What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff

Abstract

ObjectiveMedication administration errors (MAEs) are a common risk to patient safety in mental health hospitals, but an absence of in-depth studies to understand the underlying causes of these errors limits the development of effective remedial interventions. This study aimed to investigate the causes of MAEs affecting inpatients in a mental health National Health Service (NHS) hospital in the North West of England.MethodsRegistered and student mental health nurses working in inpatient psychiatric units were identified using a combination of direct advertisement and incident reports and invited to participate in semi-structured interviews utilising the critical incident technique. Interviews were designed to capture the participants’ experiences of inpatient MAEs. All interviews were transcribed verbatim and subject to framework analysis to illuminate the underlying active failures, error/violation-provoking conditions and latent failures according to Reason’s model of accident causation.ResultsA total of 20 participants described 26 MAEs (including 5 near misses) during the interviews. The majority of MAEs were skill-based slips and lapses (n = 16) or mistakes (n = 5), and were caused by a variety of interconnecting error/violation-provoking conditions relating to the patient, medicines used, medicines administration task, health care team, individual nurse and working environment. Some of these local conditions had origins in wider organisational latent failures. Recurrent and influential themes included inadequate staffing levels, unbalanced staff skill mix, interruptions/distractions, concerns with how the medicines administration task was approached and problems with communication.ConclusionsTo our knowledge this is the first published in-depth qualitative study to investigate the underlying causes of specific MAEs in a mental health hospital. Our findings revealed that MAEs may arise due to multiple interacting error and violation provoking conditions and latent ‘system’ failures, which emphasises the complexity of this everyday task facing practitioners in clinical practice. Future research should focus on developing and testing interventions which address key local and wider organisational ‘systems’ failures to reduce error.

Recommendations to prevent nursing errors: Content analysis of semi‐structured interviews with intensive care unit nurses in a developing country

“…Nurses, especially those who are novice, complained of staff shortage and lack of experienced nurses and supervisors. In line with previous studies (Faisy et al, 2016; Heidari, Yadollahi, Rafiee, Karimifard, & Lalehgani, 2017; Keers et al, 2018; MacPhee, Dahinten, & Havaei, 2017; Rivaz, Momnnasab, Yektatalab, & Ebadi, 2017; Stewart et al, 2018; Wegner et al, 2016), this finding suggests that enhancing supervision and improving the nursing staff‐to‐patient ratio are among the top promising strategies to minimize errors and improve patient safety. Considering the cost of errors and their consequences, improving human and non‐human resources may be a cost‐saving approach in many aspects.…”

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

“…Medication incidents are among the major issues jeopardising patient safety (Härkänen, Vehviläinen‐Julkunen, Murrells, Rafferty, & Franklin, 2018;Keers et al, 2018;Manias, Cranswick, et al, 2019;WHO, 2017), accruing the equivalent of 42 billion USD in global costs annually, based on estimations of World Health Organization (WHO, 2017). Communication is one of the most common (46%‐60%) contributing factors of medication incidents (Keers, Williams, Cooke, & Ashcroft, 2013;Lawton, Carruthers, Gardner, Wright, & McEachan, 2012a;Parry, Barriball, & While, 2015).…”

Prevalence, nature and predictors of omitted medication doses in mental health hospitals: A multi-centre study

“…Available evidence for the causes of unavailable drug related 'preventable' omitted doses from mental health hospitals [14][15][16] identifies causative factors such as medicines logistics, but detail is often limited to codes on prescription charts or brief descriptions in incident reports. Further in-depth investigation is therefore required as seen elsewhere for general MAEs [10] to help inform interventions tailored to the mental health setting.…”

“…high risk drug monitoring [6,7], high dose/combination psychotropic prescribing [8]) and patient population (e.g. high physical health co-morbidity [9], limited insight into illness and disturbed/withdrawn behaviours [10]).…”

“…Within psychiatric hospitals, international evidence suggests that patients are frequently placed at risk from medication errors and their adverse consequences [13], with medication administration errors (MAE) one of the most common error types [13][14][15][16]. The origins of many MAEs are multifactorial, with important differences to general hospitals [10,17].…”