Preventable Medication Errors in Healthcare

Introduction and Background

The drug error is referred to the preventable event which may lead to administration of wrong or inappropriate medication causing harm to the patient to develop health complication and increased suffering while medication administration is within the control of nurses and physicians (Lall, 2017). The study by Elliott et al. (2018) informs that each year in the UK nearly 237 million medication error occurs within the NHS in England which is avoidable by the nurses and physicians. It is reported by the University of York, Manchester and Sheffield that nearly 712 deaths in England could be avoided each year with proper nursing management that is caused due to avoidable medication errors, with resources such as healthcare dissertation help providing crucial insights. In addition, the study also mentioned that nearly 1700 to 22,303 deaths in the UK could be avoided is medication error is managed (manchester.ac.uk, 2018). In another study, it is reported that in UK medication error or monitoring error by the nurses within a year affects 38% for individual of 75 years and above and 30% patients who are having more than five drugs over a year (Avery et al. 2012). Thus, the prevalence of medication error by nurses is seen to create deteriorated health condition in the UK.

A study developed in Sweden informs that 613 medication errors are reported to occur in 585 cases as result of error in care and medication administration by the nurses (Björkstén et al. 2016). In another study, 949 medication errors in Saudi Arab are reported to be faced patients due prescription error and incorrect dosage of medication (Alshaikh et al. 2013). In another study in Mexico, it is mentioned that 1343 medication errors were reported out of which 226 of them are related to the field of oncology and each of them caused due to error in care by the nurses (Martinez et al. 2016). Thus, it indicates that the prevalence of medication error is at a concerned rate within the UK as well as internationally and requires immediate approach to determine its causes so that proper approach can be taken to lower the cost and fatal consequences as a result of it. Therefore, this study is developed to determine the factors that are contributing to the cause of medication error by the nurses so that based on the facts proper strategies can be developed to avoid the errors. The study aims to develop an international integrative literature review to examine and identify the reasons for medication error made by nurses. The research questions to be included to investigate the study include: What are the types of nurses medication error? What are the systematic factors contributing to the nurses’ medication error? What are the individual factors contributing to the nurses’ medication error?. The proposed structure of the integrative review will initially inform the search strategy to be used along with presentation of selected studies in tabular format. Further, the studies are to be evaluated and interpretation of the findings of the studies is to be discussed. In the end, the key findings of the studies are to be highlighted and recommendations are to be provided based on the summarization of the findings.

Search Strategy

The databases to be used for searching studies for the integrative literature review includes CINHAL and PubMed because they contain credible medical journals and articles to be used in the study as the topic is related to the medical field. The search terms to be used include: "medication error", "drug error", "nurses drug error" and others. The inclusion criteria for the studies involve articles published after 2015, written in English, academic and inform medication error caused by nurses. The execution criteria for the selection of studies are articles and journals published before 2015, non-academic in nature, not written in English and mentions causes of medication error caused by physicians and patients. The articles before 2015 are excluded and after 2015 is included so that most current and updated information are included in developing the study. The academic journals are included and other excluded as the academic journals contain proper scientific information that is mentioned with facts to ensure its authenticity. The non-English journals are excluded for the ease of the researcher to retrieve information and interpret them who have an understanding regarding the English language only. Since the topic is focussed on medication error caused by nurses, thus studies which contain explanation of errors caused by patients and physicians are excluded. The studies searched are done internationally as there is lack of specified information regarding the topic available in the UK. The primary research articles are only used in the study as they contain data which are personally collected by the researcher in turn relating directly to the study topic.

Evaluation and Integration of Evidence

A total of 10 primary studies are involved in the integrative review and out of them 8 are quantitative study and 2 are qualitative studies.

Theme 1: Nature of Nursing Drug Errors

The nature of medication error made by the nurses in their practice is to be explored in this theme. The study by Topcu et al. (2017) used cross-section study design to perform descriptive study to identify the type of medication error related to communication failure among nurses and physicians. The non-probability method of convenience sampling is used and 2273 participants are included in the study who is nurses and physicians. The data analysis is done by analysing the responses of the participants received through face-to-face interview. The ethical consideration in the study is properly abided by maintaining confidentiality, anonymity and informed consent. The key findings inform that incorrect administration of medication (32.8%) and administration of medication to the wrong patients (40.7%) are the major medication error executed by nurses and physicians. The strength of the study is it used face-to-face interview because it allowed the researchers to develop in-depth data by comprehensive understanding of emotion and feelings of the participants. The limitation of the study is the use of convenience sampling because may have lead to selection bias and sampling error in the study (Flynn et al. 2016). The study by Nkurunziza et al. (2018) used cross-sectional descriptive study design to determine types of medication error and factors contributing the nurses to make medication error. The use of convenience sampling is done to gather 151 nurses who are surveyed through pre-tested questionnaires. The chi-square test is used for analysing data and the ethical considerations are appropriately abided in the study. The key findings inform that administration of medication in the wrong time (20.1%), administration of non-prescribed drugs (0.7%), wrong route of medication administration (1.3%) and others are nature of medication error executed by the nurses. The findings of the study are similar to Topcu et al. (2017) who also informed incorrect drug administration as the key nature of medication error by nurses. The strength of the study is the use of chi-square test for data analysis as it leads to ensures the robustness of data. The limitation of the study is cross-sectional study as it may lead the researcher unable to develop cause-effect relationship of dependent and independent variables (Björk et al. 2016).

Theme 2: System factors contributing to Nursing Drug Errors

The way hindrance within the system of care contributed the nurses to make drug or medication error is to be present under the theme. The study by Hammoudi et al. (2018) performed descriptive cross-section study to determine the factors which contribute to the cause and reporting of medication error by the nurses. For this purpose, the non-probability method of convenience sampling is used through which 367 nurses were surveyed by using a validated questionnaire in a reputed hospital to determine the cause and reporting of drug error. The response rate in the survey was 73.4%. The ethical consideration is appropriately maintained in the study as informed consent from the participants was collected as well as confidentiality and anonymity were ensured for the participants. The data gathered in the study is analysed by using SPSS software. The key findings of the study inform that similarity in medication packaging (SD=1.32, mean=4.45) along with similarity of medication appearance (SD=1.29) was regarded as one of the few factors that contributed to medication error by the nurses. In addition, the similarity of names of medication (SD=1.44) is another reason which leads nurses to execute error ion medication administration. The study informed that lack of clarity of medication orders by the physicians and verbal orders given by physicians instead of written information led the nurses to perform error in medication administration to the patients. The incorrect dosage mentioned by the pharmacy along with frequent substitution of medication led the nurses execute error in medication delivery. The strength of the study is it used Descriptive statistics in explaining the findings which allowed simpler interpretation of data in meaningful manner. The limitation of the study was the use of convenience sampling that may have contributed to develop non-responsive bias. This is supported by the study of Etikan et al. (2016) which informs that since convenience sampling does not recruit participants as a representative of the entire population thus non-responsive biases may arise. The second limitation is that since the study focussed on considering perspective of nurses regarding the cause of medication error thus many other complex and multidimensional factors contribute to the rise of errors may not be examined.

The quantitative study by Alemu et al. (2017) is related with the current theme and supports the findings of the previous study by Hammoudi et al. (2018). The study by Alemu et al. (2017) used cross-sectional study design to determine the degree of reporting of medication error and factors contributing the nurses to make medication error. For this purpose, the non-probability method is used according to which 141 nurses. The data analysis in the study is executed by using multivariate and bivariate logistic regression. This study used semi-structured questionnaire to collect data. In this study, ethical consideration, informed consent and confidentiality of the participants were maintained like the previous study. The key findings of the study inform that improper verbal order by physicians (60%), wrong prescription (59.2%), look-alike or sound-alike medications (30%), illegible handwritten information (60.8%), incompetence of nurses (53.1) were the key reasons behind others that led to medication error. These findings are similar to the results mentioned by Hammoudi et al. (2018) as the study also informs that look-alike medication, improper information by the physicians, lack of clarified verbal orders by physicians among others led the nurses to make medication error. The strength of the study is the use of multivariate and bivariate logical regression method is analysing data which allowed determination of relative influence of dependent variable over the outcome variable. The limitation of this study is that cross-sectional design use leads the researcher to develop a proper cause and effect relationship between contributing and outcome variables in the study. This is evident as the study by Griffiths et al. (2016) informs that cross-sectional design does not offer the researcher to analyse a certain behaviour for certain period due to which cause-effect relationship of outcome and contributing variable can be determined.

Theme 3: Individual factors contributing to Nursing Drug Errors

The personal factors which led the nurses to make error in medication administration are to be discussed under the theme. The study by SHoHani and Tavan (2018) used descriptive-analytical study design to determine the factors that are contributing to the frequency of medication error by the nurses in education hospitals situated in Ilam, Iran. The researcher used probability method of simple random sampling in the study to select 120 nurses randomly from the teaching hospitals placed in Ilam. The data analysis for the study used 19.0 version of SPSS software. No information regarding ethical consideration or confidentiality was mentioned in the study. The key findings informed that 58.5% of nurses considered occupation fatigue led to perform medication error as they were facing decreased ability to perform their task out of monotony. Moreover, 65.6% of nurses reported increased workload, 56% reported personal neglect and 69.7% reported increased nurse-patient ratio led the nurses execute error while administering medication. The strength of the study is it used descriptive study design which allowed it to be performed easily and in quicker manner to reveal the results. The limitation faced in the study is the self-reported information use and fatigue of the nurses in responding to the questionnaire that may have contributed to biased data collected. In addition, the use of simple random sampling may have also led to biases in the study and acts as limitation. This is evident as the study by Yan et al. (2017) informs that random selection of sample do not offer all individuals equal opportunity to get selected in the study in turn leading to response bias. The other study by Salami et al. (2019) also relates to the same theme and shows similar findings supporting the results mentioned in the previous studies. In the study by Salami et al. (2019), the researchers have used cross-sectional study design to determine the factors and perception of Jordanian nurses regarding medication error. In order to execute the study, the convenience sampling technique of non-probability method is used through which 470 nurses from Jordan are recruited for the study. The responses were collected through questionnaire and informed consent from the participants is taken for the study to ensure ethical considerations are followed. The data analysis is done by using 21.0 version of SPSS software.

The key findings of the study inform that unfamiliarity with medication, insufficient training, increased workload, complicated physician orders and others were the reason behind nurses making error in medication administration. The findings support the results mentioned by SHoHani and Tavan (2018) regarding heavy workload being one of the individual factors for nurses to make medication error but the other individual factors are not similar as mentioned by the previous study with this article. The strength of the study is that it used SPSS software for data analysis which allows avoiding error in data presentation due to human negligence as well as allows easier descriptive analysis of information. The limitation of the study is that the results cannot be generalised as it is executed in certain regions in Jordan. The other limitation of the study is the use of cross-sectional design as cause-effect relation cannot be determined. This is evident from the study of Lake et al. (2016) which mentions cross-section design cannot examine behaviour over certain amount of time due to which the cause-effect relationship between variable in the study cannot be identified. The study by Gorgich et al. (2016) relates with the aforementioned theme and support findings of the previous study by SHoHani and Tavan. In the study by Gorgich et al. (2016) cross-sectional descriptive design is used to examine the causes of medication errors made by nurses and strategies to resolve them. The study used convenience sampling which one of the types of non-probability sampling method and included 327 nurses working in different hospitals along with 62 nursing students. The data is gathered through valid questionnaires and the data were analysed by T-test, ANOVA and others through the use of SPSS software. The ethical consideration was maintained in the study by following confidentiality and taking informed consent of the participants.

The key findings of the study informed that fatigue as a result of workload (97.8%), increased number of critically-ill patients (89.9%), low patient-nurse ratio (74%), poor communication (52.2%), blaming, lack of awareness, improper location of medication and others contributed the nurses to make medication error. The findings are similar to the study of SHoHani and Tavan (2018) and Salami et al. (2019) where it is also mentioned that heavy workload, occupational fatigue and low patient-nurses ratio were individual factors which contributed in making medication error by nurses. The strength of the study is it used test-retest method to verify the reliability of the questionnaire which helped in ensued valid and reliable data to be collected through the process. The limitation of the study is use of convenience sampling technique which may lead to biases in data collection. This is evident as the study by Etikan et al. (2016) mentions that use of convenience sampling leads to sampling error and offer little credibility of data due to influences in selecting sample beyond the control of researchers. The study by Bifftu et al. (2016) used cross-sectional study design to identify prevalence of medication error and the factors associated which is leading the nurses make error in medication administration. The convenience sampling is used and led to recruit 282 nurses for the study. The semi-structured and self-administered questionnaire was used for collecting data. The SPSS software is used for data analysis through odd ratio calculation along with bivariate and multivariate logical regression. The ethical consideration in the study is appropriately maintained. The key findings inform that the educational status of the nurses, administration reason, disagreement over time and fear were the key factors that contributed to medication error by the nurses. The finding in the study is different and does not support the findings mentioned by the previous studies by Gorgich et al. (2016) and SHoHani and Tavan (2018). The strength of the study is use of semi-structured questionnaire which allowed the participants have the freedom to inform their responses which are later to be compared and evaluated by the researcher to gathered enriched data. The limitation of the study is that it collected data through self-reported information which would raise bias in data collection. This is because the study by DeFilippis et al. (2016) informs that self-reported information is influenced by feelings and desire of the respondent hindering proper reporting of true data.

The study by Soltanian et al. (2016) used qualitative design and content analysis to determine factors according to paediatric nurses which influence medication error or safe administration of drugs. In the study, the purposive sampling technique of non-probability sampling method is used to gather 20 nurses who are to be interviewed by using semi-structured questionnaire. The data analysis is done by analysing the responses of the participants to determine the cause of medication error. The ethical consideration in the study is maintained which is evident as the principles of maintaining anonymity, informed consent, freedom of participants to participate and confidentiality is considered. The finding of the study mentions that lack of experience along with the knowledge and heavy workload as well as non-cooperation from colleagues and lack of proper medication resources created barriers in safe drug administration. The result is similar and supports the findings of the study by SHoHani and Tavan (2018), Salami et al. (2019), Bifftu et al. (2016) and Gorgich et al. (2016) where education status, lack of proper training and knowledge and heavy workload are the key factors which contributed the nurses to make medication error in care practice. The strength of the study is that it used the semi-structured interview to gather data which allowed the researcher to develop enriched data by making participants open up regarding sensitive reasons and explain in details their perception and feelings which leads to medication error. The limitation of the study is that it was executed in paediatric ward and therefore the results cannot be generalised to be used in explaining reason behind medication error in other wards. In addition, another limitation is that participants are selected from a single source that is teaching hospital. The study by Kim et al. (2017) informs that selection of sample from a single source creates limitation for the study as the selected sample cannot be representative to other healthcare field or source.

In the study by Amrollahi et al. (2017) cross-sectional design is used to determine the reason behind the cause of medication error from the perspective of the nurses in providing care to patients. The random sampling technique of probability sampling method is used for recruiting sample in the study. A total of 1278 nurses were selected and three-part questionnaire is provided to them to collect data along SPSS software is used for data analysis. The ethical consideration in the study us appropriately maintained by following al the ethical principles. The key findings of the study mention that lack of knowledge and training, insufficient attention towards patients, occupational stress, fatigue as a result of workload and fear of blaming are the key personal factors that contribute the nurses to make medication errors. The findings are similar to the study of SHoHani and Tavan (2018), Bifftu et al. (2016) and Gorgich et al. (2016) and Soltanian et al. (2016) where the researcher has mentioned that workload, occupational stress and lack of proper training and knowledge are the key reason for medication error by the nurses. The strength of this study is the use of random sampling technique as it allowed the selection of the sample to be representative of the nursing population, in turn, making the researcher understand the perspective of nurses in the wide healthcare filed by communicating with the specified sample. The limitation of the study is the sole execution of the research in teaching hospital. This is evident as the study by Kim et al. (2017) informs that executing research by considering single nature of hospitals hinders generalisation of the facts. (Refer to Appendix 2)

Key Findings

The collective consideration of the findings from the studies informs that Topcu et al. (2017) and Nkurunziza et al. (2018) mentions that incorrect drug administration is the common nature of medication error by nurses. However, the study Nkurunziza et al. (2018) informs administration of medication in wrong time and wrong route of medication administration and the study by Topcu et al. (2017) mentions administration of medication to the wrong patients are additional nature of medication error executed by the nurses. In regarding systematic factors causing medication error by nurses, the study by Hammoudi et al. (2018) and Alemu et al. (2017) mentions that look-alike and sound-alike medication, lack of clarified information by physicians and illegible handwriting are the common factors considered for leading rise of the error. However, the study by Alemu et al. (2017) mentioned that incorrect dosage of medication provided by pharmacy, frequent substitution of medication by the pharmacy and verbal orders instead of written information are the addition cause which creates hindrance in care system leading nurses to make medication error. In regarding to individual factors causing medication error, all the studies that is SHoHani and Tavan (2018), Salami et al. (2019), Soltanian et al. (2016), Gorgich et al. (2016) and Amrollahi et al. (2017) except Bifftu et al. (2016) identified that increased workload leads nurses to make medication error as they are confused and unable to manage proper care with overload of work. Among the studies, Bifftu et al. (2016) mentioned education status, disagreement with colleagues and fear is the key factors that lead nurses to personally cause medication error. These factors are not supported by any other studies used in the literature review. The additional individual factors mentioned by studies other than Bifftu et al. (2016) informs that non-cooperation from colleagues, increased nurse-patient ratio, lack of proper training, occupational stress and unfamiliarity with is leading nurses personally to make medication error.

Conclusion and Recommendations

The integrative literature review is seen to have selected 10 primary research studies which inform factors and nature of medication error made by nurses in international settings. The studies used are selected through in-depth research and examination of facts. The similarity between each of the study is that it informs the factors which contribute to nursing medication error. However, the differences in the findings across the studies are type of factors (individual and systematic) which lead to the nurse make medication errors. The gaps in studies include inappropriate use of research methods leads to create limitation in the studies. In summary, a total of 8 quantitative and 2 qualitative studies are used in the review which creates a gap in develop knowledge regarding the research topic. It is recommended that more qualitative studies are to be used in future to develop better in-depth information. In addition, 8 out of 10 articles used non-probability sampling which creates representation bias for participants. Thus, it is recommended probability sampling is to be used to recruit sample so that the biases can be avoided. Further, 8 out of 10 studies are found to use cross-sectional design that avoids the researcher to develop cause-effect relationship between variables. Thus, it is recommended experimental-based studies are to be used to understand cause-effect relationship of independent and dependent variables of the topic.

References

Alemu, W., Belachew, T. and Yimam, I., 2017. Medication administration errors and contributing factors: A cross sectional study in two public hospitals in Southern Ethiopia. International journal of Africa nursing sciences, 7, pp.68-74.

Amrollahi, M., Khanjani, N., Raadabadi, M., Hosseinabadi, M., Mostafaee, M. and Samaei, S., 2017. Nurses' perspectives on the reasons behind medication errors and the barriers to error reporting. Nursing and Midwifery Studies, 6(3), pp.132-136.

Avery, A.A., Barber, N., Ghaleb, M., Dean Franklin, B., Armstrong, S., Crowe, S., Dhillon, S., Freyer, A., Howard, R., Pezzolesi, C. and Serumaga, B., 2012. Investigating the prevalence and causes of prescribing errors in general practice: the PRACtICe study. General Medical Council. 66(10). pp.1-120.

Bifftu, B.B., Dachew, B.A., Tiruneh, B.T. and Beshah, D.T., 2016. Medication administration error reporting and associated factors among nurses working at the University of Gondar referral hospital, Northwest Ethiopia, 2015. BMC nursing, 15(1), p.43.

Björk, S., Juthberg, C., Lindkvist, M., Wimo, A., Sandman, P.O., Winblad, B. and Edvardsson, D., 2016. Exploring the prevalence and variance of cognitive impairment, pain, neuropsychiatric symptoms and ADL dependency among persons living in nursing homes; a cross-sectional study. BMC geriatrics, 16(1), p.154.

Björkstén, K.S., Bergqvist, M., Andersén-Karlsson, E., Benson, L. and Ulfvarson, J., 2016. Medication errors as malpractice-a qualitative content analysis of 585 medication errors by nurses in Sweden. BMC health services research, 16(1), p.431.

Elliott, R., Camacho, E., Campbell, F., Jankovic, D., St James, M.M., Kaltenthaler, E., Wong, R., Sculpher, M. and Faria, R., 2018. Prevalence and economic burden of medication errors in the NHS in England: Rapid evidence synthesis and economic analysis of the prevalence and burden of medication error in the UK. University of York, Sheffield and Manchester, pp. 1-174.

Flynn, F., Evanish, J.Q., Fernald, J.M., Hutchinson, D.E. and Lefaiver, C., 2016. Progressive care nurses improving patient safety by limiting interruptions during medication administration. Critical care nurse, 36(4), pp.19-35.

Griffiths, P., Ball, J., Murrells, T., Jones, S. and Rafferty, A.M., 2016. Registered nurse, healthcare support worker, medical staffing levels and mortality in English hospital trusts: a cross-sectional study. BMJ open, 6(2), p.e008751.

Kim, J., Yoon, S., Kim, L.Y. and Kim, D.S., 2017. Towards actualizing the value potential of Korea Health Insurance Review and Assessment (HIRA) data as a resource for health research: strengths, limitations, applications, and strategies for optimal use of HIRA data. Journal of Korean medical science, 32(5), pp.718-728.

Lall, S., 2017. The lived experience of making a medication administration error in nursing practice. Int J Nurs, 4, pp.11-21.

Martinez, H. JF., Perez, M.M., Vigueras, T.I., Gomez, C.DP., Garcia, P.P., and Rodriquez, S., 2016. Determination Of Medication Errors And Economic Implications To One Year Of The Establishment Of Clinical Pharmacy Service In Medical Oncology Unit: Experience In A Hospital Of Cancer In Mexico. Value in Health, 19(3), pp.12-19.

Nkurunziza, A., Chironda, G. and Mukeshimana, M., 2018. Perceived contributory factors to medication administration errors (MAEs) and barriers to self-reporting among nurses working in paediatric units of selected referral hospitals in Rwanda. International Journal of Research in Medical Sciences, 6(2), p.401.

Salami, I., Subih, M., Darwish, R., Al-Jbarat, M., Saleh, Z., Maharmeh, M., Alasad, J. and Al-Amer, R., 2019. Medication Administration Errors: Perceptions of Jordanian Nurses. Journal of nursing care quality, 34(2), pp.E7-E12.

SHoHani, M. and Tavan, H., 2018. Factors affecting medication errors from the perspective of nursing staff. J Clin Diagn Res, 12(3). pp.600-604.

Soltanian, M., Molazem, Z., Mohammadi, E., Sharif, F. and Rakhshan, M., 2016. Iranian Nurses’ Experiences on Obstacles of Safe Drug Administration: A Qualitative Study. Global journal of health science, 8(10), pp.88-99.

Yan, Z., Tian, D., Han, W., Tang, Z. and Fang, J., 2017. An assessment on the uncertainty of the nitrogen to phosphorus ratio as a threshold for nutrient limitation in plants. Annals of botany, 120(6), pp.937-942.