Nurses' identification and reporting of medication errors

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DİRİK H. F., Samur M., SEREN İNTEPELER Ş., Hewison A.

JOURNAL OF CLINICAL NURSING, vol.28, pp.931-938, 2019 (SCI-Expanded) identifier identifier identifier

  • Publication Type: Article / Article
  • Volume: 28
  • Publication Date: 2019
  • Doi Number: 10.1111/jocn.14716
  • Journal Indexes: Science Citation Index Expanded (SCI-EXPANDED), Social Sciences Citation Index (SSCI), Scopus
  • Page Numbers: pp.931-938
  • Keywords: error identification, medication error, nursing, reporting, PATIENT SAFETY, CONTENT VALIDITY, BARRIERS, ATTITUDES, KNOWLEDGE
  • Dokuz Eylül University Affiliated: Yes


Aims and objectives To investigate hospital nurses' involvement in the identification and reporting of medication errors in Turkey. Background Medication safety is an international priority, and medication error identification and reporting are essential for patient safety. Design A descriptive survey design consistent with the STROBE guidelines was used. Methods The participants were 135 nurses employed in a university hospital in Turkey. The survey instrument included 18 sample cases and respondents identified whether errors had been made and how they should be reported. Descriptive statistics were analysed using the chi-square and Fisher's exact tests. Results The sample case of "Patient given 10 mg morphine sulphate instead of 1.0 mg of morphine sulphate" was defined as a medication error by 97% of respondents, whereas the sample case of "Omitting oral/IV antibiotics because of the need to take the patient out for X-rays for 3 hr" was defined as a medication error by only 32.1%. It was found that eight sample cases (omitting antibiotics, diluting norodol drops with saline, giving aspirin preprandially, injecting clexane before colonoscopy, giving an analgesic at the nurse's discretion, dispensing undiluted morphine, preparing dobutamine instead of dopamine and administering enteral nutrition intravenously) were assessed as errors and reported, although there were significant statistical differences between the identification and reporting of these errors. Conclusion Nurses are able to identify medication errors, but are reluctant to report them. Fear of the consequences was the main reason given for not reporting medication errors. When errors are reported, it is likely to be to physicians. Relevance to clinical practice The development of a commonly agreed definition of a medication error, along with clear and robust reporting mechanisms, would be a positive step towards increasing patient safety. Staff reporting medication errors should be supported, not punished, and the information provided used to improve the system.