The underreporting of medication errors: A retrospective and comparative root cause analysis in an acute mental health unit over a 3‐year period

Morrison, Maeve; Cope, Vicki; Murray, Melanie

doi:10.1111/inm.12475

Cited by 18 publications

(11 citation statements)

References 27 publications

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“…This is in accordance with other studies [26,27]. However, the reverse was reported in other published data [28]. The increased negative score of the teamwork across the unit is the expected image for the lower scores of communication and patients transition items of the questionnaire.…”

Section: Discussionsupporting

confidence: 93%

Awareness and attitude about patient safety among health professionals in Arar, Saudi Arabia

2019

Ann Clin Anal Med

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Aim: This study was conducted to assess awareness and culture of health care workers about patient safety in healthcare facilities in Arar city. Material and Method: It is a structured questionnaire-based cross-section study. Four hundred and fifty questionnaire copies were randomly distributed to evaluate participants' knowledge and awareness about patient safety. Results: Three hundred and eleven participants were enrolled in the study (69.1% response rate). Females represented 62.7% of the responders. Physicians were 46% of the participants. Data showed overall summative scores of awareness of 77.27 %. There was a significant difference among participants according to their past experience of errors, years of work experience and medical specialties in their awareness scores (p= 0.0042, 0.0014 and 0.0076 respectively). Regarding culture data, the total composite positive perception of patient safety culture was about 59.04 ± 3.3%. The dimensions of "teamwork within the unit" showed the highest positive composites (83.1%). Discussion: More focused programs should be implemented with better training for all staff member, especially for nurses to improve their awareness and culture regarding patient safety.

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Section: Discussionsupporting

confidence: 93%

Awareness and attitude about patient safety among health professionals in Arar, Saudi Arabia

2019

Ann Clin Anal Med

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“…To be valid, all medication errors have to be identified and promptly reported. There is accumulated evidence of widespread and significant under-reporting of medication errors by healthcare profession [25][26][27][28][29][30][31][32]. A recent mixed methods study conducted in Qatar identified a number of barriers to error reporting including fear and worry,that submitting was likely to lead to further investigation,concerns over the impact on working relationships,and the potential lack of confidentiality [16].…”

Section: Discussionmentioning

confidence: 99%

Investigating the incidence, nature, severity and potential causality of medication errors in hospital settings in Qatar

et al. 2020

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Background Medication errors are a major public health concern that negatively impact patient safety and health outcomes. Effective and efficient medication error reporting systems and practices are imperative in reducing error incidence and severity. Objective The objectives were to quantify the incidence, nature and severity of medication errors, and to explore potential causality using a theoretical framework. Setting The study was conducted at Hamad Medical Corporation, the largest public funded academic healthcare center in the state of Qatar. Methods A retrospective review of medication error reports submitted to the Hamad Medical Corporation incident reporting system during 2015 to 2017. Data related to number of reports, reporter, medication, severity and outcomes were extracted. Reason’s Accident Causation Model was used as a theoretical framework for identifying potential causality. Two researchers independently categorized errors as: active failures (e.g. forgetting to administer medication at scheduled time); error provoking conditions (e.g. medication prescribed by an unauthorized physician and administered to the patient); and latent failures (e.g. organizational factors, lack of resources). Main outcome measures Incidence, classes of medications, reporter, error severity and outcomes, potential causality. Results A total of 5103 reports provided sufficient information to be included in the study giving an estimated error incidence of 0.044% of prescribed medication items. Most of the reports (91.5%, n = 4667) were submitted by pharmacists and majority (87.9%, n = 4485) were prescribing errors. The most commonly reported medications were anti-infectives for systemic use (22.0%, n = 1123) followed by medications to treat nervous system disorders (17.2%, n = 876). Only three errors reported to have caused temporary harm requiring intervention while one contributed to or resulted in temporary harm requiring initial or prolonged hospitalization. In terms of potential causality of medication errors, the majority (91.5%, n = 4671) were classified as active failures. Conclusion Almost all reports were submitted by pharmacists, indicating likely under-reporting affecting the actual incidence. Effort is required to increase the effectiveness and efficiency of the reporting system. The use of the theoretical framework allowed identification of potential causality, largely in relation to active failures, which can inform the basis of interventions to improve medication safety.

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“… 11 However, the percentages of the errors that occur in the various stages are different. 1 , 4 , 12 Healthcare professionals (HCPs) should be focused on their knowledge, attitudes, and practices toward medication errors and reporting them. 13 , 14 Having a medication error reporting system is necessary for assessing and minimizing medication errors, which, in turn, protects patients from harm.…”

Section: Introductionmentioning

confidence: 99%

Medication Error Concept and Reporting Practices in Saudi Arabia: A Multiregional Study Among Healthcare Professionals

Alshammari

Alanazi

et al. 2021

RMHP

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Background Medication errors pose a risk for individual patients and for public health, with the misuse and overuse of medications being linked to severe patient safety problems. Therefore, the objective of this study was to investigate healthcare professionals’ (HCPs’) knowledge about medication errors, their knowledge about medication error reporting systems, and predictors for HCPs to report medication errors in Saudi Arabia. Methods An observational cross-sectional study was conducted among HCPs (physicians, pharmacists, and nurses) between January and March 2020. The study included 6 distinct locations in the Saudi Arabian regions of Hail, Al-Qassim, Al-Jouf, Al-Madinah, the eastern region, and the western region. Descriptive statistical and inferential analyses were computed using Statistical Package for the Social Sciences (SPSS) v.22. Results In total, 980 questionnaires for 348 (35.5%) physicians, 144 (14.7%) pharmacists, and 488 (49.8%) nurses were distributed with a response rate of 100%. Interestingly, only 277 (28.3%) of the HCPs had a good understanding of the stages of medication errors. With regard to reporting practices, a high number of the HCPs, 576 (58.8%), had not reported medication errors in their workplaces, and nearly 369 (37.7%) of respondents said they believe that legal implications are a major barrier to the reporting of medication errors. More than half, 524 (53.5%), of HCPs revealed that no clear electronic system is available for the reporting of medication errors in most hospitals. In addition, 537 (54.8%), of the HCPs had not attended any training programs regarding medication error reporting systems within the past year, which is alarming. Conclusion Our study identified a huge lack of the reporting of medication errors, knowledge about medication error stages, and training on medication errors. Therefore, an urgent need to address these weaknesses exists.

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The underreporting of medication errors: A retrospective and comparative root cause analysis in an acute mental health unit over a 3‐year period

Cited by 18 publications

References 27 publications

Awareness and attitude about patient safety among health professionals in Arar, Saudi Arabia

Awareness and attitude about patient safety among health professionals in Arar, Saudi Arabia

Investigating the incidence, nature, severity and potential causality of medication errors in hospital settings in Qatar

Medication Error Concept and Reporting Practices in Saudi Arabia: A Multiregional Study Among Healthcare Professionals

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