Nurses’ Perceptions of Medication Errors in South India

rs. Ramya K.R.¹*, Ms. Vineetha R.²

¹Asst Professor, Baby Memorial College of Nursing, Green View Villa Colony, Kuthiravattam P O,

Calicut -16, Kerala,

²Staff Nurse, NIMHANS, Bangalore.

Corresponding Author Email: raviramya11@gmail.com

ABSTRACT

Medication use in hospitals is a complex process and depends on successful interaction among health care professionals functioning at different areas. Errors may occur at any stage of prescribing, documenting, dispensing, preparation, or administration. This descriptive survey was conducted in the cardiac wing at a private tertiary care teaching hospital in Kerala, South India during January- February 2013 among 50 registered nurses with an aim to investigate what constitutes a medication error (ME), types of commonly observed errors, drugs involved, causes of error, reasons and existing barriers to reporting medication errors and characteristics of good and effecting ME reporting system among nurses working in a cardiac care center. Analysis revealed that the overall mean of medication errors they could remember making was 3.52, over the course of their career. Antibiotics, digoxin, warfarin / acitrom, dopamine/dobutamine were mostly involved in medication errors. The most common types of errors observed were drug administering without a physician order, omission error, followed by drug calculation error, Incorrect IV therapy timing/dosage/administered technique, and wrong time. Culture of blame within team members (15), Degree of harm occurred to the patient (15),patient aware of error(14), Sense of shame(13), Lack of familiarity/skills with how best to handle a situation (12), Error tolerance of institution(10), Rapport between patient and provider(6) influenced the decision to disclose a medication error. The most common barriers to reporting medication errors were , not getting any positive feedback for passing medications error (22) possible adverse consequences like loss of job/ disciplinary action (21), not agreeing with hospital's definition of a medication error (16), feeling of incompetency from team members (15) and not recognizing occurred error (15). According to nurses the top 5 characteristics of a good and effective ME reporting system were the systems in which Medication orders are rewritten at transfer, Reasons for medication changes made at transfer are documented, non-punitive approach to reporting , Feedback of the results of the error analysis given those healthcare professionals involved, Home medications are brought in by patients. Despite a desire to deliver high quality care, errors occur on both a systems and personal level. Nurses have to take a front seat role in initiatives that have sought to address issues related to medication error, develop significant expertise in medication administration and associated systems to tackle issues of medication error.

KEY WORDS: medication errors, nursing, perception, reporting, medication administration.

INTRODUCTION:

Safety during patient hospitalization consists one of their rights and also the first priority of health professionals. Errors that occur during the application of medical/nursing interventions or patient hospitalization have drawn health researchers’ attention over the last decade.

Errors appearing in the hospital settings concern a lot of incidents like patients falls, use of wrong equipment, sores, hospital infections, improper management of clinical situations and medication errors. Medication use in hospitals is a complex process and depends on successful interaction among health care professionals functioning at different areas. Errors may occur at any stage of prescribing, documenting, dispensing, preparation, or administration¹. Medication errors (MEs) may contribute to morbidity, mortality and increased health care costs². In 2007, National Patient Safety Agency (NPSA) statistics shows that 59.3% of ME errors occur during the administration stage³. Medication administration errors are defined as any deviation from the physician's medication order as written on patient's treatment chart during medication administration to patient. Mostly ME are identified before they reach the patient, or they reach the patient but do not cause harm, or cause permanent harm and required prolonged hospitalization. Moreover, there are MEs that require necessary interventions to sustain life.

Administration of medication to patients is a fundamental role of the nurse—the responsibility to do good and avoid harm. MEs can have severe consequences for patients (Cox 2000) and affect nurses more than other members of the multidisciplinary team. Various factors identified for MEs are illegible orders, non-availability of patient information, inadequate medical knowledge, increased patient load, failure to monitor drug concentration or drug therapy, and not accounting for changes in renal & cardiac functions. No studies have demonstrated strong relationships between nurse characteristics (i.e. age, years of practice, and education) and number of MEs⁴. This would seem to indicate that any nurse is potentially at risk for making a ME⁵.

Prevention of ME is linked to accurate reporting of errors. Reporting ME is dependent on individual nurse’s decision making. MEs are typically reported through institutional reporting systems such as incident reports. Moore (1998), however, estimated that organizations relying on incident reports to provide data miss up to 95% of the medication errors⁶. Nurses themselves and Nurse managers and physicians also believe that MEs are underreported by nurses.Several studies have demonstrated underreporting among nurses^7,8. Reporting systems are dependent on the nurse’s (1) ability to recognize an error has occurred, (2) belief that the error warrants reporting, (3) belief that she/he has committed the error, and (4) willingness to overcome the embarrassment and fear of retaliation for having committed a medication administration error.

It is estimated that 95% of MEs are not reported because staff fear punishment. Disciplinary actions including job loss also affect reporting rates. Interestingly, Osborne et al, (1999) found that 15.8% of the nurses in their study were unsure as to what situation constituted a ME, and 14% were not sure when to report the error. It is essential for all types of MEs to be identified, reported, and analyzed so that the source and cause of the error can be determined, in order to prevent future errors keeping our cardiac care population safe. So such errors contribute to a general loss of trust in the healthcare system by patients and “diminished satisfaction by both patients and healthcare providers these minimal efforts have confronted some resistance from healthcare organizations and providers. Providers also perceive the medical liability system as a serious impediment to systematic efforts to uncover and learn from errors.”

An evaluation of 182 deaths from cerebrovascular accidents, pneumonia, or myocardial infarction (MI) found that between 14% and 27% of the deaths might have been avoidable. For those with death attributed to MI, preventable deaths reflected primarily errors in management as compared with errors in diagnosis⁹.Although there are many possible causes for MEs, several general categories have been specifically identified in cardiac care setting.(1) Drug Name Confusion Errors {Nifedipine (Ca channel blocker) Nimodipine/ Dobutamine (sympathomimetic amine) Dopamine} is a common cause of both outpatient and inpatient medical adverse events is drug name confusion on either handwritten or verbal orders¹⁰. (2)Prescribing and Dispensing Errors; Fibrinolytic and antithrombotic therapy, used in the treatment of MI and acute coronary syndromes, are targeted areas of concern because any deviation in dose, duration, or intensity of systemic effect could adversely influence clinical outcome. (3) Omission errors in acute cardiac care are represented most dramatically by the relatively low rates of aspirin administration in the first 24 hours of MI. This omission occurs despite the fact that aspirin reduces mortality and reinfarction¹¹, particularly when given in combination with fibrinolytic therapy¹².

There are number of studies examine MEs from several aspects, but none of them examine the cardiac care nurse perceptions of MEs. Improvement in ME prevention systems requires accurate reporting, regular analysis, and protection of reporters. An optimal detection system would be accurate, inexpensive, and involving technology and practices readily available to the majority of hospitals. So, this study examined the perceptions of MEs among cardiac nurses. More specifically, it was designed to investigate what constitutes a ME, types of commonly observed errors, drugs involved, causes of error, reasons and existing barriers to reporting medication errors and characteristics of good and effecting ME reporting system among nurses working in a cardiac care center.

MATERIALS AND METHODS:

This non-experimental, quantitative research is a descriptive/ exploratory survey and was conducted in the cardiac wing at a private tertiary care teaching hospital in Kerala, South India during January- February 2013.A total of 50 registered nurses with a minimum of one year experience, were selected using a random table, from a total of 150 nursing service professionals at the institution. Incharge nurses, nurses with bureaucratic administrative activities, nurses working in OPD, those who did not administer drugs were excluded. The instrument used to collect data measured (1) Nurses biographical data, (2) Common types of medication errors (16 items) (3) Common drugs involved in medication errors (15 items),Nurse perception of (4) what constitute a medication error (4 items), (5) causes of medication error (33 items),(6) reasons For Not Reporting Medication Error, (7) factors influencing the decision to disclose a medication error,(8) characteristics of good and effective medication error reporting system. Permission to conduct the research was obtained from the concerned hospital authorities. After screening nurses were informed about the aims and objectives of the study in a covering letter. Identity and autonomy were safeguarded by not including names and it was explained to the individuals that participation was voluntary and completion of the questionnaire was considered consent to participate. The questionnaire took around 25 minutes to complete. Anonymity & confidentiality of the subjects was maintained during the study and they were given full autonomy to withdraw from the study at any time. A pilot study was conducted among 10 subjects after establishing the validity and reliability of the tool to find out the feasibility of the study. No modifications were made in the tool or study protocol after the pilot study. The data were then transferred into SPSS 16.0 Version and was analyzed.

RESULTS AND DISCUSSION:

Out of total 50 nurses participated in the research 7(14%) were males and 43(86%) were females; 26(52%) had GNM degree compared to 24 (48%) B. Sc degree; in average 3.2 years of experience; 33(66%) were working in cardiothoracic /cardiology intensive care unit and 17(34%) cardiology/cardiothoracic wards; most of them were working in day shift 23(46%), while 8(16%) rotating, 5(10%) evening 4(8%) night.

The overall mean of medication errors they could remember making (in the whole sample) was 3.52, over the course of their career and the frequency rate of medication error in the last one year was 1.08.

Most organizations have an official definition of a medication error and reporting requirements. But a study in Australia identified a group of unspoken rules that nurses frequently followed to determine whether they really needed to report an error – rules that helped them redefine in their minds whether a “real” medication error had occurred¹³. When asked about what constitute a medication error majority said if it prevents something worse it is not an error (28), If it’s not my fault, it’s not an error (19), If I can make it right, it’s not an error (14), If everyone knows, it’s not an error(9). Rules like these have evolved over time because of the stigma attached to errors. Fearful of embarrassment, or even punishment, nurses try to protect themselves and their colleagues, and independently change practice when they feel it is in their patient’s best interest. As a result, important information about the cause of errors is lost.

Nurses were also asked to name observed medications involved in medication error in cardiac care setting. From table 1 it is evident that antibiotics (14), digoxin (12), warfarin / acitrom, dopamine/ dobutamine were mostly involved. Tang FI (2007) also found that antibiotics are were the most commonly misadministered drugs¹⁴

Table 1. Common drugs involved in medication error

Streptokinase	2	Warfrin/acitrom	10
Dopamine/dobutamine	10	Digoxin	12
GI agents	7	Antibiotics	14
Antidiabetic drugs	3	Heparin	6
Analgesics	3	Aspirin/clopidogrel	3
Respiratory drugs	3	Sedatives	7
Vitamins	3	Diuretics	6

Medication use is a complex process that involves coordination among various health care professionals. Medication errors may happen at any stage of patient care like prescribing, transcribing, dispensing, and administration. The most common types of errors observed were drug administering without a physician order (n=34), omission error (failure to administer or failure to record the administration) (27) followed by drug calculation error (n=17), Incorrect IV therapy timing/dosage/administered technique (n=14), and wrong time (n=13). The details of types of medication administration errors are given in Table No 2. Our observations are in consistent with the findings of previous studies¹⁵.In a prospective study of medication errors most common types of errors detected were belong to omissions errors (133), Improper dose errors (over doses, 9), wrong time errors (5) and administration of a discontinued medication (1). The medication administration errors detected were reported using hospital's medication error reporting system¹⁶.

Table No 2.Types of nurse observed medication errors

Type of medication error	Frequency percentage
Drug administering without a physician order	34
Dose missed/ omitted	27
Calculation errors in drug (infusion)	17
IV therapy timing/dosage/administered technique incorrect (iv rate too fast/slow, infilteration)	14
Medication given at wrong time (60 minutes before or after the prescribed time)	13
Drug given in wrong amount /dose (over-dosage, under-dosage, extra dose while crushing, spillage)	11
Wrong drug dilution administered	11
Drug compatibility (eg given along with sodium bicarbonate infusion)	9
Allergy related errors	9
Adverse reaction to drug	9
Medicine given via incorrect route	8
Drug given despite contra-indications	6
Wrong duration (continued beyond the period ordered by the physician).	4
Wrong patient	2
Wrong drug	2

Table 3 perceived causes of medication error.

causes of medication errors	Frequency percentage
Physician communication
Physician prescribes the wrong dose	12
Physicians' medication orders are not legible	11
Physicians' medication orders are not clear	27
Physicians change orders frequently	12
Abbreviations are used instead of writing the orders out completely.	11
Verbal orders are used instead of written orders	20
Poor communication between nurses and physicians	11
Medication packaging
The names of many medications are similar.	27
The packaging of many medications is similar	16
The labeling/packaging of medication is poor or damaged	11
Transcription-related
Medication orders are not transcribed to the medication chart correctly.	22
Errors are made in the medication chart	23
Pharmacy processes
Pharmacy delivers incorrect doses to this unit.	17
Pharmacy does not label the med correctly	23
Nurse staffing
Poor judgment	3
Change-of-shift mis communication	20
Frequent interruptions during medication administration to perform other duties.	17
Lack of experience with the clinical event, procedure or condition	12
Inappropriate assumptions	2
Lack of support from colleagues/ team/ supervisor	6
Confusion of zeroes and decimal points	3
Lack of experienced staff	8
Organization
Nurses get pulled between teams and from other units.( unfamiliar setting)	12
Inadequate staffing in the unit	15
Confusion due to different types and functions of infusion devices	9
Lack of consistent mentor or short length of time for nurse orientation	4
Increased noise level	4
Too many telephone calls	16
Medication errors occur when the nurse fails to check the patient’s name band with the medication administration record	9
Absence of a medication administration protocol/facility policy	9
Missing information from patient records - previous diagnoses, and lab results	16
Distraction -factors, such as lighting, heat, noise, and interruptions	4
Lack of a drug reference available for consultation	12

Table 4 Barriers/Reasons For Not Reporting Medication Errors

Barriers/Reasons	Frequency percentage
Disagree with definition
Not sure about what constitutes a medication error	4
Do not agree with hospital's definition of a medication error.	16
Do not recognize occurred error.	15
Medication error is not clearly defined.	8
Error is important enough to be reported	13
Reporting effort
Filling an incident report for a medication error takes too much time/difficult	12
Contacting the physician about a medication error takes too much time/ difficult	13
Fear
Team members will think they are incompetent if you make medication errors	15
The patient or family might develop a negative attitude, or may sue the nurse if a medication error is reported	10
Afraid that physician will reprimand them for the medication error	13
Adverse consequences like loss of job/ disciplinary action may happen	21
If something happens to the patient, may get blaming	12
Administrative response
No positive feedback is given for passing medications error	22
Too much emphasis is placed on med errors as a measure of the quality of nursing care provided	7
When med errors occur, nursing administration focuses on the individual rather than looking at the systems as a potential cause of the error.	9
The response by nursing administration does not match the severity of the error	9

Table 5 Perceived characteristics of good and effective medication error reporting system

Characteristics	Frequency percentage
Home medications should be brought in by patients	12
Reported medication errors should be used to find the root causes of the errors	9
Feedback of the results of the error analysis to be given those healthcare professionals involved	14
“In servicing ” or counseling the nurse regarding the facility’s policies and procedures that addressed the nursing error.	7
Reasons for medication changes made at transfer are documented	19
Medication orders are rewritten at transfer	24
Use of electronic medical records will improve accuracy	11
Institution should have systems in place to ensure patients are receiving proper medication	8
There should be non-punitive approach to reporting	15
Reporting of errors should be made as easy as possible to make sure that errors would not go unreported	9
Terminating the nurse’s employment after the nurse failed to demonstrate improved Competency following the error	3
Reassigning the nurse on duty	3
Suspending the nurse’s employment	2
Requiring nurse to successfully complete a medication test or one or more supervised Medication administration	1
Issuing an oral or written warning to the nurse after error report	1
Placing the nurse’s employment on probation	4

There was also a high level of agreement among the nurses that when an error occurred, the nursing administration system focused on the individual rather than the whole system as the potential cause of the error. Embarrassment and fear of feeling incompetent in front of their peers was a potentially significant barrier to nurses reporting errors in the Malta study. Fear that the nurse would be blamed if something happened to the patient as a result of an error was perceived as a strong barrier to reporting them. Similar findings have been obtained in other studies (Wakefield et al 1996)¹⁷.

According to nurses the top 5 characteristics of a good and effective medication error reporting system (table 5) were the systems in which Medication orders are rewritten at transfer (24), Reasons for medication changes made at transfer are documented (19), non-punitive approach to reporting (15), Feedback of the results of the error analysis given those healthcare professionals involved (14), Home medications are brought in by patients (12).

Adequate training and motivation to nurses, a supportive unit culture, computerized physician order entry system (CPOE) and medication administration record system will help in preventing the medication administration errors by nurse. Introduction of Medication Error reporting system in the hospital will help in preventing the medication errors. Finally, the cross-sectional nature of surveys precludes drawing any cause and effect between dependent and independent variables.

CONCLUSION:

Medication administration is an important part of delivering safe patient care. Despite a desire to deliver high quality care, errors occur on both a systems and personal level. Nurses have to take a front seat role in initiatives that have sought to address issues related to medication error, develop significant expertise in medication administration and associated systems to tackle issues of medication error.

ACKNOWLEDGEMENT:

Authors would like to express gratitude towards all the respondents for showing concern towards this issue and respond properly.

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Received on 17.06.2013 Modified on 08.09.2013

Asian J. Nur. Edu. & Research 4(1): Jan.-March 2014; Page 20-25