nurse, as observed, during the study period. 
 
Medication preparation error rate ?  Number of medication preparation errors   X 100 
                                                                  Total number of opportunities for error 
 
 
 46 
 
 
 
IV. Methodology 
 
 
Population 
The target population for this study was al the oral prescription medication doses 
prepared by the nurses in the study facility. 
 
Sample 
This is a case study based on convenience sampling and based on the wilingnes 
of the nursing home staf to alow the study to be conducted. The study site must remain 
anonymous. Thus, any generalization to other nursing facilities must be made with 
caution. 
The study inpatient care section was selected based on the highest volume of 
prescriptions administered on a given shift. The morning and the evening shifts were 
selected for observation because they were identified as the busiest shifts at the study site. 
The work areas where medications were prepared had no windows, and thus no natural 
lighting. The medication pas rounds observed are: 
? Morning med pas (8AM ? until end of the med-pas round, usualy 10 AM) 
? Evening med pas (4 PM ? until end of the med-pas round, usualy 6 PM) 
 47 
The sampling unit was an oral prescription medication dose prepared by the 
nurse-subject in the particular section of the study site and observed by the principal 
investigator, before administration to the resident, during the study period. 
The medications observed were retrieved from the nurse?s medication cart, 
located at the study section. Any medications that were not retrieved from the medication 
cart, were excluded, as the ilumination levels at the other storage/stock rooms were 
diferent than that of the study section area.  But if the drug container (or blister card) was 
brought back to the medication cart for the appropriate dose to be prepared, then it was 
included in the study. 
 
Only oral prescription medications was included in the observation study for 3 reasons: 
? Most of the doses prepared and administered at the study nursing home (around 
85%) are oral medications. 
? They are prepackaged by the pharmacy in blister cards or bottles (liquids) and 
have standardized medication labels. This helps in standardizing the visual information 
throughout the observation study. 
? Most of the oral prescription medications are stored in the medication cart. 
 
Study Subjects 
The study subjects were the nurses working in the selected nursing home unit, 
during the morning (8am-10 am) and evening (4 pm ? 6 pm) medication pas shifts. Al 
nurses (LPNs) who were involved in the medication preparation proces and who had 
signed the informed consent leter were included in the study as subjects.  
 48 
   Independent Variable 
Illumination Level 
The baseline ilumination level (control measure) of the study study medication cart was 
measured using a calibrated photometer with an iluminance sensor. (Sper Scientific light 
meter 840021) 
   The ilumination levels selected for the observation study were: 
Baseline ilumination level ? This was the current ilumination level at the study 
medication cart at the selected study section where the observations take place. 
 
Illumination level 2 ? The Illuminating Engineering Society (IESNA) provides 
recommendations and guidelines for lighting conditions in healthcare facilities (The 
IESNA Commite for Healthcare Facilities, 2006;The IESNA Lighting for the Aged and 
Partialy Sighted Commite, 2007) 
The commite suggested an ilumination level of 100fc for areas where medications are 
prepared (Refer Table: 2). Illumination level 2 (experimental measure) was set at 100 fc, 
which was obtained by fixing a supplemental lighting fixture (with constant iluminance) 
over the medication cart at the selected study section. 
 
Illumination level 3 - This served as the experimental intervention measure. The increase 
in the ilumination level (experimental measure) was obtained by fixing a supplemental 
lighting fixture (with constant iluminance) over the medication cart at the selected study 
section. A previous study by Buchanan et al (Buchanan, 1991) found that an ilumination 
 49 
level of 145 fc had a significant efect on the dispensing error rate of the study pharmacy. 
Therefore, ilumination level 3 was set at 145 fc. 
The three ilumination levels were randomly asigned during the study period 
(each medication pas round), so as to obtain equal days of observation for al the levels. 
During the observation phase, care was taken to ensure proper control of the ilumination 
level by periodic light measurements and controlling for any external sources of light 
near the study locations. Periodic light measurements were taken for the study area 
locations, during the observation phase, in order to ensure control of the ilumination 
level. 
 
Suplemental Lighting Aparatus 
In order to increase the baseline ilumination level to the higher levels of 100fc and 
145fc, supplemental lighting fixture (OtLite 508 Illumination
TM
 rechargeable fluorescent 
task lamp) was afixed to the study medication cart. 
 
Research Design 
This was an explanatory level research; with a repeated measures study design. 
Independent variable: Increased Illumination levels 
Dependent variable: Medication-preparation error rate 
The study was a (within subjects) repeated measures design. 
 
 
 
 
 50 
Design Structure 
The study was (within subjects) repeated measures design. 
                         ~X      Y
A1   
X      Y
A2         
R
a 
X - Experimental condition; ~X - Control condition 
Y
A1
 ? Measurement after the control stimulus; 
Y
A2 
? Measurements after the experimental stimulus 
R
a 
 -  Random asignment of the experimental stimulus. 
 
Controls 
This design uses the subjects (in the experimental group) as their own control, 
thus minimizing the efects of individual diferences.  
The nurse-subjects were checked for vision prior to the study. Nurses who had 
completed the visual acuity test (may have corrective glases/contact lenses) were 
included in the study. 
The nurse-subjects were administered a distractibility questionnaire, in order to 
measure their susceptibility to distractions that may occur during the observation period 
and thus help control the diferences betwen nurse-subjects? susceptibility to distractions 
from external variables during the study period. 
The observation method used had been studied and found to be unobtrusive and 
objective with minimal efect of the observer on the subjects.  
Standardization of the visual stimuli (medication labels) was achieved, as only 
oral prescription medications were included in the observation study. 
 51 
The workload data of the nurses was examined prior and during the study. The 
random asignment of the ilumination levels ensured control over workload or any other 
individual diferences. 
Additional sources of light (such as sunlight) that might influence the study were 
observed and controlled. 
The study was designed to control for the threats to internal validity in the 
following ways: 
1. Maturation - The study period was not long enough to cause maturation efects in 
the subject- nurses. The observer observed the nurse-subjects for the same shift- period 
(for eg. morning med pas rounds 8 am -10 am and evening med pas rounds 4 pm ? 6 
pm), which controlled for factors such as fatigue. 
2. Testing ? Testing in both the groups, involved observation during their regular 
med pas rounds. As the nurses are doing familiar activity, for both the groups, the efect 
of pre-testing were minimized.  
3. Instrumentation ? The observer was trained in the scientific observation method 
(Barker, 1980) Research has established that, if the observer is non-judgmental, objective 
and unobtrusive, then the efect of the observer on the observed nurse-subject were 
minimal. The observed subject adapts to the presence of an observer, if the subject is 
doing familiar activity and the observation conducted is unobtrusive, nonjudgmental and 
objective (Buchanan, 1991)
.
 
 
 
 
 52 
Data Collection 
Data collection occupied 2 phases: 
1. Initial site visit ? where the variables of interest were explored and operationaly 
defined. 
2. Explanatory phase ? where the efect of the intervention variable (increased 
ilumination level) upon the dependant variable (medication preparation errors) was 
studied.   The explanatory phase consisted of: 
Observation pilot study, conducted from May 25, 2010 to May 28, 2010; 
Explanatory level study, conducted from June 1, 2010 to August 10, 2010. 
 
Phase I : Initial Visits For Orientation To Study Site 
Initial visits for orientation to the study site were conducted from August 2009 to 
December 2009 to gather data about the study facility characteristics and workflow. A 
review was conducted to understand the dynamics of the nursing administration 
schedules, as wel as help in operationaly defining the variables of interest. The principal 
investigator also reviewed the staf job profiles and responsibilities. Lighting 
measurements of the facility and pictorial representations from early visits were noted. 
 
Site Selection 
The principal investigator and her academic advisor visited the State Nursing 
Home Association headquarters to interview top officials. They were asked to help 
identify nursing facilities which might be suitable for the research study and found one 
conveniently located in Auburn, Alabama. The principal investigator and her advisor 
 53 
received asurance from the Alabama nursing home asociation officials that the 
proposed study site was not atypical when compared to the other nursing facilities around 
the area. 
 
 
Background information about the facility 
The principal investigator obtained the following basic background information 
about the facility on the Internet. A lot of nursing home review websites had information 
about their facility, such as the number of beds, types of services offered and number of 
deficiencies cited in the previous years. Although the acuracy of al of the information is 
questionable, it helped the investigator to get a general idea of the facility. 
The nursing home study site is an average sized, non-profit facility with 85 beds. 
The facility has 73 residents indicating 97% of its beds are occupied, which is above 
average within this state. The provider participates in the Medicare & Medicaid programs 
and provides resident counseling services. A total of 49 Medicare patients were given 
1,279 days of non-swing bed care and services in 2006 and this provider gave two 
Medicare patients outpatient care and services in 2006. (Anon, 2006) 
Further background information needed for the preparation of the proposal were 
obtained in a series of trips to the study home site, as follows: 
 
 
 
 54 
Trip 1 
The first trip was to met with the nursing home administrator. The principal 
investigator and her advisor met with him around 11 am. The purpose of the meting was 
to explain the significance of the light- study research and to ask for permision to use the 
nursing facility as a study site. 
The administrator agreed to let the principal investigator explore the lay out of the 
facility. In order to acquaint the staf, he suggested that the principal investigator prepare 
a one-page memo of the intent of the research, what she were doing at the site, the 
observation start date and an atached picture. He asked to submit the memo a wek 
before the observation start date. The principal investigator drafted a memorandum citing 
some brief information about the purpose of the exploratory visits, which was to be stuck 
on the notice board, next to the clock-in machine for the nursing staf to se. Please refer 
Appendix A for a copy of the memorandum. 
It was also learned that the study facility were surveyed every 9 months 
approximately; and the last time the state surveyors visited the site was in December 
2008.  
 
Trip 2  
The investigator met with the pharmacist at the facility. The conversation 
provided the following information about the pharmacy and the study facility. 
? The on-site pharmacy was not yet functional; and was stil being set up. 
? The nursing home orders al its medications on a monthly basis from a mail-order 
pharmacy, based in Alabama. 
 55 
? The on-site pharmacy were fully functional by May 4
th
 2009. 
? The medications are packaged in blister packs and stored in the medication carts. 
? The study facility had 75 residents at that time 
? The facility had 3 sections (section X, Y and Z) and 2 nursing stations. One 
nursing station took care of Section X and the other took care of sections Y and Z. 
? Section X had the maximum number of residents and additional rooms being 
added to it. 
? For the storage of over-the-counter drugs, the study facility had a stock closet. 
? The prescription and medication records were al paper based. 
? The pharmacy catered to the medication needs for the study facility, the asisted 
living facility and hospice care. 
? She also mentioned that the nursing home was recently bought by the local 
hospital system (name confidential). 
? A consultant pharmacist visits the nursing home once every month for 
inspections.  
? The staf in the pharmacy comprised of: 
? A pharmacist 
? A fil-in pharmacist 
? A technician 
? A biling person 
? The technician wil manualy blister pack a month?s supply of medications for the 
nursing home residents. 
 56 
? A sheet containing the study facility medication schedule was handed over to the 
principal investigator. Please refer Appendix C. 
Trip 3 
The main purpose of this meting was to met with the Director of Nursing. The 
principal investigator had an appointment with her in the afternoon; wherein they spoke 
about the nursing home in general and toured the facility. The information gathered: 
? The study facility has 3 sections and 85 beds; al elderly patients. 
? No specific services are provided in the sections; they are al general residents. 
? The medication pas rounds occur at 6 am, 9 am, 1 pm, 5 pm and 9 pm 
? The medication administration window is ? 60 minutes. 
? There were around 650 medications administered at the study site during the 
busiest med pas rounds (9 am and 5 pm) 
? There were 3 medication carts in total; and the main study station overlooked the 
medication needs of sections 2 and 3. 
? Twelve new beds were being added to section 1 by the end of April; a new 
nursing station was also being built. 
? The shifts are as follows 
? 1
st
 shift  -  7 am to 3 pm ( 3 nurses administer medications) 
? 2
nd
 shift -  3 pm to 11 pm (3 nurses administer medications) 
? 3
rd
 shift ? 11 pm to 7 am (2 nurses administer medications) 
? There were 5 registered nurses in the facility during the day shift 
? A new MDS coordinator was going to be appointed by May 4
th
 
? They had no designated Quality Asurance personnel. 
 57 
 
 
 
     Figure 8 : The general layout of the room was as follows: (not to scale) 
 
 
 
 58 
Trip 4 
The fourth trip was to measure and take some pictures of the lighting fixtures in 
the facility.   
 
Trip 5 
The investigator took additional pictures and light measurements at diferent 
locations of the facility. She also visited the pharmacy, which was in the proces of 
stocking up on their medications. 
Section X 
Floor level (middle of the lobby)            ? 41.8 fc 
Mid- air level                                           - 109 fc 
Nursing station desk surface                   - 126 fc 
Near the exit doors 
Floor level                                            - 114 fc 
Mid-air level                                         - 147.8 fc 
Figure 9: Exit door 
  
 59 
Figure 10: Section X Medication cart upper surface 
 
 
 
 
 
 
 
 
 
 
 
 
Fluorescent Light 
fixture 
54 fc 
24.4 fc 
 60 
Section Y 
Floor level (middle of the lobby)           ? 34.3 fc 
Mid- air level                                          - 106 fc 
Nursing station desk surface                   - 124.3 fc 
 
Figure 11: Section Y light measurements. 
 
 
Figure 12: Dining /Activity room 
 
  A table in Dining / Activity room            - 125 fc 
 
 61 
Figure 13: Section Y Medication cart upper surface  
 
 
 
 
 
 
 
 
 
 
 
 
Fluorescent Light 
fixture 
13.18 fc 
12.8 fc 
 62 
Section Z 
Floor level (middle of the lobby)               ? 33.4 fc 
Mid- air level                                           - 125.6 fc 
Reception desk in front lobby                   - 91.8 fc 
Outside Gift shop in the front lobby          - 37.5 fc  (yelow light) 
 
The principal investigator was informed that the new section was filed with residents, 
and that there were 85 residents in the facility at the time of the study. 
 
Visit to the Pharmacy 
The pharmacy caters to the medication needs for long-term care, hospice and 
asisted living facilities. Although the medications for the hospice care were already set 
up, the long-term care section (nursing facility and asisted living facility) was stil under 
construction. 
 
 
 
 
 
 
 
 
 
 63 
Here are some pictures and light measurements from the pharmacy site: 
 
Figure 14: Security measure at the pharmacy site; al windows had bars on them. 
 
 
Figure 15: Light fixtures used in the pharmacy 
 
 
 
 64 
 
Figure 16: Blister packaging material for the medications 
 
 
 
Figure 17: Medications stacked in the cabinet; bar-coded label 
 
 
 
 
 65 
Figure 18: Hospice pharmacy cabinet 
 
Hospice pharmacy medication cabinet floor  - 10fc 
 
 Figure 19: Hospice pharmacy window 
 
Hospice pharmacy pharmacist station (near window) ? 142.3 fc 
 
 
 66 
Long term care section computer station 
Computer station 1                                       -   88 fc 
   Figure 20: Computer station 1 
 
 
Long term care section work stations 
Workstation overlooking an open window (light fixture on top)               - 127. 3 fc 
Figure 21: Workstation overlooking an open window 
 
Workstation overlooking a window with blinds (light fixture on top)        - 120 fc 
 67 
 
 Figure 22: Workstation overlooking a window with blinds 
 
 
 
 
Trip 6:  
The investigator went to the study site around 10.10 pm to measure the light levels. It was 
learned that some residents are administered their 11 pm medications, which are prepared 
at 10 PM. 
 
 
 
 
 
 
 68 
 
 
 
 
Figure 23: Section X: Medication cart light measurement 
 
The nurse giving the medication pas was observed commenting on the light quality 
being dull. In her words she said, ??we need beter lights here??. 
 
Fluorescent Light fixture 
15 fc 
14.9 fc 
14.5 fc 
8.33 fc 
8.0 fc 
15.5  fc, 
12.43 fc,  
13.0 fc 
when 
open 
14.6fc 
8.5 fc 
 69 
 
 
 
 
 
 
 
 Figure 24: Section Y Medication cart 
 
The lights in the resident rooms are turned off at night, when they slep. So, in case the 
nurses have to administer medications, they turn on the light, after entering the resident 
room. 
 
 
 
 
 
Fluorescent Light 
fixture 
45.6 fc 
35.0  fc 
22.4  fc 
 70 
Trip 7:  
The principal investigator visited the new pharmacy, now fully functional. The pharmacy 
caters to the medication needs of the hospice, nursing and asisted living facility. 
Acording to the chief pharmacist there, they fil on an average about 172 prescriptions 
per day, out of which 88 are for the study facility. 
The estimated average number of prescriptions filed, per section per day are: 
Section 1 ~ 15/day 
Section2 ~ 13/day 
Section 3 ~ 10/day 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 71 
! Figure 25: The detailed workflow diagram is as follows: 
 
 
 26 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
Some pictures from the visit: 
Physician visits once a 
month; 
telephones/dictates 
orders 
Nurse stocks the 
medication in the 
medication cart for the 
specific nursing unit 
Nurse/nurse-
secretary 
transcribes order 
Medication transcription 
is faxed to the on-site 
pharmacy 
Nurse administers 
medications to residents. 
Medication order gets 
updated on pharmacy 
database. 
Pharmacy prints out label 
and dispenses the drug in 
custom-made blister pack 
Pharmacy dispenses 
monthly suply to facility in 
the evenig everyday 
 72 
 
   Figure 26: Blister packaging at the pharmacy 
 
 
 
Figure 27: Controlled substance form and label beside it 
 
 
 73 
Explanatory Study Phase 
This phase consisted of: 
Observation pilot study was conducted from May 25, 2010 to May 28, 2010; 
Explanatory level study was conducted from June 1, 2010 to August 10, 2010. 
 
IRB Aproval 
IRB approval (March 2010) was sought from Auburn University and the Study 
site, prior to data collection for the study. The IRB was renewed (February 2011) for the 
time-period of another year. (Refer Appendices B and H). 
 
Informed Consent Letter 
The principal investigator visited the study site on April 2, 2010 during the 
monthly nurse?s meting. At the meting, the investigator was formaly introduced to al 
the nurses by the study home administrator, and got a chance to brief them about the 
observation study. Each of the nurse-subject participating in the study was read an 
introduction memorandum explaining the research study and the role of the principal 
investigator. 
The nurses who were interested in participating in the study were then asked to 
sign the consent leter. (Please refer Appendix G). They were also briefed about taking 
the visual tests and distractibility questionnaire, as part of the study protocol. Out of 10 
nurses (LPN), 9 of them signed the informed consent leter. One of the nurses semed a 
litle resistant to the visual tests and was observed teling the investigator ?You cannot 
force me to wear glases?, for which the investigator simply smiled.  
 
 74 
Demographic Information 
Literature has suggested that demographic variables like person?s age (Cullinan, 
1986; Blackwel, 1980), visual acuity have a significant impact on their visual 
performance and their reaction to diferent lighting levels. 
Prior to the start of the observation period, information about the demographic variables 
previously identified as possibly linked to medication errors like age, sex, nursing degree 
(education level), number of months employed in the study nursing home and 
employment status (RN, LPN, nurse intern) were collected from nurse-subjects who had 
signed the consent forms. The nursing home administrator provided the investigator with 
the demographic information for al the nurses. Workload information (number of 
residents and their medication regimen, number of doses prepared) for each nurse was 
also collected during the observation period by the principal investigator. 
 
Visual tests 
The nurses was administered a standardized visual acuity test by a licensed 
pharmacist ? faculty at Auburn University, helped by the principal investigator. Snelen 
chart (Wendy Strauss Wat, 2003) was used to measure the visual acuity of the nurses. 
The test was administered during the monthly nurse?s meting (for the month of July). 
One of the nurses, who did not show up for the meting was administered the test, the 
very next day. 
 
 
 
 75 
Group Embeded Figures Test 
Distractibility was defined by the score achieved by subjects on the Group 
Embedded Figures Test(GEFT). The nurses were administered a distractibility 
questionnaire (Flynn E.A, 1994), in order to measure their susceptibility to distractions 
that may occur during the observation period. This writen test requires the subject to 
visualy distinguish a simple geometric figure from within a complex figure.  One point is 
awarded for each correctly identified figure. Higher the score, the more field independent 
(les distractible) the subject.  
Each nurse was administered the test individualy, as per their convenience. The 
testing location was kept standard for al the nurses and the principal investigator briefed 
the nurses about the rules of the test. Each nurse was given sufficient time to ask 
questions, before they could begin their tests. The investigator timed each section, and the 
time limit for the test was kept constant for al the nurses. The investigator referred to the 
GEFT Manual (Witkins et.al) for instructions on administration and scoring of the 
distractibility questionnaire. 
 
Observation pilot study (May 25, 2010 - May 28, 2010) 
The main objectives of the pilot study were: 
1) To estimate the sample size for the main study; 
2) To identify and operationaly define the variables (error types) of the study; 
3) To help design the med pas observation form for the main study; 
4) To understand the med pas workload of nurses in al the three sections of the 
study site. 
 76 
5) To help acquaint the observer/principal investigator with the pace of medication 
preparation by the nurses. 
 
Explanatory level study (June 1, 2010 to August 10, 2010) 
The main explanatory study began on June 1, 2010 and was concluded on August 
10, 2010. The principal investigator observed each section for both the morning (9 am) 
and the evening (5 pm) med pas rounds.  
The observer randomized the Illumination level for that particular day by the 
using of the random number generator on the Excel software. 
The supplemental task light was placed on the study medication cart, irrespective 
of the ilumination level, in order to control for participant sensitization. 
The baseline level was achieved by measuring the light level on the medication 
cart, without switching on the supplemental task light apparatus. The experimental 
(intervention) levels were achieved by adjusting the arm of the apparatus, by moving it 
either up or down, until the desired level was met. 
 
 
 
 
 77 
 
Figure 28: Baseline measurement 
 
 
 
 
 Figure 29: Experimental (Intervention) measurement 
 
 
 
 78 
 
 
Figure 30: Sample of Visual Stimuli (medication label fixed on the oral doses) 
 
 
 
 
Figure 31: Observation instruments used during the study 
 
 79 
The observer recorded the medication preparation information as prepared by the nurse 
during the medication pas round and then noted the information from the original 
prescriber?s orders for that particular section, after the end of the observation period. 
Reconciliation of the observed data to the original orders were done after the end of the 
observation study for that particular section/nurse, in order to control for any observer 
bias. 
 
 
Statistical Analysis 
Repeated measures analysis of variance was used to compare the total medication 
preparation error rate, as detected by observation, for the three lighting conditions.  
            Chi-square analysis was used to compare the medication preparation errors, by 
error types, as detected by observation, for the three lighting conditions. 
Linear regresion was used to examine the relationship betwen the daily 
medication pas workload and the medication preparation errors. 
Chi-square analysis was used to study the relationship betwen the day of the 
ilumination period and the number of medication preparation errors made on that day. 
This was to indicate the efect of the principal investigator/observer on the performance 
of the nurse-subjects. 
 
Significance Level 
The alpha level was preset at 0.05 for an estimated efect size of 0.2 and power of 
0.8 (Cohen J, 1988). 
 
  
 
80 
 
 
 
 
V.   Results 
 
 
In this chapter, the results are presented as follows: 
? Demographic information of the study subjects 
? General description and observed results of the pilot study sample  (May 2010) 
? General description of the main observation study sample  (June - August 2010) 
? Comparison of errors for al three ilumination levels 
? Statistical tests and hypotheses 
 
 
 
 
 
 
 
 
 
 
 
  
 
81 
Study Subjects description 
This study looks at the efect of ilumination upon the performance of the nurses 
as they prepare the doses ordered by the physicians to be administered. The main focus of 
the study is the medication system, a ?non-machine system? in which the nurse-subject is 
the principal actor, though other environmental factors are present and may play a part in 
afecting the error rate. 
Of the 9 nurses, only 7 nurses who worked the day shifts were included in the 
observation study. The 2 nurses who worked the night shifts were excluded, as the 
dynamics of ilumination changes during the nighttime. 
The nurse-subjects, their eyesight, Group Embedded Figures Test (GEFT) 
scores and other demographics for which there is evidence of possible involvement in 
producing errors are shown in Table 3.  
Along with the nurse?s eyesight, the observer too recorded her eyesight and 
GEFT scores, which is provided in Table 3. 
None of the subjects in this study had significant visual impairment based on the 
results of the visual tests. The Group Embedded Figures Test (GEFT) scores ranged from 5 
to 11 (out of possible zero to 18 range) with a mean of 8.14. 
Al the nurse-subjects were Licensed Practitioner Nurses (LPNs), and their 
duration of employment ranged from 9 months to 9 years. 
 
 
 
 
 
 
  
 
82 
Table 3:  Demographic Information of the Study Subjects 
 
 
Nurse 
 
Age 
(yrs) 
 
Gen
der 
Emplo
ymt 
status  
 
Month
s 
emplo
yed at 
study 
site 
Shift 
timings 
Nurs
ing 
unit 
 
Cor
ective       
Meas
ures 
 
Left Eye 
Vision 
 
Right 
Eye 
Vision 
 
Both 
Eyes 
Vision 
 
GEFT 
Score 
 
1A 
 
47 
 
F 
 
LPN 
 
17 
6:45AM
-3:15P 
 
Z 
 
Glas
es 
 
20/20 
 
20/15 
 
20/15 
 
 
5 / 18 
 
2B 
 
24 
 
F 
 
LPN 
 
10 
2:45PM-
11:15P
M 
 
X 
 
Cont
acts 
 
20/13 
 
20/30 
 
20/15 
 
12 / 18 
 
3C 
 
38 
 
F 
 
LPN 
 
16 
2:45P-
11:15P
M 
 
Y 
 
None 
 
20/15 
 
 
20/13 
 
20/13 
 
6 / 18 
 
4D 
 
23 
 
F 
 
LPN 
 
9 
2:45P-
11:15P
M 
vari
es 
 
Glas
es 
 
 
20/40 
 
20/30 
 
20/40 
 
 
10 / 18 
 
5E 
 
42 
 
F 
 
LPN 
112     
(9yr4
mo.) 
6:45AM
-3:15P 
 
X 
 
Glas
es 
 
20/25 
 
20/25 
 
20/25 
 
6 / 18 
 
 
6F 
 
25 
 
F 
 
LPN 
 
14 
6:45AM
-3:15P 
 
Y 
 
None 
 
20/20 
 
20/30 
 
20/15 
 
11 / 18 
 
 
7G 
 
37 
 
F 
 
LPN 
 
12 
6.45 
AM ? 
3.15 PM 
 
vari
es 
 
Cont
acts 
 
20/50 
 
20/70 
 
20/50 
 
 
7 / 18 
 
Obse
rver 
 
 
 
F 
 
 
 
 
 
 
 
 
 
Cont
acts 
 
20/25 
 
20/25 
 
20/20 
 
 
15 / 18 
 
 
 
 
 
 
 
 
 
 
 
  
 
83 
Pilot Study: General description and results 
The pilot observational study was conducted at the study site from May 25, 2010 
to May 28, 2010, for the morning (9 am) and evening (5 pm) medication pas.  
The main objectives of the pilot study were: 
1) To estimate the sample size for the main study; 
2) To help design the med pas observation form for the main study; 
3) To understand the med pas workload of nurses in al the three sections of the 
nursing site. 
4) To help acquaint the observer/principal investigator with the pace of medication 
preparation by the nurses. 
A total of 653 medications were observed being prepared by the nurse subjects 
during the pilot study. A total of 34 medication preparation errors were confirmed; with 
an overal error rate of 5.2 %. The distribution of errors for each day of observation is 
shown in Table 4. 
An error-rate, excluding wrong time errors was also computed, which was 4.3%. 
The reason for computing this error rate was due to the fact that the observer noticed that 
sometimes the nurses prepared the doses wel in advance to the next medication pas 
rounds. For eg. Some of the nurses prepared the doses for the next medication pas round 
(9 pm) during their present med-pas (5 pm). Although, this may constitute a wrong time 
error, but the observer thought it would be useful to compute two error- rates, just to 
observe the efect of ilumination with and without the wrong time errors. 
 
  
 
84 
The total opportunity of errors (TOE) is the denominator of the measure of the 
workload demand upon the system, including the nurse-subjects (doses prepared and 
omited) during the observation period. 
Table 4: Pilot Study (May 25 ? May 28, 2010) 
 
Date Sec
tio
n 
Illumination 
Level 
(foot-
candles) 
Obs 
Time 
Total 
Opp. 
for 
Errors 
Errors Error 
Rate 
Error 
Rate w/o 
wrong 
time 
errors 
May 25, 
2010 
Z Baseline * 9:00 AM 82 5 6.1% 6.1% 
 
Y Baseline * 4.00 PM 79  5 6.2% 5.1% 
May 26, 
2010 
X Baseline * 9.00 AM 95 6 6.3% 6.3% 
 
X 145 4.00 PM 91 4 4.4% 1.1% 
May 27, 
2010 
Z 100 9:00 AM 80 3  3.7% 3.7% 
 
Z 145 4.00 PM 75 4 5.3% 5.3% 
May 28, 
2010 
Y 145 9.00 AM 81 3 3.7% 2.5% 
 
Y 
 
100 4:00 PM 72 4 5.5% 4.2% 
Total 
   
655 34 
 
5.2% 4.3% 
* Baseline level: Average ilumination level of 30 foot-candles. 
Figure 32: Medication Preparation Errors for three ilumination levels 
6.2 
5.8 
4.6 4.6 
4.5 
2.9 
0 
1 
2 
3 
4 
5 
6 
7 
Error rate (%) Error rate w/o wrong time (%) 
Pilot Study: Er ror rates  
Baseline 
100 
145 
 
  
 
85 
The nature and frequency of each error type detected during the pilot study is 
described in Tables 5 and 6, to judge the clinical significance of the error detected, al of 
which share equal status as an incidence of system failure. 
The distribution of error types for each ilumination level is shown in Figure 26. 
The ilumination levels 100 fc and 145 fc had fewer errors asociated with them as 
compared to the baseline measurement (an average ilumination level of 30 foot-candles) 
Table 5: Frequency of error types during pilot study 
Date Sectio
n 
Ill. Level 
(foot-
candles) 
Obs 
Time 
Errors Wrong 
dose 
errors 
Wrong 
form 
errors 
Omisio
n erors 
Wrong 
time 
errors 
May 
25, 
2010 
Z Baseline* 9:00 
AM 
5 2 3 
  
 
Y  Baseline* 
 
5.00 PM 5 2 1 
 
2 
May 
26, 
2010 
X  Baseline* 9.00 
AM 
6 3 3 
  
 
X 145 
 
5.00 PM 4 1 
  
3 
May 
27, 
2010 
Z 100 9:00 
AM 
3  
 
2 1 
 
 
Z 145 
 
5.00 PM 4 2 2 
  
May 
28, 
2010 
Y 145 9.00 
AM 
3 1 1 
 
1 
 
Y 
 
100 5:00 PM 4 
 
2 1 1 
 
Total 
    
34 
 
    
* Baseline level: Average ilumination level of 30 foot-candles. 
 
 
 
  
 
86 
 
 
 
 
 
 
 
 
   Figure 33: Frequency of error types for three ilumination levels 
 
The errors observed during the pilot study helped the observer in the preparation 
of the medication observation form.  
The pilot study results revealed that Wrong time errors were frequently observed. 
It was observed that the nurse-subjects prepared some of the doses to be administered in 
the next med-pas round, during the previous round. But, this behavior was not observed 
uniformly across al nurse-subjects, so it was decided that the observation results be 
computed with and without wrong time errors.  
 
 
 
 
 
 
 
 
1.3 
2.7 
2.6 
1.2 
0.8 
0.7 
1.6 
2.7 
1.6 
0 
0.5 
1 
1.5 
2 
2.5 
3 
Baseline 100 145 
Er
r
or
 R
ate
 (%) 
Illumination Levels 
Pilot Study: Error Types 
Omission 
Wrong Form 
Wrong Time 
Wrong Dose 
 
  
 
87 
Table 6: Description of Each Error during the Pilot Study 
Date Prescribed Drug Prepared Drug Error Type Notes 
May 25, 
2010 
9 AM 
Aspirin 81 mg Enteric 
Coated (EC) 
Aspirin 81 mg EC 
Crushed 
Wrong 
Form 
Nurse (LPN) 
said she was 
behind 
schedule and 
wanted to 
finish her 
med pas 
before 10 
AM 
 
Colace Solution 5 ml Colace solution 10 
ml 
Wrong Dose  
 
Oxybutynin ER 10 mg Oxybutynin ER 10 
mg crushed 
Wrong form  
 
Nifedipine 30 mg ER Nifedipine 30 mg 
ER 
Crushed 
Wrong form  
 
Therapeutic Vitamin # 
1 tab 
Therapeutic 
Vitamin # 2 tabs 
Wrong dose  
May 25, 
2010 
5 PM 
Senna S # 2 tabs Senna S # 1 tab Wrong dose  
 
Therapeutic Vitamin # 
1 tab 
Therapeutic 
Vitamin # 2 tabs 
Wrong dose  
 
Simvastatin 40 mg; due 
at 9PM 
Simvastatin 40 mg; 
given at 4.30PM 
Wrong time  
 
Detrol LA 4 mg Detrol LA 4mg 
crushed 
Wrong 
Form 
 
 
Diazepam 5 mg; due at 
9 PM 
Diazepam 5m; 
given at 5.35 PM 
Wrong time  
May 26, 
2010 
9 AM 
Aspirin 325 mg EC Aspirin 325 mg EC 
Crushed 
Wrong 
Form 
 
 
Bupropion HCL SR 
100 mg 
Bupropion HCL 
SR 100 mg 
Crushed 
Wrong 
Form 
 
 Aspirin 81 mg EC Aspirin 81 mg EC 
Crushed 
Wrong 
Form 
 
 Loratadine 10 mg 
#1 tab po D 
Loratadine 10 mg 
#2 tabs 
Wrong dose  
 
 
 
Senna Plus  # 2 tabs 
 
Senna Plus # 1 tab 
 
Wrong dose 
 
 
 
 
  
 
88 
 Date Prescribed Drug Prepared Drug Error Type Notes 
 
 Acetaminophen 325 mg 
#2 tabs 
Acetaminophen 
325 mg #1 tab 
Wrong dose  
May 26, 
2010 
5 PM 
 
Seroquel 100 mg @ 
9PM 
 
Seroquel 100 mg 
@ 4.35 PM 
 
Wrong time 
 
 
 
Aricept 10 mg @ 7 PM 
 
Aricept 10 mg @ 
5.17 PM 
 
Wrong time 
 
 
 
Simvastatin 20 mg @ 9 
PM 
 
Simvastatin 20 mg 
@ 5.30PM 
 
Wrong time 
 
 
 
Xanax 0.25 mg 
 
 
Xanax 0.25 mg 
Spils crushed pil; 
some leftover on 
table 
 
Wrong dose 
 
May 27, 
2010 
9 AM 
Fish Oil 3000 mg none Omision  
 
 
Aspirin 81 mg EC Aspirin 81 mg EC 
Crushed 
Wrong form  
 
 
Oxybutynin ER 10 mg Oxybutynin ER 10 
mg Crushed 
Wrong form  
May 27, 
2010 
5 PM 
Klor Con M20 CR Klor Con M20 CR 
Crushed 
Wrong form  
 
 
Senna S #2 tabs Senna S # 1 tab Wrong dose  
 
 
Aspirin EC 81 mg ER Aspirin EC 81 mg 
ER 
Crushed 
Wrong form  
 
 
Golden age Liquid 
(Vitamin) 10 ml 
Golden Age Liquid 
7 ml 
Wrong dose  
May 28, 
2010 
9 AM 
Calcium 600 + vitamin 
D; due at 7 am 
 
Calcium 600 + 
vitamin D; given at 
9.17 am 
Wrong time  
 
 
Aspirin EC 81 mg Aspirin EC 81 mg 
crushed 
Wrong 
Form 
 
 
 
Colace solution 10 ml 
 
Colace solution 7 
ml 
Wrong dose  
May 28, 
2010 
5 PM 
Calcium 600 + vitamin 
D; due at 7 am 
Calcium 600 + 
vitamin D; given at 
10.07 am 
 
Wrong time 
 
 
 
 
  
 
89 
   
Date 
 
 
Prescribed Drug 
 
Prepared Drug 
 
Error Type 
 
Notes 
 
May 28, 
2010 
5 PM 
Klor Con M10 Klor Con M10 
Crushed 
Wrong form  
 
 
Aspirin EC 81 mg Aspirin EC 81 mg 
Crushed 
Wrong 
Form 
 
 
 
 
Main Observation Study: Sample Description 
A total of 6,808 medication doses were observed being prepared by the nurse-
subjects during the 45-day study period from June 1, 2010 to August 10, 2010. An 
average of 151 doses were observed per day, with an average of 76 doses per shift. 
The observation sample size of 6808 doses achieved a 95% confidence 
interval, with a relative acuracy of ? 5%, efect size of 0.2, power of 0.8 at an 
estimated medication error rate of 11%. (Flynn et.al, 2002) 
However, 50 medication doses were excluded due to the following reasons: 
 
Table 7:  Reasons for excluded doses 
 
Reason for Exclusion # Doses Excluded 
 
Incomplete Information recorded 
 
25 
 
Illumination level not met 
 
12 
 
Physician handwriting ilegible 
 
13 
 
Total 
 
 
50 
                 
 
  
 
90 
 So, a total of 6,758 prepared doses were included in the final study. The following table 
and figure summarize the characteristics of the observed sample with respect to the 
nurse-subjects who prepared them and the corresponding ilumination levels. 
 Table 8: Total observed doses (after dose exclusion) for each nurse-subject for each 
Illumination level    
Nurse code Illumination 
Level 1 
 
Baseline 
Illumination 
Level 2 
 
100 fc 
Illumination 
Level 3 
 
145 fc 
Total doses 
observed 
 
 
1A 
 
329 
 
334 
 
327 
 
990 
 
2B 
 
389 
 
399 
 
406 
 
1194 
 
3C 
 
218 
 
230 
 
223 
 
671 
 
4D 
 
325 
 
313 
 
336 
 
974 
 
5E 
 
325 
 
332 
 
341 
 
998 
 
6F 
 
341 
 
327 
 
357 
 
1025 
 
7G 
 
293 
 
296 
 
317 
 
906 
 
Total Doses 
Observed 
 
 
 
 
 
 
 
6758 
 
 
 
 
 
 
 
 
 
  
 
91 
 
 
 
     
Figure 34: Doses prepared by each Nurse-subject (LPN) for three ilumination levels 
 
 
Medication Preparation Errors for the Study Sample (6,758 doses) 
The total number of medication preparation errors observed for al the three 
sections of the study site under three ilumination levels was 467, resulting in a total 
medication preparation error rate of 6.7%.  
The total opportunities for error (doses observed being prepared plus the doses 
omited by the nurses during the observation period) were 6,948 doses. 
          Medication Preparation Error Rate = 467 / 6948 x 100 = 6.7% 
Excluding Wrong time errors, 
         Medication Preparation Error Rate = 321 / 6948 x 100 = 4.6% 
 
 
 
 
0 
500 
1000 
1500 
1A 2B 3C 4D 5E 6F 7G 
T
otal
 d
os
e
s
 ob
s
e
r
ve
d
 
LPN Code 
Total  doses observed for each LP N  
Bas eline 
100 fc  
145 fc  
Total  Meds observed 
 
  
 
92 
Table 9: Medication Preparation Errors for the Study Site for three ilumination levels 
Illumin
ation 
level 
Average 
illuminatio
n level (fc) 
Total meds 
observed Errors TOE 
Error 
rate 
(%) 
Error rate 
excluding 
wrong time 
erors (%) 
Baselin
e 28.16 2220 196 2292 8.5 5.7 
100 100.23 2231 173 2313 7.4 4.5 
145 144.69 2307 98 2343 4.3 2.5 
Total  6758 467 6948 6.7 4.6 
 
 
     Figure 35: Error rate for the study site for three ilumination levels 
 
The most frequently observed medication preparation error was Omision (N = 
190, 40%), followed by Wrong time (N = 146, 31%), Wrong form (N = 72, 15%), Wrong 
Dose (23, 5%) and Unauthorized Drug (4, 1%). 
The observer observed that some of the nurse-subjects prepared few of the 
doses to be administered in the next med-pas round, during the previous round. But, this 
8.5 
5.7 
7.4 
4.5 
4.3 
2.5 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
Error Rate % Error Rate w/o wrong time 
Error Rate for Study Site 
Baseline 
100 fc 
145 fc 
 
  
 
93 
behavior was not observed uniformly across al nurse-subjects, so the results were 
computed with and without wrong time errors.  
Wrong Form errors frequently observed were those where the dose was crushed 
during preparation, despite a specific order to the contrary writen by the physician 
stating ?do not crush?.  Such doses were sometimes for medications, which the 
manufacturer had enteric coated or otherwise intended for extended release.  During the 
observation period, two nurses told the observer that the reason for crushing medications 
was to aid the resident in swalowing it. Although the observer understood the practical 
reason for crushing the doses, the operational definition of an error used in this study 
recognized the specific order by the physician as paramount for representing the best 
evidence of the outcome desired from the patient?s point of view.  Therefore, such doses 
were considered Wrong Form errors.  
The description of errors by types is shown in Table 10, while Figure 36 
describes the frequency of error types for each ilumination level. 
 
Table 10: Total Medication Preparation Errors, by Error Types 
Illuminati
on level 
Total 
meds Errors TOE 
Error 
rate 
Una
uth. 
Dose 
Wron
g dose 
Omisio
n 
Wron
g 
Form 
Wron
g 
Time 
 
Baseline 2220 196 2292 8.5 3 12 72 38 39 
100 2231 173 2313 7.4  6 82 19 66 
145 2307 98 2343 4.3 1 5 36 15 41 
Total 6758 467 6948 6.7 4 23 190 72 146 
 
  
 
94 
!
 
 
 
 
 
 
 
    
   
 *  Error rates for Unauthorized Drugs were to low to report (Baseline : 0.004%; 145fc : 0.002%) 
Figure 36: Frequency of Medication Preparation Error Types, by Illumination levels 
 
Medication Preparation Errors, by Study Site Sections 
Section X: 
The study site has three sections, and the following tables show the distribution 
of errors and error types, across al the sections for al the three ilumination levels.  
The medication preparation error rate for Section X was 7.4%, with 235 
detected errors for 3080 observed doses.  
 
 
 
 
 
3.1 
3.5 
1.5 
1.7 
0.8 
0.6 
1.7 
2.9 
1.7 
0.5 
0.3 
0.2 
0 
0.5 
1 
1.5 
2 
2.5 
3 
3.5 
4 
Bas eline 100 145 
Er
r
or
 R
ate
 (%) 
Illumination Le vels 
Error Types for  the Study S ite 
Omission 
Wrong F orm 
Wrong Time  
Wrong D ose 
Unauthorized Drug* 
 
  
 
95 
Table 11: Medication Preparation Errors for Section X 
Illum
n. 
 level 
Average il 
level (fc) 
Total meds 
observed Errors TOE 
Error 
rate 
(%) 
Error rate 
exclud 
wrong 
time 
erors (%) 
Baseline 29.38 964 98 988 9.8 5.0 
100 100.14 957 84 1003 8.2 5.9 
145 144.75 1159 53 1179 4.5 2.4 
Total  3080 235 3170 7.4 4.2 
 
 
 Figure 37: Medication Preparation Error rate for Section X, by Illumination levels 
 
The most frequently observed medication preparation error for Section X was 
Wrong time (N = 101, 43%) followed by Omision (N = 90, 38%), Wrong form (N = 25, 
1%), Wrong Dose (N = 15, 6%) and Unauthorized Drug (N = 4, 2%).  
The description of errors by types is shown in Table 12, while Figure 38 describes 
the frequency of error types for each ilumination level, for Section X. The description of 
each preparation error observed for Section X is provided in Appendix I. 
 
  
 
96 
Table 12: Medication Preparation Errors for Section X, by Error Types 
Ill level 
Total 
meds 
Error
s TOE 
Error 
rate 
Unaut
hDose 
Wron
g dose 
Omisio
n 
Wron
g 
Form 
Wron
g 
Time 
Baselin
e 964 98 988 9.8 3 8 24 13 50 
100 957 84 1003 8.2 0 5 46 8 25 
145 1159 53 1179 4.5 1 2 20 4 26 
Total 3080 235 3170 7.413 4 15 90 25 101 
 
 
     
      
Figure 38: Medication Preparation Errors, by Error Types for Section X 
 
 
 
 
 
 
2.4 
4.6 
1.7 
1.3 
0.8 
0.3 
5 
2.5 
2.2 
0.3 
0.08 
0.8 
0.5 
0.1 
0 
1 
2 
3 
4 
5 
6 
Baseline 100 145 
Er
r
or
 R
ate
 (%) 
Illumination Levels 
Error Types for Section X 
Omission 
Wrong Form 
Wrong Time 
Unauthorized Drug 
Wrong Dose 
 
  
 
97 
Section Y: 
The medication preparation error rate for Section Y was 6.7%, with 149 detected 
errors for 2,166 observed doses.  
Table 13: Medication Preparation Errors for Section Y 
   Il 
level 
Average 
il level 
(fc) 
Total meds 
observed Errors TOE 
Error 
rate 
(%) 
Error rate 
exclud 
wrong time 
erors (%) 
Baseline 27.74 788 68 818 8.4 6.3 
100 100.175 635 45 659 6.8 4.3 
145 144.7 743 36 756 4.8 3.4 
Total  2166 149 2233 6.7 4.6 
 
 
 
 
 
 
 
 
 
 
     Figure 39: Medication Preparation Error rate for Section Y, by Illumination levels 
 
 
 
8.4 
6.3 
6.8 
4.3 
4.8 
3.4 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
Error rate (%) Error rate w/o wrong time (%) 
Error Rate for Section Y 
Baseline 
100 
145 
 
  
 
98 
The most frequently observed medication preparation error for Section Y was 
Omision (N = 67, 45%) followed by Wrong time (N = 47, 32%), Wrong form (N = 27, 
18%) and Wrong Dose (N = 8, 5%). 
The description of errors by types is shown in Table 14, while Figure 33 describes 
the frequency of error types for each ilumination level, for Section Y. The description of 
each preparation error observed for Section Y is provided in Appendix I. 
Table 14: Medication Preparation Errors for Section Y, by Error Types 
Ill level 
Total 
meds 
Error
s TOE 
Error 
rate 
Unaut
hDose 
Wrong 
dose 
Omisi
on 
Wron
g 
Form 
Wron
g 
Time 
 
Baselin
e 788 68 818 8.4 0 4 30 13 21 
 
100 635 45 659 6.8 0 1 24 4 16 
145 743 36 756 4.8 0 3 12 10 10 
Total 2166 149 2233 6.7 0 8 67 27 47 
 
 
     
 
 
 
 
 
 
    Figure 40: Medication Preparation Errors, by Error Types for Section Y 
3.6 3.6 
1.6 1.6 
0.6 
1.3 
2.5 
2.4 
1.3 
0.5 
0.1 
0.4 
0 
0.5 
1 
1.5 
2 
2.5 
3 
3.5 
4 
Baseline 100 145 
Er
r
or
 R
ate
 (%) 
Illumination Levels 
Error Types for Section Y 
Omission 
Wrong Form 
Wrong Time 
Wrong Dose 
 
  
 
99 
Section Z: 
The medication preparation error rate for Section Z was 5.37%, with 83 detected 
errors for 1,512 observed doses.  
Table 15: Medication Preparation Errors for Section Z 
Ill 
level 
Average il 
level (fc) 
Total meds 
observed Errors TOE 
Error 
rate 
(%) 
Error rate 
exclud 
wrong time 
erors (%) 
Baseli
ne 27.88 468 30 486 6.25 6.25 
100 100.41 639 44 651 6.77 2.88 
145 144.6 405 9 408 2.22 0.94 
Total  1512 83 1545 5.4 3.4 
 
 
 
 
          Figure 41: Medication Preparation Error rate for Section Z, by Illumination levels 
 
6.25 6.25 
6.77 
2.88 
2.22 
0.94 
0 
1 
2 
3 
4 
5 
6 
7 
8 
Error Rate % Error Rate w/o wrong time 
Error Rate for Section Z 
Baseline 
100 fc 
145 fc 
 
  
 
100 
The most frequently observed medication preparation error for Section Z was 
Omision (N = 33, 40%) followed by Wrong time (N = 30, 36%) and Wrong form (N = 
20, 24%). 
The description of errors by types is shown in Table 16, while Figure 35 describes 
the frequency of error types for each ilumination level, for Section Z. The description of 
each preparation error observed for Section Z is provided in Appendix I. 
   Table 16: Medication Preparation Errors for Section Z, by Error Types 
Ill 
level 
Total 
meds 
Erro
rs TOE 
Erro
r rate 
Unaut
hDose 
Wrong 
dose 
Omisio
n 
Wrong 
Form 
Wrong 
Time 
 
Baselin
e 468 30 486 6.25 0 0 18 12 0 
100 639 44 651 6.77 
0 
 0 12 7 25 
145 405 9 408 2.22 
0 
 0 3 1 5 
Total 1512 83 1545 5.37 0 0 33 20 30 
 
 
      
 
 
 
 
 
 
     Figure 42: Medication Preparation Errors, by Error Types for Section Z 
 
3.7 
1.8 
0.7 
2.5 
1.1 
0.2 
3.8 
1.2 
0 
0.5 
1 
1.5 
2 
2.5 
3 
3.5 
4 
Baseline 100 145 
Er
r
or
 R
ate
 (%) 
Illumination Levels 
Error Types for Section Z 
Omission 
Wrong Form 
Wrong Time 
 
  
 
101 
Medication Preparation Errors, by Nurse-Subjects 
Seven nurse-subjects prepared the medication doses for the mornings and 
evening medication pas rounds (9 am and 5 pm respectively) at the study site, during the 
observation period.  
The distribution of preparation errors by nurse-subjects and ilumination levels 
is shown in Table 38. Pictorial representation is shown in Figure 43.  
Nurse-subject 7G was asociated with the highest medication preparation error rate of 
10.4%, whereas Nurse-subject 1A was asociated with an error rate of 2.8%. 
 
 
 
  Figure 43: Medication Preparation Error rate for each nurse-subject, by ilumination 
types 
 
4.2 
10.7 
9.9 
7.6 
11.3 
4.9 
11.3 
2.9 
6.8 
7.5 
12.3 
5.4 
4.8 
11.8 
1.2 
4.3 
6.2 
4.8 
2.9 
3.2 
7.2 
0 
2 
4 
6 
8 
10 
12 
14 
1A 2B 3C 4D 5E 6F 7G 
Er
r
or
 R
ate
 
LPN Code 
Med Error Rate for each LPN 
Baseline 
100 fc 
145 fc 
 
  
 
102 
Table 17: Medication Preparation Errors by Nurse-subjects for 3 Illumination levels 
Nurse 
subject 
Illumination 
level 
Average 
illumination 
level 
Total 
meds Errors TOE 
Error 
rate 
(%) 
Error rate 
exclud wrong 
time erors 
1A 
B 
 
35.25 
 
329 
 
14 
 
333 
 
4.2 
 
4.2 
 
 100 
100.48 
 
334 
 
10 
 
338 
 
2.9 
 
2.9 
 
 145 
144.68 
 
327 
 
4 
 
330 
 
1.2 
 
1.2 
 
Total 
 
  990 28 1001 2.8 2.8 
2B 
 
B 19 389 43 394 10.7 2.78 
 
 
100 99.9 399 28 407 6.8 1.88 
 
 
145 144.37 406 18 410 4.3 0.94 
Total 
 
  1194 89 1211 7.3 1.9 
 
3C B 19.4 218 22 223 9.9 4.53 
 
 
100 100.53 230 18 238 7.5 4.58 
 
 
145 144.33 223 14 226 6.2 3.09 
Total 
 
  671 54 687 7.9 4.1 
4D B 
29.87 
 
325 
 
25 
 
334 
 
7.6 
 
5.0 
 
 100 
100.16 
 
313 
 
40 
 
321 
 
12.3 
 
2.425 
 
 145 
145.1 
 
336 
 
16 
 
338 
 
4.8 
 
0.5625 
 
Total 
 
  974 81 993 8.2 2.7 
5E 
 
B 26.02 325 38 338 11.3 8.58 
 
 
100 100.17 332 18 336 5.4 4.48 
 
 
145 144.92 341 10 346 2.9 2.88 
Total 
 
  998 66 1020 6.5 5.3 
 
  
 
103 
Nurse 
subject 
Illumination 
level 
Average 
illumination 
level 
Total 
meds Errors TOE 
Error 
rate 
(%) 
Error rate 
exclud wrong 
time erors 
6F 
 
B 17.87 341 17 348 4.9 4.60 
 
 
100 100.07 327 17 340 4.8 4.17 
 
 
145 144.82 357 12 362 3.3 2.73 
Total  
 
 1025 46 1050 4.4 
 
 
3.9 
7G B 
15.36 
 
293 
 
37 
 
322 
 
11.3 
 
10.3 
 
 100 
100.32 
 
296 
 
42 
 
333 
 
11.8 
 
11.2 
 
 145 
144.65 
 
317 
 
24 
 
331 
 
7.2 
 
6.0 
 
Total 
 
  906 103 986 10.4 9.2 
 
 
The following table describes the medication error types asociated with each 
nurse-subject. Of the 467 errors, it was observed that Nurse-subject 7G was asociated 
with the highest frequency of Omision errors (N = 80, 17%), whereas Nurse-subject 2B 
was asociated with the highest frequency of Wrong time errors (N = 66, 14%). 
 
 
 
 
 
 
 
 
 
  
 
104 
Table 18: Medication Preparation Errors, by types for each nurse-subject 
Nurse 
subject 
Ilumination 
level Errors 
Unauth. 
Dose 
Wrong 
dose Omision 
Wrong 
Form 
Wrong 
Time 
1A B 329   4 10  
 100 334   4 6  
 145 327   3 1  
Total     11 17  
2B B 43  6 5  20 
 100 28   8  14 
 145 18   4  32 
Total    6 17  66 
3C B 22  3 5 2 12 
 100 18   8 3 7 
 145 14  1 3 3 7 
Total    4 16 8 26 
4D B 25  1 9 1 14 
 100 40   8  32 
 145 16   2 0 14 
Total    1 19 1 60 
5E B 38 3 1 13 12 9 
 100 18  4 4 7 3 
 145 10 1  5 4  
Total   4 5 22 23 12 
6F B 17   7 9 1 
 100 17  1 13 1 2 
 145 12   5 5 2 
Total    1 25 15 5 
7G B 293  1 29 4 3 
 100 296  1 37 2 2 
 145 317  4 14 2 4 
Total    6 80 8 9 
 
  
 
105 
 
   Figure 44: Medication Preparation Error types, by nurse-subjects 
 
 
 
 
 
 
 
 
 
 
 
6 7 7 
1 
8 
2 
6 
39 
19 
30 
23 
33 
54 
78 
61 
15 
1 
35 
33 
8 
74 
48 
74 
18 
11 
9 
0 
20 
40 
60 
80 
100 
120 
1A 2B 3C 4D 5E 6F 7G 
Er
r
or
s
 (%)  
LPN Code 
Error Types for each LPN 
Wrong Time 
Wrong Form 
Omission 
Wrong dose 
Unauth dose 
 
  
 
106 
Statistical Hypotheses and Analysis 
Research Question 
Wil increased ilumination level at the nursing home study site result in decrease of the 
medication-preparation error rate? 
Research Hypotheses 
Null (H
0A1
): An increased ilumination level at the nursing home study site wil not have 
a significant efect on the medication-preparation error rate. 
Alternative (H
1A1
): An increased ilumination level at the nursing home study site wil 
result in decrease of the medication-preparation error rate. 
Analysis 
Repeated measures analysis of variance (ANOVA) was used to compare the total 
medication preparation error rate, as detected by observation, for the three lighting 
conditions. The Statistical package used for the analysis was SPS for Windows 18.0 
version. 
 
Table 19: Descriptive Statistics of the Total Medication Preparation Error rate, for each 
nurse-subject, by Illumination level 
Illuminatn 
Mean Std. Deviation N 
Baseline 8.557 3.0199 7 
100 fc 7.357 3.5293 7 
145 fc 4.271 2.0345 7 
   * Baseline level: Average ilumination level of 28 fot-candles. 
 
 
  
 
107 
Table 20: Repeated Measures Univariate ANOVA on the total medication preparation 
error rate, for nurse-subject by ilumination level. 
Effect 
Value F 
Hypothe
sis df 
Error 
df Sig. 
Noncent. 
Parameter 
Observed 
Power
b
 
Pilai's Trace .873 17.12
a
 2.000 5.000 .006 34.233 .906 
Wilks' Lambda .127 17.12
a
 2.000 5.000 .006 34.233 .906 
Hoteling's Trace 6.847 17.12
a
 2.000 5.000 .006 34.233 .906 
 
Roy's Largest Root 6.847 17.12
a
 2.000 5.000 .006 34.233 .906 
a. Exact statistic, b. Computed using alpha = .05 
 
The data was also analyzed for linear and quadratic trends using the Repeated Measures 
Univariate Analysis of Variance as shown in Table 21. 
!
Table 21: Tests for Linear and Quadratic trends using Repeated Measures Univariate 
ANOVA on the total medication preparation error rate for each nurse-subject, by 
Illumination level 
Source  
Type II Sum 
of Squares df Mean Square F Sig. 
Linear 64.286 1 64.286 17.12 .003 Illumination 
 
 
Error 
(Illumination) 
 
Quadratic 4.149 1 4.149 .90 .191 
Linear 16.424 6 2.737   Error(ilumination) 
 
Quadratic 27.801 6 4.634   
 
 
 
 
  
 
108 
Table 22: Pairwise Comparisons of the Medication Preparation Error rate for each nurse-
subject, by Illumination levels. 
Paired Diferences 
95% Confidence 
Interval of the 
Diference 
Illumination 
Mean Std. Deviation 
Std. Error 
Mean 
Lower Upper 
t df 
Sig. (1-
tailed) 
 level1 - level2 1.2000 3.4093 1.2886 -1.9531 4.353
1 
.94 6 .194 
 level1 - level3 4.2857 2.3398 .884 2.1217 6.449
7 
4.85 6 .001 
 level2 - level3 3.0857 2.2394 .8464 1.0146 5.156
8 
3.65 6 .005 
*Level 1 : Baseline,  Level 2 : 100 fc,  Level 3 : 145 fc 
 
 
Figure 45:  Box Plot of Medication Preparation Error rates for each nurse-subject across 
three Illumination Levels 
Medication 
Preparation 
Error 
Rate 
Ilumination Levels 
 
  
 
109 
Repeated measures Analysis of Variance was conducted with the factor being the 
three Illumination levels and the dependant variable being the Medication Preparation 
Error Rate. The mean and standard deviations for the Error Rates are presented in Table 
40. The results for the ANOVA indicated a significant ilumination efect, Wilks?s ? = 
0.127,  
F
2,5
 =17.12, p < 0.05, multivariate ?
2
 = 0.54. 
The results of the paired samples t-test (Table 22) indicated that the mean 
medication preparation error rates for Illumination level 3 (M = 4.27, SD = 2.01) are 
significantly diferent from that of Illumination level 1 (M = 8.6, SD = 3.01) and 
Illumination level 2 (M = 7.4, SD = 3.5). But, there was no significant diference found 
betwen the mean medication preparation error rates of Illumination levels 1 and 2. 
Follow-up polynomial contrasts indicated a significant linear efect with mean 
error rates decreasing with increasing ilumination levels, F
1,6
 = 17.12, p < 0.05. Higher 
order polynomial contrast (quadratic) was non-significant.  
 
 
 
 
 
 
 
 
 
 
  
 
110 
Research Question 
Wil increased ilumination level at the nursing home study site have an efect on the 
medication-preparation error rate (after exclusion of wrong time errors)? 
 
Research Hypotheses 
Null (H
0A1
): An increased ilumination level at the nursing home study site wil not have 
a significant efect on the medication-preparation error rate (after exclusion of wrong 
time errors). 
Alternative (H
1A1
): An increased ilumination level at the nursing home study site wil 
have a significant efect on the medication-preparation error rate (after exclusion of 
wrong time errors). 
 
Analysis 
Repeated measures analysis of variance (ANOVA) was used to compare the total 
medication preparation error rate (excluding wrong time errors), as detected by 
observation, for the three lighting conditions. The Statistical package used for the 
analysis was SPS for Windows 18.0 version. 
 
 
 
 
 
 
 
  
 
111 
Table 23: Descriptive Statistics of the Total Medication Preparation Error rate 
(excluding wrong time errors), for each observation day by Illumination level 
Illumination 
Mean Std. Deviation N 
Baseline 5.750 3.5297 27 
100 fc 4.522 4.3421 27 
145 fc 2.467 2.0707 27 
  * Baseline level: Average ilumination level of 28 foot-candles; N: Observations for each level. 
 
 
Table 24: Repeated Measures Univariate ANOVA on the total medication preparation 
error rate (excluding wrong time errors), for each observation day by ilumination level. 
Effect 
Valu
e F 
Hypothesis 
df 
Error 
df Sig. 
Partial 
Eta 
Squared 
Noncent. 
Parameter 
Pilai's Trace .632 21.433
a
 2.000 25.000 .00 .632 42.866 
Wilks' Lambda .368 21.433
a
 2.000 25.000 .00 .632 42.866 
Hoteling's Trace 1.715 21.433
a
 2.000 25.000 .00 .632 42.866 
 
Roy's Largest Root 1.715 21.433
a
 2.000 25.000 .00 .632 42.866 
a. Exact statistic, b. Computed using alpha = .05 
 
 
 
 
 
 
  
 
112 
Table 25: Pairwise Comparisons of the Medication Preparation Error rate (excluding 
wrong time errors) for each observation day, by Ilumination levels. 
Paired Diferences 
95% Confidence 
Interval of the 
Diference 
 
Mean 
Std. 
Deviati
on 
Std. 
Error 
Mean 
Lower Upper 
t df 
Sig. (2-
tailed) 
Pair 
1 
level1 - 
level2 
1.228
1 
4.8372 .9309 -.6854 3.1417 1.319 26 .19 
Pair 
2 
level1 - 
level3 
3.283
3 
3.3417 .6431 1.9614 4.6053 5.105 26 .00 
Pair 
3 
level2 - 
level3 
2.055
2 
3.0425 .585 .8516 3.2587 3.510 26 .002 
*Level 1 : Baseline,  Level 2 : 100 fc,  Level 3 : 145 fc 
 
A repeated measures univariate Analysis of Variance was conducted with the 
factor being the three Illumination levels and the dependant variable being the 
Medication Preparation Error Rate (without wrong time errors).  
The mean and standard deviations for the Error Rates are presented in Table 23.   
The results for the ANOVA indicated a significant ilumination efect, Wilks?s ? 
= 0.37, F
2,25 
=21.4, p < 0.05, multivariate ?
2
 = 0.63. 
The results of the paired samples t-test (Table 25) indicated that the mean 
medication preparation error rates for Illumination level 3 (M =2.5, SD =2.1) are 
significantly diferent from that of Illumination level 1 (M = 5.7, SD = 3.5) and 
Illumination level 2 (M =4.5, SD =4.3). But, there was no significant diference found 
betwen the mean medication preparation error rates of Illumination levels 1 and 2. 
 
 
  
 
113 
Medication Preparation Error Types 
Research Question 
Wil increased ilumination level at the nursing home study site have an efect on the 
medication-preparation errors, by error types? 
 
Research Hypotheses 
Null (H
0B1
): An increased ilumination level at the nursing home study site wil not 
have a significant efect on the medication-preparation errors, by error types. 
Alternative (H
1B1
): An increased ilumination level at the nursing home study site wil 
have a significant efect on the medication-preparation errors, by error types. 
 
Analysis 
Chi-square (Independent samples Chi square test)!analysis was used to compare the 
medication preparation errors by error types for the three lighting conditions. The 
analysis was conducted using electronic software tool for Chi Square Analysis 
(Preacher, 2003) 
 
 
 
 
 
 
 
 
  
 
114 
Research Hypotheses 
Null (H
0B1
): An increased ilumination level at the nursing home study site wil not have 
a significant efect on the medication-preparation errors, by wrong dose error type. 
Alternative (H
1B1
): An increased ilumination level at the nursing home study site wil 
have a significant efect on the medication-preparation errors, by wrong dose error type. 
The analysis output table is as follows: 
Table 26: Chi Square Analysis for Wrong Dose Preparation Errors 
Analysis Value Degres of 
Fredom 
Significance 
Pearson?s Chi Square 3.888 2 0.143 
Yates? Chi Square 2.833 2 0.242 
 
Table 27: Wrong Dose Preparation error rate 
 Baseline 100 fc 145 fc 
Error rate 12/2292 x100 = 0.5 % 6/2313 x100 = 0.3 % 5/2343 x 100 = 0.2 % 
 
The Chi Square analysis for Wrong Dose Preparation Errors, for al three 
ilumination levels did not demonstrate significant diference (X
2 
=3.88, df =2, p>0.05).  
Thus, the error rates detected for Wrong Dose Preparation Errors across al three 
ilumination levels were not significantly diferent. So, the null hypothesis was not 
rejected. 
However it is important to note that the overal error rate for wrong dose errors 
for al three ilumination levels was found to be low, which may efect the power to test 
for significance.  
 
  
 
115 
Research Hypotheses 
Null (H
0B2
): An increased ilumination level at the nursing home study site wil not have 
a significant efect on the medication-preparation errors, by wrong form error type. 
Alternative (H
1B2
): An increased ilumination level at the nursing home study site wil 
have a significant efect on the medication-preparation errors, by wrong form error type. 
 
The analysis output table is as follows: 
 
Table 28: Chi Square Analysis for Wrong Form Preparation Errors 
Analysis Value Degres of 
Fredom 
Significance 
Pearson?s Chi Square 12.954 2 0.0015 
Yates? Chi  Square 11.798 2 0.0027 
 
Table 29: Wrong Form Preparation error rate 
 Baseline 100 fc 145 fc 
Error rate 38/2292 x 100 = 1.7 % 19/2313 x 100 = 0.8 % 15/2343 x 100 = 0.6 % 
 
              The Chi Square analysis for Wrong Form Preparation Errors, for all three 
ilumination levels demonstrated significant diference. (X
2 
=12.954, df =2, p < 0.05).  
Thus, the error rates detected for Wrong Form Preparation Errors across al three 
ilumination levels were significantly diferent. So, the null hypothesis was rejected. 
 
 
 
 
  
 
116 
Research Hypotheses 
Null (H
0B3
): An increased ilumination level at the nursing home study site wil not have 
a significant efect on the medication-preparation errors, by wrong time error type. 
Alternative (H
1B3
): An increased ilumination level at the nursing home study site wil 
have a significant efect on the medication-preparation errors, by wrong time error type. 
The analysis output table is as follows: 
Table 30: Chi Square Analysis for Wrong Time Preparation Errors 
Analysis Value Degres of 
Fredom 
Significance 
Pearson?s Chi Square 9.121 2 0.05 
Yates? Chi Square 8.423 2 0.05 
 
Table 31: Wrong Time Preparation error rate 
 Baseline 100 fc 145 fc 
Error 
rate 
39/2292 X 100 = 1.7 % 66/2313 X 100 = 2.8 % 41/2343 X 100 = 1.7 % 
 
            The Chi Square analysis for Wrong Time Preparation Errors, for all three 
ilumination levels did not demonstrate significant diference (X
2 
=9.121, df =2 , p = 
0.05). Thus, the error rates detected for Wrong Time Preparation Errors across al three 
ilumination levels were not significantly diferent. So, the null hypothesis was not 
rejected. 
It must be noted that during the study period, it observed that some of the nurse-
subjects prepared few of the doses to be administered in the next med-pas round, during 
the previous round. But, this behavior was not observed uniformly across al nurse-
subjects. 
 
  
 
117 
Research Hypotheses 
Null (H
0B4
): An increased ilumination level at the nursing home study site wil not have 
a significant efect on the medication-preparation errors, by omision error type. 
Alternative (H
1B4
): An increased ilumination level at the nursing home study site wil 
have a significant efect on the medication-preparation errors, by omision error type. 
The analysis output table is as follows: 
 
Table 32: Chi Square Analysis for Omision Errors 
Analysis Value Degres of 
Fredom 
Significance 
Pearson?s Chi Square 18.825 2 0 
Yates? Chi Square 17.951 2 0 
 
Table 33: Omision error rate 
 Baseline 100 fc 145 fc 
Error 
rate 
72/2292 X 100 = 3.1 % 82/2313 X 100 = 3.5 % 36/2343 X 100 = 1.5 % 
 
              The Chi Square analysis for Omision Errors, for al three ilumination levels 
demonstrated significant diference (X
2 
=18.825, df =2, p < 0.05).  
Thus, the error rates detected for Omision Errors across al three ilumination levels 
were significantly diferent. So, the null hypothesis was rejected. 
 
 
 
 
 
  
 
118 
Research Hypotheses 
Null (H
0B5
): An increased ilumination level at the nursing home study site wil not have 
a significant efect on the medication-preparation errors, by Unauthorized Drug error 
type. 
Alternative (H
1B5
): An increased ilumination level at the nursing home study site wil 
have a significant efect on the medication-preparation errors, by Unauthorized Drug 
error type. 
The analysis output table is as follows: 
Table 34: Chi Square Analysis for Unauthorized Drug Preparation Errors 
Analysis Value Degres of 
Fredom 
Significance 
Pearson?s Chi Square 3.559 2 0.168 
Yates? Chi Square 1.59 2 0.451 
 
Table 35: Unauthorized Drug Preparation error rate 
 Baseline 100 fc 145 fc 
Error rate 3/2292 X 100 = 0.13 % 0/2313 X 100 = 0 1/ 2343 X 100 =0.04 % 
 
The Chi Square analysis for Unauthorized Drug Preparation Errors, for al three 
ilumination levels did not demonstrate any significant diference (X
2 
=3.559, df =2, p > 
0.05). Thus, the error rates detected for Unauthorized Drug Preparation Errors for al 
three ilumination levels were not significantly diferent. So, the null hypothesis was not 
rejected. However it is important to note that the overal error rate for Unauthorized Drug 
errors for al three ilumination levels was found to be very low, which may efect the 
power to test for significance.  
 
  
 
119 
Medication Preparation Workload 
 
 
Research Question 
 
Is there an asociation betwen the total number of medications prepared by an individual 
nurse-subject each day and the medication preparation errors commited by that nurse-
subject at the study site? 
 
Research Hypotheses 
Null (H
0C
): There is no asociation betwen the total number of medications prepared by 
an individual nurse-subject each day and the medication preparation errors commited by 
that nurse-subject at the study site. 
 
Alternative (H
1C
): There is a significant asociation betwen the total number of 
medications prepared by an individual nurse-subject each day and the medication 
preparation errors commited by that nurse-subject at the study site. 
 
Analysis 
Simple linear regresion was used to investigate the relationship betwen daily 
medication pas workload and medication preparation errors for each individual nurse 
subject, across al three ilumination levels.  
An Analysis of Variance (ANOVA) procedure was used to test for Regresion. 
 
 
  
 
120 
Table 36: Analysis of Variance for Linear Regresion of Medication Preparation Errors 
with respect to the daily Medication doses prepared for Illumination level 1 (Baseline) 
Model 
Sum of Squares df Mean Square F Sig. 
Regresion 3.447 1 3.447 .196 .662
a
 
Residual 439.738 25 17.590 
  
1 
Total 443.185 26 
   
a. Computed using alpha = .05 
 
 The Regresion analysis for the daily medication pas workload and medication 
preparation errors for each individual nurse subject, for ilumination level 1 was not 
found to be significant. (F
1,26
 = 0.196, p > 0.05). 
No asociation was found betwen the total number of medications prepared by 
an individual nurse-subject each day and the medication preparation errors commited 
by that nurse-subject in the nursing home study site. The null hypothesis was not 
rejected. 
Table 37: Analysis of Variance for Linear Regresion of Medication Preparation 
Errors with respect to the daily Medication doses prepared for Illumination level 2 (100 
fc) 
Model 
Sum of Squares df Mean Square F Sig. 
Regresion .004 1 .004 .00 .989
a
 
Residual 518.515 25 20.741 
  
1 
Total 518.519 26 
   
a. Computed using alpha = .05 
 
 
  
 
121 
The Regresion analysis for the daily medication pas workload and medication 
preparation errors for each individual nurse subject, for ilumination level 2 was not 
found to be significant. (F
1,26
 = 0, p > 0.05). 
Thus, there is no asociation betwen the total number of medications 
prepared by an individual nurse-subject each day and the medication preparation errors 
commited by that nurse-subject in the nursing home study site. The null hypothesis 
was not rejected. 
 
Table 38: Analysis of Variance for Linear Regresion of Medication Preparation Errors 
with respect to the daily Medication doses prepared for Illumination level 3 (145fc) 
 
Model 
Sum of Squares df Mean Square F Sig. 
Regresion .527 1 .527 .12 .730
a
 
Residual 107.769 25 4.311 
  
1 
Total 108.296 26 
   
a. Computed using alpha = .05 
 
The Regresion analysis for the daily medication pas workload and medication 
preparation errors for each individual nurse subject, for ilumination level 3 was not 
found to be significant. (F
1,26
 = 0.122, p > 0.05). 
Thus, there is no asociation betwen the total number of medications prepared 
by an individual nurse-subject each day and the medication preparation errors 
commited by that nurse-subject at the study site. The null hypothesis was not rejected. 
 
 
 
  
 
122 
Observer Efect 
 
Research Question 
Is there an asociation betwen the day of the ilumination period and the number of 
medication preparation errors made during that day, at the nursing home study site? 
 
Research Hypotheses 
Null (H
0
): There is no asociation betwen the day of the ilumination period and the 
number of medication preparation errors made during that day, at the nursing home study 
site. 
Alternative (H
1
): There is a significant asociation betwen the day of the ilumination 
period and the number of medication preparation errors made during that day, at the 
nursing home study site. 
 
Analysis 
A Chi-Square Analysis was performed on the medication preparation error data for each 
nurse-subject to determine the relationship betwen the day of the ilumination period and 
the number of preparation errors made by the nurse-subjects during that day.  
 
 
 
 
 
 
  
 
123 
Table 39: Chi-Square Analysis of the Medication Preparation errors for each nurse-subject 
by ilumination levels 
Nurse -
subjects 
Baseline 100 fc 145 fc 
 
1A 
X
2 
=0.74 
df=3 
 p > 0.01 
X
2 
=1.907 
df=3 
 p > 0.01 
X
2 
=1.896 
df=3 
 p > 0.01 
 
2B 
X
2 
=6.048 
df=3 
 p > 0.01 
X
2 
=2.387 
df=3 
 p > 0.01 
X
2 
=2.883 
df=3 
 p > 0.01 
 
3C 
X
2 
=0.738 
df=2 
 p > 0.01 
X
2 
=0.123 
df=2 
 p > 0.01 
X
2 
=0.128 
df=2 
 p > 0.01 
 
4D 
X
2 
=1.75 
df=3 
 p > 0.01 
X
2 
=1.979 
df=3 
 p > 0.01 
X
2 
=0.733 
df=3 
 p > 0.01 
 
5E 
X
2 
=11.31 
df=3 
 p ? 0.01 
X
2 
=8.388 
df=3 
 p > 0.01 
X
2 
=1.833 
df=3 
 p > 0.01 
 
6F 
X
2 
=0.052 
df=3 
 p > 0.01 
X
2 
=8.319 
df=3 
 p > 0.01 
X
2 
=1.619 
df=3 
 p > 0.01 
 
7G 
X
2 
=1.448 
df=3 
 p > 0.01 
X
2 
=8.223 
df=3 
 p > 0.01 
X
2 
=1.649 
df=3 
 p > 0.01 
 
                 The results of the analysis for the three ilumination levels indicated that the 
proportion of medication preparation errors remained constant. 
 
 
  
 
124 
 
Figure 46: Trend-line of Medication Preparation Errors for Illumination Level 1 
(Baseline) 
 
 
Figure 47: Trend-line of Medication Preparation Errors for Illumination Level 2 (100 fc) 
 
R?!=!0.035!
0!
20!
40!
60!
80!
100!
120!
1.6! 8.6!15.6!22.6!29.6!6.7!13.7!20.7!27.7!3.8!
Errors for Illum Level 1 
Errors for Illum Level 1 
Trendline 
R?!=!0.094!
0!
2!
4!
6!
8!
10!
12!
14!
16!
18!
20!
2.6! 9.6! 16.6! 23.6! 30.6! 7.7! 14.7! 21.7! 28.7!
Errors for Illum Level 2 
Errors for Illum Level 2 
Trendline 
 
  
 
125 
 
Figure 48: Trend-line of Medication Preparation Errors for Illumination Level 3 (145 fc) 
 
 
The Regresion Analyses for the observer efect on medication preparation error rates for 
ilumination level 1 (F
1,26
 = 3.665, p > 0.05); ilumination level 2 (F
1,26
 =2.60 , p > 0.05)  
and ilumination level 3 (F
1,26
 =2.163 , p > 0.05) demonstrated no significant diference. 
 
 
 
 
 
 
 
 
 
R?!=!0.08!
0!
1!
2!
3!
4!
5!
6!
7!
8!
9!
10!
2.6! 9.6! 16.6!23.6!30.6! 7.7! 14.7!21.7!28.7! 4.8!
Errors for Illum Level 3 
Errors for Illum Level 3 
Trendline  
 
  
 
126 
Medication Preparation Errors for Sections 
 
Research Question 
Is the proportion of medication preparation errors constant over al the three sections at 
the study site? 
Research Hypotheses 
Null (H
0E
): The medication preparation errors detected at the three sections of the study 
site are not significantly diferent. 
Alternative (H
1E
): The medication preparation errors detected at the three sections of the 
study site are significantly diferent.!
Analysis 
A Chi-Square Analysis was performed on the medication preparation error data of each 
section for al three ilumination levels. 
 
 
 
 
 
 
 
 
 
 
 
  
 
127 
Table 40: Medication Preparation Errors for al three ilumination levels, by Sections 
Section Illumination 
level Total meds Errors TOE 
 
X 1 964 98 988 
 
2 957 84 1003 
 
3 1159 53 1179 
 
 Y 1 788 68 818 
 
2 635 45 659 
 
3 743 36 756 
 
Z 
1 
 
468 
 
30 
 486 
 
2 639 44 651 
 
3 405 9 328 
 
The Chi-Square Analysis results were as follows: 
 For Illumination level 1: X
2 
=4.719, df =2, p > 0.01 
For Illumination level 2: X
2 
=2.11, df =2, p > 0.01 
For Illumination level 3: X
2 
=4.698, df =2, p > 0.01 
               The results of the analysis for the three ilumination levels indicated that the 
proportion of medication preparation errors remained constant for al the sections at the 
study site. So, the null hypothesis was not rejected. 
 
 
 
 
 
 
  
 
128 
Medication Preparation Errors for Medication Pas Shifts 
Research Question 
 
Is there an asociation betwen the medication shift and the medication preparation errors 
for al three ilumination levels, at the study site? 
 
Research Hypotheses 
Null (H
0F
): There is no asociation betwen the medication shift and the medication 
preparation errors for al three ilumination levels, at the study site. 
 
Alternative (H
1F
): There is significant asociation betwen the medication shift and the 
medication preparation errors for al three ilumination levels, at the study site. 
 
Analysis 
An Analysis of Variance test was performed on the medication preparation error data to 
test for asociation betwen the preparation errors and the medication shifts for al three 
ilumination levels at the study site. 
 
 
 
 
 
 
 
  
 
129 
Table 41: Medication Preparation Errors for al three ilumination levels, by medication 
shifts 
Med Pass Shifts 
Illumination level Errors TOE 
 
9 AM 1 99 1264 
 
2 78 1206 
 
3 31 1117 
 
5 PM 1 97 1028 
 
2 95 1107 
 
3 67 1226 
 
 
Table 42: Analysis of Variance of Medication Preparation Errors with respect to med-
pas shifts for al three ilumination levels 
 
 
Sum of Squares df Mean Square F Sig. 
Betwen Groups 57.664 1 57.664 3.775 .060 
Within Groups 1206.879 79 15.277   
Total 1264.543 80    
 
               The results indicate that there was no significant diference (F
1,80
 = 3.775, p 
>0.05) betwen the medication preparation error rates, for both the medication pas shifts 
(9 am and 5 pm) for al three ilumination levels. 
 
 
 
 
  
 
130 
Observation of Medication related incidents, which were not an error. 
The observation of some of the medication-related incidents, as witnesed by the 
observers are presented in the following table. The observer recorded the prescribed dose 
the dose prepared by the nurse-subject and nurse-subject comments and actions. 
Table 43: Observation of Medication-Related Incidents 
Prescribed Drug Prepared Drug (Near) Eror 
type 
Notes 
Digoxin 125 mcg None Omision Resident refused meds 
Lisinopril 2.5 mg None Omision Resident refused meds 
Klor Con M10 None Omision Resident refused meds 
Glyburide Metformin 
2.5mg/ 5mg 
None Omision Resident refused meds 
Furosemide 40 mg None Omision Resident refused meds 
Paroxetine 20 mg None Omision Resident refused meds 
Megestrol Acetate 10 
ml 
None Omision Resident refused meds 
Lorazepam 0.5 mg None Omision Resident refused meds 
Sena S # 2 pils Sena S # 1 pil Wrong Dose Near 
Error 
Nurse re-checks the MAR 
twice; and then puts in one 
more Sena-S pil 
Coumadin 5 mg Coumadin 2.5 
mg 
Wrong Dose Near 
Error 
Nurse puts the pill in trash 
and gets the right strength. 
 
  
Wrong resident 
Near Eror 
Nurse does not recognize the 
resident, had to get help from 
the Certified Nursing 
Assistant to get to the right 
resident. 
 
 
  
 
131 
                The observer also noted down the comments/fedback that nurse-subjects made 
during or after the observation period, regarding the ilumination (supplemental lighting 
apparatus and/or the increased ilumination levels) and the observer presence. The 
comments are listed in Table 44. 
 
Table 44: Nurse-subjects? comments regarding the ilumination and the observer 
 LPN/urse Comments Observer Actions 
1 ?I like the light, can se much beter? 
 
 
2 ?I love this light, I like being able to se.? 
 
 
3 ?Are you going to tel them to give us 
the light? I realy like the light. We move 
a lot so I like this extra light!? 
 
 
4 ?Its Bright!? 
 
 
5 ?I love this light.?  
6 ? I forgot you were here? 
 
 
7 Nurse-subject to observer ?What are you 
writing in your note-pad?? 
The observer promptly shows 
the Nurse-subject the data collection 
form and observation notes. 
 
 
 
 132 
 
 
 
 
VI.   Conclusion, Discussion, Limitations and Implications 
 
 
The purpose of this chapter is to present and discuss the conclusions and general 
findings, their implications, the limitations of the study and to suggest topics for future 
research.  
 
Main Conclusions 
The main conclusions from the Statistical Analyses are as follows: 
Table 45: Results and Conclusions of Hypothesis testing  
Hypothesis  Values Conclusion based on Results 
H
0A1
 : u1 = u2 = u3 
H
1A1
: one or more treatment 
means difer 
F 
=17.12 
  p < 
0.05 
Reject the null. 
Increase in ilumination levels resulted in 
reduction of medication preparation error 
rate. 
H
0A2
 : u1 = u2  
H
1A2 
: u1 ? u2  
 
t = 0.94 
p > 0.05 
Do not reject null. 
Increase in ilumination level from Baseline 
to 100 fc did not result in reduction of 
medication preparation error rate. 
 133 
Hypothesis Values Conclusion based on Results 
H
0A3
 : u1 = u3 
H
1A3 
: u1 ? u3 
t = 4.85 
p < 0.05 
Reject the null. 
Increase in Illumination level from Baseline 
to 145 fc resulted in reduction of medication 
preparation error rate. 
H
0A4
 : u2 = u3 
H
1A4 
: u2 ? u3  
 t = 3.65 
p  < 0.05 
Reject the null. 
Increase in Illumination level from 100 fc to 
145 fc resulted in reduction of medication 
preparation error rate. 
H
0A5
 : T
linear
 = 0
 
H
1A5 
: T
linear
 ? 0 
 F = 
17.12 
p < 0.05 
Reject the null. 
There was a linear decrease in medication 
preparation error rates for increasing 
Illumination levels. 
H
0A6
 : T
quadratic
 = 0
 
H
1A6 
: T
quadratic
 ? 0 
F = 
0.895 
p > 0.05 
Do not reject null. 
The mean medication preparation error rates 
did not decrease at a quadratic trend for 
increasing ilumination levels. 
H
0B1
: u1 = u2 = u3 
H
1B1
 : one or more treatment 
means difer 
 X
2
 = 
3.89 
p > 0.05 
Do not reject null. 
Increase in ilumination levels did not result 
in reduction of Wrong dose preparation 
errors.  
 
 
 134 
Hypothesis Values Conclusion based on Results 
H
0B2 
: u1 = u2 = u3 
H
1B2
 : one or more 
treatment means difer 
X
2 
=12.95 
p < 0.05  
Reject the null. 
Increased ilumination levels resulted in 
reduction of Wrong form preparation errors. 
H
0B3
: u1 = u2 = u3 
H
1B3
 : one or more 
treatment means difer 
X
2 
= 9.12 
p = 0.05 
Do not reject null. 
Increase in ilumination levels did not result 
in reduction of Wrong time preparation 
errors 
H
0B4 
: u1 = u2 = u3 
H
1B4 
: one or more 
treatment means difer 
X
2
 = 18.8 
p < 0.05 
Reject the null. 
Increased ilumination levels resulted in 
reduction of Omision errors. 
H
0B5 
: u1 = u2 = u3 
H
1B5 
: one or more 
treatment means difer  
X
2
 = 3.56 
p > 0.05 
Do not reject null. 
Increase in ilumination levels did not result 
in reduction of Unauthorized drug 
preparation errors 
Illumination level 1 
H
0C1 
: M= 0 
H
1C1 
: M ? 0 
F = 0.196 
p > 0.05 
Do not reject null. 
Total number of medications prepared, did 
not afect the mean medication preparation 
error rate. 
Illumination level 2 
H
0C2 
: M= 0 
H
1C2 
: M ? 0 
F = 0 
p > 0.05 
Do not reject null. 
Total number of medications prepared, did 
not afect the mean medication preparation 
error rate. 
 135 
Hypothesis Values Conclusion based on Results 
Illumination level 3 
H
0C3 
: M= 0 
H
1C3 
: M ? 0 
F = 0.122 
p > 0.05 
Do not reject null. 
Total number of medications prepared, did 
not afect the mean medication preparation 
error rate. 
For each individual nurse-
subjects 
H
0D
 : u1= u2 =u3
 
H
1D
 : Error proportions 
difer for al 3 ilumination 
levels 
Chi 
square 
Analysis 
results on 
Table 60 
p > 0.01 
Do not reject null. 
The presence of an observer did not afect 
the proportions of errors, detected for each 
nurse-subject. 
Illumination level 1 
H
0E1 
: U
X
 = U
Y = 
U
Z 
H
1E1 
: Error proportions 
difer for one or more 
study-sections 
X
2 
=4.719  
p > 0.01 
Do not reject null. 
The proportions of medication preparation 
errors remained constant for al the three 
sections 
Illumination level 2 
H
0E2 
: U
X
 = U
Y = 
U
Z 
H
1E2 
: Error proportions 
difer for one or more 
study-sections 
 
 
X
2 
=2.11  
p > 0.01 
Do not reject null. 
The proportions of medication preparation 
errors remained constant for al the three 
sections 
 136 
Hypothesis Values Conclusion based on Results 
Illumination level 3 
H
0E3 
: U
X
 = U
Y = 
U
Z 
H
1E3 
: Error proportions 
difer for one or more 
study-sections. 
X
2 
=4.698 
p > 0.01 
Do not reject null. 
The proportions of medication preparation 
errors remained constant for al the three 
sections. 
For al 3 Illumination 
levels 
H
0F
 : U
9 AM 
=  U
5 PM 
H
1F 
: U
9 AM
 ?  U
5 PM
 
F = 3.78 
p > 0.05 
Do not reject null. 
The time of the medication shift (morning or 
evening) does not afect the medication 
preparation errors. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 137 
Discusion 
Exploratory Findings Related To Demographic Variables Of Nurse-Subjects 
Age 
The performance of the human eye declines with age, with the efects beginning 
to be noticeable at 40 years of age. This leads to changes in the spectral light sensitivity 
that by 80 years of age causes loss of vision. Research has established that aging eyes 
require more light as compared to younger eyes, for optimal visual performance.(M. O. 
Blackwel & Blackwel, 1980; Boyce, 1973; Crouch, 1965; Cullinan, 1986; R. G. Davis 
& Garza, Winter 2002; Smith & Rea, 1978; The IESNA Commite for Healthcare 
Facilities, 2006; The IESNA Lighting for the Aged and Partialy Sighted Commite, 
2007).  Figures 6 and 7 provide additional proof older eyes require increased lighting 
levels for beter visual performance.  
The average age of the nurse-subjects in the study was 34 years; with the oldest 
subject being 47 years and the youngest being 23 years old. The average age for this 
study is far les as compared to the national average of 51 years, as stated by the Joint 
Commision. (Joint Commision on Acreditation of Healthcare Organizations, August 
2002). 
The study results revealed no patern linking the age of the nurse-subject and the 
medication preparation errors asociated with them. 
 
 
 
 
 138 
Employment Status 
Al the nurse-subjects were employed by the study facility for at least a period of 
9 months, with the employment period ranging from 9 months to 112 months.  It was the 
investigator?s speculation that the longer the subject was employed by the facility, the 
beter the subject?s familiarity with the residents and the facility surroundings. This 
experience might provide the subject some improvement in his/her medication 
preparation and administration performance. But, there has been no research in the 
healthcare field investigating this asociation. 
Exploratory observation of the study data suggested no direct relationship 
betwen employment status and the medication preparation error rate of the nurse-
subjects. Future studies need to be conducted to further explore the asociation betwen 
medication errors and employment status (including overal nursing experience). 
 
Educational Level 
The results from literature investigating the asociation betwen level of 
healthcare staf credentials and the frequency of medication errors has been mixed. 
While some studies reported significant diferences in error rates for diferent levels of 
staf credentials (Registered Nurses (RN) and Licensed Practitioner Nurses (LPN)) and 
medication error frequency (Barker KN, Flynn EA et. al., 2002; Pape et. al., 2005; 
Peletier, 2001), the study by Scott-Cawiezel, Pepper GA et.al, 2007 found no significant 
diferences among the error rates for RNs, LPNs and CMTs (Certified Medication 
Technicians). 
 139 
Al the nurse-subjects in this study were Licensed Practitioner Nurses (LPNs), as 
only LPNs were asigned to prepare and administer medications in the study facility.  
 
Gender 
The task of medication preparation and administration often involves dosage 
calculations, which requires significant mathematical skils.  Studies have shown that as 
many as 33% of the medication errors are the result of administering the wrong dosage 
(Bates et. al, 1995); which cals into question the dosage calculation skils of the nursing 
staf involved. The vast majority of nursing personnel are women; therefore, examining 
gender-asociated factors in mathematics (dose calculations) achievement sems relevant. 
Research investigating the role of gender, personal atributes and self- eficacy in nursing 
students found no significant relationship betwen the gender of the nursing students and 
medication errors (Hodge M.B., 1999). 
All the nurse-subjects who participated in this study were females, and thus the 
asociation of gender with medication preparation error rates was excluded from 
examination in this study. 
 
Distractibility  (GEFT) Scores 
Research has shown that distractions negatively efect medication errors, wherein 
the higher the frequency of distractions, the higher the error rate of the particular subject. 
(Flynn E.A,1994). GEFT scores were used as an indicator of distractibility, where higher 
GEFT scores were asociated with lower susceptibility to distractions, hence fewer error 
 140 
rates; and lower GEFT scores were asociated with higher susceptibility to distractions, 
hence higher error rates by the study subject. (Flynn E.A, 1994). 
The GEFT scores of the nurse-subjects in the study ranged from 5 (low score) to 
11 (medium score). But, comparison of the GEFT scores with the frequency of 
medication preparation errors for individual nurse-subjects did not reveal in any 
trend/patern. The nurse-subject asociated with the lowest GEFT score (high 
susceptibility to distractions) happened to have the lowest medication preparation error 
rate in the study (2.8%). 
 
Visual test scores for nurse-subjects 
Visual performance of the nurse-subjects was tested using Snelen charts (Wendy 
Strauss Wat, 2003). As a study measuring visual performance of nurses under varying 
ilumination levels, measurement control for visual acuity of the nurses prior to the study 
was of paramount importance.  
None of the subjects in this study had significant visual impairment based on the 
results of the Snelen tests.  Most of the subjects wore corrective visual aids, such as 
glases or contacts to help with their visual performance. One of the nurses with the 
lowest overal visual acuity score (20/50) was asociated with the highest medication 
preparation error rate (10.4%) in the study. But, as the study design was repeated 
measures within-subjects design, it offered control for such personal characteristics of the 
study-subjects. 
 
 
 141 
Medication Preparation Workload 
The efect of medication preparation workload of each nurse-subject on the 
number of incorrect medications prepared by that nurse was investigated by simple 
linear regresion analysis. The analysis results did not show any significant linear 
relationship betwen medication preparation workload of the nurse-subjects and their 
medication preparation error rate for al three ilumination levels.  
These findings are contrary to the results reported by other studies (Guernsey et 
al., 1983; Buchanan, 1989) wherein the authors found significant linear relationship 
betwen dispensing errors and prescription workload. One reason for this deviation 
might be that the nurse-subjects in this study prepared an average of 85 doses (with a 
range betwen 65 to 108 doses) per medication pas round, which was much les 
compared to the prescription workload of some of the pharmacists in the Buchanan 
study. None of the nurse-subjects in the study were new to the facility and they 
prepared many of the same medications (the physician reviews the medication order 
every month) for a particular medication pas round, so they were familiar with the 
daily medications to be prepared and administered to the residents. Also, the workload 
for the medication pas rounds was relatively constant, which might help speculate the 
deviation of the study findings from previous literature. 
 
 
 
 
 
 142 
Explanatory (Observation) Study Findings 
Efect Of Illumination On Medication Preparation Error Rate 
The first main finding of the study was that there was a significant treatment 
(ilumination) efect (F
2,5 
=17.116, p < 0.05) on the medication preparation error rate. 
There was sufficient theoretical basis in the Human Factors and Ergonomics literature to 
expect a strong linear relationship betwen increased ilumination levels and error rate 
(Blackwel, 1964-1968; Buchanan TL, 1989), and the present study results support the 
theory. The study found that Illumination level 2 (100 foot-candles) had no significant 
efect on medication preparation error rate, whereas ilumination level 3 (145 foot-
candles) had a significant efect. This result was suggested by the results of previous 
studies of dispensing errors, (Buchanan TL, 1989; Buchanan & Barker, 1991), where the 
authors detected similar results. 
The overal medication preparation error rate for the baseline ilumination level 
(30 foot-candles) was 8.5%, and it decreased to 4.3% for ilumination level 3 (145 foot-
candles). The study?s results support the theoretical basis that since the task of medication 
preparation has a high visual component, the visual performance is positively afected by 
increasing the ilumination level. 
The observation data were also analyzed for polynomial contrasts, to se if there 
was a strong linear/quadratic trend to the data. The analysis revealed that the data had a 
strong linear trend, but no significant quadratic trend. That is, the relationship betwen 
ilumination level and medication preparation rate is linear (F
1,6
 = 23.48, p < 0.05), but 
not quadratic (curvilinear). By inspecting the mean error rates in Table 19, it is evident 
that the linear efect is due to decrease in medication preparation error rates with 
 143 
increasing ilumination levels; therefore the significant linear trend was due to the 
increase in ilumination levels. The strong linear trend supports the theoretical basis in 
ilumination sciences literature (Blackwel HR, 1961; Blackwel HR, 1964) that suggest 
that the positive efect of increasing ilumination levels on visual performance has a 
strong linear relationship initialy, followed by a quadratic trend at higher ilumination 
levels, as the efect levels off or even declines. 
This finding was slightly diferent from the previous study (Buchanan 1989, 
Buchanan & Barker, 1991) investigating the efect of ilumination levels on dispensing 
error rate, wherein the dispensing error rate showed significant linear and quadratic trend. 
The quadratic trend was due to the slight increase in dispensing error rate for ilumination 
level of 102 foot-candles, as compared to the baseline measurement (46 foot-candles). 
The observation error data were also analyzed after excluding the Wrong time 
errors, in order to check for any significant diferences betwen the error rate and the 
ilumination levels. The observer calculated the error rate with and without Wrong time 
errors, when it was observed that the nurse-subjects prepared some of the doses to be 
administered in the next med-pas round, during the previous round. But, this behavior 
was not observed uniformly across al nurse-subjects, so the results were computed with 
and without wrong time errors.  The analysis found a significant relationship betwen the 
medication preparation error rate, excluding Wrong time errors and ilumination levels 
(F
2,25 
=21.4, p < 0.05).  
The analysis also found that Illumination level 2 (100 foot-candles) had no 
significant efect on medication preparation error rate, whereas ilumination level 3 (145 
 144 
foot-candles) had a significant efect.!!The results were consistent with the previous 
findings. 
 
Efect Of Illumination On Medication Preparation Error Types 
The second finding of the study was that there were mixed results of significant 
asociations betwen increased ilumination levels and the medication preparation error 
types. Of the five types of error analyzed (wrong dose errors, wrong time errors, omision 
errors, wrong form errors and Unauthorized Drug errors), only wrong form errors (X
2 
=12.954, df =2, p < 0.05) and omision errors (X
2 
=18.825, df =2, p < 0.05) had a 
significant relationship with the ilumination levels. Only wrong form error was found to 
have a linear relationship with increasing linear relationship, with the mean error rate 
decreasing from 1.7% at baseline ilumination level to 0.8 % at 100 foot-candles and 
finaly to 0.6% at 145 foot-candles. (Refer Table 29). 
A reduction in the error rates of Wrong Dose (n=23) and Unauthorized Drug 
(n=4) errors occurred also, from baseline to 145 foot-candles, though the power was too 
low for statistical significance.   
It must also be noted that during the observation period, two of the nurses 
mentioned that the reason behind them crushing the medications was to aid the resident in 
swalowing the medications. Although the observer understood the practical reason for 
crushing the medications, but for the purposes of the study, for the medications on the ?do 
not crush? list or when it was contra-indicated in the prescriber?s orders, such instances 
were counted as an error of wrong form. 
 145 
The observer noted the practice of preparing few of the doses to be administered 
in the next med-pas round, during the previous round, by some of the nurses. This 
behavior was not observed uniformly across al nurse-subjects, so medication preparation 
error rates were computed with and without the wrong time errors. Wrong time errors did 
not demonstrate a significant asociation with increased ilumination levels (Table 30).  
Although there may be reason to speculate that some of the wrong form errors and 
wrong time errors may not have been afected by ilumination, it should be done with 
caution, as no follow up study (or interview) was conducted to explore the subject behavior 
or intention. 
The primary focus of this study was to explore the asociation betwen increased 
ilumination levels and medication preparation errors. It is important to note that no causal 
conclusion can be made about the efect of ilumination on medication preparation error 
types. This asociation must be further explored in future studies, with specific focus on the 
efect of ilumination on vision-related medication errors.  
Reason (2003) defined human error as the failure of a planned sequence of mental 
or physical activities to achieve its intended outcome, when these failures cannot be 
atributed to chance. Whereas he defined mistakes as deficiencies/failures in the judgmental 
and/or inferential proceses involved in the selection of an objective or in the specification 
of the means to achieve it, irrespective of whether or not the actions directed by this 
decision-scheme run acording to plan. (Reason, 2003).  So, interventions such as 
ilumination can directly afect errors, whereas actions that are clasified as mistake might 
need additional intervention tools like educational training or change in policies to addres 
them. It may be speculated that certain behavior like preparing medications for the next 
 146 
med-pas round during the present med-pas round, as wel as crushing of medications that 
are contra-indicated for crushing might be examples of a mistake (or intended action), as 
per Reason?s definitions. But such speculations must be carried out with extreme caution, 
as this study did not explore the intentions of the subjects for their behavior. 
The observer recognizes the fact that changing/increasing the ilumination levels 
is a part of the strategy (along with providing training tools, altering other environmental 
variables that impact errors) to reduce medication preparation errors. 
 
 
Efect Of The Observer On The Observed 
The efect of the presence of an observer on the nurse-subject being observed 
was analyzed using Chi-Square Analysis (Table 39) and found to be minimal. 
Specificaly, the proportion of errors for each nurse-subject, for the entire observation 
period was examined for al three ilumination levels. The analysis revealed that the 
proportions remained constant over each ilumination period for each nurse-subject.  
This finding supports the literature (Barker, 1980) which suggests that the observed 
adapt quickly to the observer after an initial aclimation period. If the observer is 
trained to be non judgmental and unobtrusive, and his/her behavior convinces the study 
subjects that he/she is no longer a threat, then the efect of the observer on the observed 
can be minimized. (Barker,1980). 
Qualitative fedback/comments from the nurse-subjects (Table 44) also helped 
reinforce the analysis findings that the nurses were not threatened by the presence of 
the observer. A graph of Medication preparation error rates was plotted for al 
 147 
observation days, by ilumination level (Figures 46 - 48). The error trend-line remained 
fairly constant for al three ilumination levels, emphasizing that the proportion of 
errors by nurse-subjects were not asociated with the presence of an observer, during 
the study period. 
 
 
Significance Of Nursing Sections 
Statistical control measures were implemented by analyzing the proportion of 
medication preparation errors for al the three sections of the long-term care study site, by 
ilumination levels. The results of the analysis for the three ilumination levels indicated 
that the proportion of medication preparation errors remained constant for al the sections 
at the study site (for baseline ilumination level: X
2 
=4.719, p > 0.01; for 100 foot-candles 
Illumination level: X
2 
=2.11, p > 0.01; for 145 foot-candles Illumination level: X
2 
=4.698, 
 p > 0.01). 
 
 
Significance of Medication Shifts 
Analysis of Variance was used to test for any asociation betwen the medications 
prepared during the medication pas shift (morning med-pas at 9 am and evening med-
pas at 5 pm) and the medication preparation error rates. The results indicate that there 
was no significant diference (F
1,80
 = 3.775, p >0.05) betwen the medication preparation 
error rates, for both the medication pas shifts (9 am and 5 pm) for al three ilumination 
levels.  
 148 
 Limitations 
Sampling Inadequacies 
Sampling inadequacies may pose a limitation to the generalization of this study.  
A. Only oral prescription medications (with pharmacy packaged medication labels) 
were included in the observation study, which limits the generalizability of the study. 
However, the study facility administered about 85% of its medications in oral form. 
B. The study seting was in a long-term care facility with some unique characteristics 
(for eg. Onsite pharmacy, medication pas timings, baseline ilumination levels etc.) 
that would be expected to difer from other facilities. Therefore, any generalization 
must be carried out with extreme caution. 
 
Efect of the Observer on the observed 
The observation method has advantages for certain kinds of studies, but there are 
some limitations that should be considered. Foremost is the danger of the efect of the 
observer on the observed. It is wel known that the observer can afect the subjects of the 
observation simply by mere presence. However this efect varies greatly with the subject 
mater. Measures to counter this efect include the observer being trained to be non 
judgmental and unobtrusive and hence been shown to be efective, in short, subjects sem 
to get used to an observer if his behavior convinces the group members that he is no 
threat.
7
 
 
 
 
 149 
Observer (Investigator) Acuracy 
Also of concern is the possibility of errors by the observer, who was subject to 
some of the same environmental factors as the nurse-subjects during the observation 
period. Scientific training by the observer in the observation method as wel as experience 
in observing medication pas rounds was important as a source of control. In addition, 
prior to the observation period, the observer had her vision checked (vision results: 20/20) 
and took the GEFT distractibility questionnaire with a medium score of 15/18. 
In case of omision errors, the observer was not permited to look at the MAR at 
the medication cart to confirm the reason for omision of certain doses. The basis of 
deciding on an omision error was by reconciling the observed information with that of 
the original physician?s orders. 
 
Blinding of the Observer 
Since the observer was not blinded to the particular ilumination level for a given 
medication shift, there might be potential bias introduced during the medication 
observation phase. In order to control for this bias, the observer masked the ilumination 
level from the observation notes, during the medication review phase.  
 
Subject Participation 
The study subjects were selected by voluntary participation. The nurse-subjects 
were briefed about the main objectives of the observation study and the data collection 
proces. The nurses who signed the Informed Consent Form (Appendix G) and met the 
 150 
study criteria were included as subjects to be observed in the study. Al the nurses, 
excluding one male nurse, signed the consent form.  
 
 
Potential Extraneous variables 
The investigator collected information on demographics such as age, level of 
experience, GEFT (distractibility) scores, educational levels and vision, as a measure of 
control for these potential extraneous variables.  
Medication preparation workload was analyzed for its efect on the preparation 
error rate, and was found to be non-significant.  
The investigator exercised caution during data collection, by keeping the 
ilumination level constant, taking multiple measurement of the ilumination levels during 
the observation period and not observing near any window or other external light sources. 
 
 
 
 
 
 
 
 
 
 
 151 
Recommendations 
Based on the study findings, the following recommendations are proposed: 
1. It is recommended that the study be repeated in other long-term care facilities. Also, 
the study should investigate ilumination level above 145 foot candles. This range of 
ilumination wil perhaps help us understand the presumed linear relationship betwen 
ilumination and medication errors; and if there is a level where the efect reaches a 
plateau or even results in a decrement. 
2. It is recommended that in addition to medication preparation errors, medication 
administration errors also be studied. This wil help in beter understanding the 
ilumination level required in patient rooms, for the visual performance of healthcare 
staf to function optimaly.  
3. It is recommended that the explanatory study be repeated for the night shift (11 PM). 
Many long-term care facilities switch off some of the lights for the night shift, in 
order to facilitate rest for the residents. This decrease in the ilumination level 
throughout the facility in addition to the resident rooms, might act as a barrier for the 
healthcare staf who are administering medications during the night shift. . Also there 
wil be a higher level of contrast betwen the task and ambient lighting. It wil also be 
interesting to look at the efect of increased ilumination levels and the visual 
performance of the healthcare staf during the night shift. 
4. It is recommended that this experimental study be expanded by simulation in a 
laboratory seting, in order to study the efects of lower ilumination levels (lower 
than 100 foot-candles) on visual performances of the nurses. A more complicated 
 152 
study would be to study the efects of ilumination and varying workload levels on the 
visual performances of the nurses. 
5. It is recommended that the efect of variables such as label contrast and font size on 
the medication preparation and administration error rate be investigated. Research 
studies in Illumination Sciences have suggested that variables such as font size and 
contrast impact visual performance; hence afect the medication preparation and 
administration error rate.  
6. It is recommended that in addition to controlling for the subject?s demographic 
variables and medication workload, an explanatory study be designed to control for 
environmental variables such as noise, interruptions and distractions. Medication 
error research studies have demonstrated that increase in the incidences of 
interruptions, distractions and high noise levels led to an increase in medication 
errors, hence the need to control these variables. 
7.  Based on the study findings, an ilumination level of 145 foot candles led to the 
lowest medication preparation error rate of 4.3%, which is lower than the 5% 
medication error standard set by the Centers for Medicare and Medicaid (CMS) for 
long-term care facilities (Centers for Medicare and Medicaid Services, 2006). The 
federal government needs to place greater emphasis in the form of high standards in 
lighting regulations requiring adherence by architects and facility designers. In the 
light of the error rate improvement, CMS should consider seting standards for 
ilumination levels at the long-term care facilities, in order to facilitate optimum 
visual performance by the healthcare staf.  
 153 
8.    It is important to note that this study found no significant improvement in the 
medication preparation error rate when the ilumination was increased from baseline 
(average of 30 foot-candles) to 100 foot-candles.  The Illumination Engineering 
Society of North America (IESNA), which serves as an expert for ilumination 
standards and guidelines across facilities, should reconsider its general ilumination 
recommendation for the medication preparation area. (Ambient lighting 
recommendation is 30 foot-candles; Task lighting recommendation is 100 foot-
candles). 
 
 
Implications for Future Research 
There is great variability among the nursing facilities in diferent states regarding 
lighting regulations.  Lack of lighting standards and specific minimum target iluminance 
values coupled with the aging nursing population catering to the increase in long term-
care residents may aggravate the problem of medication errors in these facilities. The 
consequences, that medication errors can have in terms of mortality, morbidity and 
financial loss to both the patients and the nursing facility is wel documented in literature 
(Bootman et.al, 1997).  
This study demonstrated that it was possible to achieve a medication preparation 
error rate of no more than 4.3% by increasing the ilumination level from 30 foot-candles 
to 145 foot-candles. The significance of this study in particular is to show that the 
adjustment of lighting from baseline level to 145 foot-candles, a relatively low cost 
measure requiring litle or no change in nursing procedures, can achieve a reduction in 
 154 
the medication preparation error rate of more than 50%, and thus surpas the CMS 
maximum medications error rate standard of 5% for long-term care facilities.(Centers for 
Medicare and Medicaid Services, 2006).   
The findings of this study have implications for research in the area of the efect 
of varying ilumination levels on medication errors in diferent healthcare setings. 
Future studies investigating the efect of ilumination levels (maybe greater than 145 
foot-candles) on the medication preparation error rate in diferent healthcare setings 
might help in understanding vision related medication preparation errors and likely 
reduce them to near zero. 
The findings of this research study suggest the need to investigate the efect of 
ilumination on target errors. A target error is defined as an error for which there is 
evidence or theoretical basis for hypothesizing that a particular intervention, in this case 
ilumination, wil change their occurrence or frequency.  
Future research can also addres the relation betwen label contrast and font 
size and its efect on the visual performance of the healthcare staf, under varying levels 
of ilumination. It wil be interesting to study the efects of workload, interruptions, 
distractions and environmental variables such as noise, temperature and humidity on 
the medication preparation error rate under diferent ilumination conditions.  
Research has demonstrated that the nursing homes with more deficiencies and 
those with more serious deficiencies are at higher odds of being sued as compared to 
the ones with fewer deficiencies cited by the CMS (Studdert, Spital et. al., 2011). This 
simple intervention (increasing light levels) has the ability to significantly decrease 
preparation errors and perhaps liability exposure. 
 155 
 
 
 
 
 
 
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 165 
 
 
 
APENDICES 
 
 
 
 
 
166 
 
 
 
APENDIX A 
 
MEMORANDUM OF THE PROJECT 
 
 
 
 167 
APENDIX A 
 
I. Copy of the memorandum  
To:           Al nursing staff  
From:       Investigator (Harrison School of Pharmacy, Auburn University) 
Re:       Student-researcher observing nursing staff regarding their work. 
Date:        March 31, 2009 
??????????????????????.????????????? 
 
 
 The investigator is a student - researcher from Auburn University. She is 
interested in studying the lighting levels at a nursing facility and its impact on work there. 
As part of this research, she wil be observing the nurses during their medication pas 
rounds and asking them questions, if necesary.  
The researcher wil not interrupt the daily work schedule of the staf, and wil 
shadow them without disturbing them. 
The researcher wil measure lighting levels at diferent places in the nursing 
facility, and that includes the medication carts and the nursing stations. She may also take 
pictures of certain areas to show the fixtures and equipment, while measuring the light 
levels. The data collected during the observation period wil be used for research 
purposes, and wil be kept strictly confidential. 
The researcher wil start her observation from April 7, 2009 and wil continue 
until she collects enough data for her research. 
 
If you have any questions, please contact: (Name with-held for confidentiality reasons). 
 
Aproved by: _____________________________      
 
168 
 
 
 
APENDIX B 
 
IRB APROVAL FORMS 
 
 
 
!
! 170!
!
!
!
!
!
! 170!
!
 
171 
 
 
 
APENDIX C 
 
MEDICATION SCHEDULE 
 
 
 
 
 172 
APENDIX C 
 
I. Medication schedule 
!
!
 
173 
 
 
 
APENDIX D 
 
ADITIONAL PICTURES FROM THE NURSING FACILITY 
 
 
 
 174 
 
APENDIX D 
 
Pictures of the nursing facility 
 
 
   Typical medication cart in all sections 
 
 
 
 175 
 
Blister card from Pharmacy 
 
 
 
 
Memo stuck on the notice board 
 176 
 
Resident Medication administration records stacked according to room numbers at 
the nursing stations 
 
 
 
 
MAR folder for controlled substances 
 
 177 
 
 A typical resident room  
 
 
 Resident activity room 
 
 
 
 
 178 
Light fixtures used in the facility 
 
 
 
 
 
 
 179 
 
 
 
 
180 
 
 
 
APENDIX E 
 
COPY OF INCIDENT REPORT FORM 
 
 
 
 181 
APENDIX E 
Incident report form 
!
 
182 
 
 
 
APENDIX F 
 
DATA COLECTION FORMS 
 
 
!
! 183!
Form1 : Drug pass workshet (Observation phase) 
 
Page # ______ ;  Date and Day: ___________ ; Obs time : _______; Illumination Level: 
___;  Nursing unit: __________ 
 
 
      
      
     
!
! 184!
  
Form 2: Drug Orders (Reconciliation phase) 
 
Date: _________; Resident initial/room number: _______; Nursing unit:______ 
 
     
      
      
      
     
 
!
! 185!
Form 3: Medication eror summary shet  
 
Nursing unit: _____________________ ;  Illumination level: ______________ 
 
Day/Date: ____________________; Time/shift : _______________________ 
 
 
Total Errors = _________________ ; 
Total Opportunities for errors = _______ (# of doses given ____ + doses omited _____) 
Error rate = ____________ % ; [(Total errors / T.O.E.) X 100] 
Excluding wrong time errors; Error rate = ________ % ; [{(Total errors - wrong time 
errors) / T.O.E.} X 100]     
 
186 
 
 
 
APENDIX G 
 
INFORMED CONSENT LETER 
 
 
!
! 187!
!
!
!
!
!
!
! 188!
!
 
189 
 
 
 
APENDIX H 
 
RENEWED IRB APROVAL FORMS 
 
 
!
! 190!
 
!
!
!
!
! 191!
!
!
 
192 
 
 
 
APENDIX I 
 
MEDICATION PREPARATION ERROR DESCRIPTION 
 
 
!
! 193!
Appendix I: Table 1I: Medication Preparation Error Types and Frequencies for Section X 
Date 
Nurse 
code 
Ill. 
Level Errors 
Unauth. 
Dose 
Wrong 
dose 
Omisio
n 
Wrong 
Form 
Wrong 
Time 
6/1/10 5E B     19  1 8 1 9 
6/2/10 5E 100 10  2 4 1 3 
6/3/10 5E 145 3   3   
6/9/10 5E 145 4   2 2  
6/10/10 5E 100 3  1  2  
6/11/10 5E B     6   2 4  
6/15/10 5E 100 3  1  2  
6/16/10 5E B     5 1  1 3  
6/17/10 5E 145 2 1   1  
6/23/10 5E B     8 2  2 4  
6/24/10 5E 145 1    1  
6/25/10 5E 100 2    2  
6/3/10 4D B       5   2  3 
6/4/10 4D B     5   2  3 
6/8/10 4D 145 4   1  3 
7/30/10 4D 145 4   1  3 
8/2/10 4D 145 3     3 
6/2/10 2B 145 8   1  7 
6/7/10 2B B     18  1 3  14 
6/10/10 2B 100 11   4  7 
6/11/10 2B 100 6   1  5 
6/24/10 2B 145 3   2  1 
6/25/10 2B B     6     6 
6/28/10 2B B     12  5 2  5 
7/1/10 2B 100 4     4 
!
! 194!
Date 
Nurse 
code 
Ill. 
Level Errors 
Unauth. 
Dose 
Wrong 
dose 
Omisio
n 
Wrong 
Form 
Wrong 
Time 
7/16/10 2B 145 4   1  3 
7/9/10 2B B     7     7 
7/15/10 2B 145 3     3 
7/16/10 2B 100 7   3  4 
6/4/10 7G 100 19   18  1 
6/8/10 7G 100 14  1 13   
6/22/10 7G B     7  1 2 1 3 
6/30/10 7G 145 9  1 6  2 
7/7/10 7G 145 5  1 3  1 
7/19/10 7G 100 5   3 1 1 
TOTAL   235 4 15 90 25 101 
 
Note: It might be possible that some doses categorized as omision erors were prepared 
and administered while the observer was not present at the study site. For the purposes of 
this study, if the observer did not observe the prescribed dose being prepared during the 
medication pass round (with a window of ? 60 minutes), it was termed an omision eror. 
 
 
 
 
 
 
 
 
 
!
! 195!
Table 2I : Description of Medication Preparation Errors for Section X 
Date Ilumination 
level 
Prescribed Drug Prepared Drug Error 
Type 
Notes 
6/1/10 Baseline Metronidazole 
250 mg 
None Omision  
9 AM  Aspirin EC 81 mg Aspirin EC 81 
mg crushed 
Wrong 
form 
 
  Senna Plus None Omision  
  Cetirizine 10 mg None Omision  
  Namenda 10 mg None Omision  
  Acetaminophen 
325 mg 
None Omision  
  Calcium 600 + 
Vit D 
None Omision  
  Aspirin 325 mg None Omission  
  Glimepiride 2 mg None Omision  
  Furosemide    
6/2/10 100 fc Bupropion HCL 
SR 100 mg 
Bupropion HCL 
SR 100 mg; 
crushed 
Wrong 
form 
LPN 
comme
nts ?Its 
bright? 
9 AM  Meclizine 25 mg None Omision  
  Glimepiride 2 mg None Omision  
  Loratadine 10 mg 
# 1 
Loratadine 10 
mg#2 
Wrong 
dose 
 
  Furosemide 20 
mg # ? tab 
Furosemide 20 
mg # 1 
Wrong 
dose 
 
  Ibuprofen 400 mg none Omision  
6/2/10 145 fc Famotidine 20 mg None Omision  
5 PM  Aricept 10 mg; 
due at 9 PM 
Aricept 10 mg; 
given at 4.28 PM 
Wrong 
time 
 
 
!
! 196!
Date Ilumination 
level 
Prescribed 
Drug 
Prepared Drug Error Type Notes 
6/2/10 145 fc Aricept 10 mg; 
due at 9 PM 
Aricept 10 mg; 
given at 5.20 
PM 
Wrong time  
5 PM  Meclizine 12.5 
mg; due at 7 PM 
Meclizine 12.5 
mg; given at 
4.35 PM 
Wrong time  
  Carbi-Levo 
25/100; due at 6 
PM after food 
Carbi-Levo 
25/100; given at 
4.40 PM 
Wrong time  
  Seroquel 100 
mg; due at 9 PM 
Seroquel 100 
mg; given at 5 
PM 
Wrong time  
  Metformin 25 
mg; due at 7 PM 
Metformin 25 
mg; given at 
5.10 PM 
Wrong time  
  Vytorin 10-20 
mg; due at 7 PM 
Vytorin 10-20 
mg; given at 
5.35 PM 
Wrong time  
6/3/10 145 fc Glimepiride 2 
mg 
None Omision  
9 AM  Ibuprofen 400 
mg 
None Omision  
  Therapeutic 
Vitamin 
None Omision  
6/3/10 B Aricept 10 mg; 
due at 9 PM 
Aricept 10 mg; 
given at 4.35 
PM 
Wrong time  
5 PM  Xanax 0.25 mg; 
due at 9 PM 
Xanax 0.25 mg; 
given at 4.40 
PM 
Wrong time  
  Metoprolol 50 
mg 
None Omision  
  Ferrous 
Sulphate 325 
mg; due at 9 PM 
Ferrous 
Sulphate; given 
at 4.50 PM 
Wrong time  
  Colace 100 mg None Omision  
6/4/10 100 fc Omeprazole 25 
mg 
None Omision  
9 AM  Atenolol 25 mg None Omision  
!
! 197!
Date Ilumination 
level 
Prescribed 
Drug 
Prepared Drug Error Type Notes 
  Famotidine 40 
mg 
None Omision  
  Senna Plus None Omision  
  Cetirizine 10 mg None Omision  
  Citalopram 20 
mg 
None Omision  
  Aspirin 81 mg None Omision  
6/4/10 100 fc Namenda 10 mg None Omision LPN says 
?  Light is 
good; can 
se much 
beter?. 
9 AM  Calcium + Vit D None Omision  
  Tylenol 325 mg None Omision  
  Metoprolol 25 
mg; due at 7 
AM 
Metoprolol 25 
mg; given at 
9.30 AM 
Wrong time  
  Therapeutic 
Vitamin 
None Omision  
  Metronidazole 
250 mg 
None Omision  
  KCL 10 MEQ None Omision  
  Claritin 5 mg None Omision  
  Azithromycin 
250 mg 
None Omision  
  Colace 100 mg None Omision  
  Therapeutic 
Vitamin 
None Omision  
  Sodium citrate- 
citric acid 
solution 10 ml 
 
 
None Omision  
!
! 198!
Date Ilumination 
level 
Prescribed 
Drug 
Prepared Drug Error Type Notes 
6/4/10 B Aricept 10 mg; 
due at 9 PM 
Aricept 10 mg; 
given at 4.15 
PM 
Wrong time  
5 PM  Xanax 0.25 mg; 
due at 9 PM 
Xanax 0.25 mg; 
given at 4.25 
PM 
Wrong time  
  Metoprolol 50 
mg 
None Omision  
  Ferrous 
Sulphate 325 
mg; due at 9 PM 
Ferrous 
Sulphate; given 
at 5.10 PM 
Wrong time  
  Colace 100 mg None Omision  
6/7/10 B Singulair 10 mg None Omision  
5 PM  Aricept 10 mg; 
due at 9 PM 
Aricept 10 mg; 
given at 4.30 
PM 
Wrong time  
  Simvastatin 20 
mg; due at 9 PM 
Simvastatin 20 
mg; given at 
4.45 PM 
Wrong time  
6/7/10 B Megestrol 
Acetate 
40mg/ml 
(10ml); due at 9 
PM 
Megestrol 
Acetate 
40mg/ml 
(10ml); given at 
4.45 PM 
Wrong time  
5 PM  Seroquel 100 
mg; due at 9 PM 
Seroquel 100 
mg; given at 
4.55 PM 
Wrong time  
  Benzonatate 100 
mg; due at 9 PM 
Benzonatate 
100 mg; given 
at 5.10 PM 
Wrong time  
  Doxepin 10 mg; 
due at 9 PM 
Doxepin 10 mg; 
given at 5.20 
PM 
Wrong time  
  Ibuprofen 400 
mg 
None Omision  
  Vytorin 10-40 
mg; due at 9 PM 
Vytorin 10-40 
mg; given at 
5.35 PM 
Wrong time  
  Aricept 10 mg; 
due at 9 pm 
Aricept 10 mg; 
given at 5.25 
PM 
Wrong time  
!
! 199!
Date Ilumination 
level 
Prescribed 
Drug 
Prepared Drug Error Type Notes 
  Meclizine 12.5 
mg; due at 7 PM 
Meclizine 12.5 
mg; given at 
4.53 PM 
Wrong time  
  Metronidazole 
250 mg 
None Omision  
  Metoprolol 25 
mg; due at 7 PM 
Metoprolol 25 
mg; given at 
5.18 PM 
Wrong time  
  Vytorin 10-20 
mg; due at 7 PM 
Vytorin 10-20 
mg; given at 
5.33 PM 
Wrong time  
  Aricept 10 mg; 
due at 9 PM 
Aricept 10 mg; 
given at 5.20 
PM 
Wrong time  
  Aricept 5 mg Aricept 10 mg Wrong dose  
  Mirtazapine 25 
mg; due at 9 PM 
Mirtazaping 25 
mg; given at 
5.11 PM 
Wrong time  
  Alprazolam 
0.25mg; due at 9 
PM 
Alprazolam 
0.25 mg; given 
at 5.31 PM 
Wrong time  
6/8/10 100 fc Cal-carb 600+ 
Vit D 
None Omision  
9 AM  Therapeutic 
tablet 
None Omision  
  Cefuroxine 250 
mg 
None Omision  
  Aspiring 325 
mg 
None Omision  
  Cal-carb 600+ 
Vit D 
None Omision  
  Namenda 10 mg None Omision  
6/8/10 100 fc Ibuprofen 400 
mg 
None Omision  
9 AM  Colace 100 mg None Omision  
  Alprazolam 0.25 
mg 
None Omision  
  Doxycycline 
100 mg 
None Omision  
!
! 200!
Date Ilumination 
level 
Prescribed 
Drug 
Prepared Drug Error Type Notes 
  Warfarin 
Sodium 1 mg 
None Omision  
  Atenolol 25 mg Atenolol 20 mg Wrong dose  
  Omeprazole 20 
mg 
None Omision  
  Metronidazole 
250 mg 
None Omision  
6/8/10 145 fc Metoprolol 50 
mg 
None Omision  
5 PM  Ferrous 
Sulphate 325 
mg; due at 9 PM 
Ferrous 
Sulphate 325 
mg; given at 5 
PM 
Wrong time  
  Xanax 0.25 mg; 
due at 9 PM 
Xanax 0.25 mg; 
given at 5.10 
PM 
Wrong time  
  Aricept 10 mg; 
due at 9 PM 
Aricept 10 mg; 
given at 5.35 
PM 
Wrong time  
6/9/10 145 fc Glimepiride 2 
mg 
None Omision  
9 AM  Thiamine HCL 
100 mg 
None Omision  
  Aspirin EC 81 
mg 
Aspirin EC 81 
mg; crushed 
Wrong Form  
  Aspirin EC 81 
mg 
Aspirin EC 81 
mg; crushed 
Wrong Form  
6/10/10 100 fc Bupropion SR 
100 mg 
Bupropion SR 
100 mg; 
crushed 
Wrong form  
9 AM  Aspirin EC 81 
mg; # 1 
Aspirin EC 81 
mg; #2 
Wrong dose  
  Aspirin EC 81 
mg 
Aspirin EC 81 
mg; crushed 
Wrong form  
6/10/10 100 fc Ibuprofen 400 
mg 
None Omision  
5 PM  Citalopram 40 
mg 
None Omision  
  Colace 100 mg None Omision  
!
! 201!
Date Ilumination 
level 
Prescribed 
Drug 
Prepared Drug Error Type Notes 
  Metformin HCl 
500 mg 
None Omision  
  Xanax 0.25 mg; 
due at 9 PM 
Xanax 0.25 mg; 
given at 5.20 
PM 
Wrong time  
6/10/10 100 fc Vytorin 10-20 
mg; due at 7 PM 
Vytorin 10-20 
mg; given at 
4.20 PM 
Wrong time  
5 PM  Metoprolol 25 
mg; due at 7 PM 
Metoprolol 25 
mg; given at 
4.38 PM 
Wrong time  
  Aricept 10 mg; 
due at 9 PM 
Aricept 10 mg; 
given at 4.45 
PM 
Wrong time  
  Vytorin 10-40 
mg; due at 9 PM 
Vytorin 10-40 
mg; given at 5 
PM 
Wrong time  
  Senna Plus; due 
at 9 PM 
Senna Plus; 
given at 5.15 
PM 
Wrong time  
  Simvastatin 20 
mg; due at 9 PM 
Simvastatin 20 
mg; given at 
5.20 PM 
Wrong time  
6/11/10 B Haldol 1 mg Haldol 1 mg; 
crushed 
Wrong form  
9 AM  Aspirin EC 81 
mg 
Aspirin EC 81 
mg; crushed 
Wrong form  
  Aspirin EC 81 
mg 
Aspirin EC 81 
mg; crushed 
Wrong form  
  Bupropion SR 
100 mg 
Bupropion SR 
100 mg; 
crushed 
Wrong form  
  Senna Plus None Omision  
  Tylenol 325 mg None Omision  
6/11/10 100 fc Atenolol 0.25 
mg; due at 9 PM 
Atenolol 0.25 
mg; given at 
4.18 PM 
Wrong time  
5 PM  Seroquel 100 
mg; due at 9 PM 
Seroquel 100 
mg; given at 
4.35 PM 
Wrong time  
!
! 202!
Date Ilumination 
level 
Prescribed 
Drug 
Prepared Drug Error Type Notes 
  Simvastatin 20 
mg; due at 9 PM 
Simvastatin 20 
mg; given at 
4.47 PM 
Wrong time  
  Meclizine 12.5 
mg; due at 7 PM 
Meclizine 12.5 
mg; given at 
5.10 PM 
Wrong time  
  Aricept 10 mg; 
due at 9 PM 
Aricept 10 mg; 
given at 5.13 
PM 
Wrong time  
  Klor Con None Omision  
6/15/10 100 fc Aspirin EC 81 
mg 
Aspirin EC 81 
mg; crushed and 
removed outer 
coating 
Wrong form  
9 AM  Aspirin EC 81 
mg 
Aspirin EC 81 
mg; crushed 
Wrong form  
  Hydroxyzine 25 
mg 
Hydroxyzine 20 
mg 
Wrong dose  
6/16/10 B Bupropion SR 
100 mg 
Bupropion SR 
100 mg; 
crushed 
Wrong form  
9 AM  Aspirin EC 81 
mg 
Aspirin EC 81 
mg; crushed 
Wrong form  
  Aspirin EC 325 
mg 
Aspirin EC 325 
mg; crushed 
Wrong form  
   Pyridium 200 
mg 
Unauthorize
d drug 
 
  Senna S None Omision  
6/17/10 145 fc  Pyridium 200 
mg 
Unauthorize
d drug 
Big lunch 
today, so 
med pas 
early 
9 AM  Aspirin EC 81 
mg 
Aspirin EC 81 
mg; crushed 
Wrong form  
6/22/10 B Aricept 10 mg; 
due at 9 PM 
Aricept 10 mg; 
given at 4.17 
PM 
Wrong time  
5 PM  Meclizine 12.5 
mg; due at 7 PM 
Meclizine 12.5 
mg; given at 
4.11 PM 
Wrong time  
!
! 203!
Date Ilumination 
level 
Prescribed 
Drug 
Prepared Drug Error Type Notes 
  Ceftin 250 mg; 
due at 9 PM 
Ceftin 250 mg; 
given at 4.21 
PM 
Wrong time  
  Omeprazole 20 
mg 
None Omision  
  Aspirin EC 81 
mg 
Aspirin EC 81 
mg; crushed 
Wrong form  
  KCL 10 MEQ  Wrong dose Spils the 
crushed 
contents 
  Ibuprofen 400 
mg 
None Omision  
6/23/10 B Aspirin EC 81 
mg 
Aspirin EC 81 
mg; crushed 
Wrong form  
9 AM  Aspirin EC 81 
mg 
Aspirin EC 81 
mg; crushed 
Wrong form  
6/23/10 B  Senna S Unauthorize
d drug 
 
9 AM   Senna S Unauthorize
d drug 
 
  Doxycycline 
100 mg 
None Omision  
  Lansoprazole 
SR 30 mg 
Lansoprazole 
SR 30 mg; 
crushed 
Wrong form  
  Metoprolol ER 
50 mg 
Metoprolol ER 
50 mg; crushed 
Wrong form  
6/23/10 B Ibuprofen 400 
mg 
None Omision  
9 AM      
6/24/10 145 fc Metoprolol ER 
50 mg 
Metoprolol ER 
50 mg; crushed 
Wrong form  
9 AM      
6/24/10 145 fc Meclizine 12.5 
mg; due at 7 PM 
Meclizine 12.5 
mg; given at 
4.15 PM 
Wrong time  
5 PM  Metronidazole 
250 mg 
None Omision  
!
! 204!
Date Ilumination 
level 
Prescribed 
Drug 
Prepared Drug Error Type Notes 
  Klor Con M10 None Omision  
6/25/10 100 fc Aspirin EC 81 
mg 
Aspirin EC 81 
mg; crushed 
Wrong form  
9 AM  Aspirin EC 81 
mg 
Aspirin EC 81 
mg; crushed 
Wrong form  
6/25/10 B Aricept 10 mg; 
due at 9 PM 
Aricept 10 mg; 
given at 4.45 
PM 
Wrong time  
5 PM  Seroquel 100 
mg; due at 9 PM 
Seroquel 100 
mg; given at 
4.55 PM 
Wrong time  
  Senna S; due at 
9 PM 
Senna S; given 
at 4.59 PM 
Wrong time  
  Aricept 10 mg; 
due at 9 PM 
Aricept 10 mg; 
given at 5.11 
PM 
Wrong time  
  Senna S; due at 
9 PM 
Senna S; given 
at 5.17 PM 
Wrong time  
  Meclizine 12.5 
mg; due at 7PM 
Meclizine 12.5 
mg; given at 
5.20 PM 
Wrong time  
6/28/10 B Seroquel 100 
mg; due at 9 PM 
Seroquel 100 
mg; given at 
4.01 PM 
Wrong time  
5PM  Doxepin 10 mg None Omision  
  Hydroxyzine 25 
mg 
None Omision  
  Senna S; due at 
9 PM 
Senna S; given 
at 4.57 PM 
Wrong time  
  Senna S; due at 
9 PM 
Senna S; given 
at 5.17 PM 
Wrong time  
  Meclizine 12.5 
mg; due at 7 PM 
Meclizine 12.5 
mg; given at 
5.21 PM 
Wrong time  
6/28/10 B Mirtazapine 15 
mg 
 Wrong dose 
LPN crushes 
the pills and 
drops the 
med-cup. 
More than 
half of the 
contents spil 
on the cart 
!
! 205!
Date Ilumination 
level 
Prescribed 
Drug 
Prepared Drug Error Type Notes 
5PM  Senna S  Wrong dose  
  Xanax 2.5 mg  Wrong dose  
  Aricept 5 mg  Wrong dose  
  Carbi-Levo 
25/100 
 Wrong dose  
  Aricept 10 mg; 
due at 9 PM 
Aricept 10 mg; 
given at 5.50 
PM 
Wrong time  
6/30/10 145 fc Senna Plus None Omision  
      
5 PM  Tylenol 325 mg None Omision Resident 
asks for 
it; LPN 
ignores. 
  Colace 100 mg None Omision  
      
  Mirtazapine 30 
mg 
None Omision  
  Meclizine 12.5 
mg; due at 7 PM 
Meclizine 12.5 
mg; given at 
4.15 PM 
Wrong time  
  Aricept 10 mg; 
due at 9 PM 
Aricept 10 mg; 
given at 5.30 
PM 
Wrong time  
7/1/10 100 fc Meclizine 12.5 
mg; due at 7 PM 
Meclizine 12.5 
mg; given at 
4.27 PM 
Wrong time  
5 PM  Seroquel 100 
mg; due at 9 PM 
Seroquel 100 
mg; given at 
4.31 PM 
Wrong time  
  Simvastatin 20 
mg; due at 9 PM 
Simvastatin 20 
mg; given at 
4.45 PM 
Wrong time  
  Xanax 0.5 mg; 
due at 9 PM 
Xanax 0.5 mg; 
at 4.51 PM 
Wrong time  
!
! 206!
Date Ilumination 
level 
Prescribed 
Drug 
Prepared Drug Error Type Notes 
7/6/10 145 fc Simvastatin 20 
mg; due at 9 PM 
Simvastatin 20 
mg; given at 
4.17 PM 
Wrong time  
5 PM  Meclizine 12.5 
mg; due at 7 PM 
Meclizine 12.5 
mg; given at 
4.31 PM 
Wrong time  
  Starlix 120 mg None Omision  
  Aricept 10 mg; 
due at 9 PM 
Aricept 10 mg; 
given at 4.47 
PM 
Wrong time LPN 
comment
s ? I 
forgot 
you were 
here? 
7/7/10 145 fc Sensipar 30 mg None Omision  
5 PM  Meclizine 12.5 
mg; due at 7 PM 
Meclizine 12.5 
mg; given at 
4.27 PM 
Wrong time  
  Sod- citrate + 
Citric acid 
solution 30 ml 
Sod- citrate + 
Citric acid 
solution 25 ml 
Wrong dose  
  Colace 100 mg None Omision  
  Carbi-Levo 
25/100 
None Omision  
7/9/10 B Meclizine 12.5 
mg; due at 7 PM 
Meclizine 12.5 
mg; given at 
4.11 PM 
Wrong time  
5 PM  Seroquel 100 
mg; due at 9 PM 
Seroquel 100 
mg; given at 
4.25 PM 
Wrong time  
  Aricept 10 mg; 
due at 9 PM 
Aricept 10 mg; 
given at 4.47 
PM 
Wrong time  
  Xanax 0.5 mg; 
due at 9 PM 
Xanax 0.5 mg; 
given at 4.50 
PM 
Wrong time  
  Senna S; due at 
9 PM 
Senna S; given 
at 4.55 PM 
Wrong time  
  Senna S; due at 
9 PM 
Senna S; given 
at 5.10 PM 
Wrong time  
!
! 207!
Date Ilumination 
level 
Prescribed 
Drug 
Prepared Drug Error Type Notes 
  Vytorin 10-40 
mg; due at 9 PM 
Vytorin 10-40 
mg; given at 
5.15 PM 
Wrong time  
7/15/10 145 fc Seroquel 100 
mg; due at 9 PM 
Seroquel 100 
mg; given at 
4.10 PM 
Wrong time LPN 
moves 
med cart 
to new 
spots, as 
CNAs 
kept 
distractin
g. 
5 PM  Aricept 10 mg; 
due at 9 PM 
Aricept 10 mg; 
given at 4.27 
PM 
Wrong time  
  Xanax 0.5 mg; 
due at 9 PM 
Xanax 0.5 mg; 
given at 4.30 
PM 
Wrong time  
7/16/10 100 fc Aricept 10 mg; 
due at 9 PM 
Aricept 10 mg; 
given at 4.17 
PM 
Wrong time  
5 PM  Xanax 0.5 mg; 
due at 9 PM 
Xanax 0.5 mg; 
given at 4.24 
PM 
Wrong time  
  Simvastatin 20 
mg; due at 9 PM 
Simvastatin 20 
mg; given at 
4.27 PM 
Wrong time  
  Senna S; due at 
9 PM 
Senna S; given 
at 4.54 PM 
Wrong time  
  Ibuprofen 400 
mg 
None Omision  
  Metformin HCl 
500 mg 
None Omision  
  Colace 100 mg None Omision  
7/19/10 100 fc Xanax 0.25 mg; 
due at 9 PM 
Xanax 0.25 mg; 
given at 4.45 
PM 
Wrong time  
5 PM  Famotidine 40 
mg 
None Omision  
  Senna Plus None Omision  
!
! 208!
Date Ilumination 
level 
Prescribed 
Drug 
Prepared Drug Error Type Notes 
  Senna Plus None Omision  
  Aspirin EC 81 
mg 
Aspirin EC 81 
mg; crushed 
Wrong form  
7/30/10 145 fc Ferrous 
Sulphate 325 
mg; due at 9 PM 
Ferrous 
Sulphate 325 
mg; given at 
5.10 PM 
Wrong time  
5 PM  Metoprolol 50 
mg 
None Omision  
  Xanax 0.25 mg; 
due at 9 PM 
Xanax 0.25 mg; 
given at 5.15 
PM 
Wrong time  
  Aricept 10 
mg;due at 9 PM 
Aricept 10 mg; 
given at 5.20 
PM 
Wrong time  
8/2/10 145 fc Xanax 0.25 mg; 
due at 9 PM 
Xanax 0.25 mg; 
given at 4.17 
PM 
Wrong time  
5 PM  Aricept 10 
mg;due at 9 PM 
Aricept 10 mg; 
given at 4.23 
PM 
Wrong time  
  Ferrous 
Sulphate 325 
mg; due at 9 PM 
Ferrous 
Sulphate 325 
mg; given at 
5.10 PM 
Wrong time  
 
 
 
 
 
 
 
 
 
 
!
! 209!
 
Table 3I: Medication Preparation Error Types and Frequencies for Section Y 
Date 
Nurse 
code 
Il. 
Level 
Med 
pass time 
Total 
meds Errors TOE 
Error 
rate 
Error 
rate 
exclud 
wrong 
time 
erors 
7/22/10 4D 100 5:00 PM 78 10 81 12.3 3.7 
7/23/10 4D B       5:00 PM 75 7 75 9.33 8 
7/26/10 4D B       5:00 PM 75 8 80 10 7.5 
6/28/10 7G 145 9:00 AM 76 5 79 6.33 6.33 
7/9/10 7G B       9:00 AM 79 14 92 15.2 15.2 
8/9/10 7G 145 5:00 PM 87 5 89 5.61 4.49 
6/29/10 6F B       9:00 AM 81 4 83 4.81 4.81 
6/30/10 6F 100 9:00 AM 84 10 94 10.64 10.64 
7/6/10 6F 100 9:00 AM 87 3 89 3.37 3.37 
7/7/10 6F 145 9:00 AM 92 5 95 5.26 4.21 
7/13/10 6F 145 9:00 AM 90 2 92 2.17 2.17 
7/20/10 6F B       9:00 AM 85 4 87 4.59 4.59 
7/21/10 6F 100 9:00 AM 74 3 75 4 2.66 
7/23/10 6F 100 9:00 AM 82 1 82 1.22 0 
7/27/10 6F B       9:00 AM 82 4 84 4.76 4.76 
7/28/10 6F 145 9:00 AM 90 3 90 3.33 2.22 
7/29/10 6F B       9:00 AM 93 5 94 5.32 4.25 
7/30/10 6F 145 9:00 AM 85 2 85 2.35 2.35 
6/9/10 3C B       5:00 PM 69 7 70 10 4.29 
6/14/10 3C 100 5:00 PM 73 5 75 6.66 4 
!
! 210!
Date 
Nurse 
code 
Il. 
Level 
Med 
pass time 
Total 
meds Errors TOE 
Error 
rate 
Error 
rate 
exclud 
wrong 
time 
erors 
6/15/10 3C 100 5:00 PM 81 7 85 8.23 5.88 
6/16/10 3C 100 5:00 PM 76 6 78 7.69 3.85 
6/17/10 3C 145 5:00 PM 75 5 75 6.66 1.33 
6/23/10 3C 145 5:00 PM 75 5 76 6.58 3.95 
6/29/10 3C B       5:00 PM 70 9 74 12.16 6.76 
7/5/10 3C B       5:00 PM 79 6 79 7.59 2.53 
7/8/10 3C 145 5:00 PM 73 4 75 5.33 4 
TOTAL    2166 149 2233 6.672 4.57 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
!
! 211!
Table 4I : Description of Medication Preparation Errors for Section Y 
Date Illumination 
level 
Prescribed Drug Prepared Drug Error 
Type 
Notes 
6/9/10 Baseline Sertraline 50 mg; due 
at 9 PM 
Sertraline 50 mg; 
given at 4.15 PM 
Wrong 
time 
 
5 PM  Renagel 80 mg; # 4 
pils 
Renagel 800 mg; 
#2 pils 
Wrong 
dose 
 
  Furosemide 40 mg None Omision  
  Simvastatin 20 mg; due 
at 9 PM 
Simvastatin 20 mg; 
given at 4.45 PM 
Wrong 
time 
 
  Calcium 60 mg + Vit 
D; due at 7 PM 
Calcium 60 mg + 
Vit D; given at 4.47 
PM 
Wrong 
time 
 
  Simvastatin 10 mg; due 
at 9 PM 
Simvastatin 10 mg; 
given at 5.02 PM 
Wrong 
time 
 
  Detrol LA 4 mg Detrol LA 4 mg; 
crushed 
Wrong 
form 
 
6/14/10 100 fc Hydralazine 25 mg None Omision  
5 PM  Xanax 0.25 mg None Omision  
  Detrol LA 4 mg Detrol LA 4mg 
crushed 
Wrong 
form 
 
  Simvastatin 20 mg; due 
at 9 PM 
Simvastatin 20 mg; 
given at 5.30 PM 
Wrong 
time 
 
  Ferous Gluconate 324 
mg; due at 9 PM 
Ferous Gluconate 
324 mg; given at 
5.47 PM 
Wrong 
time 
 
6/15/10 100 fc Sena Plus None Omision  
5 PM  Sena Plus None Omision  
  Megestrol Acetate 40 
mg/ml 
None Omision  
  Ferous Gluconate 324 
mg; due at 7PM 
Ferous Gluconate 
324 mg; given at 
4.50 PM 
Wrong 
time 
 
  Klor Con M10 None Omision  
 
 
!
! 212!
Date Illumination level Prescribed Drug Prepared 
Drug 
Error 
Type 
Notes 
6/15/1
0 
100 fc Calcium 60 mg 
+ Vit D; due at 7 
PM 
Calcium 60 
mg + Vit D; 
given at 5.40 
PM 
Wrong 
time 
 
5 PM      
6/16/1
0 
100 fc Sena Plus None Omision  
5 PM  Detrol LA 4 mg Detrol LA 
4mg curshes 
Wrong 
form 
 
  Aspirin 325 mg None Omision  
  Ferous 
Gluconate 324 
mg; due at 7PM 
Ferous 
Gluconate 324 
mg; given at 
4.30 PM 
Wrong 
time 
 
  Calcium 60 mg 
+ Vit D; due at 7 
PM 
Calcium 60 
mg + Vit D; 
given at 5.10 
PM 
Wrong 
time 
 
  Simvastatin 20 
mg; due at 9PM 
Simvastatin 
20 mg; gien at 
5.35 PM 
Wrong 
time 
 
6/17/1
0 
145 fc Ferous 
Gluconate 324 
mg; due at 7PM 
Ferous 
Gluconate 324 
mg; given at 
4.10 PM 
Wrong 
time 
 
5 PM  Simvastatin 20 
mg; due at 9PM 
Simvastatin 
20 mg; gien at 
4.25 PM 
Wrong 
time 
 
  Calcium 60 mg 
+ Vit D; due at 7 
PM 
Calcium 60 
mg + Vit D; 
given at 5.17 
PM 
Wrong 
time 
 
  Detrol LA 4 mg Detrol LA 
4mg curshes 
Wrong 
form 
 
  Simvastatin 10 
mg; due at 9PM 
Simvastatin 
10 mg; gien at 
5.48 PM 
Wrong 
time 
 
6/23/1
0 
145 fc Miralax Powder None Omision  
5 PM  Colace solution 
10 ML 
Colace 
solution 5 ML 
Wrong 
dose 
 
  Simvastatin 20 
mg; due at 9PM 
Simvastatin 
20 mg; at 5.1 
Wrong 
time 
 
!
! 213!
Date Illumination level Prescribed Drug Prepared 
Drug 
Error 
Type 
Notes 
  Calcium 60 mg 
+ Vit D; due at 7 
PM 
Calcium 60 
mg + Vit D; 
given at 5.21 
PM 
Wrong 
time 
 
  Detrol LA 4 mg Detrol LA 
4mg curshes 
Wrong 
form 
 
6/28/1
0 
145 fc Aspirin 81 mg, 
EC 
Aspirin 81 mg 
EC, crushes 
Wrong 
form 
 
9 AM  Sena solution 15 
ML 
Sena 
solution 
around 5 ML 
Wrong 
dose 
LPN does not 
accurately 
measure the 
solution. 
  Carvedilol 6.25 
MG 
None Omision LPN takes 
pil; but puts 
it in trash 
  Calcitrol 25 MG None Omision  
  Miralax Powder None Omision  
6/29/1
0 
B Omeprazole DR 
20 mg 
Omeprazole 
DR 20 mg; 
crushes 
Wrong 
form 
 
9AM  Metoprolol 
Sucinate ER 50 
mg 
Metoprolol 
Sucinate ER 
50 mg; 
crushes 
Wrong 
form 
 
  Megestrol Acetate 
solution 10 ml 
None Omision LPN says not 
on cart; wil 
give it later. 
Did not given 
until observer 
present at 
site. 
  Lorazepam 0.5 
mg 
None Omision  
6/29/1
0 
B Klor Con M10 None Omision 2 residents 
hospitalized; 
1 resident 
pased away; 
LPN 
expressed 
concern. 
5PM  Sertraline 50 mg; 
due at 9PM 
Sertraline 50 
mg; given at 
4.37 PM 
Wrong 
time 
 
!
! 214!
Date Illumination 
level 
Prescribed Drug Prepared 
Drug 
Error 
Type 
Notes 
  Renagel 80 mg; 
# 4 
Renagel 80 
mg; # 3 given 
Wrong 
dose 
LPN 
comented ?I 
could use a 
light here!? 
  Furosemide 40 
mg 
None Omision  
  Amoxycilin 50 
mg 
None Omision  
  Simvastatin 20 
mg; due at 9 PM 
Simvastatin 
20 mg; given 
at 5.15 PM 
Wrong 
time 
 
6/29/1
0 
B Calcium 60 mg+ 
Vit D; due at 7 
PM 
Calcium 60 
mg+ Vit D; 
given at 5.27 
PM 
Wrong 
time 
 
 
5 PM  Megestrol Acetate 
10 ml 
None Omision  
  Simvastatin 10 
mg; due at 9 PM 
Simvastatin 
10 mg; given 
at 5.30 PM 
Wrong 
time 
Stoped med-
pas at 5.30 
PM to fed 
residents. 
Asked 
observer to 
leave. 
6/30/1
0 
100 fc Carvedilol 6.25 
mg 
None Omision Interuptions 
by family 
members of a 
resident. 
LPN 
comented ?I 
like that 
light?. 
One LPN to 
another ?Do 
you like to 
keep that 
light?? 
Study LPN ?I 
don?t know; 
but I like that 
light.? 
Fire alarm 
dril from 
9.03 am to 
9.06 am; LPN 
works 
throughalarm. 
!
! 215!
Date Illumination 
level 
Prescribed Drug Prepared 
Drug 
Error 
Type 
Notes 
9 AM  Sena S None Omision Resident 
refused the 
folowing 9 
medications; 
so LPN 
trashes all the 
meds. 
  Digoxin 125 mcg None Omision  
  Lisinopril 2.5 mg None Omission  
  Klor Con M10 None Omision  
6/30/1
0 
 Glyburide 
Metformin 
2.5mg/ 5mg 
None Omision  
9 AM  Furosemide 40 
mg 
None Omision  
  Paroxetine 20 mg None Omision  
  Megestrol Acetate 
10 ml 
None Omision  
  Lorazepam 0.5 
mg 
None Omision  
7/5/10 B Detrol LA 4mg Detrol LA 
4mg; crushes 
Wrong 
form 
 
5 PM  Ferous 
Gluconate 324 
mg; due at 7 PM 
Ferous 
Gluconate 324 
mg; given at 
4.15 PM 
Wrong 
time 
 
  Calcium 60 mg 
+ Vit D; due at 7 
PM 
Calcium 60 
mg + Vit D; 
given at 4.23 
PM 
Wrong 
time 
 
  Simvastatin 20 
mg; due at 9 PM 
Simvastatin 
20 mg; given 
at 4.47 PM 
Wrong 
time 
 
  Sertraline 50 mg; 
due at 9 PM 
Sertraline 50 
mg; given at 
5.25 PM 
Wrong 
time 
 
  Sena solution 10 
ml 
Sena 
solution; 
measured 
around 5 ml 
Wrong 
dose 
 
!
! 216!
Date Illumination 
level 
Prescribed Drug Prepared 
Drug 
Error 
Type 
Notes 
7/6/10 100 fc Aspirin 325 mg None Omision  
9 AM  Miralax Powder None Omision  
  Colace solution 
10 ml 
Colace 
solution; 
around 5 ml 
Wrong 
dose 
 
7/7/10 145 fc Carvedilol 6.25 
mg 
None Omision LPN 
comented 
that she did 
not slep the 
whole night. 
9AM  Torsemide 20 mg None Omision  
  Colace 10 mg None Omision  
  Aspirin EC 81 mg Aspirin EC 81 
mg crushes 
Wrong 
form 
 
  Calcium 60 mg 
+ Vit D; due at 7 
AM 
Calcium 60 
mg + Vit D; 
given at 9.25 
AM 
Wrong 
time 
 
7/8/10 145 fc Namenda 10 mg None Omision  
5 PM  Detrol LA 4 mg Detrol LA 
4mg; crushes 
Wrong 
form 
 
  Ferous 
Gluconate 324 
mg; due at 7 PM 
Ferous 
Gluconate 324 
mg; given at 
5.10 PM 
Wrong 
time 
 
  Klor Con M10 None Omision LPN got 
distracted 
watching TV 
7/9/10 B Metformin 100 
mg 
None Omision  
9 AM  Sena solution 15 
ml 
None Omision LPN on 
seeing 
observer 
enter site ? 
oh, she is 
again on my 
face!? But did 
not stop 
observer from 
observation. 
!
! 217!
Date Illumination 
level 
Prescribed Drug Prepared 
Drug 
Error 
Type 
Notes 
  Colace solution 
10 ml 
None Omision  
  KCL 10 MEQ None Omision  
  Colace 10 mg None Omision  
  Zyrtec 10 mg None Omision  
  Protonix 40 mg; 
due at 7 AM 
Protonix 40 
mg; given at 
9.45 AM 
Omision  
  Torsemide 20 mg None Omision  
  Ranitidine 150 
mg 
None Omision  
  Sena S none Omision  
  Sena S None Omision  
  Carvedilol 6.25 
mg 
None Omision  
  Calcitrol 0.25 mg None Omision  
7/13/1
0 
145 fc Torsemide 20 mg None Omision  
9AM  Amitiza 24 mcg None Omision  
7/20/1
0 
B Omeprazole DR 
20 mg 
Omeprazole 
DR 20 mg; 
crushes 
Wrong 
form 
 
9AM  Metoprolol 
Sucinate ER 50 
mg 
Metoprolol 
Sucinate ER 
50 mg; 
crushes 
Wrong 
form 
 
  Aspirin 325 mg None Omision  
  Torsemide 20 mg None Omision  
7/21/1
0 
100 fc Aspirin EC 81 mg Aspirin EC 81 
mg; crushes 
Wrong 
form 
 
9AM  Calcium 60 mg 
+ Vit D; due at 7 
AM 
Calcium 60 
mg + Vit D; 
given at 9.23  
Wrong 
time 
 
!
! 218!
Date Illumination 
level 
Prescribed Drug Prepared 
Drug 
Error 
Type 
Notes 
  Namenda 10 mg None Omision  
7/22/1
0 
100 fc Colace 10 mg None Omission  
5PM  Warfarin sodium 
2 mg 
None Omision  
  Ferous 
Gluconate 324 
mg; due at 7 PM 
Ferous 
Gluconate 324 
mg; given at 
5.07 PM 
Wrong 
time 
 
  Klor Con M10 None Omision  
  Diazepam 5 mg; 
due at 7 PM 
Diazepam 
5mg; given at 
5.19 PM 
Wrong 
time 
 
  Simvastatin 40 
mg; due at 9 PM 
Simvastatin 
40 mg; given 
at 5.23 PM 
Wrong 
time 
 
  Haldol 2 mg; due 
at 9PM 
Haldol 2 mg; 
given at 5.26 
PM 
Wrong 
time 
 
  Simvastatin 20 
mg; due at 9 PM 
Simvastatin 
20 mg; given 
at 5.31 PM 
Wrong 
time 
 
  Calcium 60 
mg+Vit D; due at 
7 PM 
Calcium 60 
mg +Vit D; 
given at 
5.33PM 
Wrong 
time 
 
  Clonazepam 0.5 
mg; due at 9 PM 
Clonazepam 
0.5 mg; given 
at 5.35 PM 
Wrong 
time 
 
7/23/1
0 
 
 
9AM 
100 fc Calcium 60 mg+ 
Vit D; due at 7 
AM 
Calcium 60 
mg+ Vit D; 
given at 10.25 
Am 
Wrong 
time 
LPN stopped 
med-pas at 
9.30 am, as 
one of the 
resident?s 
blood sugar 
level 
elevated. 
Resumed 
med-pas , 
but remained 
concerned 
and distracted 
for rest of 
med-pas 
!
! 219!
Date Illumination 
level 
Prescribed Drug Prepared 
Drug 
Error 
Type 
Notes 
7/23/1
0 
B Renagel 80 mg # 
4 
Renagel 80 
mg #2 
Wrong 
dose 
 
5 PM  Simvastatin 10 
mg; due at 9 PM 
Simvastatin 
10 mg; given 
at 4.30 PM 
Wrong 
time 
 
  Simvastatin 40 
mg; due at 9 PM 
Simvastatin 
40 mg; given 
at 4.47 PM 
Wrong 
time 
 
  Ferous 
Gluconate 324 
mg; due at 7 PM 
Ferous 
Gluconate 324 
mg; given at 
5.11 PM 
Wrong 
time 
 
  Haldol 2 mg; due 
at 9PM 
Haldol 2mg; 
given at 5.17 
PM 
Wrong 
time 
 
  Diazepam 5 mg; 
due at 9PM 
Diazepam 5 
mg; given at 
5.27 PM 
Wrong 
time 
 
7/26/1
0 
B Simvastatin 40 
mg; due at 9 PM 
Simvastatin 
40 mg; given 
at 4.30 PM 
Wrong 
time 
 
5 PM  Colace 10 mg None Omision  
  Sena Plus None Omision  
  Sena Plus None Omision  
  Diazepam 5 mg; 
due at 9 PM 
Diazepam 5 
mg; given at 
4.47 PM 
Wrong 
time 
 
  Carvedilol 6.25 
mg 
None Omision  
  Warfarin Sodium 
2.5mg 
None Omission  
  Detrol LA 4 mg Detrol LA 
4mg; crushes 
Wrong 
form 
 
7/27/1
0 
B Omeprazole DR 
20 mg 
Omeprazole 
DR 20 mg; 
crushes 
Wrong 
form 
 
9 AM  Detrol LA 4 mg Detrol LA 4 
mg; crushes 
Wrong 
form 
 
  Amitiza 24 mcg None Omision  
!
! 220!
Date Illumination 
level 
Prescribed Drug Prepared 
Drug 
Error 
Type 
Notes 
  Calcium 60 mg 
+ Vit D 
None Omision  
7/28/1
0 
145 fc Calcium 60 mg 
+Vit D; due at 7 
AM 
Calcium 60 
mg+ Vit D; 
given at 9.10 
AM 
Wrong 
time 
 
9 AM  Detrol LA 4 mg Detrol LA 4 
mg; crushes 
Wrong 
form 
 
  Aspirin EC 81 mg Aspirin EC 81 
mg crushes 
Wrong 
form 
 
7/29/1
0 
B Calcium 60 
mg+Vit D; due at 
7 AM 
Calcium 60 
mg +Vit D; 
given at 9.17 
AM 
Wrong 
time 
 
9 AM  Lortab 7.5/50 
mg 
None Omision LPN drops 
pil, but does 
not replace it. 
  Detrol LA 4 mg Detrol LA 4 
mg crushes 
Wrong 
form 
 
  KCL 10 MEQ KCL 10 MEQ 
crushes 
Wrong 
form 
LPN 
observed 
dropping pils 
at 3 diferent 
instances. 
  KCL 10 MEQ KCL 10 MEQ 
crushes 
Wrong 
form 
 
7/30/1
0 
145 fc Detrol LA 4 mg Detrol LA 4 
mg crushes 
Wrong 
form 
 
9 AM  Klor Con M10 Klor Con M10 
crushes 
Wrong 
form 
Rx stated ?do 
not crush? 
8/9/10 145 fc Detrol LA 4mg Detrol LA 
4mg crushes 
Wrong 
form 
 
5 PM  Colace solution 
10 ml 
Colace 
solution; 
around 5 ml 
Wrong 
dose 
 
  Miralax powder None Omision  
  Verapamil 80 mg None Omision  
  Trazodone 50 mg; 
due at 9 PM 
Trazodone 50 
mg; given at 
5.10 PM 
Wrong 
time 
 
 
!
! 221!
Table 5I : Medication Preparation Error Types and Frequencies for Section Z 
Date 
Nurse 
code 
Ill. 
Level Errors 
Unauth. 
Dose 
Wrong 
dose Omision 
Wrong 
Form 
Wrong 
Time 
7/13/10 4D 100 9   1  8 
7/14/10 4D 100 14   4  10 
7/20/10 4D 145 5     5 
7/21/10 4D 100 7     7 
7/2/10 7G 100 4   3 1  
7/26/10 7G B     8   8   
8/6/10 7G B     8   6 2  
7/1/10 1A B     4   1 3  
7/2/10 1A 100 2    2  
7/5/10 1A 100 3    3  
7/8/10 1A 100 4   3 1  
7/14/10 1A 145 1   1   
7/15/10 1A 145 2   2   
7/16/10 1A 145 1    1  
7/19/10 1A 145 0      
7/22/10 1A B     2    2  
8/2/10 1A B     4   2 2  
8/3/10 1A 100 1   1   
8/9/10 1A B     4   1 3  
TOTAL   83 0 0 33 20 30 
 
 
 
 
 
!
! 222!
Table 6I: Description of Medication Preparation Errors for Section Z 
Date Illuminati
on level 
Prescribed Drug Prepared Drug Error Type Notes 
7/1/201
0 
B Colace 10 mg None Omision 
LPN said 
she was 
behind 
schedule; 
so was 
rushing 
her med-
pas. 
Wanted 
to finish 
before 
10 AM 
9 AM  Aspirin EC 81 mg Aspirin EC 81 mg 
crushes 
Wrong form 
LPN said 
for some 
reason I 
keep 
losing 
the 
Aspirin 
tablet. 
  Oxybutynin ER 
10mg 
Oxybutynin ER 10mg 
crushed 
Wrong form 
 
  KCL 10 MEQ KCL 10 MEQ; 
crushed 
Wrong form 
Order 
states? 
do not 
crush? 
7/2/10 100 fc Aspirin EC 81 mg Aspirin EC 81 mg 
crushed 
Wrong form 
 
9 AM  Oxybutynin ER 
10mg 
Oxybutynin ER 10mg 
crushed 
Wrong form 
Order 
states? 
do not 
crush? 
7/2/10 100 fc Erythromycin ER 
250 mg 
None Omision 
 
5PM  Colace 10 mg None Omision 
 
  Sena Plus None Omision 
 
  KCL 10 MEQ KCL 10 MEQ; 
crushed 
Wrong form 
Order 
states? 
do not 
crush? 
7/5/10 100 fc KCL 10 MEQ KCL 10 MEQ; 
crushed 
Wrong form 
Order 
states? 
do not 
crush? 
9 AM  Aspirin EC 81 mg Aspirin EC 81 mg 
crushed 
Wrong form 
 
  Oxybutynin ER 
10mg 
Oxybutynin ER 10mg 
crushed 
Wrong form 
do not 
crush? 
!
! 223!
Date Illuminati
on level 
Prescribed Drug Prepared Drug Error Type Notes 
7/8/10 100 fc KCL 10 MEQ KCL 10 MEQ; 
crushed 
Wrong form 
Order 
states? 
do not 
crush? 
9 AM  Colace 10 mg None Omision 
 
  Vitamin D None Omision 
 
  Therapeutic Tablet None Omision  
7/13/10 100 fc Sena tablet; due at 
9 PM 
Sena tablet; given at 
4.08 PM 
Wrong time 
LPN: 
Are you 
going to 
tell them 
to give 
us this 
light? I 
realy 
like the 
light. We 
move a 
lot, so I 
like this 
extra 
light. 
 
5 PM  Sena tablet; due at 
9 PM 
Sena tablet; given at 
4.09 PM 
Wrong time 
 
  Hydralazine 50 mg; 
due at 9 PM 
Hydralazine 50 mg; 
given at 4.20 PM 
Wrong time 
 
  Mirtazapine 30 mg; 
due at 9 PM 
Mirtazapine 30 mg; 
given at 5.11 PM 
Wrong time 
 
  Seroquel 25 mg; due 
at 9 PM 
Seroquel 25 mg; 
given at 5.15 PM 
Wrong time 
 
  Niacin SR 250 mg; 
due at 9 PM 
Niacin SR 250 mg; 
given at 5.30 PM 
Wrong time 
 
  Vytorin 10/20; due 
at 9 PM 
Vytorin 10/20; given 
at 5.47 PM 
Wrong time 
 
  Erythromycin film 
coated 250 mg 
None Omision 
 
  Simvastatin 40 mg; 
due at 7 PM 
Simvastatin 40 mg; 
given at 5.53 PM 
Wrong time 
 
7/14/10 145 fc Erythromycin film 
coated 250 mg 
None Omision 
 
9 AM     
 
!
! 224!
Date Illuminati
on level 
Prescribed Drug Prepared Drug Error Type Notes 
7/14/10 100 fc Hydralazine 50 mg; 
due at 9 PM 
Hydralazine 50 mg; 
given at 4.25 PM 
Wrong time 
 
5 PM  Sena tablet; due at 
9 PM 
Sena tablet; given at 
4.39 PM 
Wrong time 
 
  Colace; due at 9 PM Colace; given at 5.09 
PM 
Wrong time 
 
  Simvastatin 40 mg; 
due at 7 PM 
Simvastatin 40 mg; 
given at 5.20 PM 
Wrong time 
 
  Diltiazem 240 mg None Omision 
 
  Lisinopril 20 mg None Omision 
 
  Lisinopril 20 mg None Omision  
  Therapeutic tablet None Omision  
  Simvastatin 40 mg; 
due at 9 PM 
Simvastatin 40 mg; 
given at 5.27 PM 
Wrong time  
  Vytorin 10/20; due 
at 9 PM 
Vytorin 10/20; given 
at 5.31 PM 
Wrong time  
  Niacin SR 250 mg; 
due at 9 PM 
Niacin SR 250 mg; 
given at 5.37 PM 
Wrong time  
  Aspirin EC 81 mg 
due 30 mins before 
Niacin (8.30 PM) 
Aspirin EC 81 mg ; 
given at 5.40 PM 
Wrong time  
  KCL 10 MEQ; due 
at 9 P 
KCL 10 MEQ; given 
at 5.41 PM 
Wrong time  
  Mirtazapine 30 mg; 
due at 9 PM 
Mirtazapine 30 mg; 
given at 5.45 PM 
Wrong time  
7/15/10 145 fc Erythromycin film 
coated 250 mg 
None Omision  
9AM  KCL 10 MEQ KCL 10 MEQ; 
crushed 
Wrong form 
Order 
states? 
do not 
crush? 
7/16/10 145 fc Aspirin EC 81 mg Aspirin EC 81 mg 
crushed 
Wrong form 
 
9 AM      
7/20/10 145 fc Aspirin EC 81 mg 
due 30 mins before 
Niacin (8.30 PM) 
Aspirin EC 81 mg ; 
given at 4.10 PM 
Wrong time  
!
! 225!
Date Illuminati
on level 
Prescribed Drug Prepared Drug Error Type Notes 
5 PM  Colace; due at 9 PM Colace; given at 4.19 
PM 
Wrong time  
  Lipitor 80 mg; due 
at 9 PM 
Lipitor 80 mg; given 
at 4.21 PM 
  
  Seroquel 25 mg; due 
at 9 PM 
Seroquel 25 mg; 
given at 4.35 PM 
Wrong time  
  Mirtazapine 30 mg; 
due at 9 PM 
Mirtazapine 30 mg; 
given at 4.45 PM 
Wrong time  
7/21/10 100 fc Colace; due at 9 PM Colace; given at 4.09 
PM 
Wrong time  
5 PM  Aspirin EC 81 mg 
due 30 mins before 
Niacin (8.30 PM) 
Aspirin EC 81 mg ; 
given at 4.13 PM 
Wrong time  
  Niacin SR 250 mg; 
due at 9 PM 
Niacin SR 250 mg; 
given at 4.27 PM 
Wrong time 
LPN: 
This 
light is 
realy 
good. 
You 
should 
patent it. 
I wil ask 
the 
administr
ator to 
get a 
light like 
this for 
me. I 
cant see 
otherwis
e. 
  Seroquel 25 mg; due 
at 9 PM 
Seroquel 25 mg; 
given at 4.35 PM 
Wrong time 
 
  Hydralazine 50 mg; 
due at 9 PM 
Hydralazine 50 mg; 
given at 4.39 PM 
Wrong time 
 
  Simvastatin 40 mg; 
due at 9 PM 
Simvastatin 40 mg; 
given at 5.07 PM 
Wrong time 
 
  KCL 10 MEQ; due 
at 9 P 
KCL 10 MEQ; given 
at 5.1 PM 
Wrong time 
 
7/22/10 B Aspirin EC 81 mg Aspirin EC 81 mg 
crushed 
Wrong form 
 
9 AM  Oxybutynin ER 
10mg 
Oxybutynin ER 10mg 
crushed 
Wrong form 
Order 
states? 
do not 
crush? 
7/26/10 B Vitamins None Omision 
 
!
! 226!
Date Illuminati
on level 
Prescribed Drug Prepared Drug Error Type Notes 
9 AM  Dulcolax 5 mg None Omision 
 
  Miralax Powder; 1 
capful 
None Omision 
 
  Loratadine 10 mg None Omision 
 
  Nexium 40 mg None Omision 
 
  Zyrtec 10 mg None Omision 
 
  Colace 10 mg None Omision 
 
  Saltropine 0.4 mg None Omision 
 
8/2/10 B Aspirin EC 81 mg Aspirin EC 81 mg 
crushed 
Wrong form 
 
9 AM  Oxybutynin ER 
10mg 
Oxybutynin ER 10mg 
crushed 
Wrong form 
Order 
states? 
do not 
crush? 
  Dulcolax 5 mg None Omision 
 
  Erythromycin film 
coated 250 mg 
None Omision 
 
8/3/10 100 fc Erythromycin film 
coated 250 mg 
None Omision 
 
9 AM     
 
8/6/10 B KCL 10 MEQ KCL 10 MEQ; 
crushed 
Wrong form 
Order 
states? 
do not 
crush? 
9 AM  Erythromycin film 
coated 250 mg 
None Omision 
 
  Nifedipine ER 30 
mg 
None Omision 
 
  Ferous Sulphate 
325 mg 
None Omision 
 
  Paroxetine HCL 10 
mg 
None Omision 
 
  Metorpolol 
Sucinate ER 50 mg 
None Omision 
 
!
! 227!
Date Illuminati
on level 
Prescribed Drug Prepared Drug Error Type Notes 
  Aspirin EC 81 mg None Omision 
 
  Oxybutynin ER 
10mg 
Oxybutynin ER 10mg 
crushed 
Wrong form 
Order 
states? 
do not 
crush? 
8/9/10 B KCL 10 MEQ KCL 10 MEQ; 
crushed 
Wrong form 
Order 
states? 
do not 
crush? 
9 AM  Erythromycin film 
coated 250 mg 
None Omision 
 
  Aspirin EC 81 mg Aspirin EC 81 mg 
crushed 
Wrong form 
 
  Oxybutynin ER 
10mg 
Oxybutynin ER 10mg 
crushed 
Wrong form 
Order 
states? 
do not 
crush?