Medication Error Reporting Research Articles

Risk Factors, Causes, and Strategies for Reducing Medication Errors: A Narrative Review

Abstract— Medication errors, which refer to any deviation from the prescribed medication regimen, can have seriously affected patient safety and treatment outcomes. It underscores the need for healthcare professionals to follow medication orders precisely and to be vigilant in preventing errors throughout the medication use. This process involves different stakeholders, including specialists, therapists, apothecaries, patients, and their relatives. Medication errors tend to be more prevalent in hospital settings due to various factors related to the complexity of patient care, the fast-paced environment, and the involvement of multiple healthcare professionals in the medication process. The current review was conducted for reporting medication errors, risk factors, causes, and strategies for reducing medication errors in previous articles from 2015 to 2023. The brief review showed that multiple studies have reported a high incidence of medication errors following hospital discharge. These errors can include prescribing errors, incorrect dosing, medicine interactions, and omissions or duplications of medication. Medication errors following hospital discharge can lead to adverse drug events, which can result in patient harm, hospital readmissions, and increased healthcare costs. Also; some studies have evaluated the effectiveness of transitional care interventions and strategies in reducing medication errors and adverse drug events (ADEs). These interventions can include medication reconciliation processes, post-discharge follow-up, patient education programs and electronic medication management system. By addressing these interventions, future studies and interventions can contribute to improving medication safety following hospital discharge and advancing the global safety agenda.

Factors Influencing Novice and Beginner Nurses' Intention to Report Medication Errors and Near Misses.

Novice and beginner nurses make more medical errors than senior nurses. However, there is significant underreporting of medication errors and near misses among novice and beginner nurses. To identify the factors that influence the intention of novice and beginner nurses to report medication errors and near misses. A cross-sectional exploratory study was carried out among third-year nursing students in a Quebec university (n = 143). Data was collected through a self-reported questionnaire based on the adapted Theory of Planned Behavior. Simple descriptive analyses and a series of contingency analyses were performed using Chi-2 or Fisher exact tests. Correction of multiple tests was done using Bonferroni test. All theoretical constructs were significantly associated with intention. Sociodemographic factors (age, sex, experience and education program) were also associated with intention. Further studies are needed to identify the determinants of intention to report medication errors and near misses among novice and beginner nurses. More attention is required in nursing practice and education to act on these factors, thus encouraging novice and beginner nurses to report medication errors and near misses.

KNOWLEDGE AND ATTITUDE OF NURSES ABOUT MEDICATION ERROR IN THE EMERGENCY DEPARTMENT AT TERTIARY CARE HOSPITAL

Medication errors are a significant concern in healthcare, particularly in emergency departments where high workloads and resource limitations increase the risk of errors. Nurses play a critical role in minimizing medication errors through proper knowledge and positive attitudes toward error reporting. However, in Pakistan, the prevalence of medication errors remains high, and little is known about the knowledge and attitudes of nurses in this context. Objective: To assess the knowledge and attitudes of nurses regarding medication errors in emergency departments of tertiary care hospitals. Methods: A descriptive cross-sectional study was conducted among 135 nurses using a validated questionnaire. Data were analyzed using SPSS version 26, with descriptive statistics summarizing knowledge and attitude scores. Results: All participants (100%) identified medication errors as a significant preventable cause of harm. While most nurses demonstrated moderate knowledge, 54.1% expressed reluctance to report errors due to fear of being labelled troublemakers, and 76.3% agreed that fear of blame influenced their decision to avoid reporting errors. Nearly half (49.6%) were neutral regarding the impact of managerial reactions on their willingness to report errors. Conclusion: Despite moderate knowledge, negative attitudes toward reporting medication errors persist among nurses. Addressing these issues through education, policy reform, and fostering a culture of safety and accountability is essential for improving patient safety in Pakistan’s emergency departments.

Medication Errors in Psychiatric Hospitals: A Nationwide Real-World Evidence Study in Saudi Arabia.

Background: Medication errors are among the most prevalent medical errors and result in significant morbidity and mortality. They pose a major threat to patient safety in psychiatric hospitals. However, the lack of a comprehensive investigation into the root causes of these errors restricts the development of effective corrective measures. Objective: This study aimed to characterize the types of errors, determine the stages of the medication use process, and identify factors associated with errors occurring among government psychiatric hospitals in Saudi Arabia. Methods: This cross-sectional study was conducted from August 2019 to June 2020. All medication error reports submitted to the Ministry of Health General Administration of Pharmaceutical Care database from 18 government psychiatric hospitals in Saudi Arabia were assessed. The database is de-identified and contains information on all medication errors, including patient demographics, medication information, error information, causes of errors, and reporter information. Medication use was categorized as ordering/prescribing, transcribing, dispensing, administration, and monitoring. The present findings represent a descriptive analysis of the data using Statistical Analysis Software (SAS) version 9.4. Result: A total of 23,355 medication error reports were reported to the database during the study period. Among Saudi Arabian cities, Riyadh (n = 8972, 38.4%) had the highest medication error reporting rate, followed by Taif (n = 3705, 15.9%) and Jeddah (n = 2621, 11.2%). Most reported errors were frequently made by physicians (n = 20,284, 86.9%) and were primarily detected by pharmacists (n = 20,974, 89.8%). Approximately half of them (n = 13,150, 56.3%) were classified as "Category B" that occurred, but they did not reach patients. Most medication errors were reported in adults (n = 22,589, 96.7%) and male patients (n = 16,393, 70.2%). Most error reports were detected at the prescription stage (n = 16,481; 70.6%) during the medication-use process. Work overload of the staff (n = 2911, 12.8%) and drug labeling, packaging, and nomenclature (n = 2826, 12.1%) were the most common contributing factors associated with the reported errors. Olanzapine (n = 1650, 7.1%), omeprazole (n = 1350, 5.8%), and quetiapine (n = 1273, 5.5%) were the most common medications associated with medication errors. Conclusions: Preventable medication errors are typical in psychiatric hospitals and may result in severe consequences. Increased efforts are needed to control and minimize prescribing errors and improve reporting in Saudi Arabia.

A stepped wedge randomised controlled trial assessing the efficacy and patient acceptability of virtual clinical pharmacy in rural and remote Australian hospitals

BackgroundDespite medication being the most common healthcare intervention and medication-related incidents being common in hospitals, many rural and remote hospitals in Australia lack onsite pharmacy services due to resource constraints. A Virtual Clinical Pharmacy Service (VCPS) staffed by two senior, rural generalist hospital pharmacists assigned to four hospitals each was implemented in rural and remote facilities to determine whether the VCPS increased adherence to National Safety and Quality Health Service Standards (NSQHS).MethodsA stepped-wedge randomised controlled trial was employed to sequentially implement a telehealth pharmacy service at one-month intervals in eight hospitals. The primary outcomes were patient-level medication reconciliation completion rates on admission and discharge. Secondary measures evaluated compliance with other NSQHS standards (including Best Possible Medication History, Medication Reconciliation and venous thromboembolism risk assessment), patient outcomes (including representation within 48 h, readmission within 28 days and length of stay), and detection of potential medication-related harms (including pharmacist identified medication related problems, reported medication errors and falls). Patients were invited to complete a patient-reported experience questionnaire. Data were collected from electronic medical records and analysed using mixed logistic regression models to estimate the effectiveness of the VCPS. Antimicrobial usage, falls, and medication errors were analysed at the facility level, while other data were analysed at the patient level.ResultsCompared to control (n = 535), patients in the intervention period (n = 527) were more likely to have an admission medication reconciliation completed (Odds Ratio (OR) 11.16, 95% confidence interval (CI) 5.59–22.30, p < 0.001) in models adjusted for the study period. A similar improvement was observed for discharge medication reconciliation completion (OR 4.07, CI 2.38–6.95, p < 0.001), whereas a 33-fold improvement was seen in Best Possible Medication History completion (OR 33.27, CI 17.53–63.14, p < 0.001). The VCPS documented 879 medication related problems, with 61% of patients having at least one medication-related problem documented by a pharmacist. There was no change in length of stay, falls, readmission rates or reported medication error rates; however, the study was not powered to detect these changes. Patient feedback was positive and comparable to in-person care, with 95% (179/189) reporting their overall experience as ‘good’ or ‘very good.’ No unintended harms were reported.ConclusionsThe VCPS improved compliance with national standards for medication safety, had high patient acceptability and resulted in the detection of clinically relevant medication-related issues in rural and remote settings. The applicability of virtual pharmacy should be explored in further rural and remote locations in addition to other settings such as metropolitan locations with no onsite clinical pharmacists.Ethics numberGWHREC 2019/ETH13355.Trial registrationANZCTR registration number ACTRN12619001757101. Registered on 11/12/2019. Published trial protocol: A stepped wedge trial of efficacy and scalability of a virtual clinical pharmacy service (VCPS) in rural and remote NSW health facilities.

Factors influencing the reporting of medication errors and near misses among nurses: A systematic mixed methods review.

This study aimed to systematically review empirical evidence on factors influencing nurses to report medication errors and near misses. There is underreporting of medication errors among nurses, in particular among novice and beginner nurses. To improve quality of care, factors influencing the reporting of medication errors and near misses should be documented. A systematic mixed methods review was conducted. CINAHL, Cochrane Collaboration, Embase, Medline, PsycINFO and Web of Science databases were explored and analysed from December 1990 to December 2023. Two reviewers independently selected and extracted data using a standardized data extraction grid. Data were analysed using thematic analysis based on the adapted theory of planned behaviour. Forty-two studies met the eligibility criteria. Principal factors influencing the reporting of medication errors and near misses among nurses were associated with perceived behavioural control, subjective norm and attitude. Few studies examined factors influencing reporting medication errors and near misses among novice and beginner nurses, and sociodemographic and professional factors. To understand factors influencing reporting of medication errors and near misses, further studies should be conducted to investigate sociodemographic and professional factors.

Improvement proposals and actions in medication error reports: Quality and strength: A cross-sectional study.

Medication errors (MEs) are a significant source of preventable harm in patient care. Voluntary incident reporting and ME reporting systems are essential for managing medication safety. Analyzing aggregated ME reports instead of individual reports can reveal organizational risks. Organizational culture influences reporting activity and the effectiveness of safety improvements depends on their system-focus. This study uses aggregated ME reports to investigate the ME management process and reporting culture in medication safety. It aims to create a hierarchy for ME improvement actions and analyze their strength and management flow in aggregated reports. A retrospective, cross-sectional study was conducted to review improvement proposals and actions of ME reports in a Finnish tertiary hospital in 2017-2021. The improvement proposals and actions were categorized into strength classes during three stages: reporter proposals, manager proposals, and documented actions. The report management flow was analyzed. Descriptive statistics were used to describe the characteristics and the chi-squared test for categorical variables in the statistical analysis. A new strength classification hierarchy was created with three classes and corresponding numerical values: "strong (3)," "medium (2)," and "weak (1)" Additionally, categories for "no action (0)" and "vague (0)" were included. Out of 5463 ME reports analyzed, improvement proposals and actions were predominantly weak, ranging from 23.4% to 54.2% across different stages of the management process. A significant proportion had no action included (20.5-49.1%) or were vague (4.2-20.6%). Analyzing the strength of improvement proposals and actions in aggregated ME reports provides new insights into reporting culture and the ME management. The new combined strength classification hierarchy is a suitable tool for this analysis.

Incidence and type of voluntary reported perianesthetic medication errors in community veterinary clinics in Calgary, Canada.

To collect medication error (ME) data during the perianesthetic period from small animal clinics. 6 small animal general practice veterinary clinics. Small animal general practice veterinary clinics were recruited in this prospective observational study, with staff given a presentation on medical errors and instructed on how to submit medication error reports to an online reporting system. Errors were classified according to type and timing. A total of 2,728 general anesthesia or sedation procedures were performed, with 49 ME reports submitted. One duplicated report of the same error was excluded, resulting in a ME rate of 1.8%. Most reports (69% [33/48]) were near misses. The remaining 31% were MEs that reached the patient but did not cause harm. Wrong dose errors were the most common type (63% [30/48]), of which 80% (24/30) were calculation errors. Premedication/sedation and maintenance were the most reported stages, at 47% (20/43) and 23% (10/43), respectively. None of the MEs reported resulted in an adverse event, with an approximately 2:1 ratio of near-miss to no-harm MEs. The observed patterns of MEs reported, including type and timing, represent a target for further education. These results quantify the ME rate in general practice veterinary clinics, providing an initial benchmark for MEs during the perianesthetic period.

Addressing Medication Administration Safety Through Simulation: A Quasi-Experimental Study Among Nursing Students.

Healthcare institutions are dedicated to minimizing medication errors and promoting their reporting. This study investigates the impact of simulation on nursing students' attitudes toward and intention to report medication errors. A quasi-experimental one-group pre-post-test study was conducted. Third-year nursing students (N = 63) participated in a scenario-based simulation for medication administration. Participants' errors were documented. Participants self-reported attitudes toward medication administration safety and intention to report errors. The most reported error was "contraindicated in disease" (61%). The simulation increased attitudes of preparedness by the training program received (p < 0.01) and belief in the patient's involvement in preventing errors (p < 0.01), and decreased the belief that professional incompetence reveals errors (p = 0.015). Intention to report errors was influenced by medication error training received (p = 0.045), confidence in error reporting (p < 0.001), and a sense of responsibility to disclose errors (p = 0.001). Simulation effectively shapes attitudes and intentions regarding medication error reporting. Improving nursing students' awareness, skills, and clinical judgment can foster a safety culture and potentially reduce patient harm. Future research should examine the long-term effects of simulation and its impact on reducing medication errors.

Antiretroviral adverse drug events reported among adult HIV patients in a Nigerian tertiary hospital: A retrospective study

Background: The use of Highly Active Antiretroviral Therapy (HAART) has changed HIV/AIDS from a near-certainly fatal illness to one that can be managed chronically. A significant constraint of HAART is the high prevalence of adverse drug events (ADE) among HIV patients taking them. Objectives: The study determined the frequency and severity of reported antiretroviral adverse events among HIV-infected adults (≥16 years) at the Institute of Human Virology (IHV) Clinic of Nnamdi Azikiwe University Teaching Hospital Nnewi, Anambra State, Nigeria, within five years. Antiretroviral therapies implicated in the reported adverse drug events were also determined. Method: Information on reported ADEs was extracted from the NAFDAC Pharmacovigilance forms in the Pharmacovigilance section of the IHV Clinic Pharmacy. The severity of ADEs was classified using the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index for categorizing errors. Results: A hundred and nineteen (119) patients reported 161 ADEs within the 5-year study period (2017-2021). Most ADE reports came from females (74.53%) and patients 36-55 years old. Dizziness (31.1%), Rashes (14.3%), and Fatigue (13.0%) were prominent among all the ADE reports documented. TDF/3TC/EFV (57.8%) and AZT/3TC/NVP (11.8 %) combinations were the frequently implicated antiretroviral regimen. All the ADEs reported were mild (Category ‘E’). ADE reports appreciated in the second year and progressively declined afterwards. Conclusion: There is a need to improve the system for antiretroviral ADE reporting through sensitization and developing a specific tool that enhances ADE reports from patients and healthcare providers.

A Comprehensive Analysis of Medication Errors on Antimicrobials in a Tertiary Care Hospital of Northern India

Background: Medication errors, resulting from incomplete understanding, pose significant risks to patient safety. Antimicrobial medication error is a global concern further exacerbated by underreporting. This study aims to determine the prevalence of antimicrobial medication errors at a tertiary care medical facility. Methodology: A retrospective study was conducted over six months. Antimicrobial medication errors were analyzed and categorized as prescription, transcription, indenting, dispensing, and administration errors. A total of 208 antimicrobial medication errors were analyzed using the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) risk index. Results: Among 6,439 medication charts assessed, 558 (9%) medication errors were identified, with antimicrobial errors accounting for 208 (37.2%). Prescription errors were the most prevalent (61%), followed by transcription errors (16%) and administration errors (11%). Dispensing, indenting, and documentation errors occurred at rates of 8%, 2%, and 2%, respectively. The primary causes of errors were incorrect doses (47.2%) and frequencies (30%). Approximately 55.3% of antimicrobial medication errors were classified as Category C according to the NCCMERP risk assessment. Conclusion: Prescription errors represent the majority of antimicrobial medication errors, underscoring the need for enhanced vigilance among consultant physicians during prescription writing and drug schedule checks.

Impact of pharmacist-led discharge medication reconciliation on error and patient harm prevention at a large academic medical center.

Medication errors during hospital discharge can lead to adverse outcomes, medication-related readmissions, and increased health care costs. Pharmacist-led medication reconciliation at discharge is a potential solution to mitigate poor outcomes and optimize medication safety. This study aimed to quantify medication errors identified at discharge and characterize the severity of patient harm prevented following pharmacist-led discharge medication reconciliation. Cost avoidance analysis was conducted to determine its associated financial impact. Patients discharged from an adult internal medicine service during October 2022, were included in this one-month pilot prospective quality improvement study. Number of errors at discharge were documented, categorized by type, and adjudicated for severity of potential harm. Error severity was classified based on a modified National Coordinating Council for Medication Error Reporting and Prevention Medication Error Index. Cost avoidance was calculated based on whether each error would have resulted in additional medical encounters and length of stay. Thirty-one patients were included in the analysis. Forty errors were identified by pharmacist-led medication reconciliation at discharge, with a mean of 1.3±1.9 errors per patient and 68% of patients having at least one error. The most common errors were duplication of therapy (25%) and medication access barriers at discharge (25%). The severity of errors included low (22.5%), serious (75%), and life-threatening harm (2.5%). Thirty-five percent of errors could have led to emergency visits or hospital readmissions. The estimated total cost for errors was $25,600. Pharmacist labor cost for reconciliation was $816. Cost avoidance was $24,784 from the 14 errors at discharge that could have resulted in additional emergency or inpatient visits. Pharmacist-led medication reconciliation at discharge may prevent harm from reaching patients, decrease cost from unnecessary health encounters, and stop the error from continuing across transitions of care.

Association Between Professional Commitment and Reported Medication Errors in Nurses

Association Between Professional Commitment and Reported Medication Errors in Nurses

Detection of Adverse Events With the Austrian Inpatient Quality Indicators.

Indicators based on routine data are considered a readily available and cost-effective method for assessing health care quality and safety. The Austrian Inpatient Quality Indicators (A-IQI) have been introduced in all Austrian public hospitals as a mandatory quality measurement. The purpose of this study was to assess the value of conspicuous A-IQI in predicting the presence of adverse events (AEs). We conducted an exploratory study comparing all indicator-positive patient cases contributing to 18 conspicuous A-IQI indicators to randomly selected indicator-negative control cases regarding the prevalence and severity of AEs. Structured medical record review using the Institute for Healthcare Improvement Global Trigger Tool was used as the gold standard. In 421 chart reviews, we identified 158 AEs. 70.9% (n = 112) of the AEs were found in cases with a positive indicator. The relative risk of an AE occurring was 3.47 (95% confidence interval: 2.30, 5.24) in indicator-positive cases compared to indicator-negatives. The proportion of severe events (National Coordination Council for Medication Error Reporting and Prevention Index categories H and I) was 54.5% (n = 61) in indicator-positive cases and only 15.3% (n = 7) in indicator-negative cases. Overall sensitivity of the A-IQI was 68.2%, specificity 69.4%, positive predictive value 36.0%, and negative predictive value 89.6%. Our study shows that significantly more AEs and more severe AEs were found in cases with positive A-IQI than in indicator-negative control cases. However, studies with larger numbers of cases and with larger numbers of conspicuous indicators are needed for the validation of the entire A-IQI indicator set.

Prevalence of Medications Errors and Factors of Harmful Errors in Neonates and Paediatrics at Tertiary and Paediatric Hospitals: A Multicenter Study

Medication errors (ME) are human mistakes that may occur during drug use, prescribing administration or monitoring. This study aimed to determine the Prevalence of MEs among pediatric patients receiving tertiary treatment in pediatric speciality hospitals and describe their patterns and causes. Three institutions participated in a multicenter retrospective analysis. Reports of all MEs involving paediatrics aged ≤13 years who were hospitalised or visited the Emergency Department or outpatient clinics were reviewed 1 January 2019 - 31 December 2019. The National Coordinating Council for Medication Error Reporting and Prevention classification was used to categorise MEs and to define PRME (category CI) and patient–harming MEs (category EI). A retrospective study was conducted with a total of 318 MEs reported, with an overall prevalence of 0.9 per 1,000 patients. The Prevalence was markedly lower in the CHT (0.35 / 1,000 patients) than in KAMC and KFSH&amp;RC (1.73 and 3.5). The highest rate of MEs was observed in admitted wards (14.69 / 1,000 patients). Most commonly, MEs occurred at the prescribing stage (81.1%), were caused by a physician (83.3%), and were discovered by the pharmacist (85.5%). Improper medication dosage (34.0%), frequency (14.2%), and duration (10.4%) were the three most common forms of MEs. Paediatric inpatient treatment has a significant frequency of MEs, accounting for 24% of hospitalisations. The ME may not get to the patient if independent double-check prescriptions, accurate medication reconciliation of new prescriptions against the previously prescribed, and improved medicine labelling and packaging techniques are used.

Evaluation of medication errors in one of the largest public hospital: A retrospective study

BackgroundIn hospitals, medication errors still occur, especially in developing countries such as Indonesia. However, most incidents can be prevented. ObjectiveTo evaluate medication prescription errors for in and out-patients at hospitals based on pharmacists' reports of medical errors. MethodsA retrospective study was carried out between January and December 2021. Pharmacists analyzed medication error reports based on age, sex, drug name list or quantity recorded, prescription listed in the medication error report, and length of hospital stay.Statistical analysis of drug interaction and the factors affecting potential drug interactions was carried out by using multiple linear regression. ResultsApproximately 338 medication errors from 251,491 prescriptions were recorded by pharmacists across hospital departments in 2021. The age of patients with medication errors ranged from newborn babies to 86 years old, with an average of 40.9 years old (±21.03). The most common types of medication errors were prescribing errors (184, 54.4 %). The average length of hospital stay was 11.35 days (±10.36). A total of 557 potential drug interactions were recorded in 182 (53.85 %) prescriptions. The risk for potential drug interaction is increased by the number of medications per prescription (COR = 3.361, P < 0.001) and the age (COR = 1.001, P = 0.033). ConclusionsThe number of medication errors reported was 0.13 per 100 prescriptions, and most of these errors did not affect patients and were, therefore, not harmful. However, further research is needed to analyze medication error reports through collaboration with hospital healthcare professionals.

An Exploration of Nurses' Attitudes and Beliefs on Reporting Medication Errors.

Medication errors in health care are prevalent. Nurses play an important role in reporting; however errors remain underreported in incident reporting systems. Understanding the perspective of nurses will inform strategies to improve reporting and build systems to reduce errors. The purpose of this study was to explore nurses' perceptions and attitudes of medication error reporting practices. This qualitative study used direct content analysis to analyze interview sessions with 21 total nurses. Participant's description of medication error reporting practices fell into 2 themes. Internal factors described circumstances within nurses themselves that affect reporting. External factors described outside influences from processes or places. Medication error reporting is a multidimensional phenomenon with internal and external factors impacting nurses' attitudes and willingness to report errors. Nurses need support from leadership to understand that reporting medication errors can improve practice and impact patient outcomes.

Estimating Proportion and Barriers of Medication Error Reporting Among Nurses in Hail City, Saudi Arabia: Implications for Improving Patient Safety.

Determining the proportion of nurses reporting medication errors (MEs) and identifying the barriers they perceive in ME reporting are crucial to encourage nurses to actively report MEs. This study aimed to determine the proportion of nurses experiencing and reporting MEs, perceived barriers to reporting MEs and their association with nurses' sociodemographic and work-related characteristics. A cross-sectional study was conducted among 350 nurses from June to November 2023. Data about sociodemographic and work-related characteristics, and ME reporting, were collected using a validated self-administered questionnaire. The study found that 34.3% of nurses reported MEs, while 11.1% reported experiencing MEs during their practice. ME reporting was higher proportion among nurses who were older than 40 years (52.1%), males (41.4%), held a master's degree (58.7%), Saudi nationals (37.8%), experienced for more than 10 years (43.1%), working in intensive care units (44.3%), working for 48 hours or more per week (39.7%), working in hospitals with a nurse-to-patient ratio of 1:3 (44.9%) and having a system for incident reporting (37.7%) and with no training on patient safety (44.6%) compared to their counterparts. The rate of experiencing MEs was higher proportion among nurses who were older than 40 years (16.7%), males (17.3%), married (14.8%), Saudi nationals (13.4%), experienced for more than 10 years (15.6%) and with no training on patient safety (15.3%) compared to their counterparts. Lack of knowledge of the person responsible for reporting MEs was the most frequent perceived barrier to ME reporting (66.6%), followed by fears of blame (65.4%). In this study, nurses reported and experienced MEs during their practice. Most nurses perceive the lack of knowledge and fear of blame or disciplinary actions as barriers to reporting. Healthcare administrators should implement educational programs and workshops to increase nurses' awareness of ME reporting.

Competency-Based Medication Administration and Error Reporting.

Accuracy is needed with medication administration, a skill that involves rule-based habits and clinical reasoning. This pilot study investigated the use of an evidence-based checklist for accuracy with oral medication administration and error reporting among prelicensure nursing students. Checklist items were anchored in the mnemonic C-MATCH-REASON© (Client, Medication, ADRs, Time, Client History, Route, Expiration date, Amount, Site, Outcomes, Notation). Nineteen participants randomly assigned to crossover sequence AB or BA (A: checklist; B: no checklist) practiced simulation scenarios with embedded errors. Nursing faculty used an observation form to track error data. Using the C-MATCH-REASON© checklist compared with not using the checklist supported rule adherence (p = .005), knowledge-based error reduction (p = .011), and total error reduction (p = .010). The null hypothesis was not rejected for errors found (p = .061) nor reported (p = .144), possibly due to sample size. C-MATCH-REASON© was effective for error reduction. Study replication with a larger sample is warranted. [J Nurs Educ. 2024;63(5):320-327.].

Reducing Discharge Medication Reconciliation Errors at a Pediatric Neurology Inpatient Unit.

Medication reconciliation errors are a common problem in health care, particularly during transitions of care. Discharge medication reconciliation (DMR) errors in a pediatric setting can range from 26% to 42.2%. We conducted a quality improvement project to decrease DMR error rate at Dayton Children's Hospital in Dayton, Ohio. We conducted 2 interventions, each with 3 Plan-Do-Study-Act cycles from September 2021 through February 2023. The first intervention focused on using current specialty neurology nurses as scribes and creating a template note to include the plan of care and review of DMR before discharge. Our second intervention consisted of standardizing the seizure rescue medication order by creating an order panel within our electronic medical record system for all the rescue medications presently available. Medication errors were documented by the specialty neurology nurse during a phone conversation on the next business day post discharge. DMR error rates were calculated for each week using a control chart. Medication errors and patient harm were classified according to the National Coordinating Council for Medication Error Reporting and Prevention Index. One hundred six errors were noted. Of these, 98 (92%) occurred in patients with seizure and 64 (60%) were related to prescription of seizure rescue medication specifically. The baseline error rate was calculated at 15.7% or 7 errors per month (January 2021 through June 2021). The average error rate dropped from 15.7% to 5.3% (2 errors per month) after initiation of our first intervention (September 2021). Twelve weeks after initiation of the second intervention, a 2.9% (1 error per month) was noted. Afterward, there was a ten-week period of 0% errors. Sustainable reduction of DMR errors in pediatric patients with epilepsy was achieved by using specialty neurology nurses to scribe the care plan and creating order panels to facilitate accuracy of discharge medication orders without additional cost to the hospital.