science road journal

SCIENCE ROAD Journal

SCIENCE ROAD JOURNAL Year: 2014

Volume: 02

Issue: 08

Pages: 48-54

The types and causes of medication errors in nursing students

Charkhat-Gorgich Enaam-Al-Hagh Student of operating room, member of Student Research Center, Zahedan University of Medical Sciences, Zahedan, Iran Yaghoobi Maryam Pregnancy Health Research Center, Zahedan University of Medical Sciences, Zahedan, Iran Salehinia H. Ph.D. Student of Epidemiology, Tehran University of Medical Sciences, Tehran, Iran Navidian Ali Pregnancy Health Research Center, Zahedan University of Medical Sciences, Zahedan, Iran Torabpour Masoud Nursing department, Abadan School of Medical Sciences, Abadan, Iran

Abstract: Medical errors are one of the most common medical errors that threaten patient safety. These errors are well-known problems in nursing, and in all different hospital wards. The aim of this study was to investigate the nature and causes of medication errors among nursing students. This descriptive – analytical study was conducted on 62 final -year nursing students in Zahedan School of Nursing and Midwifery, Iran, enrolled through the census. Data were collected using a valid and reliable questionnaire. To analyze the data, descriptive statistics, t-test and ANOVA were applied by use of SPSS16 software. The results showed that the most common medication error among students was related to infusion rate, more or less than the prescribed dose. The most common causes of medication errors were drug calculation, (77.4%), lack of pharmacological knowledge (75.8%), and Illegibility of patients’ records (72.6%) respectively. There was no significant relationship between gender and occurrence of medication errors (p=0.95). Based on the results dealing with the occurrence of medication errors, training of students in the areas of medical errors, pharmacological information are essential and workshops in this area are appropriate.

Keywords:

Medication errors, Nursing students

Corresponding Author: Torabpour Masoud Email: [email protected] Acceptance Date: 8/23/2014 48

SCIENCE ROAD JOURNAL 1. Introduction Nowadays, medical errors are one of the most important issues in the field of public health in which patients’ safety is threatened (Grober & Bohnen, 2005). One of these medical errors, medication errors is defined as improper use of medications in each phase of medication administration. These errors are preventable (Hansen et al, 2006‫ ؛‬Hughes and Ortiz, 2005‫ ؛‬Lehman et al, 2004).Medication errors are considered as an old hospital problem and of the most common events in the existing professional nursing (Handler et al, 2004). The first report related to medication errors was released in 1940 and attracted the attention of authorities (Rahimi and Seyyed-rasouli, 2004). Studies show that about 7000 death occurs annually due to medication errors. Also this event costs for many health care systems and must be noticed that most of these costs are related to the hospitalization caused by wrong use of medications (Stratton et al., 2004). Medical errors may have consequences such as increased length of hospitalization, increased costs of hospital care, and even severe damage or death (Handler et al, 2004). In some hospital studies, prevalence of injuries due to medical errors has been reported 10 to 18 percent (Hume, 1999). Common medical errors include errors in concentration, time and rout of administration of medications, and administering more than prescribed dose (Woods & Doan-Johnson, 2002). Studies have shown that the rate of medication errors by nurses and nursing students is high, however, the report rate of such errors is low (Benner et al, 2002 ‫ ؛‬Kawamura ,2001‫ ؛‬Cullen et al,1995‫ ؛‬Blegen et al,2004). The study by McCarthy et al. showed that the rate of medication errors in nursing students was 48.5% and the most prevalent reported type of medication errors was forgetting medication (McCarthy, Kelly and Reed, 2000). In another study in Arak, Iran, to investigate the prevalence of medication errors found that 10 percent of nursing students had medication error (Koohestani, 2005). Factors such as lack of drug information, wrong drug calculation, lack of compliance with defined protocols, similarities in name, shape and packaging of drugs, and bad calligraphy of orders can be involved in medication errors (Carlton& Blegen ,2006). Because of multi-dimensional aspect of medical errors, multilateral measures must be taken; however identifying the types and causes of such errors is the first step toward preventing and controlling them. With regard to the high prevalence and dangerous aspect of these errors we aimed at conducting a study on medication errors and their causes among nursing students. By the results of this study, strategies can be discussed for understanding and controlling factors in the occurrence of medication errors among nursing students.

2. Methods This is a descriptive study to evaluate the type and causes of medication errors among nursing students. Study population is composed of all final-year nursing students at Nursing and Midwifery school, Zahedan, Iran, selected through the census in 2014. An only exit criterion was lack of completing the questionnaire. The information gathering and data collection tool was the self-made questionnaire prepared by the researchers based on literature reviews (Koohestani 2005‫ ؛‬MohammadNejad Hojjati and Ehsani, 2009). A questionnaire of three parts was prepared as follows: the first part aimed to collect the demographic information of the students (gender, age, hospital ward); the second part was related to the type of medication error with 19 items (scoring from zero, for not occurrence or report, till the number of all errors) and the third part was relate to the causes of medication errors on the students opinion with 22 items (scoring based on the frequencies). Face and content validity of the questionnaire were assessed by previous studies, books and through asking 4 members of School of Nursing of ZUMS to comment on the questionnaire, and by considering their correctional comments. The reliability of the questionnaire was determined using test-retest method among 10 students (r = 0.98). In order to comply with ethical considerations, the researchers explained the aim of the study to the study participants and then they were assured that the information will be confidential. The study protocol was approved by deputy of the research and ethics committee of the Zahedan University of Medical Sciences. Data analyses were performed by descriptive statistics (frequency, mean, and standard deviation) and inferential statistics. SPSS software version 16 was used for statistical analysis and P values less than 0.05 were considered significant.


SCIENCE ROAD JOURNAL 3. Results Sixty two students at Zahedan School of Nursing and Midwifery entered study of whom 24(%38.7) were male and 34 (%63.3) were female with average age of 21.53 ± 0.93 year. Based on the findings of the study, the most common medication errors occurred in students were: infusion rate less than or more than the prescribed amount, wrong volume of diluent, mixing two or more medications in micro-set system without attention to pharmacological interactions, not diluting medications that should be diluted, and lack of necessary measures before administration. Table 1 shows the average rate of error occurrence and the average rate of error reporting in nursing students.

Table 1-the average of the occurrence of and report any medications error of students in nursing Type of error Wrong infusion rate less or more than prescribed Wrong volume of diluent Mixing two or more medications without regard to interactions Not diluting when necessary Lack of necessary measures before administration Giving wrong dose Lack of attention to the appropriate patient position Giving meds earlier or later Giving some oral meds simultaneously Giving mistaken meds Omission of meds Mistaken diluent Preparing mistaken meds Medication at inappropriate time(before or after meal)

Occurrence Mean 0.11 0.1

Report Mean 0.36 0.35

0.08

0

0.08 0.06 0.05 0.05 0.03 0.03 0.02 0.02 0.02 0.02 0.02

0.32 0.3 0.21 0.21 0.18 0.18 0.12 0.12 0.12 0.12 0.12

By the students’ viewpoint, false medicinal calculations, insufficient pharmacological knowledge, illegibility of patients’ records, environmental factors (noise, crowding), and stress in emergency conditions are the first five factors in the occurrence of medication errors and working in educational hospital, lack of follow of treatment, administration without physician order, lack of awareness about injection equipment, and insufficient clinical skills are the last five factors that had the least impact in the occurrence of these errors. All causes of the occurrence of the medication errors based on students’ viewpoint are listed in table 2.


SCIENCE ROAD JOURNAL Table 2-Causes of medication errors from the viewpoint of nursing students Causes of medication errors False medicinal calculations Insufficient pharmacological knowledge Illegibility of patients’ records Environmental factors (noise, crowding) Stress in emergency conditions Lack of attention to dosing Giving oral orders without checking records Similarities among drug names and wrong reading Similarities among drug shapes Different diluting routines Lack of follow after infusion process Using abbreviated names Wrong recording of orders Similarities in meds classification High work loads Lack of attention to PRN orders Improper physical environment (light, temperature) Insufficient clinical skills Lack of awareness about injection equipment Administration without physician order Lack of follow of treatment Working in educational hospital

Agree 28(77.4) 47)75.8/( 45 (72.6) 41(66.1) 39(62.9) 38(61.3) 35(56.5) 34(54.8) 33(53.2) 32(51.6) 31(50) 31(50) 30(48.4) 26(41.9) 25(40.3) 23(37.1) 22(35.5) 21(33.9) 20(32.3) 19(30.6) 18(29) 15(24.2)

Disagree 14(22.6) 15(24.2) 17(27.4) 21(33.9) 23(37.1) 24(38.7) 27(43.5) 28(45.2) 29(46.8) 30(48.4) 31(50) 31(50) 32(51.6) 36(58.1) 37(59.7) 39(62.9) 40(64.5) 41(66.1) 42(67.7) 43(69.4) 44(71) 47(75.8)

There was no statistically significant relationship between demographic specifications (age, gender) and medication errors committed by students (t-test, P= 0.95) but type of ward and medication errors had significant statistically relationship (ANOVA, P= 0.02) in such a way there was the highest occurrence rate of errors in the NICU, medical and surgical wards and the lowest rate in the ED and pediatrics wards respectively. Table 3 summarizes relationships between gender and type of ward with the occurrence rate of the medication errors among the nursing students.

Table 3-Relationships between gender and type of ward with the occurrence rate of the medication errors Variable Gender

Type of Ward

Female Male Medical Surgical Pediatrics ED CCU NICU

Number

Mean ± SD

P Value

38 24 10 7 24 15 4 2

6.78 ± 5.1 6.7 ± 4.1 9.8 ± 4.46 9.85 ± 5.2 5.95 ± 6.2 3.8 ± 2.7 6.25 ± 4.85 13.5 ± 9.19

0.95 (t-test) 0.02 (ANOVA)


SCIENCE ROAD JOURNAL 4. Discussion The findings of the present study showed that false medicinal calculations, insufficient pharmacological knowledge, illegibility of patients’ records, environmental factors (noise, crowding), and stress in emergency conditions as the most common types of medication errors occurred in the nursing students. Rigitanha et al. found that about 80 percent of students have had at least one medication error in which giving meds earlier or later than prescribed time and omission of medications were the two most prevalent errors (Rigitanha, Baghaee and Feyzi, 2012). In their study, Wolf et al. mentioned that the most prevalent medication errors were medication omission and false medicinal calculation respectively. They pointed out that the most common causes of students’ medication errors were weak clinical performance, lack of follow therapy up and lack of pharmacological knowledge (Wolf, 2006). Present study showed that the five most important causes of medication errors in nursing students-by their opinionwere false medicinal calculations(77.4%), insufficient pharmacological knowledge(75.8%), illegibility of patients’ records(72.6%), environmental factors (noise, crowding)(66.1%), and stress in emergency conditions (66.9%). MohammadNejad et al. found that the rate of medication errors was 17.9 %, and also giving wrong dose, giving mistaken medications and wrong infusion rate less or more than prescribed, were the most common medication errors. The common causes of medication errors by the results of MohammadNejad’s et al. study were wrong recording of orders and lack of attention to drug dosages. On the other hand the highest rate of medication errors occurred in the emergency ward (MohammadNejad, Hojjati and Ehsani 2009). Although this study showed that the highest rate of medication errors among nursing students occurred in NICU, medical and surgical wards respectively. According to the findings of Koohestani H. the rate of medication errors was 17.1% in which the most common errors were giving wrong dose, wrong medication and wrong infusion rate less or more than prescribed which are parallel to present study. The most common causes of medication errors reported by Koohestani (2005) were insufficient pharmacological knowledge, lack of attention to dosages and false medicinal calculation which are agree with the results of present study and showed the need for more emphasis on education of nursing students during clinical courses. Among the survey conducted by McCarthy, 48.5% of nursing students had at least one medical error in which forgetting medication administration was the leading reported one (McCarthy, Kelly and Reed, 2000). In the Canilla’s study in 2005, the most common medication errors among nurses include giving wrong dose, giving mistaken medications and forgetting medication administration (Canilla, 2005). In another study which was done on nursing students in the University of La Salle, USA, weak clinical skills, lack of follow up of therapy and insufficient pharmacological knowledge were the most common causes of medication errors (Wolf, 2006). All of these errors are related to pharmacological information and many nursing researchers mention raising nurses’ pharmacological knowledge as a serious strategy for reducing medication errors, and conclude that updating the information of nurses and nursing students about medicines and in particular new medicines can be an important factor in reducing medication errors (Ehsani, 2013).

5. Conclusions According to the findings of the study, infusion rate less than or more than the prescribed amount, wrong volume of diluent, mixing two or more medications without attention to pharmacological interactions are the most common medical errors among nursing students; So with more monitoring by nursing instructors and improving students’ awareness about the consequences of medical errors it is hoped that the rate of medication errors can be reduced. To control and reduce the causative factors of medication errors, it is suggested: 1. the use of a systematic approach to investigate the factors affecting medication errors and attempts to fix them as extent as possible. 2. Use of quantitative and qualitative measures to improve nursing students' knowledge about the problem and its consequences. 3. Carrying continuous education on based on students need, permanently and periodically 4. Continuous evaluation of students’ pharmacological knowledge 5.Ease of access to any scientific resources for all students


SCIENCE ROAD JOURNAL 6. Acknowledgement This paper was an outcome of research project completed under registration No. 6189 by the financial support of the research deputy of Zahedan University of Medical Sciences (ZUMS). We hereby appreciate all nursing students participating in the present research who sincerely cooperated in obtaining the results.

7. References [1] Anderson DJ, Webster CS (2001). A System Approach to the reduction of medication error on the hospital ward. J Adv Nur; 35(1): 34-41. [2] Benner P, Sheets V, Uris P, Mallah K, Schwed K, Jamison D(2002). Individual, practice, and system causes of errors in nursing: a taxonomy. J Nurs Adm; 32(10): 509-23. [3] Blegen MA, Vaughn T, Pepper G, Vojir C, Stratton K, Boyd M. (2004). Patient and staff safety: voluntary reporting. Am J Med Qual., Mar-Apr; 19(2): 67-74. [4] Canilla M. (2005). A Review of Medication Administration Errors Reported in a Large Psychiatric Hospital in the United Kingdom. Psychiatr serv; 56(12): 1610-1613. [5] Carlton G, Blegen MA. (2006). Medication-related errors: a literature review of incidence and antecedents. Nursing Research; 24: 19-38. [6] Cullen DJ, Bates Dw, Small SD, Cooper JB, Nemeshkal AR, Leapell. (1995). The incident reporting system does not detect adverse drug events: a problem for quality improvement. Je Comm J Qual Improve 1995 Oct; 21(10): 541-8. [7] Ehsani, Seyyedeh Roghayeh(2013). Medication errors of nurses in the emergency department. Journal of Medical Ethics and History of Medicine, 6:11.28 [8] Grober ED, Bohnen JM. (2005). Defining medical error. Can J Surg; 48(1): 39-44. [9] Handler SM, Nace DH, Studenski SA, Fridsma DB. (2004). Medicatin error reporting in long term care. AM F Geriatr Pharmacother; 2(3): 190-6. [10] Hansen RA, Greene S, Williams CE, Blalock SJ, Crook KD, Akers R, et al(2006). Types of medication errors in North Carolina nursing homes: A target for quality improvement. Am J Geriatr pharmacotherapy , 4(1):5261. [11] Hughes RG, Ortiz E. (2005). Medication Error why they happen and how they can be prevented. AM J Nurs; 105(3 suppl): 14-24. [12] Hume M. (1999).Changing hospital culture and systems reduces drug errors and advers events. Qual Lett Healthc Lead 1999 Mar; 11(3): 2-9. [13] Kawamura H(2001). The approaches to factors which cause medication error-from the analyses of many nearmiss cases related to intravenous medication which nurses experienced. Gan To Kagaku Ryoho 2001 Mar; 28(3): 304-9. [14] Koohestani HR(2005). Review of medication errors by nursing students in cardiac care units. Journal Sci Forensic Medicine 2005; 13(4): 249-55. [15] Lehman CU, Conner KG, Cox JM.(2004). Preventing provider errors: online total parenteral nutrition calculator. Pediatrics; 113(4): 648-753. [16] McCarthy AM, Kelly MV, Reed DJ.(2000). Medication administration practices of school nurses. J sch Health; 70(9): 371-376. [17] MohammadNejad S, Hojjati H, Ehsani R. (2009). The amount and type of medication errors in nursing students in four teaching hospital of Tehran. Journal of Medical Ethics and History the Winter. [18] Rahimi S, Seyyed-rasouli A. (2004). Nurses drug precautions awareness. Iran J Nurs; 16(36): 53-60. [19] Rigitanha Z, Baghaee R, Feyzi A. (2012). Investigation Frequency and types of medication errors made by nursing student in University of Uromia. Bi-Monthly Journal of Nursing and Midwifery; 10(2): 139-144.


SCIENCE ROAD JOURNAL [20] Stratton KM, Blegen MA, Pepper G,Vaughn T. (2004). Reporting of medication Errors by Pediatric Nurses. J Pediatric Nurs; 19(6): 385-92. [21] Wolf ZR. (2006). Characteristics of medication error made by student during the administration phase. J Pro Nurs; 22: 39-51. [22] Woods A, Doan-Johnson S. (2002). Executive summary: toward a taxonomy of nursing practice errors. Nurs Manage; 33(10): 45-8.1
