Medication errors as malpractice-a qualitative content analysis of 585 medication errors by nurses in Sweden.

Karin Sparring Björkstén,Monica Bergqvist,Lina Benson,Eva Andersén-Karlsson,Johanna Ulfvarson

doi:10.1186/s12913-016-1695-9

Karin Sparring Björkstén, Monica Bergqvist + Show 3 more

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https://doi.org/10.1186/s12913-016-1695-9

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Abstract

BackgroundMany studies address the prevalence of medication errors but few address medication errors serious enough to be regarded as malpractice. Other studies have analyzed the individual and system contributory factor leading to a medication error. Nurses have a key role in medication administration, and there are contradictory reports on the nurses’ work experience in relation to the risk and type for medication errors.MethodsAll medication errors where a nurse was held responsible for malpractice (n = 585) during 11 years in Sweden were included. A qualitative content analysis and classification according to the type and the individual and system contributory factors was made. In order to test for possible differences between nurses’ work experience and associations within and between the errors and contributory factors, Fisher’s exact test was used, and Cohen’s kappa (k) was performed to estimate the magnitude and direction of the associations.ResultsThere were a total of 613 medication errors in the 585 cases, the most common being “Wrong dose” (41 %), “Wrong patient” (13 %) and “Omission of drug” (12 %). In 95 % of the cases, an average of 1.4 individual contributory factors was found; the most common being “Negligence, forgetfulness or lack of attentiveness” (68 %), “Proper protocol not followed” (25 %), “Lack of knowledge” (13 %) and “Practice beyond scope” (12 %). In 78 % of the cases, an average of 1.7 system contributory factors was found; the most common being “Role overload” (36 %), “Unclear communication or orders” (30 %) and “Lack of adequate access to guidelines or unclear organisational routines” (30 %). The errors “Wrong patient due to mix-up of patients” and “Wrong route” and the contributory factors “Lack of knowledge” and “Negligence, forgetfulness or lack of attentiveness” were more common in less experienced nurses. The experienced nurses were more prone to “Practice beyond scope of practice” and to make errors in spite of “Lack of adequate access to guidelines or unclear organisational routines”.ConclusionsMedication errors regarded as malpractice in Sweden were of the same character as medication errors worldwide. A complex interplay between individual and system factors often contributed to the errors.

Highlights

Many studies address the prevalence of medication errors but few address medication errors serious enough to be regarded as malpractice
The present paper reports the second phase where all Medication errors (MEs) during 11 years where a nurse was found responsible by the National Board of Health and Welfare (NBHW) were analyzed using the above classification system
The aim of this work was to increase the understanding of potentially hazardous MEs by nurses with regard to the type of error, the individual contributory factors and the work experience of the nurse and the system contributory factors of the workplace

Summary

Introduction

Medication errors (MEs) are probably the most common type of patient safety incidents worldwide and cause harm to patients, distress to medical staff and costs to the health care system. Systematic reporting of errors is fundamental for detecting patient safety problems, but there is no consensus neither concerning the terminology of MEs nor the error reporting systems. The International Medication Safety Network (IMSN) aims to develop a common and systematic terminology as a basis for powerful prevention strategies [2]. The five most common methods for detecting MEs are: 1) studies of errors reported to the authorities, 2) studies of errors reported spontaneously to local reporting systems, 3) screening of medication orders and patient medical charts, 4) observational studies, and 5) qualitative studies in which healthcare personnel are interviewed. A non-punitive ME reporting system, can be used to learn from errors, provide feedback to those involved and improve routines

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