introduction to medication errors essay

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Article Contents

Introduction, concept and incidence of medication errors, classification of medication errors, other classifications and types of medication errors, causes of medication errors, medication errors and nursing, results of medication errors, reporting medication errors of nurses, strategies for preventing medication errors, conclusion and recommendations, author contributions, conflict of interest.

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Medication errors: a focus on nursing practice

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Nasr Alrabadi, Shaima Shawagfeh, Razan Haddad, Tareq Mukattash, Sawsan Abuhammad, Daher Al-rabadi, Rana Abu Farha, Suzan AlRabadi, Ibrahim Al-Faouri, Medication errors: a focus on nursing practice, Journal of Pharmaceutical Health Services Research , Volume 12, Issue 1, March 2021, Pages 78–86, https://doi.org/10.1093/jphsr/rmaa025

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Health departments endeavor to give care to individuals to remain in healthy conditions. Medications errors (MEs), one of the most types of medical errors, could be venomous in clinical settings. Patients will be harmed physically and psychologically, in addition to adverse economic consequences. Reviewing and understanding the topic of medication error especially by nurses can help in advancing the medical services to patients.

A search using search engines such as PubMed and Google scholar were used in finding articles related to the review topic.

This review highlighted the classifications of MEs, their types, outcomes, reporting process, and the strategies of error avoidance. This summary can bridge and open gates of awareness on how to deal with and prevent error occurrences. It highlights the importance of reporting strategies as mainstay prevention methods for medication errors.

Medication errors are classified based on multifaceted criteria and there is a need to standardize the recommendations and make them a central goal all over the globe for the best practice. Nurses are the frontlines of clinical settings, encouraged to be one integrated body to prevent the occurrence of medication errors. Thus, systemizing the guidelines are required such as education and training, independent double checks, standardized procedures, follow the five rights, documentation, keep lines of communication open, inform patients of drug they receive, follow strict guidelines, improve labeling and package format, focus on the work environment, reduce workload, ways to avoid distraction, fix the faulty system, enhancing job security for nurses, create a cultural blame-free workspace, as well as hospital administration, should support and revise processes of error reporting, and spread the awareness of the importance of reporting.

Health administrations, all over the world, endeavor to give proper care to individuals when they are ill or to remain healthy. Primary care services are increasingly concentrated at the heart of integrated people-centered health care systems in many countries. [ 1 ] They provide a passage point with a useful framework focused on progressing health planning to ensure safety for individuals and their families. Availability and safe application are basics to accomplish all-inclusive wellbeing criteria and to support the United Nations sustainable development goals, that organize solid lives and advance prosperity for all. [ 2 ]

The therapeutic services’ framework is very unpredictable. It includes basic circumstances of hazard, a collaboration between different experts and institutions, and relies upon huge help from innovations. The attributes of the therapeutic framework may increase the danger of slip-ups and compound the results of these mix-ups. [ 1 , 3 ] In this sense, it is vital to evaluate hazards and harm to patients in the scan for extreme patient wellbeing. The World Health Organization’s meaning of patient wellbeing builds up of which pointless damage or potential harm related to therapeutic services ought to be decreased to a worthy least. [ 4 ]

Healthcare providers consider patient safety one of the paramount priorities in clinical settings. One of the major threats to the well being of patients is medical errors. [ 5 ] One of the main branches of medical errors is medication errors which were demonstrated to be the source of morbidity and mortality in addition to the resulted adverse economic consequences. [ 6–8 ] Patient safety is esteemed as a critical issue for our social insurance framework and human services providers, [ 9 ] and in such manner, medication errors are utilized as a list to survey quiet wellbeing in clinics. In the next sections, we will go through the concept, classification, types, causes, consequences, reporting, and those strategic plans to prevent the occurrence of medication errors.

A medication error is characterized by ignoring the condition of shaping harm, hazard, or any evadable frequency to happen amid the procedure from medicine ordering to patient consumption. [ 10 , 11 ] It might be characterized by National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) as any preventable occasion that may cause, or prompt improper medicine use or patient harm while the medicine is in the control of the healthcare worker, patient, or buyer. [ 12 , 13 ] The measurement of medication errors may vary widely in clinical settings due to the different ways of recognizing and defining the status of medication errors, how to calculate error rates, variation in numerator/dominator, and the process, documentation, and culture of settings technologies. [ 14–16 ]

Medication errors are a global issue where 5.0% is deadly, and almost 50.0% of those are preventable. [ 17 ] The in-hospital incidence for adverse drug events was reported to be high which ranged from 2 to 6 events per 100 admissions. [ 18 , 19 ] Moreover, around 7000–9000 patients’ deaths in the USA each year can be attributed to medication errors. [ 11 , 20 ] However, the rate of patient serious injuries as a result of medication errors among different studies varies, 1–2%, [ 21 ] 9–13%, [ 22 ] 29.0% [ 23 ] and 51.8% [ 24 ] and almost 30.5% death rate per year in the United States because of medication errors. [ 25 ] As indicated by the Institute of Medicine (IOM) of the National Academies in 2006, 400 000 instances of avoidable patient damage because of medication errors happen every year in emergency clinics in the USA. It is noticed that 19% of medication errors in the Intensive Care Units (ICUs) are life-threatening and 42% are considered to be paramount for further maintaining treatment. [ 26 , 27 ] Somewhere in the range of 44 000 and 98 000 emergency clinic patients have been evaluated to kick the bucket every year because of drug errors. [ 28 ] For instance, in the USA hospitals in 1995, the annual spending on medication errors for each hospital was around 2.9 million dollars and a 17% reduction in the error incidence led to 480 000 dollars saving per hospital as in the case of transcription errors. [ 29 ] For example; a patient in an Iranian hospital had given 80 units of insulin instead of eight units which led to the patient’s death, therefore, the government gave 140 million dollars to the patient’s family. [ 14 , 30 ] Add up, the overall cost of adverse outcomes that are associated with medication errors could surpass 40$ billion each year. [ 11 ] Bates et al . stated that medication errors increase the costs for each patient by 2000–2500$ and extend their hospitalization period by at least two days. [ 18 ] The total cost of these errors, including expenses of error, disability, and lost income and productivity, is expected to be between $17 billion and $29 billion per year. [ 31 , 32 ]

Grouping of medication errors occurrence into contextual, modular, or mental (psychological) is considered an ideal protocol to assess how errors happen. Contextual order assesses the specific time, place, medications, and individuals who are included. Modular characterization analyses the manners in how errors occur (i.e, by omission, repetition, or substitution). Mental order is preferred, as it clarifies occasions as opposed to just prescribing them. Its burden is that it focuses on humans as opposed to frameworks wellsprings of errors. The accompanying mental grouping depends on crafted by Reason on errors and there are four distinct types of medication errors. [ 33 , 34 ]

The first type is ‘Knowledge-based errors’ (Learning absence). As it may seem, administering penicillin to the patient without any concise information whether the patient is unfavorably susceptible. Knowledge-based errors that are connected to any kind of knowledge which could be related to expert, specific, or general. As a general knowledge, health care providers should understand that allergic reactions, for instance, could be associated with penicillins, however, realizing that the patient is allergic to penicillin can be considered specific knowledge. On the other hand, experts are those who may know that co-fluampicil has penicillin. As a result, Knowledge-based errors might be provoked when ignoring any of that information. In an Australian examination, correspondence issues with trouble in getting to suitable medication dosing data added to knowledge-based errors. [ 35–39 ] When being educated about medication is being given dispensed to patients could reduce the incidence of medication errors. [ 40 ] Errors can be blocked from occurrence through computerized prescribing entry orders, bar-coded medicine frameworks, and cross-checking by others (for instance, medicine specialists and nurses). [ 41 , 42 ] A study showed that before implantation of electronic Bar-Coded Medication Administration (BCMA-e MAR), wrong time (33.9%), omission (27.7%), wrong technique (18.0%), wrong dose (13.3%), and unauthorized drug (2.9%) were happening frequently. However, after the implementation of BCMA- e MAR, errors have been declined. [ 43 ] In another study, error rates were reduced more than a half after applying BCMA- e MAR. [ 44 ]

The second type is ‘Rule-based errors’ (utilizing a terrible standard or twisting a decent principle). For instance, infusing diclofenac into the sidelong (lateral) thigh instead of being injected into the butt cheek. Appropriate standards and instruction help to keep away from these kinds of errors, as do computerized prescribing frameworks. [ 38 , 39 , 45–47 ]

The third type is ‘Activity-based errors’ (known as slips). For example, when confusion happens between two drugs like diazepam and diltiazem from a medicine store rack. [ 38 , 46 , 47 ] In the Australian examination, most errors were because of slips in consideration that happened amid routine prescribing, dispensing, and administering organization. Slips errors could be minimized through keeping away from distraction, by cross-checking, by naming prescriptions plainly, and by utilizing identifiers, for example, standardized identifications or barcoded); alleged ‘Tall Man’ lettering (when blending lower- and upper-case letters in the same word) which showed to be a good protocol in the prevention of misreading of names, yet tall-man lettering has not been assessed in genuine conditions. [ 48 ] A branch of specialized technical errors of activity-based errors, for instance, as seen in measuring the incorrect amount of potassium chloride into an infusion bottle. Using agendas, safeguard frameworks, and computerized updates could prevent this type of error from occurring. [ 49 , 50 ]

The fourth type is ‘Memory-based errors’ (so-called lapses). For instance, giving penicillin to a patient, with a known history of allergy, but forgetting that the patient is allergic. These are difficult to keep away from; however, computerized prescribing frameworks and cross-checking can reduce the error incidence. [ 50 , 51 ]

Errors might provoke in any stage. [ 52–54 ] Prescribing errors (during drug prescription), transcription errors (wrong/incomplete transfer information from a prescription), dispensing errors (disagreement between medicine dispensed and prescription), administration errors (during drug administration), discharge summaries errors (due to discrepancy between discharged summaries and medical records), and monitoring errors (while taking the medicine of renal and liver). [ 30 ] Karthikeyan et al . reviewed the occurrence of errors among healthcare providers. [ 55 ] (a) Prescribing errors; were presented as follow; drug-drug interaction (68.2%), incomplete prescription (25.0%), monitoring (12.6%), incorrect drug (13.0%), underdose (12.6%), incorrect interval (12.0%), and overdose (7.0%). (b) Nursing errors; as in wrong rate (34.0%), wrong time administration (28.6%), wrong dose (25.3%), medication omitted (24.0%), wrong fluid (22.4%), wrong drug (21.1%), wrong route (19.9%), and wrong patient (19.7%). (c) Pharmacist errors; as in wrong medication (25.0%), excessive dose (23.0%), poor labeling (23%), wrong dosage errors (21.8%), wrong strength (10.8%), wrong quantity (6.9%), and wrong direction dispensing (2.3%). [ 55 ] Prescription and administration types of medication errors are considered common and can contribute up to 65.0%–87.0% of medication errors. [ 56 ] According to the National Patient Safety Agency (2009) in the United Kingdom, it was observed the most prominent kinds of medication errors were 16.0% in prescribing, 18.0% in dispensing, and 50.0% in the drug administration. [ 57 ] Furthermore, medication errors accounted to be 37.6% of administration errors, 21.1% of prescription errors, and 10.0% of transcription errors in Iran. [ 58 ] On the other hand, previous studies showed that in prescription errors mainly occurred at outpatient ward accounted as (39.0–44.0%) and in emergency wards were (60.0–73.5%), however, transcription errors were accounted 16.9% and 13.8% for inpatient and discharged patients, respectively, while discharge summaries errors accounted 16.0–36.0% of (omission, drug name, administration route, drug dose, and drug regimen). [ 59 , 60 ] There were 192 477 medication errors reported by staff from 482 hospitals through voluntary reporting that could occur at any stage. Errors during administration were accounted to be (33.0%), documentation (23.0%), dispensing (22.0%), prescribing (21.0%), and monitoring (1.0%). Also, errors were related to omission (25.0%), dosage (30.0%), unauthorized drugs, and the wrong time, patient, and administration technique. [ 61 ]

Moreover, 0.078 errors per patient, and 0.029 errors per medication mainly because of dosing errors, drug omission, and wrong frequency errors. [ 62 ] A previous study showed that (94.0%) out of 430 errors were omissions and only 6.0% of errors caused a major impact on patients’ life but was not considered as a life–alarming errors. [ 63 ] Medication errors are also related to the problem of wrong phenomena. These incorporate errors of course of medication, doses, timing, patient, and inability to follow up the patient. [ 53 , 64 ]

Prescription errors are a standout amongst the most widely recognized therapeutic errors and their occurrence rate in adult ward accounted to be 5.6 cases per 1000 patients and 14.8 cases per 1000 patients in the pediatrics ward. [ 65 ] As seen, a sample of 57 nurses in pediatric settings, medication errors were 67.0% compared to 56.0% of a sample of 227 nurses working with adults. [ 64 , 65 ] The occurrence of prescription errors in pediatrics is three-times higher than adults. An examination in Canada showed that the number of children who admitted to the emergency clinic accounted to be 5000 because of medication errors and of these, 2500 experienced moderate to serious side effects. [ 66 ] Prescription errors can happen because of human errors just as from fundamental errors and thus is needed for a cautiously monitoring through medication organization. [ 10 ] It is suggested that at whatever point when medication error has occurred it should be reported to the significant manager, and such notice is essential for understanding the reasons for the errors and to enable strides to be taken to lessen such errors later on. [ 67 ] The most frequent types of prescribing errors might be related to the inability to manage the medication and mistaken medication writing. [ 68 ] On the other hand, certain variables add to the high rates of prescription errors in pediatric patients. These incorporate inability to peruse the remedy, distraction, high patient/nurture proportion, and hard to get the accessibility of the right medications as endorsed. [ 65 ] Few investigations have tended to show the rates and reasons for medication errors in grown-up patients, and these examinations have regularly been founded on reports from nursing staff. [ 69 , 70 ] Moreover, few investigations have inspected medication errors from the viewpoint of pediatric nurses. [ 65 ]

The error might be identified with expert practice, which is related to human services items, to systems, or to correspondence issues including prescribing, ordering, item naming, labeling/packaging, preparation, compounding, dispensing, administration, education, and the best possible utilization of medicines. [ 2 , 11 , 71 ]

Patients are sometimes being harmed by incidents despite the safe and effective health services that are provided to them. Medication errors have been considered a global issue and it is essential to focus on the causes, results, and solutions. [ 11 , 72 ] The proportion of medication errors among nurses varies in different studies, it was 57.4% in Ethiopia, [ 16 ] 42.1% in Jordan, [ 15 ] 41.9% in Australia, [ 73 ] and 28.9% in the USA. [ 38 ] Thus, differences in rate are due to differences in organizational reporting systems, and the time frame of studies that have been conducted. Medication errors incorporate not just undesirable impacts from prescriptions, yet additionally incorporate ordering, transcription, dispensing, administration and organization mistakes. [ 11 , 74 ] Medication errors are more barely characterized than unfavorable medication occasions and incorporate mistakes of commission and omission. Errors of commission happen while abusing one of the five privileges of organization: right medication, patient, portion, course, time, and documentation. An error of omission is a mistake that consists of not doing something you should have done, or not including something such as an amount of fact that should be included, or when the patient does not get a drug that was arranged. [ 75 ] In a survey conducted on 1384 nurses in 24 ICUs in the United States hospitals regarding nurses’ perception of medication errors, [ 76 ] the main causes contributing to medication errors are illegible handwriting, mental and physical health, interruption and distraction from patient and co-workers, lack of pharmacological knowledge with problems in calculations, performance deficit, sometimes lab tests are not considered, overtime of working hours, absence of self-awareness, organizational factors (training) and failure to follow protocols. [ 15 , 46 , 53 , 77–88 ] Furthermore, it could be related to execution deficit (36.7%) and impairment of strategies realization, but knowledge, communication, drug distribution, and entry system were accounted for lesser percentages. [ 78 , 89 ] However, interruptions play a big impact on causing medication errors especially during administration. [ 46 ] As it may seem, 1354 errors occurred in 136 hours, which means 10 interruptions per hour. [ 90 ] Besides, registered nurses were interrupted (36.0–57.0%), which accounted from the patients (28.0%), other nurses (25.0%), assistive personnel (10.0%), and physician (9.0%), that led to 7.0% of medication errors from interruptions. [ 65 , 79 ] Moreover, around 20% of hospital registered nurses experienced frequent medication errors because of factors as overload, extra hours, unsatisfactory staffing with low support, and shift length. [ 91 ]

Lack of knowledge and miscalculation of doses are the factors contributing to medication errors. [ 36 , 37 , 39 ] It is noticed that competence skills in drug calculation are prerequisites to nursing registration and examining their learning abilities rather than follow strict protocol which imped nurses thinking skills. [ 11 , 92 ] Moreover, focusing on continuing education with clinical and theoretical support will help in the prevention of medication error occurrence. [ 15 , 93–95 ]

Medication errors are normally characterized as deviations from a doctor’s structure. Sources of errors could be from ordering, prescribing, transcription, dispensing, and administration errors (i.e. when the patient is administered a wrong medicine). Healthcare providers as doctors, medical specialists, pharmacists, unit assistants, and nurses could be related to the incidence of medication errors. [ 96 ] A patient can get up to 18 portions of prescription for each day, and a healthcare provider can regulate upwards of 50 medications for each move. [ 50 , 97 ] This places the healthcare provider at the forefront of administration accountability. [ 98 ]

Nurses are considered critical agents among the medical staff of clinics. One of the real undertakings of nurses is administering medicines to patients. They should be mindful of recognition significance of organized prescription to dodge potential dangers and conceivable complexities coming about because of medicine errors. [ 99 ]

Medication errors in clinics, for the most part, include 3.0–6.9% of hospitalized patients. [ 100 ] Customarily, to maintain a strategic distance from medicine errors, nurses utilized five privileges of the prescription organization; the correct patient, the correct medicine, the correct portion, the correct course, and the ideal time. Following this rule before giving any prescription, can help nurses keep away from the vast majority of medication errors. [ 30 , 52 ]

Most medicine executives are nurses and, in this manner, when errors happen, nurses are frequently considered responsible. [ 101 ] Medicine supervisors can give defend against errors made at any of the past stages, notwithstanding, and are thought to block around 86.0% of errors made by prescribers or medicine specialists. [ 102 , 103 ] Along these lines, nurses give a security guard against medication errors at the same time, can put patients in danger. [ 104 ]

Nurses have a central role in their activities to advance safety and anticipate damage to patients. [ 103 , 105 ] While this of great practice, nurses ought to assess how they work in groups to guarantee that the aggregate frameworks and procedures of training are sheltered and to help and instruct unpracticed partners. [ 46 ]

Even though that the way toward conveying medication to patients requires a joint effort between medical experts, registered nurses, and pharmacists, it is the essential obligation of healthcare providers to protect prescription administration. As indicated by Anderson and Webster administering prescription is the most noteworthy hazard undertaking a nurse can perform and can prompt destroying ramifications for the patient and the nurses’ vocation. [ 106 ] Besides, the mental injury brought about by submitting a medication error can be overpowering to the nurses, they may feel agitated, blameworthy, and panicked. [ 46 ] Therefore, medication errors might not only intend harm to patients, they additionally deface the notoriety of all medical experts in whom patients place their trust. [ 107 , 108 ]

On the off chance that nurses don’t have the fundamental capability on providing important data and capacity for the protection of human wellbeing and life, thus therapeutic errors wind up unavoidable. Notwithstanding these, reasons, for example, numerical deficiency of nurses in the workplace, persistent conditions, restlessness, tiredness, absence of consideration, unsure employment definition, insecure working hours, improper physical conditions, having an extraordinary number of patients, could trigger medication errors. [ 38 , 46 , 53 ]

Execution of medical requests is a critical piece of recovery procedure and patient consideration. Nursing execution is considered a prominent role that impacts patients’ safety. [ 109 ] Certain consequences as an impact on patient safety and treatment expenses will have resulted from medication errorss. [ 110 ] Administration of drugs is likely a standout amongst the most basic missions of nurses since the subsequent errors may have unintended, genuine complication for the patient. [ 111 ] Medication errors can prompt unfriendly results, for example, increased mortality, increased length of hospital stay, and expanded restorative expenses. [ 112 ] Although medication errors can be brought about by all individuals from healthcare providers. Most medical and therapeutic executions are done with the nurses, therefore, nursing medication errors are the most common. Besides, nurses execute most of the therapeutic requests and invest about 40.0% of their energy in the emergency clinic to manage medicines. [ 113 ] In developing and developed countries, the nursing medication error rate is observed to be high. [ 114 ]

Medical nurses are a fundamental piece of the human services group and are in charge of the wellbeing of patients yet sadly, the expansion in complaining from medical nurses and doctors in the previous years is proof of expanded frequency of errors. [ 53 ] On the other hand, no examinations have exhibited solid connections between nurse’s qualities (i.e. age, long stretches of training, and education) and the number of medication errors. [ 115 ] This would appear to show that nurses are conceivably in danger of making a medication error.

It is critical to identify medication error, regardless of whether vital or not, because of identification the error will uncover a disappointment in the treatment procedure which causes another event of hurt. There is additional proof that the demise rate from medication errors is expanding. These increments are not amazing as of late emergency clinics have seen an expanded rate of patients, new medications have developed that are progressively hard to utilize securely and viably, factors that will in general lead to increment the danger of medicine error. [ 116 , 117 ]

At the point when errors are distinguished, they can cause many disappointments because of the inability of how to deal with the resulting error, and they might cause potential harm to patients with disabilities. The backhanded results incorporate harm to the medical nurses as far as an expert and individual circumstances, decreased self-assurance, expanded pressure and clashes at work, lack of quality of the patient’s family to nurse. [ 118 , 119 ] Hence, the need to bring issues to interpret and manipulate the nature and reasons of errors is fundamental and can help nursing chiefs to recognize plans for improving the nature of medication administration, expanding the patient wellbeing, and lessening the extra cost. [ 120 ]

Handling medication is a high-recurrence movement in nursing; the potential for error increments when the normal number of prescriptions builds. Besides, prescription administration is an intricate procedure that is frequently performed under not exactly perfect conditions. Thus, the continuous flow of multifaceted prescriptions could prompt the occurrence of the hazard. [ 11 , 74 ] There is likewise a propensity to accuse people instead of the faulty system. Be that as it may, most medication errors emerge from the requests of doctors, trailed by medical organizations. [ 11 , 121 ]

A previous study about the report referring to the United Kingdom (UK) restorative safeguard associations, showed that 25.0% of all cases were because of prescription errors that included the following accompanying errors: [ 122 ] prescribing and administration errors (miscalculation, contraindicated or unlicensed medication, a wrong dose, or wrong patient), repeat dispensing without legitimate checks, failure to monitor the case, and failure to caution about antagonistic impacts (which may be that as it may, not be viewed as a medicine error).

Reporting the medication errors is critical in improving the medication management process, therefore, it is considered a legal and ethical commitment in each health care settings. Reporting medication errors could provide an effective resource of important information, therefore underreporting errors is observed as a crucial threat. [ 81 , 123 , 124 ] Regardless of whether the nurse is the wellspring of a mistake, a benefactor, or a spectator, associations depend on medical nurses as bleeding-edge staff to perceive and report medication errors. [ 15 ] A previous examination has exhibited underreporting among nurses. Adding to the weight of announcing, over 90.0% are oneself reports. [ 125 ] Moreover, in Israel, 26.0% of medication errors were reported, and 46% were self-reported. [ 126 ] In Taiwan, almost 6000 to 20000 deaths from medication errors, and 10.0% of medical lawsuits were mainly of underreporting. [ 127 ] In Turkey, 66.7% of involved nurses who caused medication errors did not report it. [ 128 ]

Medication administration is a high-risk area of nursing practice. Thus, reporting a medication error is an important step based on awareness and willingness to report it. [ 127 , 129 ] This barrier might be provoked, yet focus on the person rather than a system with fear from adverse outcomes lead to underreporting data. [ 11 , 38 , 52 , 61 , 65 , 77 , 130 ]

Precise detailing of medication errors could result in the avoidance of medication errors. Revealing prescription mistakes is reliant on the nurse’s decision making. Underreporting or not announcing medicine mistakes covers defective frameworks. [ 124 ] Besides, developing structured protocols on drug administration with an un-punitive approach could encourage reporting and improve patient safety. [ 131 ]

At present, self-revealed medication errors give negligible data to associations since disparities, as far as answered to-actual rates, are across the board. Medication errors are normally reported through institutional reporting frameworks, for example, incident reports to give information about the medication errors. [ 132 ]

Reports are created by the medical nurse who distinguishes the error and afterward is sent to the executives, quality divisions, or board offices of hazard. Detailing and reporting the issue is subject to the medical nurse in many ways: [ 117 ] capacity to perceive a mistake has happened, the conviction that the mistake warrants reporting, the conviction that she/he has submitted the error, and eagerness to beat the humiliation and dread of striking back for having submitted a medication error.

Nurses specifically are imperative in evaluating such errors since they are, for the most part, in a situation to see medication errors directly and find a way to lessen the danger of medication errors. [ 133 ] Their uncommon position is regularly fortified by their continuous learning concerning the medications in addition to their strategies regarding planning and controlling the medicines and for checking the impacts of the treatment. [ 11 ] All nurses must get comfortable with different methodologies to forestall or diminish the probability of medication errors. Here are certain techniques to follow:

1. Guarantee the five privileges of the prescription organization

Nurses must guarantee that institutional approaches identified with prescription interpretation are pursued. It isn’t adequate to translate the medicine as prescribed, however, to guarantee the right medicine is recommended for the right patient, right time, the right measurements, through the right course, and planned effectively (otherwise called the five rights). [ 88 , 134 ]

2. Pursue legitimate medication reconciliation techniques

Foundations must have instruments set up for medicine reconciliation while exchanging a patient starting with one establishment then onto the next or starting with one unit then onto the next in a similar organization. Audit and check every prescription for the right patient, right medicine, right measurements, right course, and right time against the exchange (transfer) requests, or medications recorded on the exchange archives. Nurses must contrast this with the Medication Administration Record (MAR). Frequently not all components of a medicine record are accessible for simple confirmation, yet it is of central significance to check with each conceivable source including the releasing or exchanging establishment/unit, the patient or patient’s family, and doctor, to forestall potential mistakes identified with inappropriate reconciliation. [ 135 ]

3. Have the doctor (or other nurses) read it back

This is a procedure whereby a nurse peruses back a request to the recommending doctor to guarantee the arranged medicine is deciphered accurately. This procedure can likewise be completed starting with one medical nurse then onto the next whereby a medical nurse peruses back a request deciphered to the doctor’s structure to another medical nurse as the MAR is checked on to guarantee precision. [ 136 ]

4. Document everything

This incorporates legitimate medicine naming, clear documentation, or appropriate recording of administered medicine. An absence of appropriate documentation for any prescription can result in an error. For instance, a nurse neglecting to report an as required prescription can result in another administration being directed by another healthcare provider since no documentation signifying past administration exists. Perusing the medicine name/label and expiration date of the medicine is additionally another best practice. A right prescription can have a wrong mark or the other way around, and this can likewise prompt a medicine error. [ 11 , 137 ]

5. Guarantee appropriate storage of medications for legitimate adequacy

Health care providers should avoid the medication storage with close or identical names or package on them at the same medication stock rack. Alphabetized drug storage could lead to unintentional confusion. Besides, it is essential to separate ‘high alert’ medications from other medications to avoid ambiguity. Medications that ought to be refrigerated must be kept refrigerated to look after adequacy, and medications that ought to be kept at room temperature ought to be put away in like manner. Most biologicals items require refrigeration, and if a multi-dose vial is utilized, it must be named to guarantee it isn’t utilized past its lapse/expiration date from the date it was opened. Thus, it is recommended to keep it organized and control access to it. [ 138 , 139 ]

6. Consider having a drug guide accessible consistently

Regardless of whether it’s print or electronic is a matter of personal (or institutional) inclination, however, both are similarly significant in giving imperative data on most classifications of prescription, including trade/generic names, therapeutic class, dosing, nursing consideration, side effect, drug-drug interaction and medication cautionary, for example, ‘don’t crush, or give with the meal’. [ 140 ]

7. Know institution policies, regulations, and guidelines

Nurses should be familiar with the policies and guidelines and how to apply them. Since these regulations and policies could provide necessary information regarding drug ordering, transcription, administration, and documentation. Besides, it could provide information for the nurses about black box warnings, look alike, sound alike, and warning labels. [ 138 , 141 ]

As penultimate, medication errors are multifaceted criteria. It is motivated to standardize the recommendation and make it a central goal all over the globe for the best practice. Thus, it is suggested to; (a) get a deeper meaning of the medication errors concept, (b) focus on broader causes outside of the taken picture, (c) converge on clinical settings variations and patient illness severity, (d) include questions related to nurse’s psychology, (c) create a group of expert to publish new guidelines internationally adapted to any changes according to hospital needs. Nurses are the heart of clinical settings, encouraged to be one integrated body to prevent the occurrence of medication errors. Thus, systemizing the guidelines are required such as education and training, independent double checks, standardized procedures, follow the five rights, documentation, keep lines of communication open, inform patients of drug they receive, follow strict guidelines, improve labeling and package format, focus on the work environment, reduce workload, ways to avoid distraction, fix the faulty system, enhancing job security for nurses, create a cultural blame-free workspace, as well as hospital administration, should support and revise processes of error reporting, and spread the awareness of the importance of reporting.

Initiating the idea of the manuscript: Nasr Alrabadi and Razan Haddad. Writing the first draft: Shaima Shawagfah, Nasr Alrabadi, Suzan AlRabadi, Razan Haddad, Daher Al-rabadi, and Tareq Mukattash. Reviewing and approving the final draft: Nasr Alrabadi, Sawsan Abuhammad, Rana Abu Farha, and Ibrahim Al-Faouri.

Not applicable.

The authors declared no conflict of interest.

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Preventing Medication Errors (2007)

Chapter: 1 introduction, 1 introduction.

The Institute of Medicine (IOM) report To Err Is Human: Building a Safer Health System (IOM, 2000) identified medication errors as the most common type of error in health care and attributed several thousand deaths to medication-related events. The report had an immediate impact. In response, Congress apportioned $50 million in fiscal year 2001 for a major federal initiative to improve patient safety research and directed the Agency for Healthcare Research and Quality (AHRQ) to establish a Center for Quality Improvement and Patient Safety. The American people also took notice: 51 percent of respondents to a national survey conducted in late 1999 reported closely following the media coverage on the report (Kaiser Family Foundation, 1999). 1 The report’s impact has continued. Five years after its release, two members of the committee that produced the report (Leape and Berwick, 2005) reflected that it had led to:

Broader acceptance within the health care community that preventable medical errors are a serious problem.

A number of important stakeholders (for example, the federal government, the Veterans Health Administration, and the Joint Commission on Accreditation of Healthcare Organizations [JCAHO]) taking up the challenge to improve patient safety.

Accelerated implementation of safe health care practices. For example, JCAHO in 2003 required hospitals to implement a number of evidenced-based safe-care practices, and the Institute for Healthcare Im-

provement undertook its 100,000 Lives Campaign, aimed at fostering the use of safe practices.

Likewise, an article in Health Affairs reviewing the impact of To Err Is Human (Wachter, 2004) noted that the report had led to improved patient safety processes through stronger regulation (for example, expanded patient safety regulation by JCAHO). The article also pointed to the accelerated implementation of clinical information systems that can help reduce medication errors. In addition, progress had been made on workforce issues, particularly in hospitals through the emergence of hospitalists— physicians who coordinate the care of hospitalized patients. Overall, however, the review suggested that much more needed to be done. Examples cited were the limited impact of error reporting systems and scant progress in improving accountability.

The key messages of To Err Is Human were that there are serious problems with the quality of health care delivery; that these problems stem primarily from poor health care delivery systems, not incompetent individuals; and that solving these problems will require fundamental changes in the way care is delivered. A subsequent IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001), took up the challenge of suggesting how the health care delivery system should be redesigned. It identified six aims for quality improvement: health care should be safe, effective, patient-centered, timely, efficient, and equitable (IOM, 2001).

The Quality Chasm report and the later IOM report, Patient Safety: Achieving a New Standard for Care (IOM, 2004), also emphasized the need for an information infrastructure to support the delivery of quality health care. The latter report called specifically for a national health information infrastructure to provide real-time access to complete patient information and decision-support tools for clinicians and their patients, to capture patient safety information as a by-product of care, and to make it possible to use this information to design even safer delivery systems (IOM, 2004).

To Err Is Human focused on injuries arising as a direct consequence of treatment, that is, errors of commission, such as prescribing a medication that has harmful interactions with another medication the patient is taking. Patient Safety focused not only on those errors, but also errors of omission, such as failing to prescribe a medication from which the patient would likely have benefited. Box 1-1 portrays in stark terms an example of the failure of the care delivery system to catch and mitigate a medication error and the tragic outcome that resulted.

MEDICATION ERRORS: THE MAGNITUDE OF THE CHALLENGE

Regardless of whether one considers errors of commission or omission, error rates for various steps in the medication-use process, adverse drug

event rates in various care settings, or estimates of the economic impact of drug-related morbidity and mortality, it is clear that medication safety represents a serious cause of concern for both health care providers and patients. Data from a variety of settings demonstrate that medication errors are common, although the frequency reported depends on the identification technique used and the definition of error employed.

A 1999 study in 36 hospitals and skilled nursing facilities found a 10 percent medication administration error rate (excluding wrong-time errors) (Barker et al., 2002). In observational studies of hospital outpatient pharmacies, prescription dispensing error rates of 0.2 to 10 percent have been found (Flynn et al., 2003). And in a national observational study of the accuracy of prescription dispensing in community pharmacies, the error rate was 1.7 percent—equivalent to about 50 million errors during the filling of 3 billion prescriptions each year in the United States (Flynn et al., 2003).

The mortality projections documented in To Err Is Human were derived from adverse event data collected in a New York State study (Brennan et al., 1991; Leape et al., 1991) and a Colorado/Utah study (Thomas et al., 2000). In these two studies, medication-related adverse events were found to be the most common type of adverse event—representing 19 percent of all such events. In a variety of studies, moreover, researchers have found even higher rates of inpatient adverse drug events than were observed in the New York State and Colorado/Utah studies (Classen et al., 1991; Bates et al., 1995b) using less restrictive definitions of adverse drug events and more rigorous detection methods. More recently, major studies have shown that many adverse drug events occur in the period after discharge from the hospital (Forster et al., 2003), in nursing homes (Gurwitz et al., 2000, 2005), and in ambulatory care settings (Gandhi et al., 2003; Gurwitz et al., 2003).

In a major recent study, moreover, researchers found high levels of errors of omission in the U.S. health care system across a wide range of measures. The chance of receiving high-quality care was only about 55 percent (McGlynn et al., 2003).

Nearly 10 years ago, researchers estimated that the annual cost of drug-related illness and death in the ambulatory care setting in the United States was approximately $76.6 billion (Johnson and Bootman, 1997). Using the same approach, this cost was estimated to be $177.4 billion in 2000 (Ernst and Grizzle, 2001).

MEASURES TO IMPROVE MEDICATION SAFETY

Efforts to improve medication safety are made at all levels of the health care system: by helping the patient avoid medication errors; by organizing

health care units so that care is delivered safely; by creating health care organizations (collections of health care delivery units) that foster safe care, for example, through training for health care workers; and by encouraging health care organizations to deliver safe care by such means as regulatory and fiscal measures. Many of these efforts are long-standing and predate To Err Is Human . Key examples of such efforts are described below.

Helping the Patient Avoid Medication Errors

Since the early 1980s, the People’s Medical Society has developed guidelines to help consumers avoid medication errors in hospitals and at community and mail-order pharmacies (Personal communication, Charles Inlander, March 25, 2005). Medication errors can also take place in the home, and in June 2004, the National Consumers League, jointly with the Food and Drug Administration (FDA), launched Take with Care, a public education campaign addressing the need to be careful when taking over-the-counter (OTC) pain relievers (National Consumers League, 2004).

Organizing Health Care Units to Deliver Care Safely

For more than a decade, many organizations have provided guidance on safe medication practices for health care delivery units. Since 1994 the Institute for Safe Medication Practices has provided guidance on eliminating medication errors through newsletters, journal articles, and communications with health care professionals and regulatory authorities. In 1996 the National Coordinating Council for Medication Error Reduction and Prevention began publishing a series of recommendations on strategies for reducing medication errors (NCCMERP, 2005). Professional organizations have also offered guidance on medication safety. For example, the American Society of Health-System Pharmacists has provided guidance on safe pharmacy practices in hospitals and integrated health systems. Recently, the American Academy of Pediatrics published guidelines on the prevention of medication errors in the pediatric inpatient setting (Stucky et al., 2003).

Following the publication of To Err Is Human , AHRQ funded studies to evaluate best practices. The agency commissioned the Evidence-Based Practice Center of the University of California, San Francisco–Stanford University to evaluate the evidence supporting a long list of proposed safe practices, including many related to medication (Shojania et al., 2001).

In 2003, the National Quality Forum (NQF) identified 30 practices that should be adopted in applicable care settings, including implementing a computerized prescriber order entry system (safe practice 12) (NQF, 2003). In addition, JCAHO has been active in fostering patient safety for many years. In 1995 it implemented a Sentinel Event Policy that encourages

the voluntary reporting of serious adverse events and requires the performance of root-cause analyses for such events. Beginning in 1998, JCAHO disseminated patient safety solutions via Sentinel Event Alerts, based on analyses of reported sentinel events. Since 2003, JCAHO has set annual National Patient Safety Goals (JCAHO, 2006). Many of these goals relate to medications; an example is goal 13: Encourage the active involvement of patients and their families in the patients’ care as a patient safety strategy.

In parallel with the development of guidance on the delivery of safe care, emerging technologies have been developed to improve safety. These include electronic prescribing that automates the medication ordering process; clinical decision-support systems (usually combined with electronic prescribing systems), which may include suggestions or default values for drug doses and checks for drug allergies, drug laboratory values, and drug– drug interactions; automated dispensing systems that dispense medications electronically in a controlled fashion and track medication use; bar coding for positive identification of patients, prescriptions, and medications; and computerized adverse drug event monitors that search patient databases for data that may indicate the occurrence of such an event.

Creating Health Care Organizations That Foster Safe Care

The full benefits of technologies for preventing medication errors will not be achieved unless a culture of safety is created within health care organizations that are adequately staffed with professionals whose knowledge, skills, and ethics make them capable of overseeing the medication management of patients who are vulnerable and unable to manage their medications knowledgeably themselves (IOM, 2004). Indeed, the first safe practice in the NQF report Safe Practices for Better Healthcare is the creation of a culture of safety (NQF, 2003). The IOM’s (2004) Patient Safety report outlined the elements of a culture of safety: a shared understanding that health care is a high-risk undertaking, recruitment and training with patient safety in mind, an organizational commitment to detecting and analyzing patient injuries and near misses, open communication regarding patient injury results, and the establishment of a just culture seeking to balance the need to learn from mistakes and the need to take disciplinary action (IOM, 2004).

Two of NQF’s safe practices relate to the need for adequate resources. Safe practice 3 calls for use of an explicit protocol to ensure an adequate level of nursing based on the institution’s usual patient mix and the experience and training of its nursing staff. Safe practice 5 calls for pharmacists to participate actively in the medication-use process, including, at a minimum, being available for consultation with prescribers on medication ordering, interpretation and review of medication orders, preparation of medica-

tions, dispensing of medications, and administration and monitoring of medications.

Establishing an Environment That Enables Health Care Organizations to Deliver Safe Care

Many important systems, including accreditation, information technology, education, and knowledge generation, foster safe medication use. Important developments have occurred in each of these areas since the release of To Err Is Human . The medication-related National Patient Safety Goals and associated requirements established by JCAHO are an example in the area of accreditation. With regard to information technology, several IOM reports have stressed the need for an information infrastructure to support the delivery of quality health care. A key element of this infrastructure is the development and implementation of national health care data standards. In May 2004, Secretary of Health and Human Services Thompson announced 15 health care data standards for use across the federal health care sector, building on an initial set of 5 standards adopted in March 2003 (DHHS, 2004). In 2003 the Accreditation Council on Graduate Medical Education promulgated new residency training work-hour limitations (ACGME, 2003), drawing on published research on the relationship between fatigue and errors. And in response to To Err Is Human , Congress apportioned $50 million to support patient safety research; in early 2005, AHRQ published the results of this research (AHRQ, 2005).

STUDY CONTEXT 2

Attempts to improve medication safety must be considered against the background of a number of important contextual issues. First, it is essential to recognize the ubiquitous nature of the use of prescription and OTC drugs and of complementary and alternative medications in the United States. In the 2004 Slone Survey (Slone, 2005), 82 percent of adults reported taking at least one medication (prescription or OTC drug, vitamin/mineral, or herbal supplement) during the week preceding the interview, and 30 percent reported taking at least five medications. The three most commonly used drugs were all OTC—acetaminophen (used by 20 percent of the adult population in the week prior to the interview), aspirin, and ibuprofen. In 2003, 3.4 billion prescriptions were purchased in the United States; on average there were 11.8 prescriptions per person (Kaiser Family Foundation, 2004). Fifty-

five percent of the adults interviewed in the 2004 Slone Survey reported taking at least one prescription drug in the week prior to the interview, and 11 percent reported taking five or more such drugs (Slone, 2005). In the same survey, 42 percent of the adults surveyed reported taking vitamins and 19 percent herbal or other natural supplements.

Another key contextual issue is ongoing cost containment efforts. In recent years, these efforts have failed to limit increases in health care costs to the general inflation rate or less. National health spending in 2003 was $1.679 trillion, an increase of 7.7 percent over the previous year (Smith et al., 2005). This growth rate is not much below that for the previous year; in 2002 national health spending increased 9.3 percent over that in 2001 (Levit et al., 2004). U.S. prescription drug sales have been rising more rapidly yet. IMS Health Inc., a leading provider of information and consulting services to the pharmaceutical and health care industries, reported that prescription drug sales in the United States grew 8.3 percent to $235 billion in 2004, compared with $217 billion the previous year (IMS, 2005). This increase followed an 11.5 percent growth in 2003 over 2002 and an 11.8 percent growth in 2002 over 2001 (IMS, 2003, 2004). One critical implication of these figures relevant to this study is that efforts to control health care costs at the federal and state levels and within health care organizations mean that any new investments, including investments in medication safety, will need to be thoroughly justified.

Efforts to contain health care costs have had limited success because of a number of important cost drivers (IFoM, 2003). Innovative new pharmaceuticals are displacing older agents, which are usually cheaper because they are off patent. An aging population is leading to higher consumption of health care in general and pharmaceuticals in particular. A more demanding patient population is less accepting of restrictions on health care use for cost containment reasons. And a broader definition of treatable disease is increasing the demand for health care. Implementation of the Medicare prescription drug benefit is also likely to increase the demand for pharmaceuticals. The Administration’s Financial Year Budget projected that the net federal cost of the Medicare prescription drug benefit would be $37.4 billion in 2006, rising to $109.2 billion in 2015 (Kaiser Family Foundation, 2005).

The FDA is a key player in ensuring the safety of medications, both prescription and nonprescription. The FDA approves a drug for sale in the United States after determining that its clinical benefits outweigh its potential risks. After a drug has been approved, the FDA continues to assess its benefits and risks, primarily on the basis of reports made to the agency on the effects of its use. In 2004, withdrawal of the drug rofecoxib (Vioxx) by Merck & Co. Inc. for safety reasons increased public concern about the procedures used for assessing drug safety. In response to this concern, the

FDA requested that the IOM convene an ad hoc committee of experts (the IOM Committee on Assessment of the U.S. Drug Safety System) to conduct an independent assessment of the current system for evaluating and ensuring drug safety postmarketing.

Implementation of the Medication Modernization Act of 2003 (P.L. 108-173) will make the Centers for Medicare and Medicaid Services (CMS) the largest purchaser of prescription drugs in the United States and a major player in the way prescription medications are used. The next few years will be a pivotal period as CMS decides how it will administer the prescription drug benefit. There will be opportunities for introducing into the drug benefit rules safety guidelines for both prescribing and dispensing, and to use pay-for-performance incentives to enhance adoption of whatever guidelines are proposed. Further, there will be opportunities for medication safety research arising from the data CMS will collect as part of the drug benefit (CMS, 2005).

CMS will also become an important driver of electronic prescribing standards, whose development and implementation are called for by the Medication Modernization Act. The Medicare Prescription Drug Benefit final rule (42 Code of Federal Regulations Parts 400, 403, 411, 417 and 423) requires that Part D sponsors (e.g., participating Prescription Drug Plans and Medicare Advantage Organizations) support and comply with such standards once they are in effect. The final rule does not require providers to write prescriptions electronically; if prescribers send prescription information electronically, however, they will have to use the standards.

STUDY CHARGE AND APPROACH

In this context, at the urging of the Senate Finance Committee, the United States Congress, through the Medicare Modernization Act of 2003 (Section 107(c)), mandated that CMS sponsor a study by the IOM to address the problem of medication errors. The IOM convened the Committee on Identifying and Preventing Medication Errors to conduct this study, with the following charge:

To develop a fuller understanding of drug safety and quality issues through the conduct of an evidence-based review of the literature, case studies and analysis. This review will consider the nature and causes of medication errors; their impact on patients; and the differences in causation, impact and prevention across multiple dimensions of health care delivery including patient populations, care settings, clinicians, and institutional cultures.

If possible, to develop estimates of the incidence, severity and costs of medication errors that can be useful in prioritizing resources for na-

tional quality improvement efforts and influencing national health care policy.

To evaluate alternative approaches to reducing medication errors in terms of their efficacy, cost-effectiveness, appropriateness in different settings and circumstances, feasiblity, institutional barriers to implementation, associated risk, and quality of evidence supporting the approach.

To provide guidance to consumers, providers, payers, and other key stakeholders on high-priority strategies to achieve both short-term and long-term drug safety goals, to elucidate the goals and expected results of such initiatives and support the business case for them, and to identify critical success factors and key levers for achieving success.

To assess opportunities and key impediments to broad nationwide implementation of medication error reductions, and to provide guidance to policy-makers and government agencies in promoting a national agenda for medication error reduction.

To develop an applied research agenda to evaluate the health and cost impacts of alternative interventions, and to assess collaborative public and private strategies for implementing the research agenda through AHRQ and other government agencies.

The committee comprised 17 members representing a range of expertise related to the scope of the study, as described below (see Appendix A for biographical sketches of the committee members). The committee addressed its charge by reviewing the salient research literature, government reports and data, empirical evidence, and additional materials provided by government officials and others. In addition, a workshop was held to augment the committee’s knowledge and expertise through more focused discussion of specific issues of concern, and to obtain input from a wide range of researchers, providers of health care services, and interested members of the public. The committee also commissioned several background papers to avail itself of expert, detailed, and independent analyses of some of the key issues beyond the time and resources of its members.

SCOPE OF THE STUDY

CMS determined that this study should focus on issues related to the safe, effective, appropriate, and efficient use of medications . As mentioned above, a parallel IOM committee, the Drug Safety Committee, was tasked with assessing the postmarketing surveillance system for medications . There is some overlap between the present study and the work of that committee. The two committees and their staffs have worked together closely to define common areas in the two studies and develop consistent sets of recommendations.

Definitions

Drugs and dietary supplements.

This study addressed the quality of the five steps in the medication-use process: selecting and procuring by the pharmacy, selecting and prescribing for the patient, preparing and dispensing, administering, and monitoring effects on the patient. The study examined medication use in a wide range of care settings—hospital, long-term, and community. The term medication encompasses three broad categories of products—prescription and nonprescription drugs and dietary supplements—all regulated by the FDA (see Chapter 2 ).

According to the FDA (2004), a drug is defined as a substance that is recognized by an official pharmacopeia or formulary; intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease; intended to affect the structure or any function of the body (excluding food); and intended for use as a component of a medicine, but not a device or a component, part, or accessory of a device.

Biologic products (including vaccines, blood, and blood products) are a subset of drug products. Biologics are distinguished from other drugs by their manufacturing process—biological as opposed to chemical. Some biologics, principally vaccines (excluding their long-term effects), are within the scope of this study; blood and blood products and tissues for transplantation are excluded.

Drugs include both those that require a prescription and those that do not. Nonprescription drugs are usually termed over-the-counter (OTC). The characteristics of OTC drugs are such that the potential for misuse and abuse is low, consumers are able to use them successfully for self-diagnosable conditions, they can be adequately labeled for ease and accuracy of use, and oversight by health practitioners is not needed to ensure safe and effective use (FDA, 2005).

Dietary supplements , often called complementary and alternative medications , are another group of products often used for medicinal or general health purposes. The Dietary Supplement Health and Education Act of 1994 (P.L. 103-147) defined a dietary supplement as a product (other than tobacco) intended to supplement the diet that bears or contains one or more of the following dietary ingredients: a vitamin; a mineral; an herb or other botanical; an amino acid; a dietary substance for use by man to supplement the diet by increasing the dietary intake; or a concentrate, metabolite, constituent, extract, or combination of any ingredient cited above. While the primary emphasis of the study was on prescription and OTC drugs, attention was given to dietary supplements as well, and the discussion of drugs often applies also to the latter products.

Medication Error, Adverse Drug Event, and Adverse Drug Reaction

The terms medication error , adverse drug event , and adverse drug reaction denote related concepts (see Figure 1-1 ) and are often used incorrectly. To Err Is Human (IOM, 2000, p. 28) defined error and adverse event as follows:

An error is defined as the failure of a planned action to be completed as intended (i.e., error of execution), or the use of a wrong plan to achieve an aim (i.e., error of planning).

An adverse event is an injury caused by medical management rather than the underlying condition of the patient.

The Committee on Data Standards for Patient Safety was concerned that the phrase medical management did not embrace acts of omission . The committee gave considerable thought to expanding on these two definitions and produced the following (IOM, 2004, p. 30, 32):

An error is defined as the failure of a planned action to be completed as intended (i.e., error of execution), or the use of a wrong plan to achieve an aim (i.e., error of planning). An error may be an act of commission or an act of omission.

An adverse event results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.

FIGURE 1-1 Relationship among medication errors, adverse drug events, and potential adverse drug events.

SOURCE: Gandhi et al., 2000.

The Committee on Data Standards for Patient Safety wanted to make clear that the potentially avoidable results of an underlying disease or condition—for example, a recurrent myocardial infarction in a patient without a contraindication who was not given a beta-blocker (an error of omission)—should be considered an adverse event (IOM, 2004). The Committee on Identifying and Preventing Medication Errors discussed the adverse event definition given in the Patient Safety report and decided to adopt this definition. Further attempts to operationalize the definition of adverse event may well lead eventually to additional modifications of the definition.

Consistent with the above definitions:

A medication error is defined as any error occurring in the medication use process (Bates et al., 1995a).

An adverse drug event is defined as any injury due to medication (Bates et al., 1995b).

An injury includes physical harm (for example, rash), mental harm (for example, confusion), or loss of function (for example, inability to drive a car).

Medication errors and adverse drug events have multiple sources. They may be related to professional practice; health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education of the patient or health care professional; and monitoring of use.

Implicit in the definition of medication errors is that they are preventable. However, most medication errors do not cause harm. Some do cause harm and are either potential adverse drug events or preventable adverse drug events (see Figure 1-1 ), depending on whether an injury occurred (Gandhi et al., 2000). Potential adverse drug events are events in which an error occurred but did not cause injury (for example, the error was detected before the patient was affected, or the patient received a wrong dose but experienced no harm) (Gandhi et al., 2000).

Adverse drug events can be preventable (for example, a wrong dose leads to injury) or nonpreventable (for example, an allergic reaction occurs in a patient not known to be allergic) (see Figure 1-1 ). Nonpreventable adverse drug events are also often termed adverse drug reactions 3 (Gandhi et al., 2000).

The World Health Organization has defined an adverse drug reaction as a response to a drug that is noxious and unintended and occurs at doses normally used in man for prophylaxis, diagnosis, or therapy of disease or modification of physiological function (WHO, 1975). This definition excludes injuries due to drugs that are caused by errors, which are of obvious interest. As a result, drug safety researchers coined the term adverse drug event to include both adverse drug reactions (which are nonpreventable), and preventable adverse drug events (Bates et al., 1995b). From the safety perspective, preventable adverse drug events are most important because they are known to be preventable today; adverse drug reactions are also important, however, since it may become possible to prevent them in the future by using new approaches, such as pharmacogenomic profiling.

Audiences for the Report

The committee sought to assess the roles of and make recommendations for all of the major stakeholders involved in the safe use of medications:

First and foremost, the consumer 4 or patient who uses a medication, as well as family members, friends, and neighbors who may be involved in assisting the patient.

Individual health care providers—physicians, nurses, and pharmacists.

The organizations responsible for delivering care, for example, hospitals, nursing homes, ambulatory clinics, pharmacies, and pharmacy benefit managers.

Those responsible for salient policy (Congress and state legislators), payment (CMS and commercial insurers), regulation (for example, the FDA and state regulatory bodies), accreditation (for example, JCAHO), and professional education (for example, schools of nursing).

Manufacturers of medications and the systems used in medication delivery (for example, intravenous pumps and health information technology systems) and providers of value-added services (for example, tools that indicate harmful drug–drug interactions).

In carrying out the study, the committee took the view that the goal of all these stakeholders with regard to medication use should be to optimize the relationship between the patient and the health care provider(s) so as to meet the six aims set forth in the Quality Chasm report (care should be safe, effective, timely, patient-centered, equitable, and efficient) (IOM, 2001). In

general, the health care system should enable the flow of all information needed to choose medications that optimize health to the extent possible in accordance with the preferences of the patient. In addition, all health care stakeholders should attempt to produce information on and inform patients and providers about the balance between effectiveness and safety, rather than addressing either in isolation. Effectiveness (tangible benefits— those that can be felt by the patient—in the actual setting in which the medication is used) rather than efficacy (benefit based on ideal circumstances of use) is the appropriate measure for the purpose of informing patients and providers. Further, all stakeholders should strive to produce a system in which the transactions that ensue following a decision about using a medication at a particular dose and time are free of errors.

REPORT OVERVIEW

Part I of this report addresses the causes, incidence, and costs of medication errors. By way of background, it begins with a case study illustrating how medication errors can arise through a combination of organizational and individual failures. Chapter 2 provides an overview of the system for drug development, regulation, distribution, and use, identifying the many points at which errors can occur. Chapter 3 summarizes the peer-reviewed literature on the incidence and costs of medication errors.

Part II of the report outlines the steps needed to establish a patient-centered, integrated medication-use system. It provides action agendas for achieving both short- and long-term improvements in medication safety for patients/consumers to support provider–consumer partnerships ( Chapter 4 ), for health care organizations ( Chapter 5 ), and for the industry that provides medications and medication-related products and services ( Chapter 6 ). In Chapter 7 , the committee outlines an applied research agenda designed to foster safe medication use. Finally, Chapter 8 proposes action agendas for those who set the environment in which care is delivered (for example, legislators, payers, and regulators). Appendix B provides a glossary and acronym list for the report, while Appendices C and D present detailed discussion of medication incidence rates and prevention strategies, respectively.

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In 1996 the Institute of Medicine launched the Quality Chasm Series, a series of reports focused on assessing and improving the nation's quality of health care. Preventing Medication Errors is the newest volume in the series. Responding to the key messages in earlier volumes of the series— To Err Is Human (2000), Crossing the Quality Chasm (2001), and Patient Safety (2004) —this book sets forth an agenda for improving the safety of medication use. It begins by providing an overview of the system for drug development, regulation, distribution, and use. Preventing Medication Errors also examines the peer-reviewed literature on the incidence and the cost of medication errors and the effectiveness of error prevention strategies. Presenting data that will foster the reduction of medication errors, the book provides action agendas detailing the measures needed to improve the safety of medication use in both the short- and long-term. Patients, primary health care providers, health care organizations, purchasers of group health care, legislators, and those affiliated with providing medications and medication- related products and services will benefit from this guide to reducing medication errors.

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Medication Administration Errors and Associated Factors Among Nurses

Dejene tsegaye.

1 Department of Nursing, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia

Zenaw Tessema

2 Department of Pharmacy, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia

Wubet Alebachew

3 Department of Maternal and Neonatal Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia

Introduction

Medication error has the potential to lead to harm to the patient. It is the leading cause of threatens trust in the healthcare system, induce corrective therapy, and prolong patients’ hospitalization, produces extra costs and even death. This study aimed to assess medication administration error (MAE) and associated factors among nurses in referral hospitals of Ethiopia.

Institutional-based, cross-sectional study design was used, and 422 study participants were selected using a simple random sampling method. Data were collected using a semi-structured and pre-tested self-administered questionnaire and observational checklist. The collected data were analyzed using descriptive and analytical statistics and binary logistic regression was done to identify factors associated with medication administration errors. P-value ≤ 0.05 was considered statistically significant.

Four hundred fourteen participants with a response rate of 98.1% were involved and 54.3% were females. The median age was 30 with IQR (28–34) years and the majority of them (83.8%) had BSc qualification in nursing. The prevalence of MAE in this study was 57.7% and 30.4% of them made it more than three times. Wrong time (38.6%), wrong assessment (27.5%), and wrong evaluation (26.1%) were the most frequently perpetuated medication administration errors. Significant association between medication administration errors and lack of training [AOR=2.20; 95% CI (1.09, 4.46)], unavailability of guideline [AOR=1.65; 95% CI (1.03, 2.79)], poor communication when face problem [AOR=3.31; 95% CI (2.04, 5.37)], interruption [AOR = 3.37, 95% CI (2.15, 5.28)] and failure to follow medication administration rights [AOR=1.647; 95% CI (1.00, 2.49)] was noticed.

MAE was high in the study area as compared to studies from Jimma University Specialized Hospital, Adigrat and Mekelle University Hospital, and the University of Gondar Referral Hospital and hence developing guidelines, providing training, and develop strategies to minimize distracters are better to be undertaken.

MAE is any preventable act that contributes to the failure of proper medication use in the treatment process resulting in harm for the patient to the extent of disability and death. 1 , 2 It affects human relationships, threatens trust in the healthcare system as a whole, and can also destroy life. 3–5 Errors in medication administration can occur through failures in any of the ten rights which are right patient, right medication, right time, right dose, right route, right education/advice, rights to refuse, right assessment, right evaluation/response, and documentation. 6–9 Health workers committed medication administration errors during the processes of ordering, prescribing, dispensing, preparing, or administration. 2 , 7

Globally, medication errors are leading causes of different injuries and avoidable harms in the health care system attributing to about 10% of the overall preventable harm for hospitalized patients. 10–12 In 2017, World Health Organization reported that the annual global cost associated with medication errors has been estimated to reach US ($) 42 billion accounting for 0.7% of the total health expenditure. 13 Moreover, in 2018, a British report on the prevalence and burden of medication errors estimated the occurrence of 237 million medication errors at all stages of medication administration, 14 and in Finland 700 to 1700 people died each year from medication-related errors. 15 Similarly, in the USA, medication errors caused the death of about 7000 patients and about 400,000 cases of avoidable patient harm per year, which cost US ($)3.5 billion. 2 In low and middle-income countries, the impact is about twice as much in terms of the number of years of healthy life lost. 16

MAE is a global challenge and 18.7%-56% of hospitalized patients face medication administration errors and patients who faced this problem accounted for 60% to 80% in Australia and 64% in Nigeria. 1

A study conducted in Tigray regional state of Ethiopia revealed that wrong dose, administering at the wrong time, medication omission, administering a wrong patient, administering via a wrong route, administering un-prescribed medication, and administering a wrong drug were the most common types of MAE. 17 As per the kinds of literature, MAE can be prevented with consistent reporting systems and by avoiding barriers to report the errors such as fear, heavy workload, time constraints, and negative employees’ perceptions of error. 18–20

Having a consistent reporting system and providing care based on guidelines could prevent 75% of the occurrence of harm to hospitalized patients. 21 Medication administration errors can also be prevented by the use of technology like bar-coding for medications and patients, smart infusion pumps for intravenous administration, single-use medication packages, and package design features, and minimizing interruptions during the medication administration process. 7

Medication error, mainly the administration phase, is accounted to be the most common cause of disability and death throughout the world. 22–24 It can also prolong patients’ hospital stay resulting in increased healthcare costs for patients, families, and health professionals. 16 Clinical experience observations at different public health hospitals revealed that nurses commit medication administration error administration. Normally, there are limited relevant findings concerning medication administration error in sub-Saharan African countries, especially in Ethiopia. It is the least researched and dumped health problems where significant problems related to education, economic, and trained labor is common, Besides, prior studies were merely on the six rights of medication administration and the magnitude of medication administration error and contributing factors in the study hospitals is left unknown. Therefore; the main aim of this study was to assess medication administration errors and associated factors among nurses in referral hospitals in Amhara Ethiopia.

Study Area and Period

The study was conducted among nurses working at referral hospitals of Amhara regional state which are Debre Birhan, Felegehiwot, Debre Markos, Gondar, and Dessie referral hospitals from March 1–30, 2019.

Study Design

A multicenter hospital-based cross-sectional study design triangulated with observation was conducted.

Source Populations

All nurses who were working at referral hospitals of Amhara region state.

Study Populations

Those nurses who were randomly selected from Amhara referral hospitals during the study period.

Inclusion Criteria

Nurses with a minimum of six months of working experience and involved in direct patient care were included in the study.

Exclusion Criteria

Those nurses who were not involved in medication administration practice and the ones serving in administrative positions were excluded from the study.

Sample Size Determination

Using single population proportion formula, 95% confidence interval, 5% margin of error, a reasonable estimate for the proportion of medication administration error from a prior study (51.8%), 22 the required sample size (N) is calculated as follows:

N= Minimum sample size

P= Estimated proportion of medication administration error (51.8%)

d= the margin of sampling error tolerated (5%)

Zα/2= is the standard normal distribution at 1-α%= confidence level (95%=1.96), then

Adding a 10% non-response rate, a sample of 422 nurses were included. For the observational part of the study, since it is recommended to take a maximum of 10% of the sample size participating for cross-sectional study, 42 nurses; proportionally, 5 from DBRH, 10 from FHRH, 6 from DMRH, 15 from GUSH, and 6 from DRFH were involved.

Sampling Procedure

To select 422 nurses from the total five referral hospitals in the Amhara region, all hospitals were first listed down with their respective nurse numbers after which the sample size was proportionally allocated to each hospital. Then, the sampling frame was prepared for each hospital by having lists of nurses from the hospitals’ nursing director and human resource management. Finally, eligible nurses of each hospital were selected by simple random sampling technique ( Figure 1 ).

Schematic representation of the sampling procedure in the study area, 2019 (n=422).

Dependent Variable

Prevalence of medication administration error

Independent variables

Socio-demographics characteristics, work-related factors, professional related factors, and other error producing conditions.

Data Collection Tools and Procedures

A semi-structured self-administered questionnaire was prepared and used to collect data on nurses’ socio-demographic characteristics (salary, an institution where the nurse earned, an educational award, year of experience, etc), work-related factors (nurse to patient ratio, lack of written guideline for medication administration, poor communication with other nurses while facing problems, current working unit, lack of reporting mechanism to medication errors and duration in specific unit), professional related factors (lack of training and inability to follow ten rights of medication administration practice) and other factors contributing for MAE (Unclear verbal order, illegible physicians handwriting, wrong prescription and dispensing, look like drugs, nurses’ prescription in place of physicians, nurse administer medication prepared by another nurse and physicians’ frequent alteration of their orders). Moreover, the prevalence of MAE, reporting trends of a medication error, and types of MAE were considered. Ten trained diploma nurses were involved in collecting data from the questionnaire. A structured observational checklist that contained nine direct observable medication administration rights was used to gather data on a total of 42 nurses’ adherence to the directly observable nine rights while medication administration. Observational data collection was done by five Bsc nurses working in different units of each hospital and after observation, patients’ medical records were reviewed to triangulate with a record of ordered medications’ dose, route, time, and other profiles.

Data Quality Control

To assure data quality, the questionnaire and observational checklist were adapted from previous studies. 14 , 22 , 25–31 Before two weeks of actual data collection, both the questionnaire and observational checklist were pretested on 21 nurses working at Finoteselam General Hospital after which some medications were made accordingly. To minimize bias, the nurses were not informed of being observed while medicating their patients. Moreover, one-day training and clear orientation were provided for data collectors and supervisors on the process of data collection. During data collection, data collectors were closely monitored and guided by five BSC nurse supervisors for complete and appropriate collection of the data, and reporting to the principal investigator was done daily. The collected data were double entered into Epidata version 4.2 for validation purposes. The entered data were multivariate analyzed for statistical adjustment of possible confounders.

Data Processing and Analysis

The collected data were cleaned manually, coded, and entered into Epi data version 4.2 and exported to STATA Version 12 statistical software for data transformation and further analysis. Descriptive statistics like frequencies, proportion, and summary statistics (mean, median, IQR, and standard deviation) were used to describe the study population with relevant variables and presented in tables and graphs. Multi-collinearity between the study variables was diagnosed using standard error and correlation matrix. The assumptions for the binary logistic regression model were first checked and then bivariable analysis was carried out to identify candidate variables (p<0.25) for multivariable analysis. Using these candidate variables, multivariable analysis was performed to investigate statistically significant independent predictors of medication administration error by adjusting for possible confounders. Finally, variables whose p-value less than 0.05 (p<0.05) from the multivariable analysis were declared as statistically significant. An adjusted odds ratio with 95% CI was considered to identify the strength of association between medication administration error and its predictors.

Ethical Consideration

The study was conducted as per the Declaration of Helsinki since Debre Markos University provides ethical approval based on the declaration. Data were collected after verbal informed consent was approved by the ethical review committee of health Sciences College, Debre Markos University. Patients’ consent for their medical records was waived by the committee since the data were already recorded for other medical cases. The individuals were told about the aim and the benefit of the study and ensured that there was no harm to them. Then, full consent was obtained from the participants before the commencement of the study. Participants were represented by a unique code to ensure data confidentiality.

Socio-Demographic Characteristics

Four hundred fourteen nurses participated in this study, with a 98.1% response rate. The median age of the respondents was 30 years with interquartile range (IQR) 27–33 years. Near to half (46.6%) of them were in the age group of 26–30 years and 56% of respondents were married. Regarding the educational level, the majority of the respondents (83.8%) had BSc qualification in nursing. Also, most (83.3%) of them got their current education from governmental institutions. The median work experience of respondents was 5 years (IQR 4–9) years ( Table 1 ).

Socio-Demographic Characteristics of Participants, 2019

Prevalence and Types of Medication Administration Error

Out of 414 participants, 57.7% of nurses made MAE in the last 12 months and 30.4% of them made it more than three times during the specified period ( Figure 2 ). Wrong time (38.6%) was the most frequently perpetuated MAE followed by wrong assessment (27.5%) and wrong evaluation (26.1%) ( Table 2 ). From the total dosage errors done, both overdose and underdose accounted for 37.5% ( Figure 3 ) whereas a total of forty route errors were made and all of these were parenteral route types. The majority of respondents (77.5) checked the expiry date of the medication before medication administration.

Types of Medication Administration Error, 2019

Dose error types committed in the study area, 2019 (n =414).

Frequency of medication administration errors, 2019 (n =414).

Work, Managerial, and Professional-Related Factors

Near to one-fourth (26.1%) of respondents were working in the medical ward and 72.2% of them had work experience of more than six months in their unit. The median of the nurse to patient ratio was 10 with an IQR of 4. Most of the respondents (88.4%) did not take training on safe medication administration practice and 43.7% did not communicate with other nurses when faced with doubt during medication administration or about the time when the next dose is due. Almost half (51.2%) of nurses faced interruption during medication administration. Near to one-third (36.7%) of nurses had medication administration guidelines and among them, 70.4% were using the guideline appropriately. Even though 19.6% of respondents had the system for MAE reporting, 10.43% of them did not report it in the last 12 months ( Table 3 ) due to different reasons ( Figure 4 ).

Work-Related Characteristics of Nurses, 2019

Reason for not reporting medication administration errors, 2019 (n=414).

Other Factors Contributing to a Medication Administration Error

As per the responses of the participant, lack of sufficient training (78.7%), physician change prescription frequently (75.1%), and nurse provide medication prepared by another nurse (71.5%) were the three most commonly listed contributing factors for the MAE ( Table 4 .)

Factors Contributing to Medication Administration Errors, 2019

Observational Checklist Results

To triangulate the result of the self-administered questionnaire, observational data were collected by observing nurses when administering medication at a time. The single medication administered by a nurse was considered as a single dose and a total of 109 doses of medications were observed. The results revealed that only 11% of the 109 directly observed doses of medication were administered in line with the nine directly observed rights of medication administration. Nurses’ failure to educate or inform patients before administering medication (88%) was the most observed type of error followed by failure to assess (74%) and evaluate (66.9) patients after medicating them ( Table 5 ).

Direct Observation of Nurses’ Adherence to the Directly Observable Nine Rights of Medication Administration, 2019

Factors Associated with Medication Administration Error

To identify factors associated with medication administration errors, binary logistic regression was done. In bivariate logistic regression analysis, nurse’s sex, marital status, working unit, year of experiences, nurse to patient ratio, lack of training, unavailability of the guideline, faced interruption during medication administration, poor communication when faced doubt, absence of reporting system for medication administration error, failure to follow rights of medication administration error, prescription by nurses instead of physicians, and physician change orders frequently had an association with medication administration error. All variables that have an association with the outcome variables in bivariate logistic regression analyses were entered into the multivariate logistic regression analysis models by using the backward likelihood ratio method. Then lack of training, unavailability of guidelines for medication administration, interruption during medication administration, poor communication with another nurse when they encountered a problem, and failure to follow rights of medication administration were found significantly associated with MAE.

The odds of MAE were two times higher among nurses who did not take training on safe medication administration as compared to those nurses who had taken the training [AOR=2.20; 95% CI (1.09, 4.46)]. Similarly, the odds of MAE were almost two times higher among nurses who did not have guidelines for medication administration than had the guidelines [AOR=1.65; 95% CI (1.03, 2.79)]. Nurses interrupted during medication administration and nurses who did not communicate with another nurse while facing problem were three times more likely to do medication administration error than those nurses who did not interrupt [AOR =3.37, 95% CI (2.15, 5.28)] and those nurses who communicate [AOR=3.31; 95% CI (2.04, 5.37)] respectively ( Table 6 ).

Multivariable Logistic Regression Analysis of Factors Associated with MAE, 2019

Note: *Statistical significant at P=0.05.

The finding of this study showed that the magnitude of medication administration error was 57.7% with 95% CI. The prevalence of MAE in this self-reported study was relatively consistent with studies conducted at Felege Hiwot referral hospital and research done in Kenya 25 , 27 but much higher than a study conducted in teaching hospitals in west Iran. 24 The difference might be because the previous study was done in a developed country where there is a computerized prescribing and recording system, high quality of health care institutions, voluntary error reporting system and follow up practices are common. Medication administration error was most commonly practiced at referral hospitals of Amhara region as compared Jimma University Specialized Hospital, Adigrat and Mekelle University Hospitals, and university of Gondar referral hospital. 22 , 32 , 33 Although all these findings were from Ethiopian Hospitals, the constitute of medication administration, work experiences, working load, and health care systems may be attributed to deviated study results. More importantly, this study considered ten rights while the previous studies did not consider all these rights.

On the other hand, the result of this finding was lower than studies conducted in two public hospitals of Southern Ethiopia, the pediatrics ward at JUSH and teaching hospitals in Australia. 26 , 30 , 34 This may be attributed to the variation in the number of hospitals considered during the study, involved clinical units, and setting in which the above studies were done only by involving smaller study settings and clinical units. Unlike this fact, this study involved five hospitals and more clinical units. Furthermore, some of the previous studies used an observational checklist to collect data and even used a smaller sample size as compared to this investigation.

Observationally, a total of 109 doses of medication administrations were considered of which 89% of the administered medication experienced at least one type of MAE. The medication administration error in these study Hospitals was not as much higher than the other public hospitals in Southern Ethiopia 26 and much more than a study conducted in Australia. 30 Expectedly variation in the constituents of medication administration errors, the difference in study settings can contribute to the discrepancy. In developed countries the quality of services given is high. Constituents of medication administration rights can also alter the results of a particular study. The findings of both self-reported and direct observed studies showed that medication administration errors were a common health problem in the hospitals under study. This result indicated that some participants made medication administration errors but did not report in the self-reported questionnaire. Only 6.5% of nurses reported the error to the concerned body which was lower than a study conducted in Iran 24 since variation in the willingness of nurses to report the errors, the availability of a system for reporting errors, and the extent of administrative support given to the nurses to report the error.

According to this study, near ten third of the medications were not administered at their regular scheduled time (right time) leads to the patient to develop toxicities or resistance to the drugs. This finding was lower than studies done in two public hospitals in Southern Ethiopia 26 but higher than the study done in teaching hospitals in west Iran 24 as there is a difference in several settings, sample sizes, the country where the studies were conducted and quality of health care services given. According to this study, a lack of sufficient training was the main contributed factor for MAE followed by frequent changes of prescription by physicians in whom both figures were supported by research done in medical and surgical units of MOI teaching and referral hospital and African hospitals. 25 , 35

In this study, there were factors which had a significant association with medication administration error including lack of training, poor communication with other nurses when faced problem, Interruption during medication administration, unavailability of guidelines, failure to follow ten rights of medication administration. Lack of training in this study was supported by reports from African hospitals 35 and an institution-based, cross-sectional study conducted in two public hospitals of Southern Ethiopia 26 implicating that training is mandatory for medication error reduction as there may be new diseases, new medications, and new administration techniques. Poor communication with other nurses when they had problems was another factor significantly associated with medication administration which was similar to a study conducted in South Korea. 36 Effective communication and collaboration between healthcare providers, such as open communications, error reporting, and team accountability among healthcare providers, should be facilitated and considered as a rule to reduce errors associated with medication administration and hence it is possible to reduce costs and prolonged hospitalization due to the errors and finally increase the quality of life of the patients. Interruption during medication administration was the third factor significantly associated with medication administration error and this finding was supported by research done at Felege Hiwot Referral Hospital, a systematic review in African hospitals, and two public hospitals in Southern Ethiopia. 26 , 34 , 35 Interruption occurs while performing an intervention before administration is completed and its cognitive failure concerning working memory and attentiveness.

According to this study, the unavailability of the guideline was found to be significantly associated with medication administration error which was supported by research conducted in Egypt. 1 , 37 One of WHO strategy in 2017 was to provide guidelines and strengthen health professional’s capacity through skill-building. The availability of guidelines for medication administration may improve the quality of nursing care and reduce medication administration errors. Another factor that was strongly associated with medication error in this study was the failure to follow ten rights of medication administration similar to a study conducted on Korean nurse’s perception of medication error working in 7 hospitals. 36 Unless nurses strictly follow the ten rights of medication administration, they may perpetuate errors and affect the health care provision system as a whole. All these findings implied that medication administration error affects negatively the patients, patient families, the health care systems, and the health care providers in general. Besides, the problem incurs most costs and limits the financial systems of one country. Hence the respective health care professionals, administrators, government and non-governmental organizations, collaboratives, policymakers, and planers should provide significant attention for MAE and in the future intensive researches should be conducted to show the economical, social, and psychological implications of MAE which critically attributes for policymakers.

Conclusion and Recommendations

Medication administration error was high in this study and administering medication at a wrong time was the most common type of error followed by wrong assessment and evaluation respectively. Lack of training, unavailability of guidelines for medication administration, interruption during medication administration, poor communication when faced with problems and failure to follow ten rights of medication administration were factors significantly associated with medication administration errors. Therefore, stakeholders like the regional health bureau, hospital administrators, and nurse professionals should collaborate and shared respective responsible to minimize problems owing to a medication administration error.

Limitation of the Study

This study used the cross-sectional nature of the study design and does not confirm a definitive cause and effect relationship between the variables. During the observation, the study participant may change their usual way of medication administration practices (hawthorn effect) when they are told for being an understudy. Further, concerning medication administration error and reporting may be wrongly answered due to fear of the outcome or social desirability.

Acknowledgments

The authors would like to acknowledge Debre Markos Universities for financial support to conduct this study.

Funding Statement

This study was supported by Debre Markos University.

Abbreviations

AOR, adjusted odds ratio; CI, confidence interval; COR, crude odds ratio; DBRH, Debre Birhan Referral Hospital; DMRH, Debre Markos Referral Hospital; DMU, Debre Markos University; DRH, Dessie Referral Hospital; FHRH, Felegehiwot Referral Hospital; GUSH, Gondar University Specialized Hospital; JUSH, Jima University Specialized Hospitals; IM, intramuscular; IV, intravenous; MAE, medication administration error; ME, medication error; OPD, outpatient department; OR, operation room; SAQ, self-administered questionnaire; SPSS, Statistical Package for Social Sciences; UK, United Kingdom; USA, United States of America.

Author Contributions

All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval of the version to be published, and agree to be accountable for all aspects of the work.

The authors report no conflicts of interest for this work.

Medication Errors Essays

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Medication Error Non-Reporting: Root-Cause Analysis Essay

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Introduction

Improvement plan, existing organizational resources.

Medication errors (MEs) seriously threaten patient health conditions and outcomes. Therefore, ME reporting is crucial for prevention efforts; healthcare personnel should report MEs routinely to improve patient safety and care quality. However, the real-life MEs reporting rate reaches only the 57-61% mark (Jember et al., 2018; Rishoej et al., 2018). This paper provides a root-cause analysis of ME non-reporting based on the community hospital nurses survey. In addition, evidence-based strategies to reduce ME non-reporting are discussed, and a reporting rate improvement plan is developed based on the strategies and available organizational resources.

Despite the vital importance of proper ME reporting, nurses frequently show reluctance to report the cases. For instance, a study at federal hospitals in Addis Ababa, Ethiopia, by Jember et al. (2018) found that only 57,4% of 403 participants reported their own MEs or MEs made by their colleagues. According to Rishoej et al. (2018), only 60% of pediatric nurses and physicians in Southern Denmark deemed necessary to self-report MEs to a national mandatory reporting system. In these examples, one can see that approximately 40% of MEs may remain unreported in hospital settings. As a result, hospitals cannot analyze MEs and implement the necessary changes. Therefore, ME non-reporting harms patients and healthcare organizations as the issue persists and endangers patient safety.

Considering the harmful implications of non-reporting, scholars attempted to reveal and analyze the underlying causes of the safety issue. Rutledge et al. (2018) surveyed 359 registered nurses at Magnet-accredited faith-based hospital in California with a Medication Error Reporting Barriers (MERB) questionnaire. The participants evaluated 20 items using 5-point Likert scales to indicate the barriers that disrupt proper ME reporting procedure. The answers were described via the IBM SPSS software (Rutledge et al., 2018). Overall, ME non-reporting was associated with three primary factors: procedure complexity, fear, and awareness gaps.

Reporting Procedure Complexity

Procedure complexity was the most common barrier to ME reporting. In particular, 173 nurses, or 48,2% of total respondents, claimed that documenting MEs requires extra time (Rutledge et al., 2018). In addition, 129 nurses (35,9%) argued that forms used for ME reporting were too long and time-consuming to fill (Rutledge et al., 2018). As such, the complexity of the procedure can be considered a negative communication factor in ME non-reporting.

Nurses’ sense of fear was the second-most mentioned barrier to reporting. Fear manifested in various aspects — 123 (34,3%) of respondents expressed fear of lawsuits, 118 (32,8%) were afraid of being blamed and 104 (29%) were worried about potential disciplinary actions (Rutledge et al., 2018). In this regard, fear can be considered a substantial environmental factor of ME non-reporting. Nurses were inclined not to report MEs in order to avoid legal and professional repercussions.

Awareness Gaps

Lastly, the ME non-reporting was associated with awareness gaps in several domains. In particular, 82 respondents (22,8%) did not know that reporting MEs is useful (Rutledge et al., 2018). Additionally, 77 nurses (21,4%) lacked the knowledge of which MEs should be reported, and 75 (20,4%) could not recognize that ME had occurred (Rutledge et al., 2018). In this regard, the lack of education can be considered a severe human factor in ME non-reporting.

Application of Evidence-Based Strategies to Reduce ME Non-Reporting

Since procedure complexity was found to be the most prevalent root cause of ME non-reporting, simplifying the reporting procedure is highly recommended. Most importantly, this strategy will make ME reporting less time-consuming (Rishoej et al., 2018). In turn, the increase in report sending and processing speed may convince the nurses to report MEs. For example, procedure simplification increased incident reporting rates in intensive care units (Harris et al., 2007, as cited in Rishoej et al., 2018). In this regard, the administration should encourage

ME reporting to a direct supervisor

Several changes in organizational culture can modify the fear factor. Most importantly, the hospital should offer mental support and counseling to nurses. According to Robertson and Long (2018), physicians who make medical errors usually wish to discuss their experiences. Therefore, a hospital can increase ME reporting rates by replacing the blame culture with a more supportive approach. Nurses should be convinced that MEs do not automatically render them unprofessional. In contrast, MEs should be perceived as learning opportunities to enhance patient safety.

Finally, the awareness gaps can be addressed only through additional education and timely feedback from the hospital administration. All nurses should undergo ME reporting training to learn why MEs reporting is beneficial and what defines a ME. In addition, the supervisors must provide the nurses with timely feedback once MEs are reported (Rutledge et al., 2018). In the end, a nurse cannot be expected to report MEs reliably if they cannot recognize one or doubt whether it should be reported.

The plan to improve ME reporting rates within the hospital contains two main parts. Firstly, the organizational improvement part consists of streamlining the MEs reporting procedure to make it less burdensome for nurses and addressing the fear-induced reluctance to report MEs. Rishoej et al. (2018) suggest simplifying reporting process, which can be achieved by encouraging the nurses to report MEs directly to a specifically designated supervisor. As a result, time will be saved on filing the report and receiving the feedback, which would incline the nurses to report MEs more frequently. The fear-based reluctance can be addressed by adding the elements of support and understanding to the existing organizational culture of fear and perfectionism. Counseling and open discussion would help the nurses overcome the fear of being blamed and persecuted for errors (Robertson and Long, 2018). Consequently, the ME reporting rates would increase since nurses would stop fearing legal persecution and professional status loss.

Secondly, the human factor stemming from awareness gaps can be modified through additional education. In particular, Rutledge et al. (2018) recommend training sessions within the hospital in order to increase the organization-wide understanding of the ME concept. In particular, nurses must be taught a clear ME definition and know which cases must be reported (Rutledge et al., 2018). As a result, nurses would understand what constitutes MEs and why it is helpful to report and openly discuss them. Overall, changes associated with both parts of the improvement plan can be implemented within several months.

In general, the MEs reporting improvement plan can be implemented without significant expenditures. Both organizational and human factor parts would largely depend on the skills and knowledge of existing staff members. Hiring extra staff members might be necessary only on two occasions. Firstly, training sessions and education on MEs would occupy the time of nurses and trainers. Secondly, designated supervisors would have to review an increased number of ME reports. Therefore, hiring extra nurses might be necessary to spread the workload more efficiently and avoid such adverse effects as fatigue and emotional burnout.

ME non-reporting is a significant patient safety issue since it hinders the error analysis and subsequent correction. Three primary root causes are responsible for ME non-reporting — procedure complexity, fear, and awareness gaps. The two-pronged safety and quality improvement plan can address these causes. Firstly, organizational improvement requires simplifying the ME reporting procedure and shifting organizational culture from blame to support. Secondly, nurses should be provided with additional education in order to bridge awareness gaps. In the end, the ME reporting rates should increase as the nurses’ knowledge and confidence surge.

Jember, A., Hailu, M., Messele, A., Demeke, T., & Hassen, M. (2018). Proportion of medication error reporting and associated factors among nurses: a cross sectional study. BMC Nursing , 17 (1), 1-8.

Rishoej, R. M., Hallas, J., Juel Kjeldsen, L., Thybo Christesen, H., & Almarsdóttir, A. B. (2018). Likelihood of reporting medication errors in hospitalized children: A survey of nurses and physicians . Therapeutic Advances in Drug Safety , 9 (3), 179-192.

Robertson, J. J., & Long, B. (2018). Suffering in silence: Medical error and its impact on health care providers. The Journal of Emergency Medicine , 54 (4), 402-409.

Rutledge, D. N., Retrosi, T., & Ostrowski, G. (2018). Barriers to medication error reporting among hospital nurses . Journal of Clinical Nursing , 27 (9-10), 1941-1949.

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IvyPanda . (2023) 'Medication Error Non-Reporting: Root-Cause Analysis'. 16 June.

IvyPanda . 2023. "Medication Error Non-Reporting: Root-Cause Analysis." June 16, 2023. https://ivypanda.com/essays/medication-error-non-reporting-root-cause-analysis/.

1. IvyPanda . "Medication Error Non-Reporting: Root-Cause Analysis." June 16, 2023. https://ivypanda.com/essays/medication-error-non-reporting-root-cause-analysis/.

Bibliography

IvyPanda . "Medication Error Non-Reporting: Root-Cause Analysis." June 16, 2023. https://ivypanda.com/essays/medication-error-non-reporting-root-cause-analysis/.

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