Abstract

Medication errors are commonly occurring in critical care and emergency departments transversely the states. This event was largely secondary to a series of effects that ultimately led to an increase in medication errors. To limit and alleviate these errors, it is essential to have a comprehensive knowledge of the medication-use practice in the ICU department and advance plans directed at each step. Almost of nursing time in the ICU is dedicated to medication-related processes and, therefore, nurses’ experiences with causes of those errors are important to elicit. Aim of the study: The study aimed to identify the causes of medication errors among nurses in the intensive care units of King Abdulaziz Hospital located in Mecca, Saudi Arabia. Method: A descriptive correlation cross sectional research design was utilized and 150 respondents were conveniently selected to participate in the study using the non-probability sampling technique. Result: The findings shows that the overall mean perception of nurses regarding the root causes of medication errors in the ICU was 3.58 with a SD of 1.07 which indicates that the majority of the identified causes were very rare. Furthermore, it also revealed that the demographic characteristics of the respondents were not significant to their perceived root causes of medication error which is supported by the p-value exceeded the 0.05 significance level. Conclusion: The most common medication admiration errors reported by the nurses in the intensive care units were heavy nurse workloads, interrupted thought processes, lack of medication knowledge, unaware of adverse drug effects, work pressures, poor professional relationships and communication among team members, unfamiliar abbreviations, hesitation to clarify doctors order, and medication names that looks like is necessary. Medication administration errors are a precarious part in patient safety issue and nurses are commonly accountable for administering medication to patients.

1. Introduction

It was observed that poor communication between nurses and physicians, drug names that sound alike and medications that look alike, improper use of medication abbreviations, environmental structure, ergonomics, noise altitudes, lighting, color, heating, ventilation, and air-cooling system al are considered environmental factors that impacting the incidence of medication errors ¹.

Incorrect dispensing can also lead to an increase in medication error rates; an increase of between 0.014%-55 percent has been found (BMJ Open Quality, 2018). It's inspiring to discover a systematic justification for errors and if medication errors are found it must search for a straight practicable solution that reduces the possibilities of a repeated event. By identifying unfortunate events that arise, learning from them, and dealing in the direction of avoiding them, in this case, patient safety may be enhanced ^{2, 3}.

However, a fragment of the solution is to maintain a culture that is aimed at identifying safety challenges and applying practical solutions instead of focusing on culture blame, humiliation, and penalty ⁴. Nursing errors are compounded when the hospital setting is overcrowded, prompting an increase in workload, evoking additional stress, exhaustion, and sleep deficiency among the healthcare personnel, which accelerates the incidence of further nursing errors ⁵.

Today's nursing practices' complexity makes interruptions, disruptions, and multi-tasking normal, even during complex and high-risk tasks ⁶. Meanwhile, the milestone report “To Err Is Human” was distributed by the National Academy of Medicine (NAM) in 2000; healthcare organizations and experts have amplified their target the decrease of medical errors ⁷.

Nursing errors may happen when delivering health care services, which yearly origin in a lot of patients' deaths, and, consequently, an upsurge in treatment costs ⁸. Nursing errors and proficiency can be hypothesized at two ranks, “active errors” and “latent errors”. An active error is one that is triggered by the individual on the forefront for example, medication administering. Latent error rises from errors occasioning from decisions maker in the organization such as work pressure, stress, and noise and so on ⁹.

Errors may happen at several phases of the treatment procedure, such as an incorrect treatment, incorrect or overdue laboratory results, inappropriate equipment, erroneous diagnosis, and indecorous or insufficient treatment in hospitals, doctors’ offices, clinics, surgery insides, ambulatory care, nursing homes, pharmacies, patients’ houses, critical care units, and care conveyed at home ¹⁰. But frequently, medical errors are adversative drug events and incorrect transfusions, surgical wrongs and maneuvers, restraint related damages or death, burns, suicides, bedsores, and erroneous patient characters ¹¹.

Medication errors can cause harm that would still escalate to costing the patient's life and costing the healthcare system billions of dollars every year. Although most medication errors are preventable, they occur frequently in acute care settings. It's estimated that almost one medication errors occur per day per hospitalized patient. Many errors progress without being noticed or don't cause any adverse effects. However, one medication error could cause a sentinel event for the patient and jeopardize a nurse's career ¹².

Each sub-step of the meditation practice is error-prone and errors may occur in the slightest some of the phases, although they're errors more common at some phases than others ¹³. It is known that errors in medication administration are common and preventable. Whether small or large, even an insignificant error made by a health care professional can cause huge problems and compromise patient safety. In the intensive care units (ICUs), patients are at the threat of being exposed to incidents due to extraordinary involvement in care, stark illness, core disease, and providing life-supporting treatment ¹⁴.

There is an emergent agreement that medication errors' need and might be reduced and managed and aggregating the rules necessitating that they are reported. The Joint Commission National Patient Safety Goals give a lot of standards to enhance patient safety and condense medical errors ¹⁵.

To prevent medication errors, the five pillars of medication administration should be carefully observed, which include the correct patient, drug, administration route, time, and dose ¹⁶. When a medication error occurs, it's commonly because of a mixture of things. The Institute for Safe Medication Practices (ISMP) has identified ten key elements to safe medication administration. If there's any weakness or problem in one of these elements, a medication error is probably going to happen ¹⁷.

Numerous factors founded to be the cause of nurses’ medication errors, containing environmental factors. The work environment consists of a lot of factors that impacting the incidence of medication errors such as working conditions, managerial climate, or job-related appearances. Physical factors of the work environment such as poor lighting can lead to errors in interpretation or reading of medication labels or prescriptions, also humble thermal and sound aspects can hypothetically upsurge the number of medication errors by generating stress in the health care personnel and is operative in the performance of nurses ¹⁸.

The multifaceted environment satisfied with equipment and alarm sounds is an added environmental influence that leads to medication errors in intensive care units. Rasheed, et al. 2018 ¹⁹ described the consequent environmental factors such as the absence of personal space in the working zone, the unfortunate design of the nursing stations, insufficient space in the medication recording places, the pint-sized medication chamber, consuming the imperfect apparatus and medical supplies, and inappropriate place of the nursing stations. Correspondingly, the appropriate design of the work environment can inhibit medication errors ¹⁸.

Is to determine the causes of medication errors among nurses in the intensive care units of King Abdulaziz Hospital located in Mecca, Saudi Arabia

1. What are the causes of medication errors encountered by the nurses in the intensive care unit of King Abdulaziz Hospital?

2. Is there a significant difference between the demographic characteristics and the causes of medication errors encountered by the nurses in the intensive care unit of King Abdulaziz Hospital?

2. Materials and Method

Research design; A descriptive cross-sectional study design was utilized in this study, to identify the causes of medication errors.

Settings; The study was conducted in the intensive care units of King Abdul-Aziz Hospital located in Mecca, Saudi Arabia to assess the causes of medication error.

Subjects; A convenient sampling technique was utilized in the study to select the sample size of the study. Before the beginning of data collection, the researcher first determines the population of interest for the research which were 200 hundred intensive care nurses working at King Abdul-Aziz Hospital, then the researcher use non probability convenience sampling technique to consciously select 150 nurses who are agreed and willing to participate in the study. The study included 150 intensive care nurses working at King Abdul-Aziz Hospital located in Mecca, Saudi Arabia from a total population of 200. The sample size was identified using the Slovin’s formula with a confidence level of 95% and a margin of error within ±5%. The calculation suggested having 132 respondents but the researcher added 18 to provide more accurate mean values.

Tools; the questionnaire was comprised of two parts. the first part is developed by the researcher, and it was included the socio-demographic data like (age and length of experience) the second, a part of the questionnaire was comprised of 35 questions adopted from a study done by Du Preez (2016) (20) so as to work out the foremost common causes and contributing factors of medication errors from nurses' viewpoint. A five-point Likert scale is wont to determine frequency responses including statements like ‘never (=1)’, ‘very rarely (=2) ‘sometimes (=3)’, ‘often (=4)’, and ‘always (=5)’.

The questionnaire's validity and reliability were established by its original author (20). The face and content validity of the questionnaire carried by ten critical care professors and Statistics consultants. After gathering the suggestions of those professors' minor changes developed to the questionnaire. To confirm the reliability of the questionnaire test-retest technique was castoff, which the correlation coefficients amongst the two shots answering the questions in nursing staff and undergraduate students were 89.0 and 91.0 correspondingly, and likewise the validity of the questionnaire was authorized

The ethical approval for this study was obtained from the FCMS Institutional Review Board. The face and content validity of the questionnaire carried by ten critical care professors and Statistics consultants. To confirm the reliability of the questionnaire test-retest technique was castoff, which the correlation coefficients amongst the two shots answering the questions in nursing staff and undergraduate students were 89.0 and 91.0 correspondingly, and likewise the validity of the questionnaire was authorized. A pilot study was done on 10% of the sample size to notice the simplicity and applicability of the tools. The nurses were selected according those inclusion criteria: The inclusion criteria were registered nurses including those with diploma and bachelor's and master's degree, working from the intensive care unit that provide direct nursing care to patients for at least 1 year in the unit. Nurses who did not meet the criteria were excluded from the study. Data collection was done by the researchers for 3 months from January 2022 till March 2022.

The researcher submitted the study proposal to Fakeeh College for Medical Sciences and King Abdul-Aziz Hospital Internal Review Board for review and approval. After the approval, the researcher started the data collection by distributing the tool to the respondents. The researcher obtained consent from the respondents before administering the adopted questionnaires. The data collected, sorted and submitted to the statistician for data treatment. The result was sent back to the researcher for analysis and interpretation.

The analysis of the collected data was performed using the Statistical Package of Social Sciences (SPSS) software (IBM Corporation v.26). Demographic data was managed as categorical and numerical variables; these data included (age and length of experience). Data entry for demographic variables was done using numeric code for each demographic variable in the questionnaire and it was presented using frequency and percentage. Additionally, weighted mean and standard deviation (SD) was utilized to analyzed and answered research question. Inferential statistics like independent sample t-test and ANOVA were accustomed to answer the research questions 3 to identify if there is a significant difference between the demographic profile and the root causes of medication errors encountered by the nurses in the 36 intensive care unit. The results were presented in tables and figures. Comments and interpretations were written for the results. Moreover, the researcher’s opinion in the results and private interpretation was presented.

3. Results

Table 1 shows the distribution of the respondent according to their characteristics. In relation to the gender, 50.7% were males and 49.3% were females accordingly. The age category of the respondents, were 45.3% is on the age range of 25-30 years old, 54% on the age range of 31-35 years old and 0.7% is on the range of 36-40 years old. In relation to the educational qualification of the respondents, 4% have diploma in nursing, 92% have bachelors’ degree in nursing and 4% have masters’ degree in nursing. regarding the length of experience of the respondents, were 17.3% has less than 1- 3 years’ experience, 44.0% has 4-6 years’ experience, 27.3% has 7-9 years’ experience, and 11.3% has more than 10 years’ experience. Table 2 shows the nurses’ perceived root causes of medication errors in the ICU. It appears that the overall mean perception of nurses regarding the root causes of medication errors in the ICU was 3.58 with a SD of 1.07 which indicate that majority of the identified causes were very rare. However, there are eleven occasional root causes of medication error that has been reported by the nurses. The following are medication names that looks like, failed communication, high patient/nurse ratio, hesitation to clarify physician’s order, use of abbreviations, another nurse is asked for clarification, and not the physician directly, nurses are not taught/trained to be aware of adverse drug effects, lack of medication knowledge by the 42 nurses, thought processes of the nurses are interrupted, and if the nurse are tired and exhausted. Table 3 shows the comparison of the nurses’ demographic data and their perceived root causes of medication error in the ICU. Regarding the gender, male nurses have a mean score 3.55 with a SD of 0.88 and female nurses have a mean score 3.60 with a SD of 0.79 and the mean difference was -0.04. It shows the p-value of .399 which exceeds the 0.05 significance level. This indicates that there is no significant difference between their gender and perceived root causes of medication error. regarding the age category, the respondents on the age 43 range of 25-30 years old has a mean of 3.75 with a SD of 0.80, respondents on the age range of 31-35 years old has a mean of 3.58 with a SD of 0.85, and the respondent on the age range of 36-40 years old has a mean score of 2.91 with a SD of 0.00. In relation to the educational qualification the table shows that the respondents who have a diploma in nursing has a mean of 3.50 with a SD of 0.91, respondents who have bachelor’s degree in nursing has a mean of 3.57 with a SD of 0.83, and respondents who have master’s degree has a mean of 3.56 with a SD of 0.76. Regarding the nurses length of experience the table also displays that respondents who have 1-3year experience has a mean of 3.74 with a SD of 0.72, respondents who have 4-6 year experience has a mean of 3.54 with a SD of 0.77, respondents who have 7-9 year experience has a mean of 3.64 with a SD of 0.95, and respondents who have more than 10 years’ experience has a mean of 3.92 with a SD of 0.78. The p-value was 0.201 which exceeds the 0.05 significance level. This indicates that there is no significant difference in the nurses’ perceived root causes of medication errors and their length of experience.

4. Discussion

Based on the result of the study the most common medication admiration errors reported by the nurses in the intensive care units are heavy nurse workloads (e.g.: high patient/nurse ratio), interrupted thought processes, lack of medication knowledge, unaware of adverse drug effects, work pressures, poor professional relationships and communication among team members, unfamiliar abbreviations, hesitation to clarify doctors order, and medication names that looks like is necessary.

Medication administration errors are a serious and critical patient safety issue. Nurses are commonly answerable for giving medicine to patients; consequently, their perceptions of causes of errors can reflect valued guidance for the prospect of nursing actions intended to reduce errors. Patient safety is a crucial challenge that faces the healthcare systems. The medication administration process is fundamental to patient safety, and errors in prescription administration can lead to an increased in mortality and morbidity in the health care setting, especially in the ICU ²¹.

Methods to lessen medication errors and develop patient safety and offer a high quality of care turn out to be big issues for argument globally ^{21, 22}. According to the World Health Organization (2016)’s determination of influences that lead to medication errors, they deliberated that the most common dominant causes were related to healthcare professionals ²³.

A systematic review held by Schroers et al. (2021) ²⁴ deliberated that the main knowledge-based factor of medication error was lack of medication knowledge. Personnel factors involved exhaustion and anxiety. Work-related factors comprised heavy workloads and disruptions. Work-related factors were conveyed in all the literature apprised and were repeatedly interrelated with personal and knowledge-based factors. While various supposed roots could evidently be recognized as uniquely a personal factor (for example, carelessness), the common personal and knowledge-based factors were interlocked. Moreover, supposed roots involved deficiency of drug knowledge, exhaustion, anxiety, heavy workloads, and disruptions.

A study conducted by Baraki et al. (2018) ²⁵ displayed that the foremost communal kinds of medication errors are, more than half of the participants perceive that it's related to the wrong dose, nearly one-third of them, perceived that it's related to wrong administration time and wrong patients. Another study conducted by You, et al. (2015) ²⁶ displays that the foremost common roots of medication errors that are perceived by nurses consist of nurses' shortage during shifts. They also stated that the other common root is the administration of drugs that look like or that have similar names or labels.

However, other studies reveal that heavy workloads and lack of staff can result in fatigue, physical exhaustion, and inattention in nurses which were all appeared to contribute to medication administration errors in the studies reviewed. Research on nurses’ workload has found that heavy nurse workloads cause frequent interruptions, stress, and hasty performance, which might increase medication administration errors ²⁷.

Lack of staff creates heavier workloads for nurses; Driscoll et al. (2018) ²⁸ found through their systematic review and met analysis that higher nurse staffing levels were related to decreased medication errors and reduced patient mortality. Another study publicized that there are five sorts of explanations why medication administrations errors are happening by nurses. These sorts comprised causes related to drug packaging, physician miscommunication, nursing schedules, pharmacy procedures, and drug recording ²¹.

The lack of information resulted in a wrong-time medication administration error. Inexperience and lack of coaching, which may be considered either personal or contextual factors, contribute to a lack of data. This error could have also been influenced by other contextual factors, like the shortage of supervision of inexperienced nurses, which may be a perceived contributor to medication administration errors ²⁹.

Moreover, interruptions and distractions were the foremost frequenting contextual factors that gave the impression to cause medication administration errors. Interruptions are known to be prevalent in health care settings and are related to an increased frequency ^{30, 31} and severity ^{24, 31} of medication administration errors ²⁸. Lack of confidence, a personal factor, in approaching a prescriber may be greatly influenced by contextual factors like the working relationships among the team members ¹⁴ and inter-professional communication ²⁴.

Nurses reported fear of looking incompetent and expectation of a negative response like anger as reasons they didn't seek out clarification on a medicine order from a provider. Poor communication in health care settings has been established as an explanation for errors ^{24, 32}. Improvement in staff communication is one among The Joint Commission 2020 National Patient Safety Goals ³³.

Less is thought about the factors that cause poor communication; however, this review offered some insights, as nurses intentionally do not communicate with a prescriber because of a fear of the prescriber’s response ²⁴. In an earlier study, it was conveyed that nearly half of the drug errors happened throughout night shifts, and likewise, the most common reason for medication errors was the nurses' heavy assignment ³⁴.

Manpower scheduling for nurses must be conducted consciously in order to display patient centered care in an efficient, professional, competent, harmless, and continuous manner. Nursing shortage and a mismatched nurse-to-patient proportion in Turkey is amongst the rationalizations for the emergent of medication errors. Nursing labor force arrangements for refining the nurse-to-patient proportion is a fundamental concern globally ³⁵.

What's more, it's imperative to work out the nurses’ awareness about the reasons of drug errors to antedate the incidence of medication errors and to introduce principles for increasing medication safety. Hence, it should be proposed to moderate the nurses' workloads and improvement of methodologies to extend the speediness of medication errors reporting ³⁶.

One of the abundant challenges that nurses' face is later they are allocated or affiliated across the hospital units as the medication chart they expenditure also varies. This eventuality causes insufficiency of data related to the medication information, counting the appropriate dose, the right medication time, the right drug route, drug-to-drug interactions, and contraindications ³⁷.

Appropriately, the study of Alharbi et al. (2021) ³⁸ confirmed that nurses can confront numerous hitches in gathering the right patient data, causing medication errors accompanying their managerial obligations. The manner of inhibiting medication errors is repeatedly enhanced by the overview of a patient history using electronic drug systems and other tools. This occasion supports the nurses' access to the wanted medication data in a very little period of time.

Al-Harkan et al. (2020) ³⁹ stated that the operation of medication guidelines is an essential, a part of the way of management and care of patients and it's deliberated as a noteworthy 49 element of a nurse’s assignment, and in the intervening time, patient safety has certain significance. In line with Keers et al. (2013) ²⁹ as cited by Berdot et al. (2021) ⁴⁰ additional error aggravating situations that impact administration errors might be apprised, as administrative factors (nursing shortage, miscommunication between the health care professionals, prescribing or providing errors, drug administration routes), discrete nursing factors (exhaustion, anxiety, unfamiliarity with specific prescriptions), patient influences (performance), and difficulties with the accessibility and storage (deficiency of medicine stocks on the units) of drugs.

Additionally, approaches to manage the administration practice and condense medication errors are recommended, comprising personnel-level interferences (preparation, nursing instruction, checklists, noticeable noiseless areas, double-checking, and confers) and administrative interferences (computerized drug provision and barcode-assisted medication administration system) ^{29, 40}.

The excellence of healthcare services in expressions of the safe administration of drugs will persist ambivalent if the problem of the under-reporting of medication errors rests unresolved. Medication errors are common in nursing performances, which are under-reported. This eventuality has adverse imports on patient care and safety. To inhibit medication errors, cooperation between the health care's personnel must be enhanced ²¹.

5. Conclusion

Medication errors are an all-too-common occurrence in emergency departments across the nation. This is largely secondary to a multitude of factors that create an almost ideal environment for medication errors to thrive. To limit and mitigate these errors, it is necessary to have a thorough knowledge of the medication-use process in the ICU department and develop strategies targeted at each individual step. A significant proportion of nursing time in the ICU is dedicated to medication-related processes and, therefore, nurses’ experiences with causes of those errors are important to elicit. So, this study conducted to identify the causes of medication errors among nurses in intensive care units: minimizing patient safety risk. Based on the results it can be concluded that shedding the light on both causes and contributing factors to medication errors and suggesting strategies to reduce the patient safety risk in the intensive care unit is very important because medication administration errors are a critical part in patient safety concern and nurses are frequently responsible for administering medication to patients, thus their perceptions of causes of errors can provide valuable guidance for the development of interventions aimed to mitigate errors

6. Recommendations

Based on the results of the study, the researcher recommends a combined intervention with an emphasis on hospital system change to mitigate the medication administration errors. The nursing administration should handle the commonly perceived factors of medication administration errors. Also, they must develop guidelines for nursing staff to avoid medication errors by instructing and training them on some skills such as double checks, consistent procedures, ensuring the five rights, proper documentation, using open communication methods, telling patients about medication they take, compliance on firm guidelines, refining labeling and package layout, concentrate on the work environment, decrease workload, find ways to inhibit distraction, improving job security for nurses, construct a cultural blame-free workplace, as well as hospital administration, should upkeep and review practices of error reporting, and range the warning of the significance of reporting. Based on the findings, the researcher also recommends future research on how to address the challenges of medication errors faced by ICU nurses.

This study was conducted over the critical care nurses who worked in King Abdul-Aziz Hospital. Extending the findings of the present study to other critical care nurses from different hospitals that haven't a different patient system or infrastructure or length of nurses or workload duties might be a controversial issue. Also, the study was conducted in the Makah Region. Therefore, the findings of the present study might not be applicable to other geographic regions in Saudi Arabia.

The ethical approval for this study was obtained from the FCMS Institutional Review Board. Consent was given to the respondents before administering the questionnaire. The respondents were assured that no threats or coercion was encountered while conducting the study and can freely withdraw their will to participate. The respondents ensured that all the collected data was kept confidential, and anonymous. Respondents were asked to not include their names or other identifying marks anywhere on the survey, or in their responses. No names were used on any documentation. Respondents was assured that no individual would be identified in any report or publication derived from the study. All aspects of the study, including the results, were retained strictly confidential. The data was only used for the intended explained purposes, in line with FCMS data protection principles. Participation in this study was not impulsive, meaning that the decision to refuse to take part or withdraw from the study. If respondents felt upset or distressed due to the questions, they could stop and withdraw from the study without giving a reason, as participation was voluntary.

References