Medication Administration Errors Research Articles

Child Age and Risk of Medication Error: A Multisite Children’s Hospital Study

ObjectiveTo examine associations between patient age and medication errors among pediatric inpatients. Study designSecondary analysis of datasets generated from two tertiary pediatric hospitals: (1) prescribing errors identified from chart reviews for patients on nine general wards at hospital A between April 22 to July 10, 2016, June 20 to September 20, 2017, and June 20 to September 30, 2020; prescribing errors from five wards at hospital B in the same periods; and (2) medication administration errors assessed by direct prospective observation of 5,137 administrations on nine wards at hospital A. Multilevel models examined the association between patient age and medication errors. Age was modeled using restricted cubic splines to allow for nonlinearity. ResultsPrescribing errors increased nonlinearly with patient age (P=0.01), showing little association from ages 0 to 3 years and then increasing with age until around 10 years, and remaining constant through the teenage years. Administration errors increased with patient age, with no association from 0 to around 8 years and then a steady rise with increasing age (P=0.03). The association differed by route: linear for oral, no association for intravenous infusions, and U-shaped for intravenous injections. ConclusionsOlder age is an unrecognized risk factor for medication error on general wards in pediatric hospitals. Contributors to risk may be the clinical profiles of these older children or the general level of attention paid to medication practices for this group. Further investigation may allow the design of more targeted interventions to reduce errors.

The Six Right Principles of Drug Administration to Patients with Diabetes Mellitus in Hospitals: A Case Study

Background: About one-third of adverse events are drug-related medication administration errors (MAE). One method to improve drug administration safety is the application of the six rights of drug administration which include right patient, right drug, correct dose, right time, right route, and proper documentation. Nurses must apply it generously and nursing professional students must be able to use it well too. Purpose: The purpose of this case study is to compare the application of the six right medicine principles between nursing and nursing professional students to Mrs. E with Diabetes Mellitus in Hospital. Methods: This case study uses a quantitative study approach with a comparative descriptive design. Data were obtained through observation for seven days with an observation measuring instrument for applying the six correct drug administration are consist of 33 statements. Respondents were obtained from purposive sampling consisting of 7 Nursing Profession students at the Faculty of Nursing, University of Jember, and seven nurses at the Hospital. Results: The difference in applying the six right principles of drug administration to Mrs. E for seven days (14 shifts) by 11 students and nurses (4.8%).  Conclusion: An indicator that still really needs to be improved by students and nurses is the true indicator of patients who are still below 50%. Meanwhile, the other indicators have achieved a total implementation of >70%.

Causes of medication administration errors and barriers to reporting as perceived by nurses in Saudi Arabia: A qualitative study.

Medication administration errors significantly impact patient safety, potentially leading to severe harm or fatality. Reporting such errors through active systems improves medication administration, thereby enhancing patient safety and the quality of care. However, in the context of Saudi Arabia, little is understood about the causes of medication administration errors and the obstacles hindering their reporting. This study aimed to explore nurses' perceptions of the causes of medication administration errors and the barriers to reporting them. The study employed a qualitative descriptive design, conducting face-to-face semi-structured interviews with 43 nurses from three hospitals in Taif Governorate, Saudi Arabia, between October and November 2023. Purposive sampling was used to recruit participants, and thematic analysis was utilized for data analysis. The following themes emerged regarding the causes of medication administration errors: order deficiencies, high workloads and staff shortages, and malpractice. Regarding the barriers to reporting errors, the emerging themes were fear of punishment and lack of support, lack of knowledge and awareness about reporting, and lack of feedback. This study reveals nurses' perceptions of the causes of medication administration errors and the barriers to reporting them. Recognizing and addressing these causes and barriers are essential for patient safety and the improvement of the healthcare environment. Efforts should be directed toward implementing interventions that address high workloads, enhance staff education and awareness, and promote a workplace culture conducive to reporting errors without fear of repercussions. Additionally, supportive mechanisms, such as feedback systems and resources for professional development, should be implemented to empower nurses to actively participate in error reporting and contribute to continuous improvement in medication administration practices.

The effect of electronic medical records on medication errors, workload, and medical information availability among qualified nurses in Israel– a cross sectional study

BackgroundErrors in medication administration by qualified nursing staff in hospitals are a significant risk factor for patient safety. In recent decades, electronic medical records (EMR) systems have been implemented in hospitals, and it has been claimed that they contribute to reducing such errors. However, systematic research on the subject in Israel is scarce. This study examines the position of the qualified nursing staff regarding the impact of electronic medical records systems on factors related to patient safety, including errors in medication administration, workload, and availability of medical information.MethodsThis cross-sectional study examines three main variables: Medication errors, workload, and medical information availability, comparing two periods– before and after EMR implementation based on self-reports. A final sample of 591 Israeli nurses was recruited using online private social media groups to complete an online structured questionnaire. The questionnaires included items assessing workload (using the Expanding Nursing Stress Scale), medical information availability (the Carrington-Gephart Unintended Consequences of Electronic Health Record Questionnaire), and medical errors (the Medical Error Checklists). Items were assessed twice, once for the period before the introduction of electronic records and once after. In addition, participants answered open-ended questions that were qualitatively analyzed.ResultsNurses perceive the EMR as reducing the extent of errors in drug administration (mean difference = -0.92 ± 0.90SD, p < 0.001), as well as the workload (mean difference = -0.83 ± 1.03SD, p < 0.001) by ∼ 30% on average, each. Concurrently, the systems are perceived to require a longer documentation time at the expense of patients’ treatment time, and they may impair the availability of medical information by about 10% on average.ConclusionThe results point to nurses’ perceived importance of EMR systems in reducing medication errors and relieving the workload. Despite the overall positive attitudes toward EMR systems, nurses also report that they reduce information availability compared to the previous pen-and-paper approach. A need arises to improve the systems in terms of planning and adaptation to the field and provide appropriate technical and educational support to nurses using them.

Paediatric medication incident reporting: a multicentre comparison study of medication errors identified at audit, detected by staff and reported to an incident system

ObjectivesTo compare medication errors identified at audit and via direct observation with medication errors reported to an incident reporting system at paediatric hospitals and to investigate differences in types and...

Inadvertent administration of intravenous anaesthesia induction agents via the intracerebroventricular, neuraxial or peripheral nerve route – A narrative review

Intravenous (IV) medication administration error remains a major concern during the perioperative period. This review examines inadvertent IV anaesthesia induction agent administration via high-risk routes. Using Medline and Google Scholar, the author searched published reports of inadvertent administration via neuraxial (intrathecal, epidural), peripheral nerve or plexus or intracerebroventricular (ICV) route. The author applied the Human Factors Analysis and Classification System (HFACS) framework to identify systemic and human factors. Among 14 patients involved, thiopentone was administered via the epidural route in six patients. Four errors involved the routes of ICV (propofol and etomidate one each) or lumbar intrathecal (propofol infusion and etomidate bolus). Intrathecal thiopentone was associated with cauda equina syndrome in one patient. HFACS identified suboptimal handling of external ventricular and lumbar drains and deficiencies in the transition of care. Organisational policy to improve the handling of neuraxial devices, use of technological tools and improvements in identified deficiencies in preconditions before drug preparation and administration may minimise future risks of inadvertent IV induction agent administration.

Critical Care Nurses’ Perception of Medication Administration Errors in Kelantan, Malaysia: A Cross-Sectional Study

Background. The study investigates critical care nurses’ perceptions of medication administration errors (MAEs) in a tertiary hospital in Kelantan, Malaysia, within the unique sociocultural context of East-Coast Malaysia. The research aims to understand the causes and underreporting of MAEs and assess the proportion of reported incidents according to MAE types. Methods. A cross-sectional study involving 424 critical care nurses from Hospital Raja Perempuan Zainab II (HRPZII), Hospital Sultan Ismail Petra (HSIP), and Hospital Tanah Merah (HTM) was conducted. Nurses in administrative roles or unavailable during the survey period were excluded. The study utilized a validated Medication Administration Errors Survey questionnaire to gauge nurses’ perceptions on the causes of MAEs, reasons for underreporting, and the percentage of reported incidents based on MAE types. Results. Results indicate that illegible medication orders from doctors were identified as the primary cause of MAEs, while a lack of 24-hour pharmacist availability received the lowest score. The most common reason for not reporting MAEs was identified as the nursing administration’s focus on individuals rather than systemic issues when errors occur. The majority of MAEs were non-intravenous, with incorrect timing of administration being the leading cause. Conclusion. The study sheds light on critical care nurses’ perspectives on MAEs in a Malaysian hospital setting, highlighting key factors contributing to these errors and barriers to their reporting. Understanding these perceptions is crucial for developing strategies to mitigate MAEs and enhance patient safety in critical care environments.

Effective implementations to reduce medication administration errors in a tertiary care teaching hospital

Background: Medication Administration Errors (MAEs) can lead to unmet therapeutic objectives as these errors can directly harm the patient and affect the outcome of therapy. Materials and Methods: This was an implementation research planned to evaluate the effect of interventions on the prevalence and severity of MAEs over three years, from 2020 to 2022, at a tertiary care hospital where clinical pharmacists were allotted to look into medication-related activities. Amedication error reporting form, developed by the pharmacologist, was used to collect MAE data. Analysis of this information aided in the planning of interventions to curtail the occurrence of such errors in the future. Interventions included drug and disease education leaflets, bedside training, vial/ampoule reading training, understanding different dose strengths, maintaining patient bedside boxes, antibiotic reconstitution leaflets for reference, and charts to guide safe drug administration. Results: The effect of these interventions was analyzed at the end of each year on the prevalence and nature of MAEs, where a decline of 38.97% was found in 2021 and a further 34.88% in 2022, considering the number of opportunities. The most prevalent was the wrong dose (~57%) errors commonly found with oral solid dosage forms and the cardiovascular group of drugs (42.5%). These MAEs were mainly of no harm category C (64%), while only 1.5% of them had caused harm (category E) to the patient, but none of these was sentinel. Conclusion: Interventions by clinical pharmacists successfully helped reduce MAEs and prevented patient harm in the further study period.

Examining Barriers and Perceptions in Reporting Medication Administration Errors among Nurses at the Tertiary Care Hospitals in Peshawar Pakistan

Medication administration is vital for patient safety, yet medication errors can lead to life-threatening situations and increased mortality rates. Nurses, being essential members of the healthcare team, are constantly present with patients and regularly tasked with drug administration, facing a significant burden of medication errors compared to other healthcare providers. Objectives: To explore the barriers and perceptions of nurses' regarding medication errors reporting in public sector tertiary care hospitals. Methods: A convenient sample of 209 staff nurses participated in this cross-sectional survey from June to October 2022. A three-part questionnaire was used to gather information on the general characteristics of nurses, the causes of medication errors, and the justifications for not reporting them. Results: The Pharmacy supplies inappropriate doses to this unit with a mean of (2.53 ± 1.28) and    an insufficient number of staff nurses in each working shift (4.23 ± 0.76) were the two least and most significant contributing factors to medication errors. Additionally, the two most and least significant factors for not reporting medication errors were that nurses may be held accountable if the patient suffered harm (3.94 ± 1.16) and that nurses did not agree with the hospital's definition of a medication error (2.33 ± 1.26) on average. Conclusions: The main causes of drug mistakes and failure to reveal them were nursing and management issues. Moreover, attempt to establish a blame-free culture to motivate reporting errors.  

Hospital Inpatient Nutrition Service Errors and Patient Safety Interventions: A Scoping Review.

Food service errors are prevalent in healthcare hospital inpatient settings. Like medication administration errors, these mistakes can result in disastrous consequences. This scoping review aimed to identify the evidence describing hospitals' nutrition department service errors and subsequent patient safety interventions. The review was conducted on four electronic databases, OVID MedlinePlus, PubMed, Scopus, and CINAHL, to search for articles reporting hospital food-related errors. All studies and reports on parenteral nutrition were excluded, and errors reported by departments other than nutrition services were excluded. A total of 245 studies published from 1984 to 2022 were identified. After removing duplicates, 98 abstracts were evaluated, with particular attention given to dietary errors, meal accuracy, and interventions. Twenty-nine articles were selected, and 14 (n = 14) were considered relevant to the review after a full-text review. More than half of the studies (n = 8) were conducted outside the United States. Eight studies (n = 8) were descriptive, retrospective, and observational; 3 were mixed-method studies (n = 3), 2 (n = 2) were quality improvement projects, and 1 was an implementation study (n = 1). Four (n = 4) studies were published before the year 2000. Various types of nutrition service inaccuracies were identified. The severity, causes, and stages of food service provision where errors occur were also documented. These errors were used as the basis for interventions to improve patient safety, justify implementing computerized dietary services systems, or add resources to augment dietary department service offerings. This review also generated valuable recommendations to promote patient safety by mitigating food service errors.

Nurses’ Perceptions of Patient Safety and Errors in Nursing Practice: A Qualitative Study

Despite all the advances in the healthcare sector, many adverse events that threaten patient safety still occur. Among these errors are those involving nursing. The study aimed to explore nurses’ perceptions regarding patient safety and errors in nursing practice. &#x0D; This is a descriptive study with a qualitative approach. An online, open-ended questionnaire was used. A total of 47 nurses from various healthcare institutions in different regions of Brazil took part in the study. Qualitative content analysis was carried out.&#x0D; Five themes were identified: (1) most common errors made during nursing practice; (2) feelings regarding errors that can occur during nursing practice; (3) measures taken to prevent errors during nursing practice; (4) actions taken after errors occurred during nursing practice, and (5) reasons for errors during nursing practice. The obtained results highlight that errors in medication administration, patient identification, patient mobilization, hand hygiene, and nursing documentation require special attention. Barriers caused by inadequate working conditions, poor communication, deficiencies in academic education, lack of in-service training and distractions were identified as reasons for errors in nursing practice. &#x0D; Administrators of educational and healthcare institutions, along with nursing educators and managers, play essential roles in developing strategies to prevent errors in nursing practice.

Developing a process to measure actual harm from medication errors in paediatric inpatients: From design to implementation.

The potential harm associated with medication errors is widely reported, but data on actual harm are limited. When actual harm has been measured, assessment processes are often poorly described, limiting their ability to be reproduced by other studies. Our aim was to design and implement a new process to assess actual harm resulting from medication errors in paediatric inpatient care. Prescribing errors were identified through retrospective medical record reviews (n =26 369 orders) and medication administration errors through direct observation (n =5137 administrations) in a tertiary paediatric hospital. All errors were assigned potential harm severity ratings on a 5-point scale. Multidisciplinary panels reviewed case studies for patients assigned the highest three potential severity ratings and determined the following: actual harm occurrence and severity level, plausibility of a link between the error(s) and identified harm(s) and a confidence rating if no harm had occurred. Multidisciplinary harm panels (n =28) reviewed 566 case studies (173 prescribing related and 393 administration related) and found evidence of actual harm in 89 (prescribing = 22, administration = 67). Eight cases of serious harm cases were found (prescribing = 1, administration = 7) and no cases of severe harm. The panels were very confident in 65% of cases (n =302) where no harm was found. Potential and actual harm ratings varied. This harm assessment process provides a systematic method for determining actual harm from medication errors. The multidisciplinary nature of the panels was critical in evaluating specific clinical, therapeutic and contextual considerations including care delivery pathways, therapeutic dose ranges and drug-drug and drug-disease interactions.

Admission Medication Reconciliation Discrepancies in Trauma Patients: Consistent Nursing Care May Not Be the Answer.

Inadvertent medication reconciliation discrepancies are common among trauma patient populations. We conducted a prospective study at a level 1 trauma center to assess incidence of inadvertent medication reconciliation discrepancies following decreased reliance on short-term nursing staff. Patients and independent sources were interviewed for home medication lists and compared to admission medication reconciliation (AMR) lists. Of the 108 patients included, 37 patients (34%) never received an AMR. Of the 71 patients that had a completed AMR, 42 patients (59%) had one or more errors, with total 154 errors across all patients, for a rate of 3.7 per patient with any discrepancy. Patients taking ≥ 5 medications were significantly more likely to have an incomplete or inaccurate AMR than those taking <5 medications (89% vs 41%, P < .0001). Decreased reliance on short-term nursing staff did not decrease inadvertent admission medication reconciliation discrepancies. Additional interventions to decrease risk of medication administration errors are needed.

Risk Factors Associated with Medication Administration Errors in Children: A Prospective Direct Observational Study of Paediatric Inpatients.

Limited evidence exists regarding medication administration errors (MAEs) on general paediatric wards or associated risk factors exists. The aim of this study was to identify nurse, medication, and work-environment factors associated with MAEs among paediatric inpatients. This was a prospective, direct observational study of 298 nurses in a paediatric referral hospital in Sydney, Australia. Trained observers recorded details of 5137 doses prepared and administered to 1530 children between 07:00h and 22:00h on weekdays and weekends. Observation data were compared with medication charts to identify errors. Clinical errors, potential severity and actual harm were assessed. Nurse characteristics (e.g. age, sex, experience), medication type (route, high-risk medications, use of solvent/diluent), and work variables (e.g. time of administration, weekday/weekend, use of an electronic medication management system [eMM], presence of a parent/carer) were collected. Multivariable models assessed MAE risk factors for any error, errors by route, potentially serious errors, and errors involving high-risk medication or causing actual harm. Errors occurred in 37.0% (n=1899; 95% confidence interval [CI] 35.7-38.3) of administrations, 25.8% (n=489; 95% CI 23.8-27.9) of which were rated as potentially serious. Intravenous infusions and injections had high error rates (64.7% [n=514], 95% CI 61.3-68.0; and 77.4% [n=188], 95% CI 71.7-82.2, respectively). For intravenous injections, 59.7% (95% CI 53.4-65.6) had potentially serious errors. No nurse characteristics were associated with MAEs. Intravenous route, early morning and weekend administrations, patient age ≥ 11 years, oral medications requiring solvents/diluents and eMM use were all significant risk factors. MAEs causing actual harm were 45% lower using an eMM compared with paper charts. Medication error prevention strategies should target intravenous administrations and not neglect older children in hospital. Attention to nurses' work environments, including improved design and integration of medication technologies, is warranted.

Patient-perceived understanding of home-going medication with transitions of care services at a pediatric institution

BackgroundTransitions of care (TOC) is the coordination and continuity of health care as a patient transfers between different settings. This can include a wide range of services, such as medication reconciliation, patient counseling, bedside delivery of medications, and others that meet individual patient needs. In the pediatric population, patients are at increased risk of potential medication errors and subsequent harm owing to reduced patient and/or caregiver health literacy, limited dosage form availability, and errors in medication administration. The use of TOC services at the time of hospital discharge in this population has the potential to make a positive impact on patient safety and the treatment of medical conditions. ObjectivesThe primary objective of this study was to determine whether patient-perceived understanding of home-going medications was greater in patients and/or caregivers who received medication bedside delivery and education from a pharmacy-led TOC service at a large pediatric academic medical center. The secondary objective was to determine whether the primary practice area of the pharmacist providing medication education led to changes in understanding of home-going medication(s). MethodsUsing institution-wide, patient satisfaction surveys from January 1, 2021, to December 31, 2021, patient and/or caregiver responses were queried for 2 questions about home-going medications, relating to the understanding of administration and the potential side effects. Patients were divided into 2 groups depending on TOC services received, as documented in the electronic medical record (EMR). Survey responses for each of the 2 questions were categorized as top-box percentage by study group. Hypothesis testing between study groups for the primary and secondary outcomes were conducted using chi-squared tests at an alpha of 0.05. Statistical analyses were conducted using SAS version 9.4. ResultsOf the 1159 patients included in the study, 441 received TOC services, deemed the intervention group, and 718 did not receive TOC services, deemed the control group. When the intervention and control group were asked about understanding of medication administration, 96.37% versus 93.18% of patients (P = 0.007) gave the most favorable response of “yes, definitely,” respectively. Furthermore, 78.51% versus 77.44% of patients (P = 0.053) gave the most favorable response when asked about understanding potential medication side effects, respectively. ConclusionPatients receiving TOC services by a member of the pharmacy team had a greater score for understanding of both medication administration and side effects. Furthermore, this greater score was consistent among the education provided by the inpatient and outpatient pharmacist.

Medication administration errors in the selected Czech hospitals: an observational study

Abstract Aim. The study aimed to identify the occurrence of medication administration errors in clinical practice. Material and methods. This was a direct observational study. The study included observing the medication administration process over three years in four hospitals in the Czech Republic. STROBE was used as a checklist. Results. A total of 18,370 medication administrations to hospitalized patients were observed and recorded, including morning, noon, and evening administrations. The most common MAE was substituting a prescribed medication without the doctor’s consent, especially among nurses aged 35-44 (p &lt; 0.001). These MAEs involved giving a medication of diff erent strength than prescribed (p &lt; 0.001), giving the wrong medication (p &lt; 0.001), and giving a diff erent dose (p &lt; 0.001). Substitutions of MAEs occurred most often during morning medication administration (p &lt; 0.001). Conclusions. A critical fi nding of this study was the substitution of medications without a doctor’s consent. It has been found that MAEs were not uncommon in clinical practice, and factors such as the nurse’s age, overall length of clinical practice, education, and workplace interruptions played a role.

Describing Medication Administration and Alert Patterns Experienced by New Graduate Nurses During the First Year of Practice.

The aim of this study was to describe medication administration and alert patterns among a cohort of new graduate nurses over the first year of practice. Medical errors related to clinical decision-making, including medication administration errors, may occur more frequently among new graduate nurses. To better understand nursing workflow and documentation workload in today's clinical environment, it is important to understand patterns of medication administration and alert generation during barcode-assisted medication administration. Study objectives were addressed through a descriptive, longitudinal, observational cohort design using secondary data analysis. Set in a large, urban medical center in the United States, the study sample included 132 new graduate nurses who worked on adult, inpatient units and administered medication using barcode-assisted medication administration. Data were collected through electronic health record and administration sources. New graduate nurses in the sample experienced a total of 587 879 alert and medication administration encounters, administering 772 unique medications to 17 388 unique patients. Nurses experienced an average medication workload of 28.09 medications per shift, 3.98% of which were associated with alerts, over their first year of practice. In addition to high volume of medication administration, new graduate nurses administer many different types of medications and are exposed to numerous alerts while using barcode-assisted medication administration.

Factors Influencing Medication Administration Errors as Perceived by Nurses in Pediatric Units in a Jordanian Tertiary Hospital: A Qualitative Descriptive Study.

The World Health Organization declared that medication errors are the third largest global patient safety challenge. The medication administration stage is a common and susceptible stage for medical errors to occur. To explore the factors contributing to medication administration errors specifically in pediatric care units as perceived by nurses in a Jordanian hospital. A qualitative descriptive study was conducted involving face-to-face audio-recorded interviews with 9 nurses in a tertiary hospital located in the north of Jordan. A convenience sampling technique was used to select the participants of our study. Data were collected between October 2022 and November 2022. The data were analyzed using inductive thematic analysis. Four themes emerged affecting medication administration errors in pediatric care units. These were environmental, staff, parents and patient, and medication-related factors. The findings of this study raise awareness of the most frequent sources of medication errors in a Jordanian hospital. Holding training and supervision to raise awareness among nurses and the availability of equipment and supplies could improve medication safety practices.

Health Literacy–Informed Communication to Reduce Discharge Medication Errors in Hospitalized Children

Inadequate communication between caregivers and clinicians at hospital discharge contributes to medication dosing errors in children. Health literacy-informed communication strategies during medication counseling can reduce dosing errors but have not been tested in the pediatric hospital setting. To test a health literacy-informed communication intervention to decrease liquid medication dosing errors compared with standard counseling in hospitalized children. This parallel, randomized clinical trial was performed from June 22, 2021, to August 20, 2022, at a tertiary care, US children's hospital. English- and Spanish-speaking caregivers of hospitalized children 6 years or younger prescribed a new, scheduled liquid medication at discharge were included in the analysis. Permuted block (n = 4) randomization (1:1) to a health literacy-informed discharge medication communication bundle (n = 99) compared with standard counseling (n = 99). A study team member delivered the intervention consisting of a written, pictogram-based medication instruction sheet, teach back (caregivers state information taught), and demonstration of dosing with show back (caregivers show how they would draw the liquid medication in the syringe). Observed dosing errors, assessed using a caregiver-submitted photograph of their child's medication-filled syringe and expressed as the percentage difference from the prescribed dose. Secondary outcomes included caregiver-reported medication knowledge. Outcome measurements were blinded to participant group assignment. Among 198 caregivers randomized (mean [SD] age, 31.4 [6.5] years; 186 women [93.9%]; 36 [18.2%] Hispanic or Latino and 158 [79.8%] White), the primary outcome was available for 151 (76.3%). The observed mean (SD) percentage dosing error was 1.0% (2.2 percentage points) among the intervention group and 3.3% (5.1 percentage points) among the standard counseling group (absolute difference, 2.3 [95% CI, 1.0-3.6] percentage points; P < .001). Twenty-four of 79 caregivers in the intervention group (30.4%) measured an incorrect dose compared with 39 of 72 (54.2%) in the standard counseling group (P = .003). The intervention enhanced caregiver-reported medication knowledge compared with the standard counseling group for medication dose (71 of 76 [93.4%] vs 55 of 69 [79.7%]; P = .03), duration of administration (65 of 76 [85.5%] vs 49 of 69 [71.0%]; P = .04), and correct reporting of 2 or more medication adverse effects (60 of 76 [78.9%] vs 13 of 69 [18.8%]; P < .001). There were no differences in knowledge of medication name, indication, frequency, or storage. A health literacy-informed discharge medication communication bundle reduced home liquid medication administration errors and enhanced caregiver medication knowledge compared with standard counseling. Routine use of these standardized strategies can promote patient safety following hospital discharge. ClinicalTrials.gov Identifier: NCT05143047.

Medication Administration Errors among Nurses and Midwives in Ghana

Medication Administration Errors among Nurses and Midwives in Ghana