scholarly journals Factors Influencing Clinical Nurses’ Intention to Report Medication Administration Errors

2021 ◽  
Vol 14 (3) ◽  
pp. 62-72
Author(s):  
Seul Hee Lee ◽  
Eun Ji Seo
2021 ◽  
pp. 106002802199964
Author(s):  
Matthew D. Jones ◽  
Jonathan Clarke ◽  
Calandra Feather ◽  
Bryony Dean Franklin ◽  
Ruchi Sinha ◽  
...  

Background: In a recent human reliability analysis (HRA) of simulated pediatric resuscitations, ineffective retrieval of preparation and administration instructions from online injectable medicines guidelines was a key factor contributing to medication administration errors (MAEs). Objective: The aim of the present study was to use a specific HRA to understand where intravenous medicines guidelines are vulnerable to misinterpretation, focusing on deviations from expected practice ( discrepancies) that contributed to large-magnitude and/or clinically significant MAEs. Methods: Video recordings from the original study were reanalyzed to identify discrepancies in the steps required to find and extract information from the NHS Injectable Medicines Guide (IMG) website. These data were combined with MAE data from the same original study. Results: In total, 44 discrepancies during use of the IMG were observed across 180 medication administrations. Of these discrepancies, 21 (48%) were associated with an MAE, 16 of which (36% of 44 discrepancies) made a major contribution to that error. There were more discrepancies (31 in total, 70%) during the steps required to access the correct drug webpage than there were in the steps required to read this information (13 in total, 30%). Discrepancies when using injectable medicines guidelines made a major contribution to 6 (27%) of 22 clinically significant and 4 (15%) of 27 large-magnitude MAEs. Conclusion and Relevance: Discrepancies during the use of an online injectable medicines guideline were often associated with subsequent MAEs, including those with potentially significant consequences. This highlights the need to test the usability of guidelines before clinical use.


2010 ◽  
Vol 95 (2) ◽  
pp. 113-118 ◽  
Author(s):  
M. A. Ghaleb ◽  
N. Barber ◽  
B. D. Franklin ◽  
I. C. K. Wong

2017 ◽  
Vol Volume 6 ◽  
pp. 47-51 ◽  
Author(s):  
Tezeta Fekadu ◽  
Mebrahtu Teweldemedhin ◽  
Eyerusalem Esrael ◽  
Solomon Weldegebreal Asgedom

Author(s):  
Kuem-Sun Han ◽  
Eunyoung Park ◽  
Young Hee Park ◽  
Hee Su Lim ◽  
Eun Mi Lee ◽  
...  

Author(s):  
Dalal Salem Al- Dossari ◽  
Mohammed Ibrahim Alnami ◽  
Naseem Akhtar Qureshi

Background: Drug prescription error is a medication error that most frequently happens in healthcare organizations and adversely affects the healthcare consumers. Most medication errors (MEs) but not all are captured and corrected before reaching the patient by designed system controls. Medication administration errors (MAEs) mostly are made by nurses but frequently reported by clinical pharmacists in hospitals in Saudi Arabia. Objective: This study aimed to analyze exclusively the voluntarily reported drug administration errors in a tertiary care hospital in Riyadh city. Methods: This cross-sectional, retrospective study evaluated consecutively collected medication administration report forms over a period of one year from January 1, 2015 to December 31, 2015. Results: The number of MAEs occurring during stage of drug administration constituted 7.1% (n=971) of total medication errors (n=13677). The maximum number of MEs (n=6838, 50%) and MAEs (n=455, 46.9%) occurred during the 4th quarter of the year 2015. The most common MAE happened to be category C (n=888, 91.5%) which means error occurred, reached the patient but without causing any harm. Concerning MAE types, the most common error included wrong frequency (40%) followed by wrong drug (17%), wrong time of administration (16%) and wrong rate of infusion (10%). Nurses made the most of the errors (92.2%) while the clinical pharmacists reported the most MAEs (75.5%). High alert medications (HAM) errors constituted 32.3% (n=314) of MAEs (n=971) and most common HAM errors included the wrong route of administration of Lanus Insulin (15%) followed by Insulin Aspart (15%), Enoxaparin (13%) and Insulin Protamine-Nvomix (12%). Look-alike and sound-alike (LASA) errors constituted 55.2% of MAEs (971/536) and most common LASA drugs identified were Gentamycin (13%), Insulin Mixtard (11%), NPH Insulin (8%) Intralipid vial (8%) and Insulin regular (6%). Conclusion: This retrospective study provides some important tentative pharmacovigilance insights into MAEs, which are partially comparable with current international trends in drug administration errors. Further studies on MAEs are warranted not only in the Kingdom of Saudi Arabia but also other Gulf countries.


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