Assessment of Medication Administration Error Reporting Among Hospital Nurses in Indonesia

Document Type : Original Article

Authors

Health Administration and Policy, Faculty of Public Health, University of Indonesia, Depok, Indonesia

Abstract

Introduction:
Nurses play a vital role in the maintenance and promotion of patient safety, as well as medication administration in hospitals.  In one small state government-owned hospital in South Jakarta, medication errors were the most reported type of patient safety incidents accounting for 52.5% of incidents which occurred within 2016 to September 2018. Nonetheless, only a small percentage (9.25%) of those reports was presented by nurses. The present study aimed to determine the factors associated with medication administration error (MAE) reporting among nurses.
Materials and Methods:
A cross-sectional study, followed by qualitative research, was conducted at a state government-owned hospital in Jakarta Indonesia within November 2018-April 2019.  Total sampling was used to obtain the 44 clinical nurses included in the quantitative study. The qualitative study used focus group discussion and in-depth interviews of selected informants.
Results:
Consequences of reporting was found to be correlated with MAE reporting among nurses (P=0.013). There was no statistically significant organizational factor or socio-demographic characteristic associated with medication administration error reporting. Through qualitative measures, the factors that most influenced and inhibited error reporting included administrative response and the consequences of reporting. Moreover, managers’ support, understanding and self- awareness of the importance of reporting, and a non-blaming culture were recognized as the factors which support error reporting.
Conclusion:
As evidenced by the obtained results, medication administration error reporting is still low.  Reporting incidents can be improved by fostering a non-blaming safety culture. Further studies are recommended to investigate the occurrence of medication errors, as well as reported errors.

Keywords

References

  1. National Coordinating Council for Medication Error Reporting and Prevention. About Medication Errors [Internet]. 2018 [cited 2018 May 1]. Available from: https:// www. nccmerp. org/about-medication-errors
  2. WHO. WHO launches global effort to halve medication-related errors in 5 years [Internet]. WHO. 2017 [cited 2018 Jun 1]. Available from: http://www.who.int/news-room/detail/ 29-03-2017-who-launches-global-effort- to-halve-medication-related-errors-in-5-years
  3. KARS. Standar Nasional Akreditasi Rumah Sakit. 2017;421.
  4. Latif A, Rawat N, Pustavoitau A, Pronovost PJ, Pham JC. National study on the distribution, causes, and consequences of voluntarily reported medication errors between the ICU and non-ICU settings [Internet]. Vol. 41, Critical Care Medicine. 2013. p. 389–98. Available from: https:// www.copus.com/ inward/record. uri?eid=2-s2.0-84873352956& doi=10.1097% 2FCCM. 0b013e318274156a&partnerID= 40 &md 5= b2f580f8614d21925d72640 c3ae f3179
  5. Chalasani SH, Ramesh M. Towards patient safety: assessment of medication errors in the intensive care unit in a developing country’s tertiary care teaching hospital. Eur J Hosp Pharm [Internet]. 2017 Nov 1;24(6):361 LP – 365. Available from: http:// ejhp.bmj. com/ content/24/6/361.abstract
  6. Wakefield BJ, Uden-Holman T, Wakefield DS. Development and validation of the Medication Administration Error Reporting Survey. Adv Patient Saf From Res to Implement Vol 4 Programs, Tools, Prod (AHRQ Publ No 05-0021-4). 2005;
  7. Bahadori M, Ravangard R, Aghili A, Sadeghifar J, Gharsi Manshadi M, Smaeilnejad J. The Factors Affecting the Refusal of Reporting on Medication Errors from the Nurses’ Viewpoints: A Case Study in a Hospital in Iran. ISRN Nurs [Internet]. 2013 Apr 9;2013:876563. Available from: http://www.ncbi.nlm. nih.gov/pmc/ articles/ PMC3649500/
  8. Rutledge DN, Retrosi T, Ostrowski G. Barriers to medication error reporting among hospital nurses. J Clin Nurs [Internet]. 2018 Mar 1;27(9–10):1941–9. Available from: https:// doi.org/10.1111/jocn.14335
  9. Handler SM, Perera S, Olshansky EF, Studenski SA, Nace DA, Fridsma DB, et al. Identifying Modifiable Barriers to Medication Error Reporting in the Nursing Home Setting. J Am Med Dir Assoc [Internet]. 2007 Nov 22;8(9):568–74. Available from: http:// www. ncbi.nlm.nih.gov/pmc/articles/PMC2151929/
  10. Richter JP, McAlearney AS, Pennell ML. Evaluating the Effect of Safety Culture on Error Reporting: A Comparison of Managerial and Staff Perspectives. Am J Med Qual [Internet]. 2014 Jul 28;30(6):550–8. Available from: https:// doi.org/ 10.1177/1062860614544469
  11. Hwang J-I, Ahn J. Teamwork and Clinical Error Reporting among Nurses in Korean Hospitals. Asian Nurs Res (Korean Soc Nurs Sci) [Internet]. 2015 Mar;9(1):14–20. Available from: https://search.proquest.com/docview/1667271464?accountid=17242.
  12. Maurer MJ. Nurses’ perceptions of and experiences with medication errors. Univ Toledo [Internet]. 2010;2(1):12–4. Available from: http://www.ncbi.nlm.nih.gov/pued/17335520
  13. Archer S, Hull L, Soukup T, Mayer E, Athanasiou T, Sevdalis N, et al. Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature. BMJ Open [Internet]. 2017 Dec 1;7(12). Available from: http://bmjopen.bmj. com/content/7/12/e017155.abstract
  14. 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 [Internet]. 2018 Mar;17(1):9. Available from: https:// doi.org/10. 1186/s12912-018-0280-4
  15. Sorra J, Gray L, Streagle S. Hospital Survey on Patient Safety Culture: User’s Guide [Internet]. AHRQ Publication. 2016. Available from: http://www. ahrq.gov/ professionals/ quality-patientsafety/ patientsafetyculture/ hospital/ index.html
  16. National Patient Safety Agency. Seven steps to patient safety A guide for NHS staff Seven steps to patient safety Step 1 Build a safety culture Step 2 Lead and support your staff Step 3 Integrate your risk management activity Step 4 Promote reporting Step 5 Involve and communicate with. London: National Patient Safety Agency; 2013.
  17. Wakefield DJ Wakefield B, Uden-Holman T, Blegen M. Perceived barriers in reporting medication administration errors. Vol. 1, Best practices and benchmarking in healthcare : a practical journal for clinical and management application. 1996. 191–197 p.
  18. Bayazidi S, Zarezadeh Y, Zamanzadeh V, Parvan K. Medication Error Reporting Rate and its Barriers and Facilitators among Nurses. J caring Sci [Internet]. 2012;1(4):231–6. Available from: http://www. ncbi.nlm.nih. gov/pubmed/ 25276700%5Cnhttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC4161082.
  19. Engeda E. Incident Reporting Behaviours and Associated Factors among Nurses Working in Gondar University Comprehensive Specialized Hospital, Northwest Ethiopia. Vol. 2016, Scientifica. 2016. 1–7 p.
  20. Hewitt T, Chreim S, Forster A. Sociocultural Factors Influencing Incident Reporting Among Physicians and Nurses: Understanding Frames Underlying Self- and Peer-Reporting Practices. Vol. 00, Journal of patient safety. 2014.
  21. Neuspiel DR, Stubbs EH, Liggin L. Improving Reporting of Outpatient Pediatric Medical Errors. Pediatrics [Internet]. 2011 Dec 1; 128(6):112–3. Available from: http:// pediatrics. aappublications. org/content/128/6/e1608. abstract.
  22. Rogers E, Griffin E, Carnie W, Melucci J, Weber RJ. A Just Culture Approach to Managing Medication Errors. Hosp Pharm [Internet]. 2017 Apr;52(4):308–15. Available from: https:// www.ncbi.nlm.nih.gov/pubmed/28515512.
  23. Battard J. Nonpunitive response to errors fosters a just culture. Vol. 48, Nursing Management (Springhouse). 2017. 53–55 p.


 

 

 

 

 

Journal of Patient Safety & Quality Improvement
Volume 8, Issue 1
January 2020
Pages 13-23

Files

Share

How to cite

Statistics