Evaluation of medication errors in the hospital environment
Authors:
Iva Brabcová 1; Valérie Tóthová 1; Hana Hajduchová 1; Ivana Chloubová 1; Martin Červený 1; Radka Prokešová 2; Josef Malý 3; Martin Doseděl 3
Authors‘ workplace:
Jihočeská univerzita v Českých Budějovicích, Zdravotně sociální fakulta, Ústav ošetřovatelství, porodní asistence a neodkladné péče
1; Jihočeská univerzita v Českých Budějovicích, Zdravotně sociální fakulta, Ústav humanitních studií v pomáhajících profesích
2; Farmaceutická fakulta Univerzity Karlovy v Hradci Králové, Katedra sociální a klinické farmacie
3
Published in:
Vnitř Lék 2022; 68(E-6): 3-9
Category:
Original Contributions
doi:
https://doi.org/10.36290/vnl.2022.084
Overview
Introduction: Healthcare is inherently associated with a risk to patient health. One risk is associated with medication-related errors, which are commonly reported adverse events. By analyzing the root causes of medication errors, effective preventive measures can be proposed to reduce their likelihood. This study aimed to identify the reasons of medication administration errors, determine the number of medication administration errors reported, and describe the barriers hindering reporting.
Methodology: The study used a standardized Questionnaire Medication Administration Error Survey (MAE survey) that was quantitatively analyzed. The study involved 112 nurses from four hospitals in the South Bohemian Region.
Results: Risk factors that increase the likelihood of medication administration errors include similarity of drug names (3.7 ± 1.3) and packaging (3.9 ± 1.5), frequent prescription changes for patients (3.2 ± 1.5), illegibility of written prescriptions (3.1 ± 1.6), a lack of clarity of medical records (2.6 ± 1.5). Only a proportion of medication administration errors are reported by nurses (16% to 21%). The reluctance of nurses to report medication administration errors is linked to fear of being blamed for the deterioration of the patient‘s health (3.3 ± 1.7), fear of the doctor‘s reaction to a medication administration error (2.6 ± 1.4), and repressive responses from hospital management to reported misconduct (2.9 ± 1.5).
Conclusion: Measures to reduce the likelihood of medication administration errors include building a non-punitive system for reporting adverse events and medication errors, introducing electronic prescription systems, promoting open communication within the team, involving clinical pharmacists in the pharmacotherapy process, and regular comprehensive training of nursing staff.
Keywords:
nurse – medication error – administration of drugs – reporting of adverse events
Sources
1. Liukka M, Steven A, Vizcaya Moreno MF et al. Action after Adverse Events in Healthcare: An Integrative Literature Review. Int J Environ Res Public Health 2020; 17:4717.
2. Schwendimann R, Blatter C, Dhaini S et al. The occurrence, types, consequences and preventability of in‑hospital adverse events – a scoping review. BMC Health Serv Res 2018; 18:521.
3. Bezpečí pacientů. Příručka k osnově a bezpečí pacientů. Multiprofesní edice. Praha: MZČR, 2016.
4. Feleke SA, Mulatu MA, Yesmaw A S. Medication administration error: magnitude and associated factors among nurses in Ethiopia. BMC Nurs 2015; 14(1).
5. Bişkin Çetin S, Cebeci F. Perceptions of Clinical Nurses About the Causes of Medication Administration Errors: A Cross‑Sectional Study. Florence Nightingale J Nurs 2021; 29(1):56-64.
6. Wakefield BJ, Uden‑Holman T, Wakefield DS. Development and Validation of the Medication Administration Error Reporting Survey. In: Henriksen K, Battles JB, Marks ES, et al. (eds). Advances in Patient Safety: From Research to Implementation. Volume 4: Programs, Tools, and Products. Rockville (MD): AHRQ (US); 2005. Dostupné z: https://www.ncbi.nlm. nih.gov/books/NBK20599/
7. Jain K. Use of failure mode effect analysis (FMEA) to improve medication management process. Int J Health Care Qual Assur 2017; 30(2):175-186.
8. Mekonen EG, Gebrie MH, Jemberie SM. Magnitude and associated factors of medication administration error among nurses working in Amhara Region Referral Hospitals, Northwest Ethiopia, JDA 2020; 9(1):151-158.
9. Pokorná A et al. Management nežádoucích událostí ve zdravotnictví. Praha: Grada. 2019. ISBN 978-80-271-0720-9.
10. SHNU: Národní portál - Systém hlášení nežádoucích událostí. [online] ÚZIS ČR [10-10- 2021]. Dostupné z: https://shnu.uzis.cz/browser/analyzy
11. Lee E. Reporting of medication administration errors by nurses in South Korean hospitals. Int J Qual Health Care 2017; 29(5):728-734.
12. You MA, Choe MH, Park GO et al. Perceptions regarding medication administration errors among hospital staff nurses of South Korea. Int J Qual Health Care 2015; 27(4):276-283.
13. Kim MS, Kim CH. Canonical correlations between individual self‑efficacy/ organizational bottom‑up approach and perceived barriers to reporting medication errors: a multicenter study. BMC Health Serv Res 2019; 19:495.
14. Zákon č. 201/2017 Sb., kterým se mění zákon č. 96/2004 Sb., o podmínkách získávání a uznávání způsobilosti k výkonu nelékařských zdravotnických povolání a k výkonu činností souvisejících s poskytováním zdravotní péče, v platném znění.
15. Brabcová I, Prokešová R, Tóthová V et al. Využití analýzy FMEA v řízení rizik ošetřovatelské péče. Onkologie 2021; 15(4):197-203.
16. Malý J. Lékové problémy v teorii a příkladech v podmínkách České republiky. Klin Farmakol Farm 2020; 34(3):116-121.
17. Evropské statementy o nemocničním lékárenství, 2014. [online] [07-07-2022]. Dostupné z: https://www.eahp.eu/sites/default/files/evropske_statementy_final_verze_cz.pdf
18. Elasrag GAE, Abu‑Snieneh HM. Nurses’ Perception of Factors Contributing to Medication Administration Errors. Int J Res Pharm Sci 2020; 11(1):44-56.
19. Plevová I, Jarošová D, Janíková E et al. Přidělená ošetřovatelská péče jako jeden z indikátorů výskytu medikačních pochybení. Vnitř Lék 2020; 66(7):e31–e3.
20. Yung HP, Yu S, Chu C et al. Nurses’ attitudes and perceived barriers to the reporting of medication administration errors. J Nurs Manag 2016; 24(5):580–588.
Labels
Diabetology Endocrinology Internal medicineArticle was published in
Internal Medicine
2022 Issue E-6
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