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 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 P25 Incidents involving paediatric parenteral nutrition

2020 ◽  
Vol 105 (9) ◽  
pp. e19.1-e19
Author(s):  
Kouzhu Zhu ◽  
Andrea Gill
Keyword(s):  
Parenteral Nutrition ◽  
Medication Error ◽  
Total Parenteral Nutrition ◽  
Medication Errors ◽  
Error Reporting ◽  
List Type ◽  
Error Type ◽  
Safe Medication ◽  
Medication Error Reporting ◽  
Coordinating Council

AimParenteral nutrition (PN) is one of the medications most frequently reported to be involved in medication errors in hospital.1 PN is a class of high alert medications listed by The Institute for Safe Medication Practices.2 Medication errors involving PN may have potentially serious consequences especially in infants.3 The purpose of this study was to determine the type of incidents reported, who reported it, severity of incidents and the part of the process involved in the error with the aim of ensuring quality and safety in PN processes.MethodThe incidents involving PN reported on the Ulysses system in a specialist children’s hospital were surveyed between April 2018 and March 2019. Incidents were assigned to different error-type categories. We focused on the whole process of prescribing, transcription, preparation, and administration of PN. Severity classification was based on the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index.4ResultsThere were 34 incidents involving PN ranging from 1 to 8 per month. Job titles who reported these incidents were nurses (16 incidents), pharmacists (14 incidents), dieticians (2 incidents) and unknown (2 incidents). The most common types of incidents were omitted medicine/dose (7 incidents), labelling error (6 incidents), wrong quantity supplied (4 incidents) and wrong/unclear dose (4 incidents). The processes during which the incident had occurred were administration/supply of a medicine (14 incidents), preparation of medicines/dispensing in a pharmacy (13 incidents) and prescribing (7 incidents). The majority of incidents (82.4%, 28/34) were assigned category C (no harmful consequences), while 14.7% (5/34) and 2.9% (1/34) were assigned to category B (an error occurred but the error did not reach the patient) and category D (an error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm) respectively. The following actions have been taken to try to prevent error with PN: training, providing information, introduction of new labels, changes to the profiles on infusion pumps, reinforcing independent checking and the increased use of standard PN solutions.ConclusionNurses and pharmacists are the main reporters of incidents of PN. Omitted medicine/dose is the most common incident reported. The majority of errors involved administration of PN. The majority of all incidents did not cause harm to patients.ReferencesRinke ML, Bundy DG, Velasquez CA, et al. Interventions to reduce pediatric medication errors: a systematic review[J]. Pediatrics, 2014, 134(2):338–60.Institute for Safe Medication Practices. ISMP List of High-Alert Medications in Acute Care Settings. Horsham, PA. Available from: http://www.ismp.org/Tools/institutionalhighAlert.asp (accessed January 15, 2017)NHS/PSA/W/2017/005,Risk of severe harm and death from infusing total parenteral nutrition too rapidly in babies. Available from: https://improvement.nhs.uk/news-alerts/infusing-total-parenteral-nutrition-too-rapidly-in-babies/National Coordinating Council for Medication Error Reporting and Prevention. NCC MERP Index for Categorizing Medication Errors. Available from http://www.nccmerp.org/sites/default/files/indexColor2001-06-12.pdf (accessed March 10, 2017)

National Program for Medication Error Reporting and Benchmarking: Experience with MedMARx

2001 ◽  
Vol 36 (5) ◽  
pp. 509-513 ◽  
Author(s):  
Marjorie A Shaw Phillips
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Careful Analysis ◽  
Error Reporting ◽  
National Database ◽  
Patient Harm ◽  
Near Misses ◽  
Medication Error Reporting ◽  
Causes Of Errors ◽  
Reporting Rates

This article explains the value of moving to a standardized national reporting program for medication errors. Early benchmarking activities related to medication errors were ineffective due to difficulties in reporting and the stigma associated with higher reporting rates. One institution's participation and experience with MedMARxSM (an Internet-accessible program for tracking and analyzing medication error reports with a link to an anonymous national database) is described, and some useful features of the program are highlighted. Ninety-five percent (95%) of the errors reported in the database did not result in patient harm, yet these records provide information that may guide efforts to reduce errors. Participation in the MedMARx program has helped our institution's medication error reporting program focus on performance improvement through more careful analysis of the causes of errors and “near misses.”

scholarly journals The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems

Medicines ◽  
2021 ◽  
Vol 8 (9) ◽  
pp. 46
Author(s):  
Abbas Al Mutair ◽  
Saad Alhumaid ◽  
Abbas Shamsan ◽  
Abdul Rehman Zia Zaidi ◽  
Mohammed Al Mohaini ◽  
...  
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
The United States ◽  
Population Based ◽  
Error Reporting ◽  
Effective Strategies ◽  
Medication Error Reporting ◽  
Background Population ◽  
Safety Improvement ◽  
Reporting Systems

Background: Population-based studies from several countries have constantly shown excessively high rates of medication errors and avoidable deaths. An efficient medication error reporting system is the backbone of reliable practice and a measure of progress towards achieving safety. Improvement efforts and system changes of medication error reporting systems should be targeted towards reductions in the likelihood of injury to future patients. However, the aim of this review is to provide a summary of medication errors reporting culture, incidence reporting systems, creating effective reporting methods, analysis of medication error reports, and recommendations to improve medication errors reporting systems. Methods: Electronic databases (PubMed, Ovid, EBSCOhost, EMBASE, and ProQuest) were examined from 1 January 1998 to 30 June 2020. 180 articles were found and 60 papers were ultimately included in the review. Data were mined by two reviewers and verified by two other reviewers. The search yielded 684 articles, which were then reduced to 60 after the deletion of duplicates via vetting of titles, abstracts, and full-text papers. Results: Studies were principally from the United States of America and the United Kingdom. Limited studies were from Canada, Australia, New Zealand, Korea, Japan, Greece, France, Saudi Arabia, and Egypt. Detection, measurement, and analysis of medication errors require an active rather than a passive approach. Efforts are needed to encourage medication error reporting, including involving staff in opportunities for improvement and the determination of root cause(s). The National Coordinating Council for Medication Error Reporting and Prevention taxonomy is a classification system to describe and analyze the details around individual medication error events. Conclusion: A successful medication error reporting program should be safe for the reporter, result in constructive and useful recommendations and effective changes while being inclusive of everyone and supported with required resources. Health organizations need to adopt an effectual reporting environment for the medication use process in order to advance into a sounder practice.

Medication Without Harm: Developing optimal medication error reporting systems

2021 ◽  
Vol 16 ◽  
Author(s):  
Yuko Shiima ◽  
Muzaffar Malik ◽  
Michael Okorie
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Traditional Approach ◽  
Incident Reporting ◽  
Error Reporting ◽  
Contributing Factors ◽  
Medication Error Reporting ◽  
Incident Reporting Systems ◽  
Reporting Systems ◽  
Life Threatening

: Medication errors are amongst the most frequently occurring health care related incidents and have the potential to lead to life-threatening harm to patients. An incident reporting system is a traditional approach to improvement of patient safety and entails the retrieval of information from incident reports. This not only provides a better understanding of causes and contributing factors but also enables the collection of data on the severity of incidents, system deficiencies and the role of human factors in safety incidents. Medication error reporting systems are often developed as a part of larger incident reporting systems which deal with other types of incidents. Although a rise in the prevalence of medication errors has led to an increased demand for medication error reporting, little is known about characteristics and limitations of medication error reporting systems. The authors broach the subject of medication error reporting systems and propose a more robust and standardized approach.

scholarly journals Exploring Nurses' Knowledge of Medication Error Reporting

2020 ◽  
Author(s):  
Karina Santos
Keyword(s):  
Critical Care ◽  
Medication Error ◽  
Medication Errors ◽  
Thinking Skills ◽  
Critical Care Nurses ◽  
Near Miss ◽  
Error Reporting ◽  
Care Hospital ◽  
Institute Of Medicine ◽  
Medication Error Reporting

Managing the care of critically ill patients is a highly complex and stressful position requiring high levels of critical thinking skills and judgment. Medical errors, including medication errors continue to happen in hospitals across the nation. Despite decades of focus and efforts on this area from the Institute of Medicine and other national and federal agencies, literature suggests that medication errors in critical care are highly prevalent and underreported. The purpose of this project was to explore the knowledge base of critical care nurses in relation to medication error reporting. A survey was created, which included 10 questions that were relevant to medication errors and reporting of these in the critical care setting. No demographical data was collected on respondent nurses to protect anonymity and privacy. A total of 77 completed surveys were collected from ten critical care units at a large academic acute care hospital in Rhode Island. The results of the survey showed that the majority of nurses had no knowledge of the hospital’s policy or the official definition of a medication error as adopted by the facility. A significant number of nurses weren’t aware that near miss events are medication errors. This project found that critical care nurses and their patients would benefit from enhanced education programs aimed at closing these knowledge gaps. Providing clarification, guidelines and detailed policies and procedures may enhance their confidence, efficacy and skills to be able to adequately and consistently report all near miss events and actual medication errors thereby improving the overall culture of safety and patient outcomes.

Adverse Drug Reaction and Medication Error Reporting by Pharmacy Students

2005 ◽  
Vol 39 (3) ◽  
pp. 452-459 ◽  
Author(s):  
Erin L Sears ◽  
Joyce A Generali
Keyword(s):  
Medication Error ◽  
Medication Errors ◽  
Work Experience ◽  
Adverse Event Reporting System ◽  
Adverse Event Reporting ◽  
Pharmacy Students ◽  
Error Reporting ◽  
Positive Trend ◽  
Medication Error Reporting ◽  
Reporting Programs

BACKGROUND: The reporting of adverse drug reactions (ADRs) and medication errors is the responsibility of all who are involved, particularly pharmacists. Since pharmacists are often privy to information surrounding ADRs and medication errors, it is of utmost importance that they are educated regarding the procedures of reporting. OBJECTIVE: To determine pharmacy students' knowledge of and ability to report ADRs and medication errors. METHODS: A total of 1322 students from 9 colleges of pharmacy were surveyed. RESULTS: The largest group of respondents was fifth-year pharmacy students (38%) followed by third-, fourth-, and sixth-year students (28%, 26%, and 8%, respectively). The majority of students reported learning about ADR and medication error reporting programs via didactic experiences. In comparison, fewer students cited alternative mechanisms of learning, including experiential rotations and work experience. Overall, respondents demonstrated the most experience with MedWatch and the least experience with the Vaccine Adverse Event Reporting System (VAERS). As students progressed through pharmacy curricula, there was a positive trend in the ability to locate and complete MedWatch forms. For VAERS and Medication Error Reporting (MER) program forms, however, this positive trend was broken at year 4. For all programs, significantly fewer students demonstrated appropriate use of the forms compared with those indicating familiarity with the programs. CONCLUSIONS: This study demonstrated that students are becoming familiar with ADR and MER programs via the college curriculum; however, there is opportunity for greater exposure and understanding. Colleges of pharmacy should continually seek methods to strengthen the education provided to pharmacy students regarding these programs.

scholarly journals Pharmacist-Initiated Medication Error-Reporting and Monitoring Programme in a Developing Country Scenario

Pharmacy ◽  
2018 ◽  
Vol 6 (4) ◽  
pp. 133 ◽  
Author(s):  
Sri Chalasani ◽  
Madhan Ramesh ◽  
Parthasarathi Gurumurthy
Keyword(s):  
Patient Safety ◽  
Medication Error ◽  
Medication Errors ◽  
Reporting System ◽  
Improve Patient Safety ◽  
Monitoring Programme ◽  
Error Reporting ◽  
Medication Error Reporting ◽  
Hospitalised Patients ◽  
Improve Patient

Medication errors (MEs) often prelude guilt and fear in health care professionals (HCPs), thereby resulting in under-reporting and further compromising patient safety. To improve patient safety, we conducted a study on the implementation of a voluntary medication error-reporting and monitoring programme. The ME reporting system was established using the principles based on prospective, voluntary, open, anonymous, and stand-alone surveillance in a tertiary care teaching hospital located in South India. A prospective observational study was carried out for three years and a voluntary Medication Error-reporting Form was developed to report medication errors MEs that had occurred in patients of either sex were included in the study, and the reporters were given the choice to remain anonymous. The analysis was carried out and discussed with HCPs to minimise the recurrence. A total of 1310 medication errors were reported among 20,256 hospitalised patients and the incidence was 6.4%. Common aetiologies were administration errors [501 (38.2%)], followed by prescribing and transcribing errors [363 (28%)]. Root-cause of these MEs were distractions, workload, and communications. Analgesics/antipyretics (19.4%) and antibiotics (15.7%) were the most commonly implicated classes of medications. A clinical pharmacist initiated non-punitive anonymous ME reporting system could improve patient safety.

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