Why nurses make medication errors: A simulation study

Kazaoka, Tamayo; Ohtsuka, Kuniko; Ueno, Kuniko; Mori, Misato

doi:10.1016/j.nedt.2006.05.011

Cited by 31 publications

(23 citation statements)

References 9 publications

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“…[1] Medication errors may occur in any step of prescription and drug distribution process as prescribing medication is a sophisticated process and needs knowledge, decision making and proper function of the staffs working in various hospital wards. [2]…”

Section: Introductionmentioning

confidence: 99%

Efficacy of purposeful educational workshop of medical and nonmedical interventions based on needs assessments in nurses

Attari

Aminoroaia

Maracy

2017

J Edu Health Promot

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Background:The medical and nonmedical care of patients is the necessary skills in nursing profession. That it needs proper knowledge and attitude. Hence, it is important to promote nurses’ knowledge and attitude by education based on need assessment. This study aimed to define the efficacy of a medical and nonmedical intervention educational workshop on nurses’ knowledge and attitude until 3 months after holding the workshop in psychiatric wards of educational hospitals in Isfahan.Materials and Methods:This is a quasi-experimental study. The study population comprised all nurses working in psychiatric wards of Nour and Farabi Hospitals (64) in Isfahan in 2012. An educational workshop was held through educational sessions in the form of lectures and group discussion in two above-mentioned hospitals. Nurses’ level of knowledge and attitude were investigated by a researcher made questionnaire before, immediately after and 3 months after intervention. Data were analyzed by descriptive statistical tests of repeated measure ANOVA and Bonferroni.Results:A significant increase was observed in mean scores of nurses’ knowledge immediately after and 3 months after education compared to before education (P < 0.001). Also, the mean of attitude score in 3 phases have significant different (P < 0.009). Nurses have the high satisfaction (86.3%) of need assessment based education workshop. Moreover, it is effective in the science information revival of nurses.Conclusion:Educational sessions notably affected the promotion of nurses’ knowledge and attitude. With regard to nurses’ satisfaction with the workshop which was held, designing and organizing educational workshops based on constant needs assessment is suggested for the promotion of nursing cares.

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Section: Introductionmentioning

confidence: 99%

Efficacy of purposeful educational workshop of medical and nonmedical interventions based on needs assessments in nurses

Attari

Aminoroaia

Maracy

2017

J Edu Health Promot

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“…Prior research has addressed responses to observed medication errors (Kazaoka 2007;McBride-Henry and Foureur 2006;Nicholson 2006), incident reporting (Cohen et al 2003;Mayo and Duncan 2004), safety practices in medication administration (Cohen et al 2003;O'Shea 1999;Sim and Joyner 2002;Winson 1991), perceived sources of errors (Hicks et al 2004;Leape et al 1995;Mayo and Duncan 2004;Osborne 1999) and the impact of mentorship programs on new nurses (Casey et al 2004;Duchscher and Cowin 2006;Stewart and Kreuger 1996;Thomka 2001;Thomka 2007). Literature has shown that senior nurses, as preceptors, may take risks as a result of their comfort or familiarity with the medication process, and junior nurses, as "preceptees," may feel pressured to emulate the practices of the senior nurses, thus quickly adopting and fitting into the culture of the patient care unit (Thomka 2007).…”

mentioning

confidence: 99%

Survey of Nursing Perceptions of Medication Administration Practices, Perceived Sources of Errors and Reporting Behaviours

Armutlu¹,

Foley²,

Surette³

et al. 2008

hcq

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In January 2003, St. Mary's Hospital Center in Montreal, Quebec, established an interdisciplinary Committee on the Systematic Approach to Medication Error Control to review the whole process of medication administration within the hospital and to develop a systematic approach to medication error control. A cross-sectional survey on medication administration practices, perceived sources of errors and medication error reporting of nurses, adapted from a nursing practice survey and medication variance report (Sim and Joyner 2002), was conducted over a two-week period in February 2004. The results were analyzed by years of experience (greater or less than five years) and patient care unit of practice. The perceived source of error most often cited was transcription (processing), and the second most frequently cited source was the legibility of handwritten medication orders (prescribing).The results demonstrate no significant difference in medication safety practices or in perceptions of errors by years of experience. Nurses appear to adapt to the safety culture of the unit rather quickly, certainly within their first five years on the unit. Good medication error reporting behaviour was noted, with no differences between all comparative groups within both years of experience and unit of practice. Quality improvement initiatives to improve the safety of medication administration practices have included the development of a nursing medication administration handbook, the revision of policies and procedures related to medication administration safety, the standardization of solutions and limited variety of high-risk medication dosages and the reduction of handwritten reorders. The need for ongoing education and information sessions on policies and procedures specific to safe medication practices for all nurses, regardless of years of experience, was identified.

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“…These lead to a loss of confidence in one's abilities and practice, which are common events for the professional who, in many cases, feels unsettled, guilty and terrified about committing a medication error (12,14) . Shame appears as a feeling that diminishes the professional image, even when considering that all human beings can make an error.…”

Section: Discussionmentioning

confidence: 99%

“…It seemed to turn the medication moment into an interaction space among professional, staff and client, instead of a mere mechanical act (4,(14)(15)(16) . Exploring psychological mechanisms that are hidden by the error makes sense when we look for a way to overcome them, turning the error into a lesson for anyone trying to prevent it, considering that, if you know something, you can control it (15) .…”

Section: Discussionmentioning

confidence: 99%

Sentimentos de profissionais de enfermagem após a ocorrência de erros de medicação

et al. 2007

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Objective: To understand the feelings of nursing professionals who have committed medication errors. Methods: Descriptive and exploratory study with a qualitative approach. The subjects were 15 nursing professionals from a university hospital in Goiânia. Data were collected by interviews guided by a semi-structured instrument, which were recorded and analyzed according to the premises of Bardin. Results:The results showed that the most common feelings are panic, despair, fear, guilt and shame, among others. The coping strategies they adopt include looking for someone to share the problem, formally communicating the error and looking for information and knowledge. Conclusion: Hospitals should not ignore that human beings can err, but turn this into a motive to implement systemic strategies, such as the review of medication processes, ideal work conditions, psychological support and investment in continuing education. Keywords: Medication errors/psychology; Nurses/psychology; Feelings; Behavior RESUMO Objetivo: Conhecer os sentimentos dos profissionais de enfermagem que cometeram erro de medicação. Métodos: Estudo descritivo, qualitativo, realizado com 15 profissionais de enfermagem de um hospital universitário de Goiânia. Os dados foram coletados através de entrevistas semi-estruturadas, gravadas e analisadas segundo os pressupostos de Bardin. Resultados: Os resultados mostraram que os sentimentos mais comuns são pânico, desespero, medo, culpa, vergonha, entre outros. Adotam, como estratégias de enfretamento buscar alguém para compartilhar o problema, realizar comunicação formal do erro e buscar informação e conhecimento. Conclusão: Os hospitais não devem negligenciar a falha do ser humano, mas fazer disso um motivo para a implementação de estratégias sistêmicas como a revisão dos processos de medicação, condições ideais de trabalho, apoio psicológico e investimento em educação continuada. Descritores: Erros de medicação/psicologia; Enfermeiras/psicologia; Sentimentos; Conduta RESUMEN Objetivo: Conocer los sentimientos de los profesionales de enfermería que cometieron error en la medicación. Métodos: Se trata de un estudio descriptivo, cualitativo, realizado con 15 profesionales de enfermería de un hospital universitario de Goiânia. Los datos fueron recolectados a través de entrevistas semi-estructuradas, grabadas y analizadas según las premisas de Bardin. Resultados: Los resultados mostraron que los sentimientos más comunes son pánico, desesperación, miedo, culpa, vergüenza, entre otros. Adoptan, como estrategias de enfretamiento buscar a alguien para compartir el problema, realizar comunicación formal del error y buscar información y conocimiento. Conclusión: Los hospitales no deben descuidar la falla del ser humano, sino hacer de ello un motivo para la implementación de estrategias sistémicas como la revisión de los procesos de medicación, condiciones ideales de trabajo, apoyo psicológico e inversión en educación continuada.

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Why nurses make medication errors: A simulation study

Cited by 31 publications

References 9 publications

Efficacy of purposeful educational workshop of medical and nonmedical interventions based on needs assessments in nurses

Efficacy of purposeful educational workshop of medical and nonmedical interventions based on needs assessments in nurses

Survey of Nursing Perceptions of Medication Administration Practices, Perceived Sources of Errors and Reporting Behaviours

Sentimentos de profissionais de enfermagem após a ocorrência de erros de medicação

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