scholarly journals Improving patient safety through identifying barriers to reporting medication administration errors among nurses: an integrative review

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Agani Afaya ◽  
Kennedy Diema Konlan ◽  
Hyunok Kim Do
Keyword(s):  
Medication Error ◽  
Hospital Setting ◽  
Medication Administration ◽  
Integrative Review ◽  
Medication Administration Error ◽  
Medication Administration Errors ◽  
Inadequate Knowledge ◽  
Administration Error ◽  
Uniform Definition ◽  
Definition Of

Abstract Background The aim of the third WHO challenge released in 2017 was to attain a global commitment to lessen the severity and to prevent medication-related harm by 50% within the next five years. To achieve this goal, comprehensive identification of barriers to reporting medication errors is imperative. Objective This review systematically identified and examined the barriers hindering nurses from reporting medication administration errors in the hospital setting. Design An integrative review. Review methods PubMed, Web of Science, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) including Google scholar were searched to identify published studies on barriers to medication administration error reporting from January 2016 to December 2020. Two reviewers (AA, and KDK) independently assessed the quality of all the included studies using the Mixed Methods Appraisal Tool (MMAT) version 2018. Results Of the 10, 929 articles retrieved, 14 studies were included in this study. The main themes and subthemes identified as barriers to reporting medication administration errors after the integration of results from qualitative and quantitative studies were: organisational barriers (inadequate reporting systems, management behaviour, and unclear definition of medication error), and professional and individual barriers (fear of management/colleagues/lawsuit, individual reasons, and inadequate knowledge of errors). Conclusion Providing an enabling environment void of punitive measures and blame culture is imperious for nurses to report medication administration errors. Policymakers, managers, and nurses should agree on a uniform definition of what constitutes medication error to enhance nurses’ ability to report medication administration errors.

scholarly journals Improving patient safety through identifying barriers to reporting medication errors among nurses: an integrative review

2021 ◽  
Author(s):  
Agani Afaya ◽  
Kennedy Diema Konlan ◽  
Hyunok Kim Do
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Feedback System ◽  
Medication Administration ◽  
Integrative Review ◽  
Error Reporting ◽  
Medication Error Reporting ◽  
Inadequate Knowledge ◽  
Uniform Definition ◽  
Definition Of

Abstract Background: The aim of the third WHO challenge released in 2017 was to attain a global commitment to lessen the severity and to prevent medication-related harm by 50% within the next five years. To achieve this goal, comprehensive identification of barriers to reporting medication errors is imperative.Objective: This review aimed to identify studies that investigated barriers to reporting medication administration errors among nurses, systematically summarize the findings to make recommendations for improving error reporting, and for future investigation.Design: An integrative review Review methods: PubMed, Web of Science, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) including Google scholar were searched to identify published studies on barriers to medication error reporting from January 2016 to December 2020. The reviewers independently assessed the quality of all the included studies using the Mixed Methods Appraisal Tool (MMAT) version 2018.Results: Of the 10937 articles reviewed, 14 studies were included. The main themes and subthemes identified after the integration of results from qualitative and quantitative studies were; organizational barriers (inadequate reporting systems, management behavior, and unclear definition of medication error), and professional and individual barriers (fear of management/colleagues/lawsuit, individual reasons and inadequate knowledge of errors).Conclusion: It is not expected that nurses will freely report medication errors in a fearful, punitive, and blaming culture. Providing an enabling environment void of punitive measures and blame culture is imperative for nurses to report medication errors. To minimize the burden on nurses reporting medication errors, an effective, non-time consuming, and uncomplicated anonymous system is required. An open feedback system for motivating or rewarding nurses for reporting medication errors is imperative and will therefore increase the rate of error reporting. Policymakers, managers, and nurses should agree on a uniform definition of what constitutes medication error to enhance nurses' ability to report.

scholarly journals The Effectiveness of Interventions to Reduce the Nurses’ Distractions during Medication Administration: A Systematic Review

Jurnal NERS ◽  
2020 ◽  
Vol 14 (3) ◽  
pp. 132
Author(s):  
Chandra Apriadi Panduwal ◽  
E. C. Bilaut
Keyword(s):  
Systematic Review ◽  
Relevant Literature ◽  
Hospital Setting ◽  
Medication Administration ◽  
Error Rates ◽  
Limited Evidence ◽  
Post Intervention ◽  
Medication Administration Error ◽  
Medication Administration Errors ◽  
Administration Error

Introduction: Nurses constitute the largest group of health professionals who work in the hospital setting and most of the medications in the setting are administered by nurses. Errors related to medication conducted by a nurse frequently occur during medication administration. Interruptions or distractions during medication administration have been identified as significant contributory factors to medication administration errors (MAEs).Methods: This systematic review critically reviewed the evidence of the effectiveness of the interventions that aim to reduce nurse interruptions or distractions during medication administration. The search for the relevant literature was conducted in August 2018 using three databases; Medline, Cinahl and Embase.Results: Nineteen full text articles were retrieved and reviewed, and 7 articles were included in this review. Five of these studies showed evidence of a reduction in the interruption or distraction rates in post-intervention measurements, while 4 studies reported a statistically significant reduction in the interruption or distraction rates, with p values between 0.0005 and 0.002.Conclusion: There was limited evidence available to support the effectiveness of the interventions in terms of either reducing the interruptions or distractions of the nurses during the medication administration or in terms of reducing the medication administration error rates.

Analisis Faktor Perawat Dalam Pelaksanakan Keselamatan Pasien Terhadap Kejadian Medication Administration Error di Rumah Sakit

2020 ◽  
Author(s):  
Bintang Marsondang Rambe
Keyword(s):  
Patient Safety ◽  
Literature Review ◽  
Medication Error ◽  
Medication Errors ◽  
Medication Administration ◽  
Prescribing Error ◽  
Medication Administration Error ◽  
Administration Error

Latar Belakang Keselamatan pasien (patient safety) rumah sakit adalah suatu sistem dimana rumah sakit membuat asuhan pasien lebih aman yang meliputi assessment risiko, identifikasi dan pengelolaan hal yang berhubungan dengan risiko pasien, pelaporan dan analisis insiden, kemampuan belajar dari insiden dan tindak lanjutnya serta implementasi solusi untuk meminimalkan timbulnya risiko dan mencegah terjadinya cedera yang disebabkan oleh kesalahan akibat melaksanakan suatu tindakan atau tidak mengambil tindakan yang seharusnya diambil yang dilakukan oleh perawat (Kemenkes, 2011).Salah satu kesalahan yang dapat merugikan pasien adalah medication error. Menurut WHO (2016) medication error adalah setiap kejadian yang dapat dicegah yang menyebabkan penggunaan obat yang tidak tepat yang menyebabkan bahaya kepasien, dimana obat berada dalam kendali profesional perawatan kesehatan. proses terjadi medication error dimulai dari tahap prescribing, transcribing, dispensing,dan administration. Kesalahan peresepan (prescribing error), kesalahan penerjemahan resep (transcribing erorr), kesalahan menyiapkan dan meracik obat (dispensing erorr), dan kesalahan penyerahan obat kepada pasien (administration error). Medication error yang paling sering terjadi adalah pada fase administration / pemberian obat yang dilakukan oleh perawat.Administration error terjadi ketika pemberian obat kepada pasien tidak sesuai dengan prinsip enam benar yaitu benar obat, benar pasien, benar dosis, benar rute pemberian, benar waktu pemberian dan benar pendokumentasian. Secara global, kesalahan pemberian obat (medication errors) sampai saat ini masih menjadi isu keselamatan pasien dan kualitas pelayanan di beberapa rumah sakit (Depkes RI, 2015; AHRQ, 2015). Perawat sebagai bagian terbesar dari tenaga kesehatan di rumah sakit, mempunyai peranan dalam kejadian medication error. Perawat berkontribusi karena perawat banyak berperan dalam proses pemberian obat. Pemberian obat/ Medication Administration adalah salah satu intervensi keperawatan yang paling banyak dilakukan, dengan sekitar 5- 20% waktu perawat dialokasikan untuk kegiatan ini (Härkänen et al.,, 2019). Pemberian obat juga mencakup tugas-tugas lain, seperti menyiapkan dan memeriksa obat obatan, memantau efek obat-obatan, mengedukasi pasien tentang pengobatan, dan memperdalam pengetahuan perawat tentang obat – obatan sendiri (DrachZahavy et al., 2014 dalam Yulianti et al., 2019)Berdasarkan isu tersebut, penulis tertarik untuk melakukan literature review terkait faktor perawat dalam pelaksanakan keselamatan pasien terhadap kejadian medication administration error di Rumah Sakit.

scholarly journals Magnitude of Medication Administration Error and Associated Factors Among Nurses Working in Madda Walabu University Goba Referral Hospital, Bale Zone Oromia Region, Southeast Ethiopia

2020 ◽  
Author(s):  
Hiwot Fikadu Haile ◽  
Abulie Melku Takele ◽  
Addisu Gemechu Abdi
Keyword(s):  
Medication Error ◽  
Drug Administration ◽  
Work Experience ◽  
Associated Factors ◽  
Medication Administration ◽  
Referral Hospital ◽  
P Value ◽  
Medication Administration Error ◽  
Administration Error ◽  
Bale Zone

Abstract Background: Administration of medication is the primary responsibility of nurses. Medication errors occurring during the drug administration process can be attributed to a variety of safety effects, ranging from undetected errors to prolonged hospital stays, discomfort and death.Objective: To determine the magnitude of the medication administration error and associated factors among nurses working at Madda Walabu University Goba Referral Hospital, Bale Zone Oromia Region, South East Ethiopia.Methods: A facility-based cross-sectional study was conducted at Madda Walabu University Goba Referral Hospital Inpatient Department from February to March, 2020. The study included three hundred ninety-eight medication interventions administered by 89 inpatient unit working nurses during the study period. Data were collected using a pre-tested, structured questionnaire and drug administration assessment using a checklist. Data were analyzed using SPSS version 22 and Frequency , Percentage, Means and SD were analyzed for descriptive analysis. COR and AOR were calculated to see the association of independent variables and uncontrolled hypertension at 95% CI and p-value <0.05 was considered statistically significant.Result: The magnitude of the medication error was 248 (62.3%). The most common type of medication error was wrong documentary evidence (53.5% ) , followed by wrong time (39.2%) and wrong dosage (28.%). Variables that were substantially associated with medication administration error include work experience of nurses 0-4 years (AOR = 10.8, 95% CI (4.5-25.86), 5-9 years of service (AOR = 4.05, 95% CI (1.47-11.715), nurses 1-6 (AOR = 0.36, 95% CI (0.17-0.76) nurses 7-10 (AOR = 0.45, 95%CI (0.21-0.96) route IV of medication (AOR =0.13, 95 % CI (0.03 - 0.60) and IM route (AOR =.0.12, 95 % CI (0.02 -0.74) at p-value <0.05. Conclusion: Medication administration error was highly prevalent. Work experience, nurse to patient ratio and route of medication administration were statistically significant factors associated with occurrence of medication administration error. The preparation of nurses and the hospital staff profile would be helpful in minimizing mistakes in the administration of drugs.

scholarly journals Kesalahan Penggunaan Obat Ibu dan Balita Peserta Posyandu di Kecamatan Sukolilo, Surabaya

2017 ◽  
Vol 1 (1) ◽  
pp. 35-44
Author(s):  
Anita Purnamayanti ◽  
Agnes Nuniek Winantari ◽  
Nani Parfati ◽  
Ida Diana ◽  
Nurul Latifah ◽  
...  
Keyword(s):  
Medication Error ◽  
Medication Administration ◽  
Error Reporting ◽  
Medication Administration Error ◽  
Medication Error Reporting ◽  
Administration Error

Kesalahan penggunaan obat (Medication Administration Error, MAE) pada ibu hamil dan anak merupakanjenis kesalahan penggunaan obat yang lazim dijumpai di komunitas. Orang tua berperan pentingdalampemberian obat bagi anak, terutama pada balita. Pos Pelayanan Terpadu (Posyandu) di Indonesia merupakanUpaya Kesehatan Berbasis Masyarakat (UKBM) yang secara terpadu meningkatkan kesehatan ibu dan balita,yang bertujuan untuk mengatasi ketimpangan akses terhadap fasilitas pelayanan kesehatan maupun terhadaptenaga kesehatan. Penelitian observasional yang dilaksanakan di Posyandu di Kecamatan Sukolilo secara prospektifini dirancang untuk mengkaji kesalahan penggunaan obat yang mungkin terjadi di masyarakat. Sukolilomerupakan Kecamatan yang unik, karena keragaman di bidang sosioekonomi, maupun kemampuan masyarakatnyauntuk mengakses tenaga kesehatan dan fasilitas pelayanan kesehatan. Penelitian ini berlangsung selamabulan Januari sampai Mei 2013, dengan metode wawancara penggunaan obat oleh ibu hamil dan orang tua untukanak balitanya. Hasil penelitian dikelompokkan berdasarkan algoritma dan diagram National CoordinatingCouncil for Medication Error Reporting and Prevention. Terdapat MAE pada penggunaan obat ibu hamil dan balita.Jenis kesalahan penggunaan obat yang tersering adalah “Terjadi kesalahan, tidak membahayakan” kategori“B”, “C”, dan “D”. Selain itu, “Terjadi kesalahan, Membahayakan” kategori “E” dan “F” juga terdapat, namun tidakada “Terjadi Kesalahan, Mematikan”. Jenis MAE tersering adalah “obat tidak diberikan”, dan “dosis dan frekuensiobat tidak tepat”, terutama pada penggunaan antibiotik. Kesalahan ini dapat dicegah melalui pemberian edukasikepada orang tua untuk meningkatkan pemahaman mengenai cara penggunaan obat.

Medication Administration Error and Associated Factors among Nurses in Referral Hospitals, Amhara region, Ethiopia, 2019

2020 ◽  
Author(s):  
Wubet Alebachew ◽  
Dejene Tsegaye ◽  
Girma Alem ◽  
Zenaw Tesema
Keyword(s):  
Statistical Significance ◽  
Sampling Technique ◽  
Simple Random Sampling ◽  
Medication Administration ◽  
Binary Logistic Regression Model ◽  
Cross Sectional ◽  
Medication Administration Error ◽  
Medication Administration Errors ◽  
Referral Hospitals ◽  
Administration Error

Abstract Background: Medication administration error is a failure in the treatment process resulting in potential harm to the patient. Medication errors are the leading causes of mistrust in the healthcare system, inducing corrective therapy and prolonged hospitalization thereby producing extra costs and even death. These errors are most common and can occur through failures in any of the ten rights of medication administration. About 10% of the overall preventable harm to hospitalized patients is attributed to the wrong use of medications. However, there is limited data regarding the magnitude and determinants of medication administration errors both nationally and in the study area in particular. Methods: A multicenter hospital based, cross-sectional study design was employed on a sample of 422 nurses selected by simple random sampling technique. Pre-tested structured questionnaire and observational checklist were used for data collection from March 1-30/2019. The collected data were cleaned, coded and entered into Epi-data version 4.2 and exported to STATA version 14. Binary logistic regression model was considered and those variables with P<0.25 in the bivariable analysis were included in to final model after which statistical significance was declared at P< 0.05 using adjusted odds ratio at 95% confidence interval. The study findings were presented using tables and figures. Multicollinerity was diagnosed using standard error and correlation matrix. Result: From the overall nurses, 239 (57.7%) of them made medication administration error in the last 12 months. 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 while facing problems [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)] were significantly associated with medication administration errors. Conclusion and recommendation: Medication administration error was high in Amhara referral hospitals. Therefore, interventions like developing guideline, providing training and developing strategies to minimize distracters should be given much emphasis by different stakeholders to decrease the burden of medication error.

scholarly journals FAKTOR PERAWAT TERHADAP KEJADIAN MEDICATION ADMINISTRATION ERROR DI INSTALASI RAWAT INAP

2017 ◽  
Vol 5 (1) ◽  
pp. 52
Author(s):  
Vidia Sabrina Budihardjo
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Medication Administration ◽  
Inpatient Ward ◽  
Medication Incident ◽  
Medication Administration Error ◽  
Administration Error ◽  
Initial Survey ◽  
Service Standards ◽  
Observational Descriptive Study

Medication administration error is one of medication error that happened due to unfulfillment of drug instruction or drug administration that is different with the recipe. From the initial survey conducted in 2015, there were 13 events medication errors known in 2014-2015 in RSU Haji Surabaya. Based on Kepmenkes RI nomor 129/Menkes/SK/II/2008 about Minimum Service Standards, medication incident should not be any error occurred in the Hospital.This study was an observational descriptive study aimed to identify factors that contribute to the incidence of medication errors. Respondents were 56 nurses that worked on 7 inpatient wards. Variablesi n this research  are: the skills of nurses, nurse's knowledge, and communication between nurse and patients. The result showed that the incidence of medication error in 2014-2016 amounted to 14 events that occurred in most of the inpatient ward (57.1%). Most of inpatient ward  (57.41%) had good skill of nurses, most of the inpatient wards (57.1%) had a sufficient knowledge and communication of nurses.From this study it can be concluded that the skills of nurses, nurse's knowledge, communication between nurse and patients are contributing to the incidence of medication errors in RSU Haji Surabaya. Keywords: inpatient ward, medication errors, nurses

scholarly journals Changes in medication administration error rates associated with the introduction of electronic medication systems in hospitals: a multisite controlled before and after study

2020 ◽  
Vol 27 (3) ◽  
pp. e100170
Author(s):  
Johanna I Westbrook ◽  
Neroli S Sunderland ◽  
Amanda Woods ◽  
Magda Z Raban ◽  
Peter Gates ◽  
...  
Keyword(s):  
Medication Administration ◽  
Error Rates ◽  
Teaching Hospitals ◽  
Medication Administration Error ◽  
Medication Systems ◽  
Before And After ◽  
Wrong Dose ◽  
Administration Error ◽  
Trained Observers ◽  
Before And After Study

BackgroundElectronic medication systems (EMS) have been highly effective in reducing prescribing errors, but little research has investigated their effects on medication administration errors (MAEs).ObjectiveTo assess changes in MAE rates and types associated with EMS implementation.MethodsThis was a controlled before and after study (three intervention and three control wards) at two adult teaching hospitals. Intervention wards used an EMS with no bar-coding. Independent, trained observers shadowed nurses and recorded medications administered and compliance with 10 safety procedures. Observational data were compared against medication charts to identify errors (eg, wrong dose). Potential error severity was classified on a 5-point scale, with those scoring ≥3 identified as serious. Changes in MAE rates preintervention and postintervention by study group, accounting for differences at baseline, were calculated.Results7451 administrations were observed (4176 pre-EMS and 3275 post-EMS). At baseline, 30.2% of administrations contained ≥1 MAE, with wrong intravenous rate, timing, volume and dose the most frequent. Post-EMS, MAEs decreased on intervention wards relative to control wards by 4.2 errors per 100 administrations (95% CI 0.2 to 8.3; p=0.04). Wrong timing errors alone decreased by 3.4 per 100 administrations (95% CI 0.01 to 6.7; p<0.05). EMS use was associated with an absolute decline in potentially serious MAEs by 2.4% (95% CI 0.8 to 3.9; p=0.003), a 56% reduction in the proportion of potentially serious MAEs. At baseline, 74.1% of administrations were non-compliant with ≥1 of 10 procedures and this rate did not significantly improve post-EMS.ConclusionsImplementation of EMS was associated with a modest, but significant, reduction in overall MAE rate, but halved the proportion of MAEs rated as potentially serious.

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