Title: To Study Drug Administration Errors and Different Factors Responsible for These Errors in a Large Teaching Hospital in North India
Authors: Sajad Hussain Bhat, Farooq A Jan, G H Yatoo, Haroon Rashid, Ifrah Khalil
DOI: https://dx.doi.org/10.18535/jmscr/v5i2.05
Abstract
Background: Medication errors can occur at any of the three steps of the medication use process: prescribing, dispensing and administration. We aimed to study drug administration errors and different factors responsible for drug administration errors.
Objective: To study different factors responsible for drug administration errors.
Methods: A prospective observational study was carried out for a period of one year to study drug administration errors and factors responsible for these errors at Sher– I – Kashmir institute of medical sciences Soura Srinagar. Administration of drugs was observed and compared with concerned patient’s prescription. Any deviation between administration and prescription was taken as error.
To study factors responsible for drug administration errors, the reasons noted by researcher for these errors were noted down. An interview of the staff members who were observed for drug administration errors, nursing administrators, and doctors for reasons of such errors was conducted at the end of study. The demographic details of the staff including age, qualification, experience were taken from hospital administration.
Results: A total of 4752 drug administrations were observed involving 312 drug rounds and 138 staff members. In a total of 4752 drug administrations, 592 errors were noticed. Among these drug administrations 536 dosages had one error, 16 had two errors and 8 had three errors.
The most common reasons noticed by researcher were interruptions during drug rounds, shortage of staff, and lack of communication between healthcare professionals among themselves as well as with patients. The major reasons cited by staff as well as doctors were excess workload, interruptions and poor communication. Other less common reasons were fatigue, stress, knowledge deficit, miscalculation of dose etc. There was no significant effect of gender and age of staff on the occurrence of medication administration errors. However the error rate was less with more qualified and experienced staff.
Conclusion: Drug administration errors need to be reduced by identifying the factors responsible for these errors.
Keywords: Medication Administration Errors.
References
1. Preventing pediatric medication errors: Sentinel Event Alert, 39: Retrieved May 4, 2009 from: http: // www. Joint commission. org/ sentinelevents/sentinel-eventalert/sea_39.htm
2. Kohn L, Corrigan J, & Donaldson M. (2000): To err is human: Building a safer health system. Washington DC: National Academy Press: The Joint Commission (2008, April 11).
3. NCC MERP: The first ten years. Defining the problem and developing solutions.[http :// www. nccmerp. Org / pdf /report Final2005-11-29.pdf website]
4. Allan EL, Barker KN: Fundamentals of medication error research: Am J Hosp Pharm (1990) 47: 555-571.
5. Susan P. Beyond the Five Rights: Improving Patient Safety in Pediatric Medication Administration through Simu-lation: Clinical Simulation in Nursing 2009; 5: 181-86.
6. Fanak F, Parham A, Mehrdad F et al: Errors in preparation and administration of intravenous medications in the intensive care unit of a teaching hospital; An observational study: Australian College of Critical Care Nurses 2008; 21: 110-16
7. Reason J: Human error. Cambridge: Cambridge University Press; 1990.
8. Corrigan JM, et al. Institution of medicine: shaping the future for health. To err is human: building a safer health system. Washington, DC: National academy press; 1999. IOM document repository
9. Chua SS, Tea MH, Rahman MH et al. An observational study of drug administration errors in a Malaysian hospital (study of drug administration errors): J Clin Pharm Ther. 2009; 34 (2):215–23.
10. Chua SS, Chua HM, Omar A: Drug administration errors in paediatrics wards: a direct observation approach. Eur J Paediatr. 2010;169(5):603–11
11. Tissot E, Cornette C, Limat S et al. Observational study of potential risk factors of medication administration errors. Pharm World Sci 2003 25(6):264–26
12. M Labuschagne, W Robbetze, J Rozmi-arek: Errors in drug administration by anesthetists in public hospitals in the Free State
13. Kumar K.S, Venkateswarlu K, Ramesh Arun: A Study of medication administ-ration errors in a tertiary care hospital: Indian Journal of Pharmacy Practice, 2011; 4(2):37-42
14. Westbrook JI, Woods A, Rob MI, et al. Association of interruptions with an increased risk and severity of medication administration errors: Arch Intern Med. 2010; 170 (8):683–9097.
15. Manias E, Aitken R, Dunning T: Graduate nurse’ communication with health professionals managing patients’ medications: J ClinNurs 2005; 14:354-62.
16. AlaSzczepura, Deidre, Wild and Sara, Nelson: Medication administration errors for older people in long-term residential care: BMC Geriatrics 2011, 11:82
17. Chua SS, Chua HM, Omar A: Drug administration errors in paediatrics wards: a direct observation approach. Eur J Paediatr. 2010;169(5):603–11
18. Keers RN, Williams SD, Cooke J, et al. Prevalence and nature of medication administration errors in healthcare settings: a systematic review of direct observational evidence: Ann Pharmac other. 2013; 47 (2):237–56.