Medication error reporting: A survey of nursing staff

The objective of this article is to describe findings from a medication err or (ME) survey, to estimate the extent of ME underreporting by comparison o f survey results with written incident reports (IRs), and to determine fact ors associated with IR reporting of MEs. Participants were registered nurse s from the 38-bed infant unit of a pediatric hospital. Most recent ME in ea ch of four stages of the medication process was classified as to: tinting, nature, whether the error was prevented from the patient, patient injury, a nd completed IR. Surveys were administered to nurses during mandatory skill s session and were compared with IRs for MEs for the previous 6 months. The survey response rate was 93.5 percent; 72 nurses described 177 errors, 40. 3 percent observed an ME in the previous week, 62.1 percent were prevented from reaching the patient and the likelihood of prevention was reduced in t he later stages of the medication process. About 30 percent of MEs resulted in IRs. Administration errors were more likely to result in IRs compared w ith ordering errors, especially when the error was not prevented from the p atient. There were 51 IRs for MEs. A multivariate logistic regression with completed IRs as the dependent variable showed a decreased likelihood of IR s for ordering than administration errors. IRs were more likely for wrong m edication or dose errors and IRs were less likely for errors prevented from reaching the patient. The study found that by augmenting IR reporting of M Es and classifying errors by stage, anonymous ME surveys can be used for mo nitoring and guiding improvements to hospital medication systems.