PhD Research Scholar (Department of Pharmacy Practice) JSS College of Pharmacy, Mysuru Mysore, India
Background: Despite the existence of numerous frameworks to enhance medication safety, a number of factors have been identified to be associated to medication errors (MEs) acting at both the individual and organizational/ system levels.
Objectives: To identify the contributing factors (CFs) associated with the reported MEs.
Methods: A qualitative study was carried out for a period of 6-months in a tertiary care hospital in South India. Data collection forms were designed and developed to capture all the MEs occurring and their CFs. The NCC MERP scale was used to categorize the reported MEs. The concerned healthcare professionals (HCPs) who were involved in the reported MEs were subjectively interviewed. The open-ended questions were specific in order to elicit the opinion, experience, and behavior of the error-prone nature of the concerned HCPs involved in the MEs. Each interview was designed for about 20 - 30 minutes, which was recorded and transcribed. All the transcripts were uploaded into NVivo-12 for coding. Two reviewers individually analyzed the transcripts for possible themes and any discrepancies were resolved by a third reviewer. The data were entered into MS Excel and categorically analyzed.
Results: A total of 1567 MEs were reported amongst 835 study participants during the study period, for which 8177 CFs were identified. The average number of CFs per ME identified for a prescription was 5 factors. Amongst the total, CFs, [6392 (78.2%)] factors were due to prescribing, followed by [1480 (18.1%)] documentation errors, [227 (2.8%)] administration errors, and [78 (0.9%)] dispensing errors. A total of 17 themes were identified and coded from the responses given by the concerned HCPs. The most common themes that emerged during the interview with the HCPs were work-related stress [1538 (18.8%)], followed by peak working hours [1526 (18.7%)], workload [1511 (18.5%)], carelessness [1329 (16.3%)], lack of attention [1268 (15.5%)], new staff [279 (3.4%)], emergency situations [215 (2.6%)], fatigue [175 (2.1%)], communications [169 (2.1%)], distractions [78 (0.9%)], duty shift [42 (0.5%)], illegible prescriptions [15 (0.2%)], patient identification failure [10 (0.1%)], storage issues[7 (0.08%)], patient-related factors [7 (0.08%)], Look-alike/ Sound-alike drugs [7 (0.08%)], and interdepartmental patient transfer [1 (0.01%)].
Conclusions: HCPs experience intense mental and psychological factors such as anger, stress, workload, and so on. Fear of punishment and a prevailing ‘No-Blame’ culture in the workplace constitutes HCPs' hesitant behavior to report any MEs. Hence, there is a significant need for the advancement of a system that detects, identifies, and rectifies these CFs, thus preventing future occurrences of any MEs.
