Апстракт
Background: Reporting medication administration error (MAEs) is a significant strategy to ensure patient safety. Literature had it that most of what is reported as errors of administration is just a tip of the iceberg, suggesting that a lot more go unreported. The methods of reporting medication administration errors in Nigeria have not been well explored. This study examined the methods of reporting MAEs by nurses in selected wards in the University College Hospital, Ibadan. Nigeria.
Methods: A cross sectional survey of 286 nurses, who were conveniently selected from Medical, Surgical and Accident and Emergency departments of the University College Hospital, Ibadan. Nurses who gave consent to participate completed a 42-item structured questionnaire on the methods and reasons for non-reporting MAEs.
Results: Among the study cohort, 162(64.8%) admitted to have committed MAEs in the past, of which 137(84.4%) voluntarily reported. Common methods included reporting to immediate supervisor (88; 34%), and confiding in a colleague 62 (24.8%). Only 39 (15.6%) documented and completed report forms. In addition, 183 (73.2%) believed that anonymous reporting enhances the rate of reporting errors. The major reason for non-reporting was the fear of being punished and labelled as incompetent practitioner (Mean 3.82, ± 1.09).
Conclusion: Findings suggest that not all MAEs committed by the study cohort were reported, and the methods used differ with individuals and units of practice. There is therefore a need to create more awareness that disclosure of MAEs will help to identify the specific causes of errors, thereby fostering safe practice.
Keywords: Medication error, incident reporting, patients’ safety, quality care.
Résumé
Contexte: Rapporterl’ erreur d’administration des médicaments (MAEs) est une stratégie importante pour assurer la sécurité des patients. La littérature l’avait que la plupart de ce qui est rapporté comme erreurs d’administration est juste une pointe de l’iceberg, suggérant que beaucoup plus ne sont pas signalés. Les méthodes de déclaration d’erreurs d’administration des médicaments au Nigeria ne sont pas bien explorées. Cette étude a examiné les méthodes de déclaration des MAEs par les infirmières dans des salles de services sélectionnésau Collège Hospitalier Universitaired’ Ibadan, Nigeria.
Méthodes: Une étude transversale de 286 infirmières, qui ont été commodément choisis parmi lesdépartements de service médical, chirurgical et d’accidents et d’urgence du Collège Hospitalie Universitaired’ Ibadan. Les infirmières qui ont donné leurs consentements à participer rempli un questionnaire structuré à42-point sur les méthodes et raisons pour la non-déclarationdes MAEs.
Résultats: Parmi la cohorte de l’étude, 162 (64,8%) ont admis avoir commis des MAEs dans le passé, dont 137 (84,4%) ont volontairement déclarés. Les méthodes communes comprenaient des rapports au superviseur immédiat (88; 34%), et se confieràdans un collègue 62 (24,8%). Seulement 39 (15,6%) ont documenté et complété les formulaires de rapport. En outre, 183 (73,2%) croyaient que le signalement anonyme améliore le tauxde déclaration d’erreurs. La principale raison de la non-déclaration était la crainte d’être puni et étiquetés comme praticien incompétent (Moyenne de 3,82 ± 1,09).
Conclusion: Les résultats suggèrent que pas tous les MAEs commises par la cohorte de l’étude ont été signalés, et les méthodes utilisées diffèrent avec les individus et les unités de pratique. Il est donc nécessaire de créer une plus grande sensibilisation que la divulgation des MAEs aidera à identifier les causes spécifiques des erreurs, ainsi favorisant une pratique sécuritaire.
Mots-clés: Erreur de médication, rapports d’incident, sécurité des patients, soin de qualité.
Correspondence: Dr. Rose E Ilesanmi, Department of Nursing, College of Medicine, University of Ibadan, Nigeria. E-mail: ekamailesanmi@yahoo.com
Референце
Benjamin D.M. Reducing medication errors and increasing patient safety: case studies in clinical pharmacology. Journal of Clinical Pharmacology, 2003; 43:768 -783.
Koohestani H. R. and Baghcheghi N. Barriers to reporting medication errors among nursing students. Advanced Journal of Nursing 2009; 27: 66 74.
Montesi G. and Lechi A. Prevention of medication errors: detection and audit. British journal of Clinical Pharmacology. 2009; 67(6): 651-655
Institute of Medicine. (IOM). . To err is human: building a safer health system. Washington, DC: 2000; National Academy Press.
Ehsani S.R., Cheraghi M,A., Nejati A., Esmaeilpoor A, H., and Nejad E.M. Medication errors of nurses in the emergency department. Journal of Medical Ethics and History of Medicine. 2013; 2:11 PMCID 3885144.
Mrayyan MT, Shishani K and Al-Faouri I. Rate, causes and reporting of medication error in Jordan: nurses’ perspectives. Journal of Nursing Management, 2007; 15(6):659-670
Morimoto T, Gandhi TK, Seger AC, et al. Adverse drug events and medication errors: detection and classification methods. Quality Safety Health Care. 2004; 13: 306–14. [PubMed]
Hogan H, Olsen S, Scobie S, et al. What can we learn about patient safety from information sources within an acute hospital: a step on the ladder of integrated risk management? Quality Safety Health Care. 2008; 17:209–15. [PubMed]
National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP). What is A medication error? Available at http//: www.nccmerp.org/aboutMedErrors.html 2007
Fontan J., Meneglier V., Nguyen, V.X. et al. Medication errors in hospital: Computerized unit drug dispensing systems versus ward stock distribution system. Pharmacy world of science. 2003 25:12-117.
Mark B., and Burleson D. Measurement of patient outcomes: data availability and consistency across hospitals. JONA 1995 25(4):52-59.
Headford C., McGowan S. and Clifford R. Analysis of medication incidents and development of a medication incident rate clinical indicator. Collegian 2001, 8(3): 26-31.
Davydov I., Caliendo G., Mehl B. and Smith L. Investigation of correlation between house- staff work hours and prescribing errors. American Journal of Health System Pharmacy, 2004. 61(1):1130-1134.
Wolf Z . Medication errors and Nursing responsibility. Holistic Nursing Practice 1989 4(1) 8-17.
McBride-Henry K and Foureur M Medication administration errors: Understanding the issues. Australian Journal of Advanced Nursing, 2006. 23 (3) 33-41.
Roughead L. and Semple S.: Literature review: Medication safety in acute care in Australia. Australian Commission on Safety and Quality healthcare. 2008 Available at www.safetyandquality.gov.au
Websta C.S. and Anderson DJ. A practical guide to the implementation of an effective incident reporting scheme to reduce medication errors on the hospital ward. International Journal of Nursing Practice 2002; 8(4)176-83.
Lehmann CU, Conner KG and Cox JM. Preventing provider errors: Online total parenteral nutrition calculator. Pediatrics. 2004; 113 (4) 148-153.
Ross LM, Wallace J and Paton JY. Medication errors in a pediatric teaching hospital in the UK: five years operational experience. Archives of Disease in Childhood. 2000; 83(6) 492-497.
Thomas L, Cordonnier-Jourdin C, Benhamou-Jantelet G, Diviné C and Le Louët H. Medication errors management process in hospital: a 6-month pilot study. Fundamentals Clinical Pharmacology. 2011; Dec;25(6):768-75. doi: 10.1111/j.1472-8206.2010.00907.
Roughead L.,Semple S. and Rosenfield E. Literature review: Medication safety in Australia. Australian Commission on Safety and Quality in Healthcare. 2013 Available @safetyandquality.gov.au.
Sneck S, Isola Arja and Saarnio, R. Nurses’ perceptions of verification of medication competence. Journal of Nursing Education and Practice, 2015; 5(6) 114-121. Doi 10.5430/jnep.v5n6p114
National Library of Medicine. Medical Subject Headings {Internet} 2015. Available at http://www.nlm.nih.gov/mesh/MBrowser.html.
International Council of Nurses (ICN). The ICN Code of Ethics for nurses Geneva, Switzerland: ICN-International Council of Nurses; 2012.
Johnstone MJ and Kanitsaki O. The ethics and practical importance of defining, distinguishing and disclosing nursing errors: a discussion paper. International Journal of Nursing Studies, 2006, 43:367-376.
Brady AM, Malone AM and Fleming S. A literature review of the individual and system factors that contribute to medication errors in nursing practice. Journal of Nursing Management 2009, 17(6):679-697
Copping C. Preventing and reporting drug administration errors. Nursing Times. 2005 101, 33, 32.
Stump S. Re-engineering the medication error-reporting process: removing the blame and improving the system. American Journal Health Syst Pharm. 2000; 57 (Suppl. 4):S10–7. PubMed.
Pierson S, Hansen R, Green S, et al. Preventing medication errors in long-term care: results and evaluation of a large scale web-based error reporting system. Quality Safety Health Care. 2007; 16:297–302. PubMed.
Fatemeh H, Alireza NN and Fariba A. Factors associated with reporting nursing errors in Iran: a qualitative study BMC Nursing 2012,11:20 doi:10.1186/1472-6955-11-20Available@athttp://www.biomedcentral.com
Oshikoya KA, Oreagba IA., Ogunleye OO, et al. Medication administration errors among paediatric nurses in Lagos public hospitals: an opinion survey. International Journal of Risk and Safety In Medicine, 2013; 25(2)67-78 doi: 10.3233/JRS-130585.
Reid-Searl K., and Happel B. Supervising nursing students administering medication: a perspective from registered nurses. Journal of clinical Nursing, 21, 1998-2005, doi 10.1111/j.1365-2702.2011.03976.
Sarvadika A., Prescott G. and William D. Attitudes to reporting medication errors among differing healthcare professionals. European Clinical Pharmacology 2010. 66: 843-853.
Lawton R. and Parker D. Barriers to incident reporting in a health care system. Quality Safety Heath Care 2002;11:7doi:10.1136/qhc.11.1.7
Stratton KM., Blegen MA., Pepper G and Vaughn T. Reporting medication errors by pediatric nurses Journal of Pediatric Nursing 2004;. 19(6):385-392.doi: 10.1016/j.pedn.2004.11.007 PubMed
Cohen H., Robinson E. S. and Mandrack M. Getting to the root of medication errors. Nursing Times,2003 33:36–45.