Barriers to medication error reporting among hospital nurses

Rutledge, Dana N.; Retrosi, Tina; Ostrowski, Gary

doi:10.1111/jocn.14335

Cited by 75 publications

(88 citation statements)

References 19 publications

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“…As an answer, we found in our study that collegial feedback and respectful atmosphere minimises incidents. Discouraging nonverbal communication or fear of authority was marginal, which might be a signal of good collegiality (Kohn, Corrigan, & Donaldson, 2000;Rutledge et al, 2018). However, we did not find evidence of mandatory mentoring as a method used for preventing medication errors.…”

Section: Discussionmentioning

confidence: 99%

“…Evidence of medication communication exists for a variety of care process situations (Braaf, Rixon, Williams, Liew, & Manias, 2015a;Liu, Manias, & Gerdtz, 2012;Manias, Braaf, et al, 2019;Yu, Li, Gao, Liu, & Lin, 2018), and concerning a diverse range of communication methods (Foged, Nørholm, Andersen, & Petersen, 2017;Redley & Botti, 2013). Medication communication has been assessed ethnographically from the interplay viewpoint between nurses, patients, physicians and students (Liu, Gerdtz, & Manias, 2015, 2016;Rutledge, Retrosi, & Ostrowski, 2018;Schoenthaler, Allegrante, Chaplin, & Ogedegbe, 2012;Tobiano et al, 2019), but also concerning professionals’ tendency to follow communicated guidelines (Karttunen et al, 2020). Studies of medication communication have been conducted on emergency situations concerning language barriers (Pun, Chan, Murray, Slade, & Matthiessen, 2016), racial issues affecting medication communication (Schoenthaler et al, 2012) and environmental issues of communication (Liu et al, 2014;Manias, Cranswick, et al, 2019;Yu et al, 2018).…”

Section: Introductionmentioning

confidence: 99%

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Communication issues contributing to medication incidents: Mixed‐method analysis of hospitals’ incident reports using indicator phrases based on literature

Syyrilä

Vehviläinen‐Julkunen

Härkänen

2020

Journal of Clinical Nursing

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Aim To identify the types and frequencies of communication issues (communication pairs, person related, institutional, structural, process and prescription‐related issues) detected in medication incident reports and to compare communication issues that caused moderate or serious harm to patients. Background Communication issues have been found to be among the main contributing factors of medication incidents, thus necessitating communication enhancement. Design A sequential exploratory mixed‐method design. Methods Medication incident reports from Finland (n = 500) for the year 2015 in which communication was marked as a contributing factor were used as the data source. Indicator phrases were used for searching communication issues from free texts of incident reports. The detected issues were analysed statistically, qualitatively and considering the harm caused to the patient. Citations from free texts were extracted as evidence of issues and were classified following main categories of indicator phrases. The EQUATOR’s SRQR checklist was followed in reporting. Results Twenty‐eight communication pairs were identified, with nurse–nurse (68.2%; n = 341), nurse–physician (41.6%; n = 208) and nurse–patient (9.6%; n = 48) pairs being the most frequent. Communication issues existed mostly within unit (76.6%, n = 383). The most commonly identified issues were digital communication (68.2%; n = 341), lack of communication within a team (39.6%; n = 198), false assumptions about work processes (25.6%; n = 128) and being unaware of guidelines (25.0%; n = 125). Collegial feedback and communication from patients and relatives were the preventing issues. Moderate harm cases were often linked with lack of communication within the unit, digital communication and not following guidelines. Conclusions The interventions should be prioritised to (a) enhancing communication about work‐processes, (b) verbal communication about digital prescriptions between professionals, (c) feedback among professionals and (f) encouraging patients to communicate about medication. Relevance to clinical practice Upon identifying the most harmful and frequent communication issues, interventions to strengthen medication safety can be implemented.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Communication issues contributing to medication incidents: Mixed‐method analysis of hospitals’ incident reports using indicator phrases based on literature

Syyrilä

Vehviläinen‐Julkunen

Härkänen

2020

Journal of Clinical Nursing

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“…Nurses' knowledge and attitudes to reporting practice errors and the complexity of reporting tasks affected error reporting. Nurses' lack of confidence and knowledge, the time-consuming nature of error reporting, and fear of repercussions have been recognized as barriers to error disclosure in all levels of healthcare systems [60,61]. Since nurses collaborate with other healthcare professionals to inform patients regarding therapeutic decisions and their outcomes, they need to have sufficient knowledge and positive attitudes towards disclosing and reporting errors if they are to manage challenging conversations about patient safety with patients and families [62].…”

Section: Discussionmentioning

confidence: 99%

Disclosing and Reporting Practice Errors by Nurses in Residential Long-Term Care Settings: A Systematic Review

et al. 2020

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Patient safety is crucial for the sustainability of the healthcare system. However, this may be jeopardized by the high prevalence of practice errors, particularly in residential long-term care. Development of improvement initiatives depends on full reporting and disclosure of practice errors. This systematic review aimed to understand factors that influence disclosing and reporting practice errors by nurses in residential long-term care settings. A systematic review using an integrative design was conducted. Electronic databases including PubMed (including Medline), Scopus, CINAHL, Embase, and Nordic and Spanish databases were searched using keywords relating to reporting and disclosing practice errors by nurses in residential long-term care facilities to retrieve articles published between 2010 and 2019. The search identified five articles, including a survey, a prospective cohort, one mixed-methods and two qualitative studies. The review findings were presented under the categories of the theoretical domains of Vincent’s framework for analyzing risk and safety in clinical practice: ‘patient’, ‘healthcare provider’, ‘task’, ‘work environment’, and ‘organisation & management’. The review findings highlighted the roles of older people and their families, nurses’ individual responsibilities, knowledge and collaboration, workplace atmosphere, and support by nurse leaders for reporting and disclosing practice errors, which had implications for improving the quality of healthcare services in residential long-term care settings.

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“…There are many different studies that have focused on the reporting of MEs by nursing professionals [9,29,30], however, there is a lack of research concerning the knowledge, attitudes and behaviors of nursing professionals in the preparation and administration of IVs [4,31,32]. With this in mind, Di Muzio, Tartaglini, De Vito and La Torre [32] developed a questionnaire in order to measure the knowledge and attitudes of nurses in the preparation of medication.…”

Section: Introductionmentioning

confidence: 99%

Factors related to medication errors in the preparation and administration of intravenous medication in the hospital environment

et al. 2019

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Background Medication errors have long been associated with low-quality medical care services and significant additional medical costs. Objective The aim of this study was to culturally adapt and validate the questionnaire on knowledge, attitudes and behaviors in the administration of intravenous medication, as well as to explore these factors in a hospital setting. Methods The study was divided into two phases: 1) validation and cross-cultural adaptation, and 2) cross-sectional study. A total of 276 hospital-based nursing professionals participated in the study. Results A Cronbach’s alpha value of 0.849 was found, indicating good internal consistency. In the multivariate analysis, statistically significant differences were found between knowledge and attitudes, demonstrating that having greater suitable knowledge correlates with having a more positive attitude. It was also discovered that having a positive attitude as well as the necessary knowledge increases the possibility of engaging in adequate behaviors. Conclusions The knowledge, attitudes and behavior questionnaire has a satisfactory internal consistency in order to be applied to the Spanish context. Implications for nursing management: Knowledge acquisition and positive attitude are both factors which promote adequate behavior, which in turn seems to have an impact on medication errors prevention. Health institutions must encourage continuous education for their employees.

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Barriers to medication error reporting among hospital nurses

Cited by 75 publications

References 19 publications

Communication issues contributing to medication incidents: Mixed‐method analysis of hospitals’ incident reports using indicator phrases based on literature

Communication issues contributing to medication incidents: Mixed‐method analysis of hospitals’ incident reports using indicator phrases based on literature

Disclosing and Reporting Practice Errors by Nurses in Residential Long-Term Care Settings: A Systematic Review

Factors related to medication errors in the preparation and administration of intravenous medication in the hospital environment

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