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Takhtinejad NJ, Stewart D, Nazar Z, Hamad A, Hadi MA. Identifying factors influencing clinicians' reporting of medication errors: a systematic review and qualitative evidence synthesis using the theoretical domains framework. Expert Opin Drug Saf 2024:1-12. [PMID: 39192820 DOI: 10.1080/14740338.2024.2396397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 05/08/2024] [Accepted: 08/14/2024] [Indexed: 08/29/2024]
Abstract
INTRODUCTION Medication errors have a significant impact on patient safety and professional practice. The widespread under-reporting of errors by clinicians indicates the critical need for behavioral change. This systematic review aimed to identify and synthesize qualitative evidence on factors influencing clinicians' reporting of medication errors. AREAS COVERED Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, PubMed, and Embase were searched until March 2023 for studies on factors influencing clinicians' reporting of medication errors. Two independent reviewers conducted the screening, data extraction, and quality appraisal. Using framework synthesis approach, the identified themes were mapped to Theoretical Domains Framework (TDF). EXPERT OPINION The review analyzed fourteen high-quality studies across various regions. Facilitators of reporting were identified in the TDF domains of beliefs about consequences knowledge and social/professional role and identity. More themes emerged as barriers, mapped to the domains of beliefs about consequences, emotions, environmental context and resources and knowledge. The review suggests aligning these barriers with key behavior change techniques, such as emphasizing the risks of non-reporting, promoting emotional well-being, improving accessibility of reporting systems and advancing knowledge through educational programs. Future work should focus on developing these behavior change techniques into practical interventions.
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Affiliation(s)
- Neda J Takhtinejad
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
- Pharmacy Department, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Derek Stewart
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Zachariah Nazar
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Anas Hamad
- Pharmacy Department, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Muhammad A Hadi
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
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Braiki R, Douville F, Gagnon MP. Factors influencing the reporting of medication errors and near misses among nurses: A systematic mixed methods review. Int J Nurs Pract 2024:e13299. [PMID: 39225448 DOI: 10.1111/ijn.13299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 02/05/2024] [Accepted: 08/13/2024] [Indexed: 09/04/2024]
Abstract
AIM This study aimed to systematically review empirical evidence on factors influencing nurses to report medication errors and near misses. BACKGROUND There is underreporting of medication errors among nurses, in particular among novice and beginner nurses. To improve quality of care, factors influencing the reporting of medication errors and near misses should be documented. METHOD A systematic mixed methods review was conducted. CINAHL, Cochrane Collaboration, Embase, Medline, PsycINFO and Web of Science databases were explored and analysed from December 1990 to December 2023. Two reviewers independently selected and extracted data using a standardized data extraction grid. Data were analysed using thematic analysis based on the adapted theory of planned behaviour. RESULTS Forty-two studies met the eligibility criteria. Principal factors influencing the reporting of medication errors and near misses among nurses were associated with perceived behavioural control, subjective norm and attitude. Few studies examined factors influencing reporting medication errors and near misses among novice and beginner nurses, and sociodemographic and professional factors. CONCLUSION To understand factors influencing reporting of medication errors and near misses, further studies should be conducted to investigate sociodemographic and professional factors.
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Affiliation(s)
- Raouaa Braiki
- Nursing Sciences Faculty, Laval University, Québec City, Québec, Canada
| | - Frédéric Douville
- Nursing Sciences Faculty, Laval University, Québec City, Québec, Canada
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Henry Basil J, Premakumar CM, Mhd Ali A, Mohd Tahir NA, Seman Z, Voo JYH, Ishak S, Mohamed Shah N. Prevalence and factors associated with medication administration errors in the neonatal intensive care unit: A multicentre, nationwide direct observational study. J Adv Nurs 2024. [PMID: 38803148 DOI: 10.1111/jan.16247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 04/29/2024] [Accepted: 05/09/2024] [Indexed: 05/29/2024]
Abstract
AIM(S) To determine the prevalence of medication administration errors and identify factors associated with medication administration errors among neonates in the neonatal intensive care units. DESIGN Prospective direct observational study. METHODS The study was conducted in the neonatal intensive care units of five public hospitals in Malaysia from April 2022 to March 2023. The preparation and administration of medications were observed using a standardized data collection form followed by chart review. After data collection, error identification was independently performed by two clinical pharmacists. Multivariable logistic regression was used to identify factors associated with medication administration errors. RESULTS A total of 743 out of 1093 observed doses had at least one error, affecting 92.4% (157/170) neonates. The rate of medication administration errors was 68.0%. The top three most frequently occurring types of medication administration errors were wrong rate of administration (21.2%), wrong drug preparation (17.9%) and wrong dose (17.0%). Factors significantly associated with medication administration errors were medications administered intravenously, unavailability of a protocol, the number of prescribed medications, nursing experience, non-ventilated neonates and gestational age in weeks. CONCLUSION Medication administration errors among neonates in the neonatal intensive care units are still common. The intravenous route of administration, absence of a protocol, younger gestational age, non-ventilated neonates, higher number of medications prescribed and increased years of nursing experience were significantly associated with medication administration errors. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE The findings of this study will enable the implementation of effective and sustainable interventions to target the factors identified in reducing medication administration errors among neonates in the neonatal intensive care unit. REPORTING METHOD We adhered to the STROBE checklist. PATIENT OR PUBLIC CONTRIBUTION An expert panel consisting of healthcare professionals was involved in the identification of independent variables.
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Affiliation(s)
- Josephine Henry Basil
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Chandini Menon Premakumar
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Adliah Mhd Ali
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Nurul Ain Mohd Tahir
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Zamtira Seman
- Sector for Biostatistics & Data Repository, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, Malaysia
| | - James Yau Hon Voo
- Department of Pharmacy, Hospital Duchess of Kent, Ministry of Health Malaysia, Sabah, Malaysia
| | - Shareena Ishak
- Department of Pediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Noraida Mohamed Shah
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Rosen AK, Beilstein-Wedel E, Chan J, Borzecki A, Miech EJ, Mohr DC, Yackel EE, Flynn J, Shwartz M. Standardizing Patient Safety Event Reporting between Care Delivered or Purchased by the Veterans Health Administration (VHA). Jt Comm J Qual Patient Saf 2024; 50:247-259. [PMID: 38228416 DOI: 10.1016/j.jcjq.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Increasing community care (CC) use by veterans has introduced new challenges in providing integrated care across the Veterans Health Administration (VHA) and CC. VHA's well-recognized patient safety program has been particularly challenging for CC staff to adopt and implement. To standardize VHA safety practices across both settings, VHA implemented the Patient Safety Guidebook in 2018. The authors compared national- and facility-level trends in VHA and CC safety event reporting post-Guidebook implementation. METHODS In this retrospective study using patient safety event data from VHA's event reporting system (2020-2022), the research team examined trends in patient safety events, adverse events, close calls (near misses), and recovery rates (ratio of close calls to adverse events plus close calls) in VHA and CC using linear regression models to determine whether the average changes in VHA and CC safety events at the national and facility levels per quarter were significant. RESULTS A total of 499,332 safety events were reported in VHA and CC. Although VHA patient safety event trends were not significant (p > 0.05), there was a significant negative trend for adverse events (p = 0.02) and positive trends for close calls (p = 0.003) and recovery rates (p = 0.004). In CC there were significant negative trends for patient safety events and adverse events (p = 0.02) and a significant positive trend for recovery rates (p = 0.03). There was less variation in VHA than in CC facilities with significant decreases (for example, interquartile ranges in VHA and CC were 0.03 vs. 0.05, respectively). CONCLUSION Fluctuations in different safety events over time were likely due to the disruption of care caused by COVID-19 as well as organizational factors. Notably, the increases in recovery rates reflect less staff focus on harmful events and more attention to close calls (preventable events). Although safety practice adoption from VHA to CC was feasible, additional implementation strategies are needed to sustain standardized safety reporting across settings.
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Wei LC. The Significance of Near Misses in Enhancing Patient Safety: A Response and Perspective From Taoyuan Psychiatric Center. J Patient Saf 2023; 19:e68. [PMID: 37796193 DOI: 10.1097/pts.0000000000001176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Affiliation(s)
- Lien-Chung Wei
- Department of Addiction Psychiatry, Taoyuan Psychiatric Center Ministry of Health and Welfare Republic of China (Taiwan)
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Idilbi N, Dokhi M, Malka-Zeevi H, Rashkovits S. The Relationship Between Patient Safety Culture and the Intentions of the Nursing Staff to Report a Near-Miss Event During the COVID-19 Crisis. J Nurs Care Qual 2023; 38:264-271. [PMID: 36947813 DOI: 10.1097/ncq.0000000000000695] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
BACKGROUND Reporting a near-miss event has been associated with better patient safety culture. PURPOSE To examine the relationship between patient safety culture and nurses' intention to report a near-miss event during COVID-19, and factors predicting that intention. METHODS This mixed-methods study was conducted in a tertiary medical center during the fourth COVID-19 waves in 2020-2021 among 199 nurses working in COVID-19-dedicated departments. RESULTS Mean perception of patient safety culture was low overall. Although 77.4% of nurses intended to report a near-miss event, only 20.1% actually did. Five factors predicted nurses' intention to report a near-miss event; the model explains 20% of the variance. Poor departmental organization can adversely affect the intention to report a near-miss event. CONCLUSIONS Organizational learning, teamwork between hospital departments, transfers between departments, and departmental disorganization can affect intention to report a near-miss event and adversely affect patient safety culture during a health crisis.
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Affiliation(s)
- Nasra Idilbi
- Departments of Nursing (Dr Idilbi) and Health Systems Management (Dr Rashkovits), Max Stern Yezreel Valley Academic College, Emek Yezreel, Israel; Galilee Medical Center, Nahariya, Israel (Dr Idilbi and Mss Dokhi and Malka-Zeevi); and University of Haifa, Haifa, Israel (Ms Dokhi)
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Feng T, Zhang X, Tan L, Su Y, Liu H. Near-miss organizational learning in nursing within a tertiary hospital: a mixed methods study. BMC Nurs 2022; 21:315. [PMID: 36380309 PMCID: PMC9667619 DOI: 10.1186/s12912-022-01071-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 10/05/2022] [Accepted: 10/10/2022] [Indexed: 11/17/2022] Open
Abstract
Background Near-miss organizational learning is important for perspective and proactive risk management. Although nursing organizations are the largest component of the healthcare system and act as the final safety barrier, there is little research about the current status of near-miss organizational learning. Thus, we conducted this study to explore near-miss organizational learning in a Chinese nursing organization and offer suggestions for future improvement. Methods This was a mixed methods study with an explanatory sequence. It was conducted in a Chinese nursing organization of a tertiary hospital under the guidance of the 4I Framework of Organizational Learning. The quantitative study surveyed 600 nurses by simple random sampling. Then, we applied purposive sampling to recruit 16 nurses across managerial levels from low-, middle- and high-scored nursing units and conducted semi-structured interviews. Descriptive statistics, structured equation modelling and content analysis were applied in the data analysis. The Good Reporting of A Mixed Methods Study (GRAMMS) checklist was used to report this study. Results Only 33% of participants correctly recognized near-misses, and 4% of participants always reported near-misses. The 4I Framework of Organizational Learning was verified in the surveyed nursing organization (χ2 = 0.775, p = 0.379, RMSEA < 0.01). The current organizational learning behaviour was not conducive to near-miss organizational learning due to poor group-level learning (βGG = 0.284) and poor learning absorption (βMisalignment= -0.339). In addition, the researchers developed 13 codes, 9 categories and 5 themes to depict near-miss organizational learning, which were characterized by nurses’ unfamiliarity with near-misses, preferences and the dominance of first-order problem-solving behaviour, the suspension of near-miss learning at the group level and poor learning absorption. Conclusion The performance of near-miss organizational learning is unsatisfactory across all levels in surveyed nursing organization, especially with regard to group-level learning and poor learning absorption. Our research findings offer a scientific and comprehensive description of near-miss organizational learning and shed light on how to measure and improve near-miss organizational learning in the future. Supplementary information The online version contains supplementary material available at 10.1186/s12912-022-01071-1.
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Woo MWJ, Avery MJ. Nurses' experiences in voluntary error reporting: An integrative literature review. Int J Nurs Sci 2021; 8:453-469. [PMID: 34631996 PMCID: PMC8488811 DOI: 10.1016/j.ijnss.2021.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/26/2021] [Accepted: 07/28/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE This integrative review aimed to examine and understand nurses' experiences of voluntary error reporting (VER) and elucidate factors underlying their decision to engage in VER. METHOD This is an integrative review based on Whittemore & Knafl five-stage framework. A systematic search guided by the PRISMA 2020 approach was performed on four electronic databases: CINAHL, Medline (PubMed), Scopus, and Embase. Peer-reviewed articles published in the English language from January 2010 to December 2020 were retrieved and screened for relevancy. RESULTS Totally 31 papers were included in this review following the quality appraisal. A constant comparative approach was used to synthesize findings of eligible studies to report nurses' experiences of VER represented by three major themes: nurses' beliefs, behavior, and sentiments towards VER; nurses' perceived enabling factors of VER and nurses' perceived inhibiting factors of VER. Findings of this review revealed that nurses' experiences of VER were less than ideal. Firstly, these negative experiences were accounted for by the interplays of factors that influenced their attitudes, perceptions, emotions, and practices. Additionally, their negative experiences were underpinned by a spectrum of system, administrative and organizational factors that focuses on attributing the error to human failure characterized by an unsupportive, blaming, and punitive approach to error management. CONCLUSION Findings of this review add to the body of knowledge to inform on the areas of focus to guide nursing management perspectives to strengthen institutional efforts to improve nurses' recognition, reception, and contribution towards VER. It is recommended that nursing leaders prioritize and invest in strategies to enhance existing institutional error management approaches to establish a just and open patient safety culture that would promote positivity in nurses' overall experiences towards VER.
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Affiliation(s)
- Ming Wei Jeffrey Woo
- School of Health & Social Sciences, Nanyang Polytechnic, Singapore
- Department of Health Services Management, School of Medicine, Griffith University, Brisbane, Australia
| | - Mark James Avery
- Department of Health Services Management, School of Medicine, Griffith University, Brisbane, Australia
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Aljabari S, Kadhim Z. Common Barriers to Reporting Medical Errors. ScientificWorldJournal 2021; 2021:6494889. [PMID: 34220366 PMCID: PMC8211515 DOI: 10.1155/2021/6494889] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/03/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Medical errors are the third leading cause of death in the United States. Reporting of all medical errors is important to better understand the problem and to implement solutions based on root causes. Underreporting of medical errors is a common and a challenging obstacle in the fight for patient safety. The goal of this study is to review common barriers to reporting medical errors. METHODS We systematically reviewed the literature by searching the MEDLINE and SCOPUS databases for studies on barriers to reporting medical errors. The preferred reporting items for systematic reviews and meta-analyses guideline was followed in selecting eligible studies. RESULTS Thirty studies were included in the final review, 8 of which were from the United States. The majority of the studies used self-administered questionnaires (75%) to collect data. Nurses were the most studied providers (87%), followed by physicians (27%). Fear of consequences is the most reported barrier (63%), followed by lack of feedback (27%) and work climate/culture (27%). Barriers to reporting were highly variable between different centers.
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Affiliation(s)
- Salim Aljabari
- Child Health Department, University of Missouri-Columbia, Columbia, MO, USA
| | - Zuhal Kadhim
- Department of Family and Community Medicine, University of Missouri-Columbia, Columbia, MO, USA
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Zhao X, Zhao S, Liu N, Liu P. Willingness to Report Medical Incidents in Healthcare: a Psychological Model Based on Organizational Trust and Benefit/Risk Perceptions. J Behav Health Serv Res 2021; 48:583-596. [PMID: 33851309 DOI: 10.1007/s11414-021-09753-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2021] [Indexed: 11/30/2022]
Abstract
Many healthcare organizations have incident reporting systems to reduce and prevent medical errors. However, many systems have failed or not been implemented due to medical professionals' reluctance to report errors made by themselves or others. This study investigated the factors influencing their willingness to report incidents voluntarily. A psychological model based on the trust heuristic was proposed, hypothesizing that organizational trust could affect willingness to report based on the perceived benefits and risks of incident reporting or directly influence willingness to report. Three hundred twenty participants were recruited from 19 provinces in China to participate in an online survey conducted between June and July 2018. Participants included doctors, nurses, medical technicians, medical service staff, and administrative staff from different hospitals. All had access to incident reporting systems. Partial least squares structural equation modeling (PLS-SEM) was applied to examine the proposed psychological model. Participants had a modest willingness of reporting. Organizational trust was found to, directly and indirectly, affect participants' willingness to report their own incidents. Compared with perceived risk, perceived benefit was a more important predictor for willingness of reporting and a more important mediator in the effect of organizational trust on willingness of reporting. Our results highlight the importance of increasing the perceived benefit from incident reporting and building a "trust culture" for improving incident reporting.
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Affiliation(s)
- Xiaosong Zhao
- College of Management and Economics, Tianjin University, Tianjin, 300072, China
| | - Shumeng Zhao
- College of Management and Economics, Tianjin University, Tianjin, 300072, China
| | - Na Liu
- College of Management and Economics, Tianjin University, Tianjin, 300072, China
| | - Peng Liu
- Center for Psychological Sciences, Zhejiang University, Hangzhou, 310058, China.
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Alrabadi N, Shawagfeh S, Haddad R, Mukattash T, Abuhammad S, Al-rabadi D, Abu Farha R, AlRabadi S, Al-Faouri I. Medication errors: a focus on nursing practice. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2021. [DOI: 10.1093/jphsr/rmaa025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Abstract
Objectives
Health departments endeavor to give care to individuals to remain in healthy conditions. Medications errors (MEs), one of the most types of medical errors, could be venomous in clinical settings. Patients will be harmed physically and psychologically, in addition to adverse economic consequences. Reviewing and understanding the topic of medication error especially by nurses can help in advancing the medical services to patients.
Methods
A search using search engines such as PubMed and Google scholar were used in finding articles related to the review topic.
Key findings
This review highlighted the classifications of MEs, their types, outcomes, reporting process, and the strategies of error avoidance. This summary can bridge and open gates of awareness on how to deal with and prevent error occurrences. It highlights the importance of reporting strategies as mainstay prevention methods for medication errors.
Conclusions
Medication errors are classified based on multifaceted criteria and there is a need to standardize the recommendations and make them a central goal all over the globe for the best practice. Nurses are the frontlines of clinical settings, encouraged to be one integrated body to prevent the occurrence of medication errors. Thus, systemizing the guidelines are required such as education and training, independent double checks, standardized procedures, follow the five rights, documentation, keep lines of communication open, inform patients of drug they receive, follow strict guidelines, improve labeling and package format, focus on the work environment, reduce workload, ways to avoid distraction, fix the faulty system, enhancing job security for nurses, create a cultural blame-free workspace, as well as hospital administration, should support and revise processes of error reporting, and spread the awareness of the importance of reporting.
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Affiliation(s)
- Nasr Alrabadi
- Department of Pharmacology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Shaima Shawagfeh
- Department of Pharmacology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Razan Haddad
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Tareq Mukattash
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Sawsan Abuhammad
- Department of Maternal and Child Health Nursing, Faculty of Nursing, Jordan University of Science and Technology, Irbid, Jordan
| | - Daher Al-rabadi
- Department of Nursing, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
| | - Rana Abu Farha
- Department of Pharmacology and Pharmacotherapy, Applied Science Private University, Amman, Jordan
| | - Suzan AlRabadi
- Faculty of Pharmacy, Philadelphia University, Amman, Jordan
| | - Ibrahim Al-Faouri
- Department of Nursing, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan
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Ghezeljeh TN, Farahani MA, Ladani FK. Factors affecting nursing error communication in intensive care units: A qualitative study. Nurs Ethics 2020; 28:131-144. [PMID: 32985367 DOI: 10.1177/0969733020952100] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Error communication includes both reporting errors to superiors and disclosing their consequences to patients and their families. It significantly contributes to error prevention and safety improvement. Yet, some errors in intensive care units are not communicated. OBJECTIVES The aim of the present study was to explore factors affecting error communication in intensive care units. DESIGN AND PARTICIPANTS This qualitative study was conducted in 2019. Participants were 17 critical care nurses purposively recruited from the intensive care units of 2 public hospitals affiliated to Iran University of Medical Sciences, Tehran, Iran. Data were collected through in-depth semi-structured interviews and were analyzed through the conventional content analysis method proposed by Graneheim and Lundman. ETHICAL CONSIDERATIONS The Ethics Committee of Iran University of Medical Sciences, Tehran, Iran approved the study (code: IR.IUMS. REC.1397.792). Participants were informed about the study aim and methods and were ensured of data confidentiality. They were free to withdraw from the study at will. Written informed consent was obtained from all of them. FINDINGS Factors affecting error communication in intensive care units fell into four main categories, namely the culture of error communication (subcategories were error communication organizational atmosphere, clarity of processes and guidelines, managerial support for nurses, and learning organization), the consequences of errors for nurses and nursing (subcategories were fear over being stigmatized as incompetent, fear over punishment, and fear over negative judgments about nursing), the consequences of errors for patients (subcategories were monitoring the effects of errors on patients and predicting the effects of errors on patients), and ethical and professional characteristics (subcategories were ethical characteristics and inter-professional relationships). DISCUSSION The results of this study show many factors affect error communication, some facilitate and some prohibit it. Organizational factors such as the culture of error communication and the consequences of error communication for the nurse and the patient, as well as individual and professional characteristics, including ethical characteristics and interprofessional relationship, influence this process. CONCLUSION Errors confront nurses with ethical challenges and make them assess error consequences and then, communicate or hide them based on the results of their assessments. Health authorities can promote nurses' error communication through creating a supportive environment for them, developing clear error communication processes and guidelines, and providing them with education about the principles of ethical practice.
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Thibaut B, Dewa LH, Ramtale SC, D'Lima D, Adam S, Ashrafian H, Darzi A, Archer S. Patient safety in inpatient mental health settings: a systematic review. BMJ Open 2019; 9:e030230. [PMID: 31874869 PMCID: PMC7008434 DOI: 10.1136/bmjopen-2019-030230] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Patients in inpatient mental health settings face similar risks (eg, medication errors) to those in other areas of healthcare. In addition, some unsafe behaviours associated with serious mental health problems (eg, self-harm), and the measures taken to address these (eg, restraint), may result in further risks to patient safety. The objective of this review is to identify and synthesise the literature on patient safety within inpatient mental health settings using robust systematic methodology. DESIGN Systematic review and meta-synthesis. Embase, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium, MEDLINE, PsycINFO and Web of Science were systematically searched from 1999 to 2019. Search terms were related to 'mental health', 'patient safety', 'inpatient setting' and 'research'. Study quality was assessed using the Hawker checklist. Data were extracted and grouped based on study focus and outcome. Safety incidents were meta-analysed where possible using a random-effects model. RESULTS Of the 57 637 article titles and abstracts, 364 met inclusion criteria. Included publications came from 31 countries and included data from over 150 000 participants. Study quality varied and statistical heterogeneity was high. Ten research categories were identified: interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorised leave, clinical decision making, falls and infection prevention and control. CONCLUSIONS Patient safety in inpatient mental health settings is under-researched in comparison to other non-mental health inpatient settings. Findings demonstrate that inpatient mental health settings pose unique challenges for patient safety, which require investment in research, policy development, and translation into clinical practice. PROSPERO REGISTRATION NUMBER CRD42016034057.
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Affiliation(s)
- Bethan Thibaut
- NIHR Imperial Patient Safety Tranlsational Research Centre, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Lindsay Helen Dewa
- NIHR Imperial Patient Safety Tranlsational Research Centre, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Sonny Christian Ramtale
- NIHR Imperial Patient Safety Tranlsational Research Centre, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Danielle D'Lima
- Centre for Behaviour Change, Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Sheila Adam
- NIHR Imperial Patient Safety Tranlsational Research Centre, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Hutan Ashrafian
- NIHR Imperial Patient Safety Tranlsational Research Centre, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ara Darzi
- NIHR Imperial Patient Safety Tranlsational Research Centre, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Stephanie Archer
- NIHR Imperial Patient Safety Tranlsational Research Centre, Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK
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Interventions to improve reporting of medication errors in hospitals: A systematic review and narrative synthesis. Res Social Adm Pharm 2019; 16:1017-1025. [PMID: 31866121 DOI: 10.1016/j.sapharm.2019.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND In 2017, the World Health Organisation pledged to halve medication errors by 2022. In order to learn from medication errors and prevent their recurrence, it is essential that medication errors are reported when they occur. OBJECTIVES The aim of this systematic review was to identify studies in which interventions were carried out in hospitals to improve medication error reporting, to summarise the findings of these studies, and to make recommendations for future investigations. METHODS A comprehensive search of five electronic databases (PubMed, Medline (OVID), Embase (OVID), Web of Science, and CINAHL) was conducted from inception up to and including December 2018. Studies were included if they described an intervention aiming to increase the reporting of medication errors by healthcare providers in hospitals and excluded if there was no full-text English language version available, or if the reporting rate in the hospital prior to the intervention was not available. Data extracted from included studies were described using narrative synthesis. RESULTS Of 12,025 identified studies, seventeen were included in this review - fifteen uncontrolled before versus after studies, one survey and one non-equivalent group controlled trial. Five studies carried out a single intervention and twelve studies conducted multifaceted interventions. The most common intervention types were critical incident reporting, implemented in fifteen studies, and audit and feedback, implemented in seven studies. Other intervention types included educational materials, educational meetings, and role expansion and task shifting. As only one study compared a control and intervention group, the effectiveness of the different intervention types could not be evaluated. CONCLUSION This is the first review to address the evidence on medication error reporting in hospitals on a global scale. The review has identified interventions to improve medication error reporting that were implemented without evidence of their effectiveness. Due to the essential role played by incident reporting in learning from and preventing the recurrence of medication errors more research needs to be done in this area.
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15
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Teal T, Emory J, Patton S. Analysis of Medication Errors and near Misses Made by Nursing Students. Int J Nurs Educ Scholarsh 2019; 16:ijnes-2019-0057. [DOI: 10.1515/ijnes-2019-0057] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 10/01/2019] [Indexed: 11/15/2022]
Abstract
Abstract
Despite extensive research and technological advancements, errors related to medication administration continue to rise annually. The body of evidence surrounding medication errors has focused largely on licensed practicing nurses. Nursing students can offer a unique perspective regarding medication administration as their foundation for professional psychomotor skills and cognitive abilities are developed. The purpose of this study was to explore the variables related to medication errors made by pre-licensure nursing students. Data were collected from 2013–2015 in a pre-licensure program. Students completed a post-error survey available in Google Forms. One hundred thirteen responses to the error report were completed. By exploring the factors related to medication errors among nursing students, teaching and learning strategies forming the foundations of medication administration can improve professional nursing practice and improve safety and quality of care.
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Affiliation(s)
- Tabatha Teal
- Nursing , Univ Arkansas , 606 N Razorback Road , Fayetteville , AR 72701 , USA
| | - Jan Emory
- Nursing , Univ Arkansas , 606 N Razorback Road , Fayetteville , AR 72701 , USA
| | - Susan Patton
- Nursing , Univ Arkansas , 606 N Razorback Road , Fayetteville , AR 72701 , USA
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Shawahna R, Abbas A, Ghanem A. Medication transcription errors in hospitalized patient settings: a consensual study in the Palestinian nursing practice. BMC Health Serv Res 2019; 19:644. [PMID: 31492182 PMCID: PMC6729077 DOI: 10.1186/s12913-019-4485-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 08/28/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Medication transcription errors (MTEs) are frequent in hospitalized patient settings. Definitions and scenarios that represent potential MTEs in the Palestinian nursing practice were not previously approached using formal consensus techniques. This investigation was conducted to develop a consensual definition of MTEs and scenarios that represent different MTE situations by a panel of nurses and other healthcare professionals. METHODS In this observational study, consensus was sought using the Delphi technique. Panelists (n = 64) were invited and recruited from different hospitals in Palestine and a two-iterative rounds Delphi technique was used to achieve consensus on a proposed definition of MTEs and 76 different scenarios representing potential MTEs. RESULTS Consensus was achieve to accept the definition and to consider 69 of the 76 proposed scenarios (77.6%) as MTEs, exclude 3 scenarios (3.9%), and 4 scenarios (5.3%) remained equivocal. Equivocal scenarios might be considered as MTEs or not depending on the clinical situation. CONCLUSIONS Consensus was achieved on a definition of MTEs and scenarios representing MTEs by a panel of nurses and other healthcare professionals. This study showed that it was possible to develop and achieve consensus on a definition and scenarios representing MTE situations using formal consensus techniques. Such consensual definitions could be useful in future epidemiological studies investigating MTEs. Using consensual definitions might reduce methodological variations, promote congruence in error counting and reporting, and permit comparing error rates in different hospital settings.
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Affiliation(s)
- Ramzi Shawahna
- Department of Physiology, Pharmacology and Toxicology, Faculty of Medicine and Health Sciences, An-Najah National University, New Campus, Building: 19, Office: 1340, P.O. Box 7, Nablus, Palestine. .,An-Najah BioSciences Unit, Centre for Poisons Control, Chemical and Biological Analyses, An-Najah National University, Nablus, Palestine.
| | - Abbas Abbas
- Department of Medicine, Faculty of Medicine and health Sciences, An-Najah National University, Nablus, Palestine
| | - Ameed Ghanem
- Department of Medicine, Faculty of Medicine and health Sciences, An-Najah National University, Nablus, Palestine
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17
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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. [PMID: 31311542 PMCID: PMC6636092 DOI: 10.1186/s12913-019-4194-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 05/28/2019] [Indexed: 11/23/2022] Open
Abstract
Background Individual and organizational factors correlate with perceived barriers to error reporting. Understanding medication administration errors (MAEs) reduces confusion about error definitions, raises perceptions of MAEs, and allows healthcare providers to report perceived and identified errors more frequently. Therefore, an emphasis must be placed on medication competence, including medication administration knowledge and decision-making. It can be helpful to utilize an organizational approach, such as collaboration between nurses and physicians, but this type of approach is difficult to establish and maintain because patient-safety culture starts at the highest levels of the healthcare organization. This study aimed to examine the canonical correlations of an individual self-efficacy/bottom-up organizational approach variable set with perceived barriers to reporting MAEs among nurses. Methods We surveyed 218 staff nurses in Korea. The measurement tools included a questionnaire on knowledge of high-alert medication, nursing decision-making, nurse-physician collaboration satisfaction, and barriers to reporting MAEs. Descriptive statistics, t-tests, analysis of variance (ANOVA), Pearson’s correlation coefficient, and canonical correlations were used to analyze results. Results Two canonical variables were significant. The first variate indicated that less knowledge about medication administration (− 0.83) and a higher perception of nurse-physician collaboration (0.42) were related to higher disagreement over medication error (0.64). The second variate showed that intuitive clinical decision-making (− 0.57) and a higher perception of nurse-physician collaboration (0.84) were related to lower perceived barriers to reporting MAEs. Conclusions Enhancing positive collaboration among healthcare professionals and promoting analytic decision-making supported by sufficient knowledge could facilitate MAE reporting by nurses. In the clinical phase, providing medication administration education and improving collaboration may reduce disagreement about the occurrence of errors and facilitate MAE reporting. In the policy phase, developing an evidence-based reporting system that informs analytic decision-making may reduce the perceived barriers to MAE reporting.
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Affiliation(s)
- Myoung Soo Kim
- Department of Nursing, Pukyong National University, 599-1, Daeyeon 3 dong, Namgu, Busan, 48513, South Korea
| | - Chul-Hoon Kim
- College of Medicine, Dong-A University Hospital, 26 Daesingongwon-ro, Seo-gu, Busan, 49201, South Korea.
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18
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Evaluating the Use of High-Reliability Principles to Increase Error Event Reporting: A Retrospective Review. J Nurs Adm 2019; 49:310-314. [PMID: 31135638 DOI: 10.1097/nna.0000000000000758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Assess the relationship between educating caregivers about high-reliability principles and reporting of potential adverse safety events. BACKGROUND Persuading caregivers to report potential safety events is challenging. Learning high-reliability principles may help caregivers identify and report potential safety problems. METHODS Event reports submitted by caregivers 6 months before and after high-reliability training were examined for event types, event significance, and shift when events occurred. χ Tests assessed relationships between variables. RESULTS The number and type of caregiver event reports before and after training were not significantly different; however, clinical process error reports significantly decreased (χ = 9.251, P = .003). There was a significant difference in reports submitted by day and night shifts (χ = 5.942, P = .02). CONCLUSIONS Trends suggest staff report actual, rather than potential, events regardless of training. Further research is needed to determine what motivates caregivers to report safety concerns.
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19
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Farag A, Lose D, Gedney-Lose A. Nurses' Safety Motivation: Examining Predictors of Nurses' Willingness to Report Medication Errors. West J Nurs Res 2018; 41:954-972. [PMID: 30516452 DOI: 10.1177/0193945918815462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Medication errors are common in health care settings. Safety motivation, such as willingness to report error, is needed to contain medication errors. Limited evidence exists about measures to enforce nurses' safety motivation. The purpose of this study was to test a proposed model explaining the mechanism by which organizational and social factors influence nurses' safety motivation. Survey for this cross-sectional study was mailed to a random sample of 500 acute care nurses. Data collection started in January 2014 and lasted 6 months. Path analysis results showed a good fitting final model with 15% of explained variance on nurses' safety motivation. Safety climate dimensions of error feedback (β = .38, p ⩽ .00) and nonpunitive response to errors (β = .22, p = .01) significantly predicted the outcome. There is a need for both organizational and social factors to motivate nurses to report errors. Leadership practices emphasizing safety as a priority is needed to enhance nurses' safety motivation.
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Affiliation(s)
| | - Daniel Lose
- 2 University of Iowa Hospitals & Clinics, Iowa City, IA, USA
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20
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Abdi M, Piri S, Mohammadian R, Asadi M, Khademi E. Factors associated with medication errors in the psychiatric ward of Razi Hospital in Tabriz: Perspectives of nurses. PREVENTIVE CARE IN NURSING AND MIDWIFERY JOURNAL 2018. [DOI: 10.29252/pcnm.8.2.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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21
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Okpala P. Nurses’ perspectives on the impact of management approaches on the blame culture in health-care organizations. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2018. [DOI: 10.1080/20479700.2018.1492771] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Paulchris Okpala
- Department of Health Science and Human Ecology, California State University San Bernardino, San Bernardino, USA
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22
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Migowski ER, Oliveira Júnior N, Riegel F, Migowski SA. Interpersonal relationships and safety culture in Brazilian health care organisations. J Nurs Manag 2018; 26:851-857. [PMID: 29923235 DOI: 10.1111/jonm.12615] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2017] [Indexed: 11/30/2022]
Abstract
AIM To examine the association between interpersonal relationships, nursing leadership and patient safety culture and the impact on the efficiency of hospitals. BACKGROUND Hospitals are still affected by the increased complexity of the treatments offered and by the diverse knowledge of professionals involved, which has made this assistance model ineffective, expensive and unsustainable over time. METHOD A qualitative study of 32 professionals from three large hospitals in Southern Brazil was made. Semi-structured interviews, document analysis and analysis of electronic records were used. RESULTS All the hospitals had infection rates and an average stay higher than their goal. Lack of interpersonal relationships and physicians failing to commit to organisational objectives were demonstrated. CONCLUSION Nursing leadership styles are not definitive factors to improving patient safety and efficiency. The flaws in consolidating interpersonal relationships seem to be related to difficulties in consolidating patient safety culture, which prevented hospitals reaching their efficiency indicators. IMPLICATIONS FOR NURSING MANAGEMENT Professionals who work at the patients' bedside should be involved in the development of strategies, in order to commit them to the organisational objectives. The consolidation of interpersonal relationships of nursing professionals can lead to improvements with medical professionals, with positive impacts on patient safety and efficiency.
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Affiliation(s)
- Eliana R Migowski
- Department of Health School, Faculdade de Desenvolvimento do Rio Grande do Sul (FADERGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Nery Oliveira Júnior
- Department of Health School, Faculdade de Desenvolvimento do Rio Grande do Sul (FADERGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Fernando Riegel
- Department of Health School, Faculdade de Desenvolvimento do Rio Grande do Sul (FADERGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - Sérgio A Migowski
- Instituto Federal do Rio Grande do Sul (IFRS), Canoas, Rio Grande do Sul, Brazil
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Ni Y, Lingren T, Hall ES, Leonard M, Melton K, Kirkendall ES. Designing and evaluating an automated system for real-time medication administration error detection in a neonatal intensive care unit. J Am Med Inform Assoc 2018; 25:555-563. [PMID: 29329456 PMCID: PMC6018990 DOI: 10.1093/jamia/ocx156] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 12/05/2017] [Accepted: 12/18/2017] [Indexed: 11/12/2022] Open
Abstract
Background Timely identification of medication administration errors (MAEs) promises great benefits for mitigating medication errors and associated harm. Despite previous efforts utilizing computerized methods to monitor medication errors, sustaining effective and accurate detection of MAEs remains challenging. In this study, we developed a real-time MAE detection system and evaluated its performance prior to system integration into institutional workflows. Methods Our prospective observational study included automated MAE detection of 10 high-risk medications and fluids for patients admitted to the neonatal intensive care unit at Cincinnati Children's Hospital Medical Center during a 4-month period. The automated system extracted real-time medication use information from the institutional electronic health records and identified MAEs using logic-based rules and natural language processing techniques. The MAE summary was delivered via a real-time messaging platform to promote reduction of patient exposure to potential harm. System performance was validated using a physician-generated gold standard of MAE events, and results were compared with those of current practice (incident reporting and trigger tools). Results Physicians identified 116 MAEs from 10 104 medication administrations during the study period. Compared to current practice, the sensitivity with automated MAE detection was improved significantly from 4.3% to 85.3% (P = .009), with a positive predictive value of 78.0%. Furthermore, the system showed potential to reduce patient exposure to harm, from 256 min to 35 min (P < .001). Conclusions The automated system demonstrated improved capacity for identifying MAEs while guarding against alert fatigue. It also showed promise for reducing patient exposure to potential harm following MAE events.
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Affiliation(s)
- Yizhao Ni
- Department of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Todd Lingren
- Department of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Eric S Hall
- Department of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Neonatology and Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Matthew Leonard
- Department of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Kristin Melton
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Neonatology and Pulmonary Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Eric S Kirkendall
- Department of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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24
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Rutledge DN, Retrosi T, Ostrowski G. Barriers to medication error reporting among hospital nurses. J Clin Nurs 2018; 27:1941-1949. [PMID: 29495119 DOI: 10.1111/jocn.14335] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2018] [Indexed: 10/17/2022]
Abstract
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.
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Affiliation(s)
- Dana N Rutledge
- St. Joseph Hospital, Orange, CA, USA.,California State University Fullerton, Fullerton, CA, USA
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25
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Jember A, Hailu M, Messele A, Demeke T, Hassen M. Proportion of medication error reporting and associated factors among nurses: a cross sectional study. BMC Nurs 2018; 17:9. [PMID: 29563855 PMCID: PMC5848571 DOI: 10.1186/s12912-018-0280-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 03/06/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND A medication error (ME) is any preventable event that may cause or lead to inappropriate medication use or patient harm. Voluntary reporting has a principal role in appreciating the extent and impact of medication errors. Thus, exploration of the proportion of medication error reporting and associated factors among nurses is important to inform service providers and program implementers so as to improve the quality of the healthcare services. METHODS Institution based quantitative cross-sectional study was conducted among 397 nurses from March 6 to May 10, 2015. Stratified sampling followed by simple random sampling technique was used to select the study participants. The data were collected using structured self-administered questionnaire which was adopted from studies conducted in Australia and Jordan. A pilot study was carried out to validate the questionnaire before data collection for this study. Bivariate and multivariate logistic regression models were fitted to identify factors associated with the proportion of medication error reporting among nurses. An adjusted odds ratio with 95% confidence interval was computed to determine the level of significance. RESULT The proportion of medication error reporting among nurses was found to be 57.4%. Regression analysis showed that sex, marital status, having made a medication error and medication error experience were significantly associated with medication error reporting. CONCLUSION The proportion of medication error reporting among nurses in this study was found to be higher than other studies.
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Affiliation(s)
- Abebaw Jember
- Department of Medical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mignote Hailu
- Department of Medical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Anteneh Messele
- Unit of Community Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tesfaye Demeke
- Department of Pediatric and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mohammed Hassen
- Department of Medical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Brooke J, Manneh C. Caring for a patient with delirium in an acute hospital: The lived experience of cardiology, elderly care, renal, and respiratory nurses. Int J Nurs Pract 2018. [DOI: 10.1111/ijn.12643] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Joanne Brooke
- Oxford Institute of Nursing, Midwifery and Allied Health Research; Oxford Brookes University; Oxford UK
| | - Claire Manneh
- Royal Berkshire NHS Foundation Trust; Royal Berkshire Hospital; Reading UK
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27
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Kim SA, Kim EM, Lee JR, Oh EG. Effect of Nurses' Perception of Patient Safety Culture on Reporting of Patient Safety Events. ACTA ACUST UNITED AC 2018. [DOI: 10.11111/jkana.2018.24.4.319] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Sun Aee Kim
- College of Nursing, Graduate School, Yonsei University, Korea
- CHA Bundang Medical Center, University of CHA, Korea
| | - Eun-Mi Kim
- College of Nursing, Graduate School, Yonsei University, Korea
- Department of Nursing, Sunlin University, Korea
| | - Ju-Ry Lee
- College of Nursing, Graduate School, Yonsei University, Korea
- Asan Medical Center, University of Ulsan, College of Medicine, Korea
| | - Eui Geum Oh
- College of Nursing · Mo-Im Kim Nursing Research Institute, Yonsei university, Korea
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28
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Degnan DD, Hertig JB, Peters MJ, Stevenson JG. Board of Pharmacy Practices Related to Medication Errors and Their Potential Impact on Patient Safety. J Pharm Pract 2017. [PMID: 28629304 DOI: 10.1177/0897190017715562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
State boards of pharmacy are generally responsible for the governance of the practice of pharmacy. While the regulatory process and methods for accomplishing this task may vary by state, all boards of pharmacy must address medication errors committed by pharmacists. The National Association of Boards of Pharmacy (NABP) has recommended that state boards of pharmacy implement best practices and enforcement actions that are aimed to promote patient safety and reduce medication errors. The current study was designed to identify and compare current corrective action practices among boards of pharmacy in response to medication errors. An electronic survey regarding board policies and anticipated board actions in response to hypothetical medication error scenarios was sent to boards of pharmacy for completion. Approximately 45% of pharmacy boards responded. Survey responses demonstrated that corrective actions and consequences were levied against pharmacists inconsistently among state boards. Corrective action plans and process improvement components were lacking in a majority of state board of pharmacy practices. Medication safety education for pharmacists and for members on boards of pharmacy was insufficient in many states. Responses to hypothetical error scenarios indicated that most board actions are educational and punitive in nature, rather than focusing on systems improvement.
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Affiliation(s)
- Daniel D. Degnan
- Center for Medication Safety Advancement, Purdue University College of Pharmacy, West Lafayette, IN, USA
| | - John B. Hertig
- Center for Medication Safety Advancement, Purdue University College of Pharmacy, West Lafayette, IN, USA
| | - Michael J. Peters
- Center for Medication Safety Advancement, Purdue University College of Pharmacy, West Lafayette, IN, USA
| | - James G. Stevenson
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
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Vrbnjak D, Denieffe S, O’Gorman C, Pajnkihar M. Barriers to reporting medication errors and near misses among nurses: A systematic review. Int J Nurs Stud 2016; 63:162-178. [DOI: 10.1016/j.ijnurstu.2016.08.019] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 08/06/2016] [Accepted: 08/31/2016] [Indexed: 10/21/2022]
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30
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Vrbnjak D, Pahor D, Štiglic G, Pajnkihar M. Content validity and internal reliability of Slovene version of Medication Administration Error Survey. OBZORNIK ZDRAVSTVENE NEGE 2016. [DOI: 10.14528/snr.2016.50.1.69] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction: In Slovenia there is a lack of valid and reliable instruments for measuring medication administration errors. The aim of research is to determine the content validity and internal reliability of the Slovenian version of the ''Medication Administration Error Survey''. Methods: We used the translation and back translation tested the questionnaire for its content validity on the basis of an agreement of eight experts. Content validity was quantified by the content validity index and a modified Cohen kappa index. A cross-sectional design, with a convenience sample of 91 caregivers working in internal or surgical wards in two health care institutions, was used to test the internal consistency by calculating Cronbach's α and corrected item-total correlations. Results: 64 items showed an excellent content validity index, ranging from 0.875 to 1.000, and modified kappa index over 0.740. Two items had a content validity index 0.750 and modified kappa index 0.560. The average content validity index for three main parts of the questionnaire ranged from 0.940 to 0.959. Cronbach's α for these three parts ranged from 0.832 to 0.989. The corrected item-total correlations reached a required criterion for all items, except one. Discussion and conclusion: Instrument has an acceptable content validity and internal reliability, however, due to some methodological shortcomings results should be interpreted with caution. Further psychometric testing is needed.
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31
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Kim MY, Kim YM, Kang SW. A survey and multilevel analysis of nursing unit tenure diversity and medication errors. J Nurs Manag 2016; 24:634-45. [DOI: 10.1111/jonm.12366] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Min Young Kim
- College of Nursing; Jeju National University; Jeju City Korea
| | - Young Mee Kim
- Department of Nursing; Seoul National University Hospital; Seoul Korea
| | - Seung-Wan Kang
- College of Business; Gachon University; Sujeong-gu Seongnam City Gyeonggi-do Korea
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32
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Shawahna R, Masri D, Al-Gharabeh R, Deek R, Al-Thayba L, Halaweh M. Medication administration errors from a nursing viewpoint: a formal consensus of definition and scenarios using a Delphi technique. J Clin Nurs 2016; 25:412-23. [DOI: 10.1111/jocn.13062] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Ramzi Shawahna
- Department of Physiology and Pharmacology; Faculty of Medicine and Health Sciences; An-Najah BioSciences Unit; Center for Poisons Control, Chemical and Biological Analyses; An-Najah National University; Nablus Palestine
| | - Dina Masri
- Department of Pharmacy; Faculty of Medicine and Health Sciences; An-Najah National University; Nablus Palestine
| | - Rawan Al-Gharabeh
- Department of Pharmacy; Faculty of Medicine and Health Sciences; An-Najah National University; Nablus Palestine
| | - Rawan Deek
- Department of Pharmacy; Faculty of Medicine and Health Sciences; An-Najah National University; Nablus Palestine
| | - Lama Al-Thayba
- Department of Pharmacy; Faculty of Medicine and Health Sciences; An-Najah National University; Nablus Palestine
| | - Masa Halaweh
- Department of Pharmacy; Faculty of Medicine and Health Sciences; An-Najah National University; Nablus Palestine
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Wang HF, Jin JF, Feng XQ, Huang X, Zhu LL, Zhao XY, Zhou Q. Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: a trend analysis during the journey to Joint Commission International accreditation and in the post-accreditation era. Ther Clin Risk Manag 2015; 11:393-406. [PMID: 25767393 PMCID: PMC4354453 DOI: 10.2147/tcrm.s79238] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Medication errors may occur during prescribing, transcribing, prescription auditing, preparing, dispensing, administration, and monitoring. Medication administration errors (MAEs) are those that actually reach patients and remain a threat to patient safety. The Joint Commission International (JCI) advocates medication error prevention, but experience in reducing MAEs during the period of before and after JCI accreditation has not been reported. Methods An intervention study, aimed at reducing MAEs in hospitalized patients, was performed in the Second Affiliated Hospital of Zhejiang University, Hangzhou, People’s Republic of China, during the journey to JCI accreditation and in the post-JCI accreditation era (first half-year of 2011 to first half-year of 2014). Comprehensive interventions included organizational, information technology, educational, and process optimization-based measures. Data mining was performed on MAEs derived from a compulsory electronic reporting system. Results The number of MAEs continuously decreased from 143 (first half-year of 2012) to 64 (first half-year of 2014), with a decrease in occurrence rate by 60.9% (0.338% versus 0.132%, P<0.05). The number of MAEs related to high-alert medications decreased from 32 (the second half-year of 2011) to 16 (the first half-year of 2014), with a decrease in occurrence rate by 57.9% (0.0787% versus 0.0331%, P<0.05). Omission was the top type of MAE during the first half-year of 2011 to the first half-year of 2014, with a decrease by 50% (40 cases versus 20 cases). Intravenous administration error was the top type of error regarding administration route, but it continuously decreased from 64 (first half-year of 2012) to 27 (first half-year of 2014). More experienced registered nurses made fewer medication errors. The number of MAEs in surgical wards was twice that in medicinal wards. Compared with non-intensive care units, the intensive care units exhibited higher occurrence rates of MAEs (1.81% versus 0.24%, P<0.001). Conclusion A 3-and-a-half-year intervention program on MAEs was confirmed to be effective. MAEs made by nursing staff can be reduced, but cannot be eliminated. The depth, breadth, and efficiency of multidiscipline collaboration among physicians, pharmacists, nurses, information engineers, and hospital administrators are pivotal to safety in medication administration. JCI accreditation may help health systems enhance the awareness and ability to prevent MAEs and achieve successful quality improvements.
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Affiliation(s)
- Hua-Fen Wang
- Division of Nursing, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Jing-Fen Jin
- Division of Nursing, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Xiu-Qin Feng
- Division of Nursing, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Xin Huang
- Division of Nursing, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Ling-Ling Zhu
- Geriatric VIP Ward, Division of Nursing, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Xiao-Ying Zhao
- Office of Quality Administration, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
| | - Quan Zhou
- Department of Pharmacy, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People's Republic of China
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Atwal A. Discharge planning: learning from near misses. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2014. [DOI: 10.12968/ijtr.2014.21.9.408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Anita Atwal
- Senior Lecturer in Occupational Therapy, Brunel University London, UK
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Haw C, Stubbs J, Dickens G. Medicines management: an interview study of nurses at a secure psychiatric hospital. J Adv Nurs 2014; 71:281-94. [PMID: 25082212 DOI: 10.1111/jan.12495] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2014] [Indexed: 11/30/2022]
Abstract
AIMS To explore mental health nurses' knowledge, attitudes and clinical judgement concerning medicines management in an inpatient setting with a view to enhancing training. BACKGROUND Medicines management is a key role of mental health nurses, but little research has been conducted into their training needs. DESIGN An exploratory mixed-methods design was used involving individual interviews with participants to investigate their responses to hypothetical medicine administration scenarios. METHODS Interviews were held with a convenience sample of 50 Registered Nurses working in a specialist mental health hospital between November 2012-February 2013. Participants were presented with clinical vignettes describing eight scenarios they might encounter as part of their medicines management role and asked about how they would respond. Responses were assessed by two independent raters against ten quality standards underpinning the vignettes. RESULTS The median number of responses that were judged to demonstrate adequate awareness of associated quality standards was 4 (range 1-7), indicating that many participants did not appear to be aware of, or compliant with, current UK medicines management guidance and local policy. Many would not report a 'near miss' or medicines administration error. There was a lack of awareness of guidance on verbal prescribing, consent to treatment rules and the administration of off-label/unlicensed drugs. Past year attendance on a medicines management course, time since registration and self-reported knowledge of national standards for medicines administration did not discriminate between total score on the 10 quality standards. CONCLUSION The medicines management training needs of participants appeared not to be fully met by the existing learning sources. The use of vignettes to assess nurses' training needs requires evaluation in other settings.
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Affiliation(s)
- Camilla Haw
- St Andrew's, Cliftonville, Northampton, UK; School of Health, University of Northampton, UK; Institute of Psychiatry, King's College, London, UK
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Huckels-Baumgart S, Manser T. Identifying medication error chains from critical incident reports: A new analytic approach. J Clin Pharmacol 2014; 54:1188-97. [DOI: 10.1002/jcph.319] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 04/25/2014] [Indexed: 11/06/2022]
Affiliation(s)
| | - Tanja Manser
- Department of Psychology; University of Fribourg; Fribourg Switzerland
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