International Journal of Nursing Education. DOI Number: January-June 10.5958/j.0974-9357.5.2.054 2014, Vol. 6, No.1 19 Registered Nurses Perception of Medication Errors: A Cross Sectional Study in Southeast of Iran Zahra Esmaeli Abdar 1, Haleh Tajaddini 2, Azam Bazrafshan 1, Hadi Khoshab 3, Asghar Tavan 4, Giti Afsharpoor 5, RN Masoud Amiri 6, Hossein Rafiei 7, Mohammad Esmaeili Abdar 8 1 Department of Clinical Research, 2 Neuroscience Research Center, Kerman University of Medical Sciences, Kerman, Iran, 3 Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Bam University of Medical Sciences, Bam, Iran, 4 Shafa Hospital, 5 Shahid Bahonar Hospital, 6 Social Health Determinants Research Center, 7 Department of Intensive and Critical Care, School of Nursing and Midwifery, Shahrekord University of Medical Sciences, Shahrekord, Iran, 8 Department of Medical- Surgical Nursing, School of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran ABSTRACT Aim: Nurses have an important role in decreasing Medication Errors (MEs). The purpose of this study was to determine registered nurses perception of MEs. Method: In a cross-sectional study conducted in four educational hospitals in southeast of Iran, 238 registered nurses working within these hospitals were studied. Data were collected using Iranian nurses' medication errors questionnaire. Results: Of the 238 nurses, 93.1% were women. Factors such as lack of staff to patients ratio, nurses fatigue from hard work, having difficulty to read physician's writing on the patients file, nurses' heavy workload and work in night shift were the most common causes of MEs development which determined by nurses. Conclusion: MEs may affect negatively on patients' health. Nursing educational systems should have more attention to nurses' perception on MEs and could consider their view in planning and education in order to decline MEs. Keywords: Medication Error, Nurse, Perception, Cross Sectional INTRODUCTION Medication errors (MEs) are of the most important problems in all hospitalized patients 1 which can be used as an indicator for determining the level of patient s safety in hospitals 2. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) defines a medication error as: any preventable event that may cause or Corresponding author: Mohammad Esmaeli Abdar Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran Email : Mesmaeli87@gmail.com Phone: 989133425513 lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use 3. These errors not only may have adverse influences on patients, 4, 5 but also may negatively affect nurses and organizations 4. Incidence of MEs of hospitals settings in developing countries is high 1, 4. Jennane and colleagues in 2011 surveyed on the incidence of MEs in an intensive care unit (ICU) of an educational hospital in North Africa 1.
20 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 They reported that most of patients in their ICU encountered with MEs especially in time of drug ordering and transcribing 1. They have also found that increasing use of antibiotics and anticoagulants may raise the rate of MEs in ICU 1. In 2012, Seidi and colleagues examined pediatric nurses perceptions on the causes of MEs and potential barriers to report them in the pediatric wards of an educational hospital in Iran 6. Most common causes of MEs reported by Iranian pediatric nurses were being unable to check medicinal orders (73.9%) and errors in the medication administration (64%). Seidi and colleagues also reported that less than half of MEs errors occurred in pediatric wards, had been reported by Iranian pediatric nurses to their supervisor 6. In another study, Tang and colleagues surveyed nurses views on the factors contributing to MEs 7. Main affecting factors on MEs rate determined by Tang were the personal neglect, heavy workload and new staff 7. They also reported that risk of MEs occurrence is higher in some wards such as medical wards and ICU 7. In addition, Koohestani and colleagues focused on the barriers to report the medication administration errors by nursing students 8. They reported that nursing students usually did not report MEs to their instructors. Two main reasons for not reporting ME among nursing students were administrative barriers such as its potential negative feedback and fear of being recognized as inappropriate staff 8. Overcrowding ward and lack of nurses personnel as well as high volumes of activity combined with increased numbers and dosages of medication prescribed could be increase the risk of MEs by nurses 7, 9. Despite the importance of the nurse s task in preventing MEs, 7, 10 very few studies have been performed in this regards in Iranian context. In order to plan for preventing and decreasing rate of MEs, understanding of nurse s perception of MEs could be very helpful. This study was thus designed to examine the Iranian registered nurses perception of MEs. METHOD In a cross-sectional study conducted from September 2012 to January 2013 in four educational hospitals in Kerman, Southeast of Iran, 239 qualified registered nurses working within these hospitals were studied. Nursing, as a general practice, can be studied in universities; however, unlike some western countries, Iran does not differentiate by rank within licensed nursing personnel, and RN is the only professionally recognized rank. On successful completion of nurse education programs, graduates are automatically granted the status of registered nurse, which is the minimum legal and educational requirement for professional nursing practice. Registered nurses must complete a four year bachelor s degree at a nursing college. The written permission was obtained from deputy of research and also the Ethics Board of the Kerman University of Medical Sciences and written consent letters were filled in by all respondents. In addition, all participants were promised that all data would remain anonymous, kept confidential and be stored safely. Participants answered individually and returned the tests to the researcher. Data collection tool was Iranian Nurses Medication Errors Questionnaire developed by Soozani. This questionnaire contains 21 question related tothe nurses perception of MEs. Each question was scored as none=0; low=1; moderate= 3 and high= 4. The questionnaire was divided into three categories including: 1) items related to nurses (questions number 1 to 7), 2) items related to work setting (questions number 8 to 13) and 3) items related to nurses mangers (questions number 14 to 21) 11. Data were presented by mean and standard deviation and SPSS software (version 18.0) were used. RESULT Of 238 nurses participated in this study, 93.1% (n= 213) were women. The mean age of participants was 32± 7.4 years and mean years of experience was 9.3±7.5 years. 47% (n= 112) of participants have worked in acute care setting (ICU, NICU, CCU and emergency department). Nurses responses to 21 questions have been shown in table 1. Nurses reported that items related to category one (items related to nurses) had more effect on MEs compared to other categories. In category 1 (items related to nurses), most common causes determined by nurses were lack of staff to patients ratio and nurses fatigue from hard work. In category 2 (items related to work setting), most common reasons determined by nurses were having difficulty to read physician s writing on the patients file. In category 3 (items related to nurses mangers), most common issue determined by nurses was nurses heavy workload.
International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 21 Table 1: Nurses response to questionnaire items Question Without effect Low effect Moderate effect High effect 1. Disappointment and indifference towards the nursing profession 50 (21%) 60 (25.2%) 59 (24.8%) 69 (30%) 2. Unfamiliarity of nurses with medication 22 (9.1%) 62 (26.1%) 60 (25.2%) 94 (39.5%) 3. Nurses financial problems 48 (20.2%) 65 (27.3%) 62 (26.1%) 63 (26.5%) 4. Nurses family problems 40 (16.8%) 63 (26.5%) 75(31.6%) 60 (25.2%) 5. Nurses psychological problems 17 (7.1%) 43 (18.1%) 75 (31.6%) 103 (43.2%) 6. lack of staff to patients ratio 5 (2.1%) 14 (5.9%) 46 (19.3%) 173 (72.7%) 7. Nurses fatigue from hard work 3 (1.3%) 13 (5.5%) 54 (22.7%) 168 (70.6%) 8. Wards environmental noise 10 (4.2%) 71 (29.8%) 96 (40.3%) 61 (25.6%) 9. Methods that used for control and supervising wards 29 (12.2%) 62 (26.1%) 102 (42.9%) 45 (18.9%) 10. Medication room environment (light, physical space, etc.) 15 (6.3%) 59 (24.8%) 106 (44.5%) 58 (24.4%) 11. Type of drugs arrangement in shelves 18 (7.6%) 54 (22.7%) 105 (44.1.8%) 61 (25.6%) 12. Routs of drugs administration (oral, intravenous, etc.) 23 (9.7%) 81 (34%) 84 (35.3%) 50 (21%) 13. Difficult to read physician s writing on the patients file 11 (4.6%) 33 (13.9%) 70 (29.4%) 124 (52.1%) 14. Difficult to read patients drugs forms 15 (6.3%) 47 (19.7%) 77 (32.4%) 99 (41.6%) 15. Lack of enough time because of workload 12 (5%) 48 (20.2%) 102 (42.9%) 76 (31.9%) 16. Nurses heavy workload 6 (2.5%) 23 (9.7%) 75 (31.5%) 134 (56.3%) 17. Type of worked setting 36 (15.1%) 48 (20.2%) 88 (37%) 66 (27.7%) 18. Morning work shift 65 (27.3%) 90 (37.8%) 49 (20.6%) 34 (14.3%) 19. Evening work shift 66 (27.7%) 71 (29.8%) 78 (32.8%) 23 (9.7%) 20. Night work shift 35 (14.7%) 42 (17.6%) 87 (36.6%) 74 (31.1%) 21. Complicated rules of drug administration 32 (13.4%) 63 (26.5%) 90 (37.8%) 53 (22.3%) DISCUSSION Our results revealed that lack of staff to patients ratio, nurses fatigue from hard work, having difficulty to read physician s writing in the patients files, nurses heavy workload and working at night shifts were most common causes of MEs determined by Iranian registered nurses. Medication therapy is an important nursing task of Iranian nurses 11. It should be considered that physicians are responsible for prescribing medications and nurses are only responsible for preparing and administering medications. Having appropriate knowledge about nurses perception on MEs may be effective for planning of decreasing incidence of this problem. Results of present study showed that items related to own characteristics of nurses had more effects on MEs. Unver and colleagues studied perspectives of newly graduated and experienced nurses about MEs in a military hospital in Turkey 12. Similar to our findings, they used modified Gladstone s scale of MEs and found that nurse exhaustion and distraction are two most common causes of MEs 12. For decreasing rate of MEs, they suggested that educational systems have to consider during the training process of nurses the understanding causes of MEs and related prevention methods 12. Using the same questionnaire, Soozani and colleagues studied nurses perception of MEs in Iran 11. They have also reported that lack of staff to patients ratio, nurses fatigue from hard work and having difficulty to read physician s writing on the patients files is most common causes of MEs 11. They have also suggested that lack of trained nurses in medication therapy may affect negatively on patients health and it should be considered by nursing manager 11. Our participants have also reported that some environmental factors such as noise, light and having difficulty to read physician s writing on the patients files may increase the risk of MEs. Mahmood and colleagues in USA examined nurses perceptions of effects of physical environmental factors on occurrence of MEs in acute care settings 13. Some physical environmental factors determined by nurses in Mahmood s study were inadequate space in charting and documentation area, lengthy walking distances to patient rooms, insufficient patient surveillance opportunity, lack of visibility to all parts of the nursing unit, small size of the medication room, inappropriate organization of medical supplies, high noise levels in
22 International Journal of Nursing Education. January-June 2014, Vol. 6, No.1 nursing unit, poor lighting, and lack of privacy in the nursing stations 13. Soozani and colleagues have also mentioned environmental factors effect on rate of MEs. Most common environmental cause determined by Soozani was high level of noise 11. With regards to the items related to the manger nurses, working shift (morning, evening and night) was a factor determined as an effective factor in increasing risk of MEs in previous studies. Our nurses reported that risk of MEs development is higher at night shifts. Similar to our finding, Soozani and colleagues reported similar findings 11. However, in contrast to our finding, Kim and colleagues who studied on Nurses perceptions of medication errors and their contributing factors in South Korea reported that most MEs occurred by nurses at day shifts 14. This difference might be due to the differences in nursing systems between Iran and the South Korea hospitals; i.e., in Iran, less number of nurses allocated to work at night shifts in comparison with morning and evening shifts. In addition, in Iran, more experienced nurses usually work at day shifts (Morning and evening). Lack of nurses to patients ratio and lack of experienced nurses at night shifts in Iranian hospitals setting may be increase the risk of MEs development in this work shift. At night shifts, some environmental factors such as poor lighting could also increase the risk of MEs development in this work shift compared to morning and evening shifts. Limitations The respondents were predominantly female, which limits the generalisability of the results to male nurses. As this study was based on a convenience sample and participation was voluntary, there might have been a selection bias which could affect on generalizability of the results to all nurses. Furthermore, use of the self-reported questionnaires may have lead to an overestimation of some of the findings due to the variance observed in different methods. CONCLUSION Nursing educational systems should have more attention to nurses perception on MEs and may consider their view during planning and education towards decreasing MEs. Lack of staff to patients ratio, nurses fatigue from hard work, having difficulty to read physician s writing on the patients files, nurses heavy workload, working at night shift, nurses financial problems and lack of knowledge about medication therapy are the most important factors which may affect on the increasing risk of MEs development by nurses. REFERENCES 1. Jennane N, Madani N, Oulderrkhis R, Abidi K, Khoudri I, Belayachi J, Dendane T, Zeggwagh AA, Abouqal R. Incidence of medication errors in a Moroccan medical intensive care unit. Int Arch Med 2011;4:32. 2. Cheraghi MA, Nikbakhat Nasrabadi AR, Mohammad Nejad M, Salari A. Medication Errors Among Nurses in Intensive Care Units (ICU). J Mazand Univ Med Sci 2012; 22(Supple 1): 115-119. 3. http://www.nccmerp.org/about MedErrors. html. 4. Mrayyan MT, Shishani K, Al-Faouri I. Rate, causes and reporting of medication errors in Jordan: nurses perspectives. J Nurs Manag 2007;15(6):659-70. 5. Schelbred AB, Nord R. Nurses experiences of drug administration errors. J Adv Nurs 2007;60(3):317-24. 6. Seidi M, Zardosht R. Survey of nurses viewpoints on causes of medicinal errors and barriers to reporting in pediatric units in hospitals of Mashhad University of medical sciences. Journal of Fasa University of Medical Sciences 2012;3: 142-147. 7. Tang FI, Sheu SJ, Yu S, Wei IL, Chen CH. Nurses relate the contributing factors involved in medication errors. J Clin Nurs 2007;16(3):447-57. 8. Koohestani HR, Baghcheghi N. Barriers to the reporting of medication administration errors among nursing students. Aust JAN 2009; 27(1): 66-74. 9. Chang Y, Mark B. Effects of learning climate and registered nurse staffing on medication errors. J Nurs Adm 2011;41(7-8 Suppl):S6-13. 10. Mark BA, Belyea M. Nurse staffing and medication errors: cross-sectional or longitudinal relationships? Res Nurs Health 2009;32(1):18-30.
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