Long-term care physical
environments – effect on
Atiya Mahmood and Habib Chaudhury
Department of Gerontology, Simon Fraser University, Vancouver, Canada
Faculty of Medicine/Department of Pediatrics, University of British Columbia,
Vancouver, Canada, and
Department of Psychology, University of Alberta, Edmonton, Canada
Purpose – Few studies examine physical environmental factors and their effects on staff health,
effectiveness, work errors and job satisfaction. To address this gap, this study aims to examine
environmental features and their role in medication and nursing errors in long-term care facilities.
Design/methodology/approach – A mixed methodological strategy was used. Data were collected
via focus groups, observing medication preparation and administration, and a nursing staff survey in
Findings – The paper reveals that, during the medication preparation phase, physical design, such
as medication room layout, is a major source of potential errors. During medication administration,
social environment is more likely to contribute to errors. Interruptions, noise and staff shortages were
Research limitations/implications – The survey’s relatively small sample size needs to be
considered when interpreting the findings. Also, actual error data could not be included as existing
records were incomplete.
Practical implications – The study offers several relatively low-cost recommendations to help staff
reduce medication errors. Physical environmental factors are important when addressing measures to
Originality/value – The findings of this study underscore the fact that the physical environment’s
influence on the possibility of medication errors is often neglected. This study contributes to the scarce
empirical literature examining the relationship between physical design and patient safety.
Keywords Medication errors, Physical environment, Long-term care facility, Canada, Health care,
Patient care, Environmental health and safety
Paper type Research paper
Medication errors contribute significantly to patient morbidity and mortality, and are
associated with considerable healthcare costs. The human and financial costs following
preventable medical errors are high; data in the US suggest an estimated 44,000
inpatients die each year owing to preventable medical errors (Kohn et al., 2000a).
The current issue and full text archive of this journal is available at
The authors are grateful for the CapitalCare Foundation’s funding which supported this research.
Received 16 April 2010
Revised 29 July 2010
Accepted 1 November 2010
International Journal of Health Care
Vol. 25 No. 5, 2012
q Emerald Group Publishing Limited
National, preventable adverse event costs have been estimated at $17 billion (Kohn et al.,
2000b). Although reliable, Canadian data are not available, such errors and costs are felt
to be comparable (Baker and Norton, 2001). It has been estimated that medication errors
are high in long-term care facilities (Gurwitz et al., 2005) because elderly patients are
usually taking more medications, increasing error risks (Hodgkinson et al., 2006; Cafiero,
2003; Thomas and Brennan, 2000; Scott-Cawiezell et al., 2007). Medication error rates in
long-term care facilities vary – some are at 59 percent (Cafiero, 2003). Errors typically
involve deviating from drug, dose, route or timing in the physician’s orders,
manufacturer’s guidelines or best practices and they can arise during ordering,
dispensing or administration (Cafiero, 2003; O’Shea, 1999; Hellier et al., 2006).
Errors most often occur during the ordering and monitoring stages. Ordering errors
include: wrong dose; prescribing drugs that interact with other medication and wrong
choice. Enhanced surveillance and reporting systems for adverse drug events in
nursing homes may help reduce errors (Gurwitz et al., 2000). Safety is pointed out in
multiple studies; for example, Kapp (2003) said that medication errors are caused by:
faulty communication when patients are transferred from hospital; excess dosage;
drug interactions; poor drug selection; poor baseline or infrequent monitoring; failure
to act on information; contraindicated drug use; confusing abbreviations; sound-alike
and look-alike drugs; and errant orders. Barriers to reporting errors include: staff
worrying about regulatory sanctions; prosecution fears; and strained rapport with
families, which discourages open discussion.
Medication administration in long-term care facilities is among many nursing
responsibilities. Nursing work is physically and psychologically intense. Burnout,
stress and errors are a risk. Nursing errors can be conceptualized at two levels: active
failures; and latent conditions (Reason, 2000). Active failures can be attributed to
cognition, memory and decision making. Latent conditions refer to failures resulting
from decisions made by managers and architects, including: time pressure; stress;
fatigue and physicalfactors such as noise, privacy and temperature. These issues show
that environments need to support nursing work and be responsive to nurses’ needs.
Ulrich and Zimring (2004) argued that reducing staff stress and subsequent errors
using ergonomic interventions and environmental considerations (such as air quality,
acoustics, lighting, etc.) can significantly influence staff health. It can also influence
staff efficiency and contribute towards patient safety. It is claimed by Harrison (2004),
McCarthy (2004), Reiling et al. (2003), Rollins (2004) and Scott (2004) that specific
environmental conditions, such as: artificial versus natural lighting; room temperature
and humidity affect performance; for example, artificial or inadequate lighting can
cause staff to feel drained and tired leading to medication errors. Topf and Dillon (1988)
found that high noise levels are detrimental to work performance. Healthcare facility
design and function have a major impact on nurse recruitment and retention (Scott,
2004). Though nursing staff spend significant time in their work settings, working day
and night shifts, often they are not consulted about decisions regarding their work
environments and this can contribute to demoralization. Empirical studies examining
environmental effects on medical errors are scarce (Chaudhury et al., 2009). To address
this gap, we examine the physical environment’s role in medication and nursing errors
in long-term care facilities and identify key environmental features that need to be
considered to reduce errors.
Design and methods
A mixed methodological strategy (Patton, 2002; Teddlie and Tashakkori, 2003) was
used to triangulate data-collection (Lincoln and Guba, 1985) using: focus groups with
nursing and pharmacy staff; observing medication preparation and administration in
selected facilities; and staff surveys. All participants were staff members working with
a large, continuing care organization located in Edmonton, Alberta. Four long-term
care facilities were selected based on direct consultation with the organization’s
administrative and nursing staff. The care facilities were selected to represent diverse
physical environments; e.g. one recently built facility was designed as a “household”
with no designated medication room. An old building had a traditional medication
room and nurse station. The other two had some variation in the resident rooms,
medication room, dining space and physical layout. Here, we report findings from our
observations and staff survey, as the focus groups were used primarily to identify
issues that might inform the other two methods.
Registered nurses (RN), licensed practical nurses (LPN) and auxiliary care workers
(ACW) in three long-term care units (one unit was not included in the observation phase
as staff performed medication-related activities, such as: stocking medication carts (MC);
preparing medications; administering medications; and handling related documentation.
The physical and social contexts in which these activities occurred were also noted. The
observations were guided by a structure that included: activities; associated
environmental features (location, space, furniture, lighting, noise, etc.); environmental
aspects potentially contributing to errors; and social factors.
The researchers modified a recently developed questionnaire (Mahmood et al., n.d.) on
medication and nursing errors, and nurse efficiency in acute care environment based on
focus groups (see above). This questionnaire included structured questions about
physical environment; medication types and errors; potential environmental and
organizational factors contributing to medication and nursing errors. Survey item
validity and reliability are supported by previous studies (Mahmood et al., n.d.).
Sampling and distributing the questionnaires was assisted by administrative personnel
in the four facilities with the objective to include various staff categories; e.g. ACWs;
LPNs and RNs. Participants responded to a verbal and written invitation from the
facility administrators. The sample in this cross-sectional survey comprised 54 nurses
working at four facilities. Almost all respondents were female (n ¼ 50, 92.6 percent) and
most fell within 36-55 years (n ¼ 34, 65.3 percent). Over half were LPNs (n ¼ 28, 53.8
percent) followed closely by staff nurses (n ¼ 23, 44.2 percent). Respondents averaged
10.2 years (sd ¼ 8.9) in their current employment and had approximately 17.8 years
(11.2) experience in their profession. Participants completed the questionnaire at a time
convenient to them and were provided with a $10 gift card in appreciation.
Results – observations
The RNs, LPNs and ACWs were shadowed as they performed medication-related
activities. Table I describes the three units we observed and their medication
delivery systems. In all three units, MCs are stocked in a standard manner prior to
the “medication pass”; i.e. medication delivery and administration. They typically
contain medication packs for each resident, ward stock, applesauce, spoons, water,
cups, straws, gloves, hand sanitizer and the narcotics record. Medication packs are
stored in individual compartments on the MC and are organized by resident room
number. During the medication pass, the medication administration record is kept
on the MC.
Medication preparation errors
The MR physical environment was a predominant source of potential errors during the
medication preparation stage. Design characteristics impeding efficient workflow were
the biggest problem. For example, unit A’s MR was too small for even one person to
work comfortably. Staff needed to divide their attention between preparing
medications and maneuvering safely around the room. This divided attention could
lead to errors. One MR was not well-stocked, so staff had to stop what they were doing
to retrieve what was needed. The unit B MR was sufficient and well-organized, but its
location at one end of the unit was inconvenient for staff, especially those on the other
side, who may need to retrieve supplies during the medication pass. On unit C, fridge
location could contribute to errors because it was located next to the entrance room
Unit A Unit BUnit C
Unit population 25 beds for general
68 beds for advanced
dementia or comfort
40 beds for advanced
Medication passMost medications are
administered at 0730,
1100, 1600 and
administers some PRN
provided at 0800, 1100,
1700 and 2000hrs.
LPN or ACW
and PRN narcotics
administered at 0800,
1100, 1700 and
1100hrs) and others
with the RN
Medication room (MR) Small but adequate for
one person; well-lit and
quiet with door closed
Spacious, adequate for
and clearly labeled;
well-lit and quiet when
door is closed
Small and cramped
when both MCs are in
the room; well-lit and
quiet when door is
MC One MC – generally
well-stocked, but one
requested had to be
obtained from the MR
Two MCs – well-
Two MCs – insulin
had to be retrieved
from the medication
room (MR); was not
fully stocked prior to
one medication pass,
so staff retrieved items
where incoming/outgoing staff impeded fully opening the fridge door. Shelf height was
right for most staff and offered good visual and physical access.
Medication administration errors
Interruptions were the top source of potential error in all three units – commonly,
interruptions from other staff asking questions or residents needing assistance. If there
was not another staff member nearby to help, the practitioner administering medications
would stop to provide assistance or redirect the resident. For example, staff stopped
administering medications to: check a resident when a bed alarm sounded; assist a
resident looking unsteady in a hallway; fix a tube feed (unit C); travel to another unit to
find a bandage and change a dressing; call housekeeping to repair a toilet (unit A); and
assist a resident who had fallen (unitB). One LPN remarked that the interruption resulted
in her crushing medication for someone who takes them whole. Staff were also
interrupted by telephone calls(all units), providing after-hours access tothe building (unit
B) and by family members wanting to make small talk or to discuss patient care. Unit A
and B MCs were generally well-stocked; however, unit C’s MC was not fully stocked prior
to one medication pass, so medication administration was interrupted each time the nurse
had to stop and retrieve supplies or medications from the MR. Disruptive noise included
particularly loud and gregarious staff. Residents were also noisy; for example, on units B
and C, residents called out or yelled things such as “help me, help me” or “nurse, nurse”
during medication administration. Other sources included overhead paging (unit A), loud
televisions in common areas and resident rooms (all units), food service and dining room
noise (all units), construction noise (unit B), floor polishing equipment (units B and C), call
bells (units A and C) and a malfunctioning pill crusher (unit C).
Staff indicated that workload and working short-staffed were primary stressors. In
unit B, the LPN responsible for medication administration had a heavy workload
because staff went to help a short-staffed unit. On unit C, staff indicated that they try to
finish the medication pass quickly so that they can help with resident care when they
are short-staffed. Workload can also lead to interruptions and distractions while
completing the medication pass. Staff on units A and C mentioned it was difficult to try
and remember everything that had to be done at once. On unit B, staff were frustrated
by balancing their responsibilities as team leaders, which requires monitoring staff,
while trying to focus on medication administration. Staff on units B and C reported
being stressed and poor teamwork – particularly because team members either do not
know their jobs or are not familiar with a unit.
Medication administration records (MARs) varied between units. On units B and C,
out-of-date information was an issue. For example, photographs used to help identify
residents were out-of-date, making it difficult (especially for casual staff) to correctly
identify residents. Many residents on these units have dementia and tend to wander, so
staff cannot assume the person in a room or even bed is the one to whom the room
belongs. On Unit B, the MAR had two residents listed with incorrect room or unit
information, which was confusing for staff because medication packs are organized by
room number. Other unit B MAR issues included two different medication dosages
listed in different places for the same resident, inconsistent information between the
drug name on the MAR (brand name) and medication pack (generic name) requiring
extra checking, and extra pills in the medication pack not specified on the MAR. On
unit C, the degree to which staff consulted the MAR varied, ranging from not at all to
checking it against every pill in the packet. On unit A, staff were frustrated by absent
mechanisms to flag residents who refuse or are unavailable for medications, which
could lead to missed doses.
Survey results – errors
Errors rarely occurred according to most respondents (Table II). The commonest
medication error occurring somewhat or frequently was missed medication doses
(n ¼ 18, 33.3 percent). Several respondents indicated that missed medication rarely
occurred (n ¼ 16, 29.6 percent). However, a percentage said that wrong medications
were administered (n ¼ 16, 29.7 percent) somewhat often, neither frequently nor rarely
and somewhat frequently. Regarding documentation errors, a plurality of respondents
felt omission or partial information input in charts/records rarely occurred (n ¼ 21,
38.9 percent); however, one third indicated this documentation error occurred
somewhat often in their unit (n ¼ 18, 33.3 percent). Other documentation errors
included not signing medications when given (n ¼ 3, 50 percent).
Staff and organizational issues leading to error
Allbut twostaff issuesandorganizationalfactorsweexaminedwereendorsedasplaying
an important role in medication or nursing errors by most respondents. Staff and
organizational factors most commonly indicated (.65 percent of respondents) as playing
an important role included: insufficient nursing staff (n ¼ 50, 94.3 percent); overwork,
stress or fatigue (n ¼ 46, 86.8 percent); poor training (n ¼ 41, 80.4 percent); and health
professionals not working together or not communicating as a team (n ¼ 40, 76.9
percent). Poor supervision was seen as an important issue leading to nursing errors by
slightly less than half the respondents (n ¼ 22, 46.8 percent), while lacking computerized
medicalrecordswasviewedasasomewhatimportantissueleadingtoerrors(n ¼ 24,45.3
percent). All staff and organizational solutions suggested in the survey were endorsed as
effective by most respondents. Those solutions most frequently indicated (.65 percent of
respondents) as very effective included better training (n ¼ 44, 81.5 percent); increasing
staffing (n ¼ 42, 77.8 percent); and requiring hospital managers to develop medical errors
avoiding systems (n ¼ 35, 67.3 percent). The two computer-related solutions in the
survey, more computerized medical records and more computers rather than paper
records for drugs and medical tests were most commonly viewed as somewhat effective
by respondents (n ¼ 26, 49.1 percent and n ¼ 28, 51.9 percent respectively). Automated
medication dispensation was indicated as an effective solution by most respondents;
however opinions were split regarding effectiveness levels. Twenty respondents (40.8
percent) endorsed it as very effective, while 21 (42.9 percent) felt it would be somewhat
effective in preventing errors and increasing efficiency.
Physical environmental issues leading to errors
All physical environmental factors we examined were endorsed as playing an
important role in nursing or medication errors. The environmental factors most
commonly indicated (.65 percent) as playing an important role in medication errors
included interruptions from residents or co-workers while administering medicines
(n ¼ 47, 87 percent); inappropriate medication organization and supplies (n ¼ 40, 74.1
percent); high environmental stimulation (i.e. noise and lighting levels) (n ¼ 38, 71.7
percent); lacking privacy in work areas (n ¼ 37, 68.5 percent); and insufficient counter
Administered at wrong time
Medication IV rate too fast
Wrong IV concentration or medication dose delivered
Wrong medication administered
Wrong medication delivered owing to misidentifying resident
Putting wrong information in resident’s chart/record
Omission or partial information input in charts/records
Charting procedures or medications before they were completed
and storage space for charting/record keeping (n ¼ 37, 68.5 percent). Nursing station
location was viewed as a somewhat important environmental issue leading to
medication errors (n ¼ 22, 41.5 percent). All the physical environmental solutions
suggested in the survey were endorsed as effective by most (.50 percent) respondents.
Table III lists those solutions most frequently indicated (.65 percent) as effective.
These included appropriate medication organization (n ¼ 85.2 percent); reduced
interruptions/distractions in dining room (n ¼ 54, 85.2 percent), adequate privacy in
workspace (n ¼ 42, 77.8 percent); sufficient space for charting/record keeping (n ¼ 41,
75.9 percent); adequate work surface in medicines room/area (n ¼ 41, 75.9 percent);
adequate lighting in medication room/area (n ¼ 40, 74.1 percent); reduced noise
(n ¼ 39, 72.2 percent); appropriate nursing station lighting (n ¼ 39, 72.2 percent) and
adequate dining room lighting (n ¼ 36, 66.7 percent).
Most respondents felt the MR was appropriately located (n ¼ 34, 64.2 percent); i.e.,
central(n ¼ 11, 44.0 percent). Those who felt otherwise did so mainly because itwas in a
high-traffic area, too close to distractions, providing no privacy (n ¼ 8, 44.4 percent).
Respondents felt that two MR-related solutions were important: ensuring it was located
appropriately (n ¼ 34, 64.2 percent); and that floor space was adequate (n ¼ 33, 63.0
percent). When asked about the MR, most respondents found the way medications and
supplies were organized was helpful (n ¼ 30, 55.6 percent); medication dispensation
method was helpful (n ¼ 43, 86.0 percent); and lighting adequate (n ¼ 46, 86.8 percent).
However,mostfelttheMRwastoosmall(n ¼ 42,77.8percent).NonefelttheMRwastoo
large. Respondents indicating that the MR was inappropriately located, felt that in a
high-traffic area, that it was too close to distractions, providing no privacy (n ¼ 8, 44.4
percent). Most respondents proposing an alternate MR-location suggested a quiet alcove
or an enclosed/screened off area away from noise and distractions (n ¼ 11, 21.6 percent).
During medication preparation, MR layout and location were most likely to cause
medication errors. However, during medication administration, social environment,
such as interruptions and noise were most likely to cause medication errors. This is
consistent with Reason’s (2000) conceptualization of latent conditions and active
failures creating the possibility for error. It also highlights the importance of ensuring
that nurse work environments are supportive.
Physical environmental solutions
Not at all
Appropriate medication organization
Reduced interruptions/distractions in dining room
Adequate workspace privacy
Sufficient space for charting/record keeping
Adequate work surface in medication room/area
Adequate lighting in medication room/area
Appropriate lighting in nursing station
Reduced noise in nursing unit
Adequate lighting in dining room
Practice and policy implications
Modifying the physical environment may help decrease medication errors during the
preparation stage. Long-term care facility managers should focus on MR design
because our data suggest that a well-designed and centrally located MR can reduce
errors. The MR should have: sufficient space for more than one person to work
comfortably; adequate lighting; and enough counter space to prepare medications and
to write notes. Additionally, they should be centralized and close to the nursing station,
yet remain a sufficient distance from the unit entrance and dining room to minimize
interruptions. Adequate lighting in nursing workspaces (e.g. the nursing station) and
the dining room may also help. Incorporating design features that ensure privacy by
keeping staff who are working on medication-related activities out-of-sight of other
staff, residents and family members, will help to reduce interruptions.
Increased workload that includes high degrees of attention for medication preparation
and administration, accompanied by other distracting activities, creates a higher error
risk. Long-term care facility managers could implement workflow processes and
organizational policies that limit environmental stimulation for staff performing
medication-related activities. In many cases, simply standardizing work environments
could reduce errors. Our data suggest that how medications are organized, stored and
delivered may help reduce the cognitive workload required to prepare medications.
Simplifying medication ordering procedures (such as only one person responsible for
the person making an error to fill out an incident report.Currently this is an expected, but
not mandatory activity. Regularly updating the MAR (such as resident photos or census
information) is another simple, yet effective way to reduce potential errors. Minimizing
interruptions and distractions during medication administration are essential. Our
observational data suggests that medication administration should be separated from
other tasks (i.e. those staff members administering medications should not be responsible
foranswering telephonesorprovidingaccessto theunit).Otherssuggest that signageisa
simple way to reduce interruptions from staff or family, either by wearing a red tunic
(Tonks, 2008) or a displaying a “do not disturb” sign on the MC (Pape et al., 2005).
Data indicate that staff thought that organizational solutions such as better training
and developing systems to avoid errorswould reduce problems. However, it is not clear
what training is needed (i.e. for new or casual staff members or if all staff need better
training on how to avoid medication errors). Future research could investigate what
training or systems for avoiding errors are most effective in long-term care. Staffing
issues are a potential source of error; however, recommendations on appropriate
workload and staffing were outside our scope and future research should investigate
how they relate to medication errors. Our study helped identify solutions to improve
staff working environments: a conveniently located break room that is accessible only
to staff members could help provide a quiet place where staff could rest and recuperate
to deliver quality care. Finally, this study demonstrates that nurses and other health
professionals working in long-term care facilities are willing to offer design solutions
that increase effectiveness and efficiency.
Our study has several limitations; it does not include a medication error frequency
measure. However, all participating facilities had a low percentage and the report
forms lacked any variables relevant to the physical environment. The study used
several facilities belonging to the same organization, which may limit how far results
can be generalized.
The physical environment potentially contributes to medication errors in long-term care
facilities. Medication room size and layout are a major source of potential errors during
medication preparation. During medication administration, the social environment is
more likelytocause errors; e.g. interruptions, noise and staff shortages wereidentifiedas
particular problems. An organizational intervention to reduce medication errors and
create a safety culture should take into account modifying negative physical
environmental factors to make a meaningful impact. The pathway to error from
environmental features can be direct or indirect. For example, interruptions owing to
poorly located and designed MRs directly affect error rates. High stimulation in the unit
could contribute to staff stress and fatigue, which in turn raises the possibility of errors.
to fully understand environment-error relationships. Simple modifications may help
reduce error potentials and improve nurse working environments. Also, research in this
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