Medication error reporting and the work environment in a military setting

Evaluation of pharmacovigilance systems for reporting medication errors in Africa and the role of patients using a mixed-methods approach

Background

Reviewing the epidemiological profile of medication errors (MEs) reported by African countries and the systems put in place to report such errors is crucial because reporting plays an important role in improving patient safety. The objectives of this study were to characterize the profile of spontaneously reported MEs submitted by African countries to VigiBase; the World Health Organization (WHO) global database of individual case safety reports, describe systems in place for reporting these errors, and explore the challenges and facilitators for spontaneous reporting and understand the potential role of patients.

Methods

In the present study, we used, a mixed-methods sequential explanatory design involving a quantitative review of ME reports over a 21-year period (1997–2018) and qualitative interviews with employees from African countries that are members of the WHO Program for International Drug Monitoring (WHO PIDM). Descriptive statistics were used to summarize key variables of interest.

Results

A total of 4,205 ME reports were submitted by African countries to VigiBase representing 0.4% of all reports in the database. Only 15 countries out of the 37 WHO PIDM members from Africa contributed ME to reports, with 99% (3,874) of them reports originating from Egypt, Morocco, and South Africa. The reasons given for low reporting of MEs were weak healthcare and pharmacovigilance systems, lack of staff capacity at the national centers, illiteracy, language difficulties, and socio-cultural and religious beliefs. Some facilitators suggested by the participants to promote reporting included proactive engagement of patients regarding issues relating to MEs, leveraging on increased technology, benchmarking and mentoring by more experienced national centers. Sixteen of the twenty countries interviewed had systems for reporting MEs integrated into adverse drug reaction reporting with minimal patient involvement in seven of these countries. Patients were not involved in directly reporting MEs in the remaining 13 countries.

Conclusions

MEs are rarely reported through pharmacovigilance systems in African countries with limited patient involvement. The systems are influenced by multifactorial issues some of which are not directly related to healthcare.

Knowledge, perceived barriers and facilitators of medication error reporting: a quantitative survey in Malaysian primary care clinics

Background Medication errors are the most common types of medical errors that occur in health care organisations; however, these errors are largely underreported. Objective This study assessed knowledge on medication error reporting, perceived barriers to reporting medication errors, motivations for reporting medication errors and medication error reporting practices among various health care practitioners working at primary care clinics. Setting This study was conducted in 27 primary care clinics in Malaysia. Methods A self-administered survey was distributed to family medicine specialists, doctors, pharmacists, pharmacist assistants, nurses and assistant medical officers. Main outcome measures Health care practitioners' knowledge, perceived barriers and motivations for reporting medication errors. Results Of all respondents (N = 376), nurses represented 31.9% (n = 120), followed by doctors (n = 87, 23.1%), pharmacists (n = 63, 16.8%), assistant medical officers (n = 53, 14.1%), pharmacist assistants (n = 46, 12.2%) and family medicine specialists (n = 7, 1.9%). Of the survey respondents who had experience reporting medication errors, 56% (n = 62) had submitted medication error reports in the preceding 12 months. Results showed that 41.2% (n = 155) of respondents were classified as having good knowledge on medication error and medication error reporting. The mean score of knowledge was significantly higher among prescribers and pharmacists than nurses, pharmacist assistants and assistant medical officers (p < 0.05). A heavy workload was the key barrier for both nurses and assistant medical officers, while time constraints prevented pharmacists from reporting medication errors. Family medicine specialists were mainly unsure about the reporting process. On the other hand, doctors and pharmacist assistants did not report primarily because they were unaware medication errors had occurred. Both family medicine specialists and pharmacist assistants identified patient harm as a motivation to report an error. Doctors and nurses indicated that they would report if they thought reporting could improve the current practices. Assistant medical officers reported that anonymous reporting would encourage them to submit a report. Pharmacists would report if they have enough time to do so. Conclusion Policy makers should consider using the information on identified barriers and facilitators to reporting medication errors in this study to improve the reporting system to reduce under-reported medication errors in primary care.

Managing care errors in the wards

Purpose

The importance of an error management culture (EMC) that integrates error prevention with error management after errors occur has been highlighted in the existing literature. However, few empirical studies currently support the relationship between EMC and errors, while the factors that affect EMC remain underexplored. Drawing on the conceptualisation of organisational cultures, the purpose of this paper is to verify the contribution of authentic leadership in steering EMC, thereby leading to reduced errors.

Design/methodology/approach

The authors conducted a cross-sectional survey study. The sample included 280 nurses.

Findings

Results of a full structural equation model supported the hypothesised model, showing that authentic leadership is positively associated with EMC, which in turn is negatively associated with the frequency of errors.

Practical implications

These results provide initial evidence for the role of authentic leadership in enhancing EMC and consequently, fostering error reduction in the workplace. The tested model suggests that the adoption of an authentic style can promote policies and practices to proactively manage errors, paving the way to error reduction in the workplace.

Originality/value

This study was one of the first to investigate the relationship between authentic leadership, error culture and errors. Further, it contributes to the existing literature by demonstrating both the importance of cultural orientation in protecting the organisation from error occurrence and the key role of authentic leaders in creating an environment for EMC development, thus permitting the organisation to learn from errors and reduce their negative consequences.

Exploring facilitators and barriers to medication error reporting among healthcare professionals in Qatar using the theoretical domains framework: A mixed-methods approach

Background

There is a need for theory informed interventions to optimise medication reporting. This study aimed to quantify and explain behavioural determinants relating to error reporting of healthcare professionals in Qatar as a basis of developing interventions to optimise the effectiveness and efficiency of error reporting.

Methods

A sequential explanatory mixed methods design comprising a cross-sectional survey followed by focus groups in Hamad Medical Corporation, Qatar. All doctors, nurses and pharmacists were invited to complete a questionnaire that included items of behavioural determinants derived from the Theoretical Domains Framework (TDF), an integrative framework of 33 theories of behaviour change. Principal component analysis (PCA) was used to identify components, with total component scores computed. Differences in total scores among demographic groupings were tested using Mann-Whitney U test (2 groups) or Kruskal-Wallis (>2 groups). Respondents expressing interest in focus group participation were sampled purposively, and discussions based on survey findings using the TDF to provide further insight to survey findings. Ethical approval was received from Hamad Medical Corporation, Robert Gordon University, and Qatar University.

Results

One thousand, six hundred and four questionnaires were received (67.9% nurses, 13.3% doctors, 12.9% pharmacists). Questionnaire items clustered into six components of: knowledge and skills related to error reporting; feedback and support; action and impact; motivation; effort; and emotions. There were statistically significant higher scores in relation to age (older more positive, p<0.001), experience as a healthcare professional (more experienced most positive apart from those with the highest level of experience, p<0.001), and profession (pharmacists most positive, p<0.05). Fifty-four healthcare professionals from different disciplines participated in the focus groups. Themes mapped to nine of fourteen TDF domains. In terms of emotions, the themes that emerged as barriers to error reporting were: fear and worry on submitting a report; that submitting was likely to lead to further investigation that could impact performance evaluation and career progression; concerns over the impact on working relationships; and the potential lack of confidentiality.

Conclusions

This study has quantified and explained key facilitators and barriers of medication error reporting. Barriers appeared to be largely centred on issues relating to emotions and related beliefs of consequences. Quantitative results demonstrated that while these were issues for all healthcare professionals, those younger and less experienced were most concerned. Qualitative findings highlighted particular concerns relating to these emotional aspects. These results can be used to develop theoretically informed interventions with the aims of improving the effectiveness and efficiency of the medication reporting systems impacting patient safety.

Nursing care providers' perceptions on their role contributions in patient care: An integrative review

AIMS AND OBJECTIVES

To explore registered nurses', licensed practical nurses' and healthcare aides' perceptions of their own and each other's role contributions.

BACKGROUND

In response to contemporary economic and political pressures, healthcare institutions across the world have endeavoured to download job duties to less educated healthcare providers. As a result, nursing care is usually delivered by a team of nursing staff that have different roles. This means that there are fewer registered nurses and more licensed practical nurses and healthcare aides on nursing teams, despite evidence that increased numbers of registered nurses improve patient safety and care outcomes.

DESIGN

This study was an integrative review using Whittemore and Knafl's stages for ensuring rigour. These stages include problem identification, literature searching, data evaluation, data analysis and presentation.

METHODS

Four electronic databases were searched according to previously designed search strategies. The 14 retrieved articles were appraised using MMATs for quality. Data were extracted and analysed thematically.

RESULTS

The findings of the integrative review revealed that registered nurses, licensed practical nurses and healthcare aides had little understanding about the roles of their fellow nursing team members and had difficulties describing their own roles. However, no studies concurrently examined registered nurses', licensed practical nurses' and healthcare aides' perceptions on their own or each other's roles and little were written about licensed practical nurses.

CONCLUSION

More research is needed to examine the entire nursing team's perceptions about the various nursing roles.

The state of the science of nurse work environments in the United States: A systematic review

A healthy nurse work environment is a workplace that is safe, empowering, and satisfying. Many research studies were conducted on nurse work environments in the last decade; however, it lacks an overview of these research studies. The purpose of this review is to identify, evaluate, and summarize the major foci of studies about nurse work environments in the United States published between January 2005 and December 2017 and provide strategies to improve nurse work environments. Databases searched included MEDLINE via PubMed, CINAHL, PsycINFO, Nursing and Allied Health, and the Cochrane Library. The literature search followed the PRISMA guideline. Fifty-four articles were reviewed. Five major themes emerged: 1) Impacts of healthy work environments on nurses' outcomes such as psychological health, emotional strains, job satisfaction, and retention; 2) Associations between healthy work environments and nurse interpersonal relationships at workplaces, job performance, and productivity; 3) Effects of healthy work environments on patient care quality; 4) Influences of healthy work environments on hospital accidental safety; and 5) Relationships between nurse leadership and healthy work environments. This review shows that nurses, as frontline patient care providers, are the foundation for patient safety and care quality. Promoting nurse empowerment, engagement, and interpersonal relationships at work is rudimental to achieve a healthy work environment and quality patient care. Healthier work environments lead to more satisfied nurses who will result in better job performance and higher quality of patient care, which will subsequently improve healthcare organizations' financial viability. Fostering a healthy work environment is a continuous effort.

Barriers to medication error reporting among hospital nurses

AIMS AND OBJECTIVES

The study purpose was to report medication error reporting barriers among hospital nurses, and to determine validity and reliability of an existing medication error reporting barriers questionnaire.

BACKGROUND

Hospital medication errors typically occur between ordering of a medication to its receipt by the patient with subsequent staff monitoring. To decrease medication errors, factors surrounding medication errors must be understood; this requires reporting by employees. Under-reporting can compromise patient safety by disabling improvement efforts.

DESIGN

This 2017 descriptive study was part of a larger workforce engagement study at a faith-based Magnet^® -accredited community hospital in California (United States).

METHODS

Registered nurses (~1,000) were invited to participate in the online survey via email. Reported here are sample demographics (n = 357) and responses to the 20-item medication error reporting barriers questionnaire. Using factor analysis, four factors that accounted for 67.5% of the variance were extracted. These factors (subscales) were labelled Fear, Cultural Barriers, Lack of Knowledge/Feedback and Practical/Utility Barriers; each demonstrated excellent internal consistency.

RESULTS

The medication error reporting barriers questionnaire, originally developed in long-term care, demonstrated good validity and excellent reliability among hospital nurses. Substantial proportions of American hospital nurses (11%-48%) considered specific factors as likely reporting barriers. Average scores on most barrier items were categorised "somewhat unlikely." The highest six included two barriers concerning the time-consuming nature of medication error reporting and four related to nurses' fear of repercussions.

CONCLUSIONS

Hospitals need to determine the presence of perceived barriers among nurses using questionnaires such as the medication error reporting barriers and work to encourage better reporting.

RELEVANCE TO CLINICAL PRACTICE

Barriers to medication error reporting make it less likely that nurses will report medication errors, especially errors where patient harm is not apparent or where an error might be hidden. Such under-reporting impedes collection of accurate medication error data and prevents hospitals from changing harmful practices.

The Meaning of Intraoperative Errors: Perioperative Nurse Perspectives

Medical errors involve different health care professionals, are multifaceted, and can occur at the individual practitioner or system level. The conditions for errors vary in the health care environment; some practice areas may be more vulnerable to errors than others. Limited research exists that explores perioperative nursing errors. The purpose of this study was to describe and interpret the experiences of perioperative nurses related to intraoperative errors. We used the hermeneutic phenomenological method. Ten perioperative RNs participated in focus group interviews that we audio-recorded and transcribed. We analyzed data using thematic analysis, and three themes emerged that represent the essence of the experience of nurses involved in intraoperative errors: environment, being human, and moving forward. The findings support efforts to improve quality care and foster a culture of safety in the OR through strategies such as perioperative staff training, interprofessional team building, and controlling environmental factors that are distracting.

Relationships between Army nursing practice environments and patient outcomes

Favorable nursing practice environments have been associated with lower patient mortality, failure to rescue, nurse-administered medication errors, infections, patient complaints, and patient falls. Favorable environments have also been associated with higher nurse-reported care quality and patient satisfaction in civilian hospitals. However, limited information exists on the relationship between favorable nursing practice environments and positive outcomes in military facilities. Using 4 years of secondary data collected from 45 units in 10 Army hospitals, generalized estimating equations were used to test the associations between nurses' scores on the Practice Environment Scale of the Nursing Work Index (PES-NWI) and patient outcomes of falls with and without injury, medication administration errors with and without harm, and patient experience. Four significant associations were found between the PES-NWI subscales and the patient outcomes under study. The Staffing and Resource Adequacy subscale was significantly associated with patient falls, the Collegial Nurse Physician Relations subscale was significantly associated with the rate of nurse-administered medication errors, and the Nursing Foundations for Quality Care and Collegial Nurse Physician Relations subscales were both significantly associated with patient experience with nursing care. As in civilian hospitals, favorable nursing practice environment was associated with improved patient outcomes within these military nursing units.

Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature

OBJECTIVES

The development and implementation of incident reporting systems within healthcare continues to be a fundamental strategy to reduce preventable patient harm and improve the quality and safety of healthcare. We sought to identify factors contributing to patient safety incident reporting.

DESIGN

To facilitate improvements in incident reporting, a theoretical framework, encompassing factors that act as barriers and enablers ofreporting, was developed. Embase, Ovid MEDLINE(R) and PsycINFO were searched to identify relevant articles published between January 1980 and May 2014. A comprehensive search strategy including MeSH terms and keywords was developed to identify relevant articles. Data were extracted by three independent researchers; to ensure the accuracy of data extraction, all studies eligible for inclusion were rescreened by two reviewers.

RESULTS

The literature search identified 3049 potentially eligible articles; of these, 110 articles, including >29 726 participants, met the inclusion criteria. In total, 748 barriers were identified (frequency count) across the 110 articles. In comparison, 372 facilitators to incident reporting and 118 negative cases were identified. The top two barriers cited were fear of adverse consequences (161, representing 21.52% of barriers) and process and systems of reporting (110, representing 14.71% of barriers). In comparison, the top two facilitators were organisational (97, representing 26.08% of facilitators) and process and systems of reporting (75, representing 20.16% of facilitators).

CONCLUSION

A wide range of factors contributing to engagement in incident reporting exist. Efforts that address the current tendency to under-report must consider the full range of factors in order to develop interventions as well as a strategic policy approach for improvement.

Factors associated with medication administration errors and why nurses fail to report them

BACKGROUND

Patient safety is a significant challenge facing healthcare systems. The administration of medication is pivotal to patient safety, and errors in drug administration are associated with mortality and morbidity. In this study, we assessed the factors contributing to the occurrence and reporting of medication errors from the nurse's perspective.

METHODS

In this descriptive cross-sectional study, we distributed a validated questionnaire to 367 nurses at a large public hospital and obtained a response rate of 73.4%. The questionnaire comprised 65 questions, including 29 on the causes of medication errors, 16 on the reasons why medication errors are not reported and 20 that estimated the percentages of the different medication errors actually reported. Informed consent was obtained from all participants, and the anonymity and confidentiality of participants' information were preserved throughout the process. This study received institutional review board approval. Descriptive statistics were used for data analysis.

RESULTS

The main factors associated with medication errors by nurses were related to medication packaging, nurse-physician communication, pharmacy processes, nurse staffing and transcribing issues. The main barriers to the reporting of errors by nurses were related to the administrative response, fear of reporting and disagreements regarding the definitions of errors.

CONCLUSION

Medication errors by nurses are related to medication packaging, poor communication, unclear medication orders, workload and staff rotation. To prevent medication errors, teamwork must be improved. All healthcare settings should emphasise awareness of the culture of safety, provide support and guidance to nurses and improve communication skills. We also recommend the use of integrated health informatics, including computerised drug administration systems. The limitations of this study include the potential for nonresponse bias associated with the sampling method. Further research is required to explore the complex and multidimensional causes of medication errors and review the responses of nurses regarding the errors reported.

Perceptions and Attitudes towards Medication Error Reporting in Primary Care Clinics: A Qualitative Study in Malaysia

OBJECTIVE

To explore and understand participants' perceptions and attitudes towards the reporting of medication errors (MEs).

METHODS

A qualitative study using in-depth interviews of 31 healthcare practitioners from nine publicly funded, primary care clinics in three states in peninsular Malaysia was conducted for this study. The participants included family medicine specialists, doctors, pharmacists, pharmacist assistants, nurses and assistant medical officers. The interviews were audiotaped and transcribed verbatim. Analysis of the data was guided by the framework approach.

RESULTS

Six themes and 28 codes were identified. Despite the availability of a reporting system, most of the participants agreed that MEs were underreported. The nature of the error plays an important role in determining the reporting. The reporting system, organisational factors, provider factors, reporter's burden and benefit of reporting also were identified.

CONCLUSIONS

Healthcare practitioners in primary care clinics understood the importance of reporting MEs to improve patient safety. Their perceptions and attitudes towards reporting of MEs were influenced by many factors which affect the decision-making process of whether or not to report. Although the process is complex, it primarily is determined by the severity of the outcome of the errors. The participants voluntarily report the errors if they are familiar with the reporting system, what error to report, when to report and what form to use.

Quantifying behavioural determinants relating to health professional reporting of medication errors: a cross-sectional survey using the Theoretical Domains Framework

PURPOSE

The aims of this study were to quantify the behavioural determinants of health professional reporting of medication errors in the United Arab Emirates (UAE) and to explore any differences between respondents.

METHODS

A cross-sectional survey of patient-facing doctors, nurses and pharmacists within three major hospitals of Abu Dhabi, the UAE. An online questionnaire was developed based on the Theoretical Domains Framework (TDF, a framework of behaviour change theories). Principal component analysis (PCA) was used to identify components and internal reliability determined. Ethical approval was obtained from a UK university and all hospital ethics committees.

RESULTS

Two hundred and ninety-four responses were received. Questionnaire items clustered into six components of knowledge and skills, feedback and support, action and impact, motivation, effort and emotions. Respondents generally gave positive responses for knowledge and skills, feedback and support and action and impact components. Responses were more neutral for the motivation and effort components. In terms of emotions, the component with the most negative scores, there were significant differences in terms of years registered as health professional (those registered longest most positive, p = 0.002) and age (older most positive, p < 0.001) with no differences for gender and health profession.

CONCLUSION

Emotional-related issues are the dominant barrier to reporting and are common to all professions. There is a need to develop, test and implement an intervention to impact health professionals' emotions. Such an intervention should focus on evidence-based behaviour change techniques of reducing negative emotions, focusing on emotional consequences and providing social support.

KEY MESSAGES

• This research used the Theoretical Domains Framework to quantify the behavioural determinants of health professional reporting of medication errors. • Questionnaire items relating to emotions surrounding reporting generated the most negative responses with significant differences in terms of years registered as health professional (those registered longest most positive) and age (older most positive) with no differences for gender and health profession. • Interventions based on behaviour change techniques mapped to emotions should be prioritised for development.

Medication errors in the intensive care unit: literature review using the SEIPS model

Medication errors in intensive care units put patients at risk for injury or death every day. Safety requires an organized and systematic approach to improving the tasks, technology, environment, and organizational culture associated with medication systems. The Systems Engineering Initiative for Patient Safety model can help leaders and health care providers understand the complicated and high-risk work associated with critical care. Using this model, the author combines a human factors approach with the well-known structure-process-outcome model of quality improvement to examine research literature. The literature review reveals that human factors, including stress, high workloads, knowledge deficits, and performance deficits, are associated with medication errors. Factors contributing to medication errors are frequent interruptions, communication problems, and poor fit of health information technology to the workflow of providers. Multifaceted medication safety interventions are needed so that human factors and system problems can be addressed simultaneously.

Medication Errors in the Intensive Care Unit

Medication errors in intensive care units put patients at risk for injury or death every day. Safety requires an organized and systematic approach to improving the tasks, technology, environment, and organizational culture associated with medication systems. The Systems Engineering Initiative for Patient Safety model can help leaders and health care providers understand the complicated and high-risk work associated with critical care. Using this model, the author combines a human factors approach with the well-known structure-process-outcome model of quality improvement to examine research literature. The literature review reveals that human factors, including stress, high workloads, knowledge deficits, and performance deficits, are associated with medication errors. Factors contributing to medication errors are frequent interruptions, communication problems, and poor fit of health information technology to the workflow of providers. Multifaceted medication safety interventions are needed so that human factors and system problems can be addressed simultaneously.

The changing skill mix in nursing: considerations for and against different levels of nurse

AIM

To investigate the current literature to gain an understanding of skill mix, why it is being manipulated and how it affects patient care and health-care costs.

BACKGROUND

Due to workforce shortages, economic constraints and increasing patient acuity, employers are looking at methods of providing patient care whilst maintaining costs. Registered nurses make up a large percentage of the health-care budget. The manipulation of skill mix (i.e. the percentage of registered nurses available for patient care) is seen as one method of managing the increasing cost whilst still ensuring patient care.

EVALUATION

Research literature was used to determine the current use of skill mix and its impact on patient care and health-care costs.

KEY ISSUE

The use of a higher proportion of registered nurses is associated with better health outcomes, shorter length of stay and reduced patient morbidity.

CONCLUSION

Economic savings from substituting registered nurses with other health professionals may be offset by increased patient length of stay in hospital and increased patient mortality.

IMPLICATIONS FOR NURSING MANAGEMENT

When evaluating nursing skill mix, a higher percentage of registered nurses may result in health-care facility cost savings by providing a shorter length of stay and decreased patient complications.