Expert opinion survey on medication error awareness, reporting and its challenges among nursing leaders in India
DOI:
https://doi.org/10.18203/2320-6012.ijrms20253153Keywords:
Nurses, Healthcare management, Medication errors, Patient safety , Medication error reportingAbstract
Background: Medication errors (MEs) remain a significant concern in healthcare settings globally, particularly in India, where Nurses play a vital role in preventing MEs. This expert opinion survey explored the experience of nursing leaders in handling and reporting of MEs.
Methods: This expert opinion study was based on a descriptive survey conducted among 51 nursing leaders from top corporate hospitals in India. The survey consisted of 15 questions covering four key areas: (1) frequency and types of errors, (2) barriers to error reporting, (3) department-related factors, and (4) training/education. Responses were collected through an online self-administered questionnaire between June and November 2024.
Results: Most of the nursing leaders (96%) reported encountering MEs. Among them, 39.2% of respondents observed MEs weekly, while 19.6% encountered these errors daily. The common types of errors included prescribing errors (71%), dispensing errors (69%), wrong dosages (63%), and wrong timing (61%). Notably, 37% of nursing leaders perceived underreporting of MEs. Identified barriers to MEs reporting included extra time for documentation (47%), fear of blame (45%), lack of knowledge (47%), absence of anonymous reporting systems (33%), and inadequate information for reporting errors (31%). A significant proportion of respondents (86%) emphasized the need for more comprehensive training to improve ME reporting practices.
Conclusions: This survey highlighted the need for transformative changes in ME awareness and reporting in hospitals. Establishing blame-free, anonymous reporting systems and enhancing training are essential. Additionally, advanced technological solutions should be utilized to support nursing staff in improving patient safety via prevention of MEs.
Metrics
References
Coelho F, Furtado L, Mendonça N, Soares H, Duarte H, Costeira C, et al. Predisposing factors to medication errors by nurses and prevention strategies: a scoping review of recent literature. Nurs Rep. 2024;14(3):1553-69. DOI: https://doi.org/10.3390/nursrep14030117
WHO. Global burden of preventable medication-related harm in health care: a systematic review. 1st ed. World Health Organization; 2024.
Kumar S, Mal S, Manoj A. Assessment of medication errors of drugs in emergency department of a tertiary care teaching hospital. AJPR. 2024:125-8. DOI: https://doi.org/10.52711/2231-5691.2024.00021
Patel N, Desai M, Shah S, Patel P, Gandhi A. A study of medication errors in a tertiary care hospital. Perspect Clin Res. 2016;7(4):168. DOI: https://doi.org/10.4103/2229-3485.192039
Elliott RA. Economics of medication safety, with a focus on preventable harm. In: Jose J, Cox AR, Paudyal V, eds. Principles and Practice of Pharmacovigilance and Drug Safety. Springer International Publishing; 2024:105-133. DOI: https://doi.org/10.1007/978-3-031-51089-2_5
Roy AD, Kundu R, Gadre S, Sahoo P, Mazumdar S. A prospective study: impact of medication error in a tertiary care hospital. World J Pharm Pharm Sci. 2018;7(6):1148-54.
Parameshwari V. Prevention of medication errors by using failure mode effect analysis in a multi-speciality hospital. IJAR. 2021;7(5):08-11.
Mukherjee S, Mukherjee D, The Neotia University Kolkata, West Bengal, India, Singh WS, The Neotia University Kolkata, West Bengal, India. Incidences and classification of medication errors- a case study. Ro J Med Pract. 2023;18(4):192-7. DOI: https://doi.org/10.37897/RJMP.2023.4.6
Moudgil K, Premnath B, Shaji JR, Sachin I, Piyari S. a prospective study on medication errors in an intensive care unit. Turk J Pharm Sci. 2021;18(2):228-32. DOI: https://doi.org/10.4274/tjps.galenos.2020.95825
Zirpe KG, Seta B, Gholap S, Aurangabadi K, Gurav SK, Deshmukh AM, et al. Incidence of medication error in critical care unit of a tertiary care hospital: where do we stand? Indian J Crit Care Med. 2020;24(9):799. DOI: https://doi.org/10.5005/jp-journals-10071-23556
Mahmoud MA, Ibrahim AA, Alolayan SO. Medication-related challenges in lower middle-income countries of Asia: a review of four countries and recommendations for improvement. Syst Rev Pharm. 2020;11(11):355-9.
Raja V, Babu LN, Priyadarshini R. Knowledge, attitude, and practices related to medication errors among nursing professionals: a questionnaire-based study in a tertiary care hospital. Front Nurs. 2023;10(4):457-63. DOI: https://doi.org/10.2478/fon-2023-0048
Parthasarathi A, Puvvada R, Patel H, Bhandari P, Nagpal S. Evaluation of medication errors in a tertiary care hospital of a low- to middle-income country. Cureus. 2021 Jul 31;13(7). DOI: https://doi.org/10.7759/cureus.16769
Sewal R, Singh P, Prakash A, Kumar B, Medhi B. A prospective study to evaluate awareness about medication errors amongst health-care personnel representing North, East, West Regions of India. Int J App Basic Med Res. 2014;4(1):43. DOI: https://doi.org/10.4103/2229-516X.125694
Ravi R, Ramesh M, Chalasani SH, Mathias J, Kulkarni P. Barriers and facilitators of voluntary medication errors reporting according to the nursing staff in India. J Holist Nurs Midwife. 2024;34(1):71-81 DOI: https://doi.org/10.32598/jhnm.34.1.2580
Adil MS, Sultana R, Khulood D. PRIME study: Prescription review to impede medication errors. JRS. 2020;31(2):67-79. DOI: https://doi.org/10.3233/JRS-191025
Chaithra K, Sparshadeep E, Priyadarshini B, Rajesh B, Kavana V, Shabeena B, et al. Evaluation of pattern of medication errors in a tertiary care hospital in South India: A prospective observational study. Nat J Physiol Pharm Pharmacol. 2023;13(8):1. DOI: https://doi.org/10.5455/njppp.2023.13.06320202326062023
Bharathi BP, Raj J, Saldanha K, Suman Rao P, Devi DP. Medication errors in neonatal intensive care unit of a tertiary care hospital in South India: a prospective observational study. Indian J Pharmacol. 2020;52(4):260. DOI: https://doi.org/10.4103/ijp.IJP_611_19
Shrestha S, Ramanath K. Study and evaluation of medication errors in medicine and orthopedic wards of a tertiary care hospital. Br J Pharm Res. 2015;7(3):183-95. DOI: https://doi.org/10.9734/BJPR/2015/18736
Bhowmick S, Jana S, Bandyopadhyay A, Kundu D, Banerjee M, Das A, et al. Medication errors reported in a tertiary care private hospital in Eastern India: a three years experience. Int J Basic Clin Pharmacol. 2020;9(6):937. DOI: https://doi.org/10.18203/2319-2003.ijbcp20202186
Chalasani SH, Ramesh M. Towards patient safety: assessment of medication errors in the intensive care unit in a developing country’s tertiary care teaching hospital. Eur J Hosp Pharm. 2017;24(6):361-5. DOI: https://doi.org/10.1136/ejhpharm-2016-001083
Braithwaite J, Westbrook MT, Travaglia JF, Hughes C. Cultural and associated enablers of, and barriers to, adverse incident reporting. Qual Saf Health Care. 2010;19(3):229-33. DOI: https://doi.org/10.1136/qshc.2008.030213
Kagan I, Barnoy S. Organizational safety culture and medical error reporting by Israeli Nurses. J Nurs Schol. 2013;45(3):273-80. DOI: https://doi.org/10.1111/jnu.12026
JIPMER medication error reporting. https://jipmer.edu.in/sites/default/files/Medication-error-reporting-form.pdf. Accessed on 3 May 2025.
Rutledge DN, Retrosi T, Ostrowski G. Barriers to medication error reporting among hospital nurses. J Clin Nurs. 2018;27(9-10):1941-9. DOI: https://doi.org/10.1111/jocn.14335
Worringer B, Genrich M, Müller A, Gündel H, Contributors of the SEEGEN Consortium, Angerer P. Hospital Medical and Nursing Managers’ Perspective on the Mental Stressors of Employees. IJERPH. 2020;17(14):5041. DOI: https://doi.org/10.3390/ijerph17145041
Petrova E, Baldacchino D, Camilleri M. Nurses’ perceptions of medication errors in Malta. Nurs Stand. 2010;24(33):41-8. DOI: https://doi.org/10.7748/ns2010.04.24.33.41.c7717
Dahlawi S, Menezes RG, Khan MA, Waris A, Saifullah, Naseer MM. Medical negligence in healthcare organizations and its impact on patient safety and public health: a bibliometric study. F1000Res. 2021;10:174. DOI: https://doi.org/10.12688/f1000research.37448.1
Ministry of Home Affairs, Government of India. National Crime Records Bureau. ncrb.gov.in. 2023. Available from: https://ncrb.gov.in/crime-in-india.html. Accessed on 3 May 2025.
Ravi K, Devnath GP, James RI. Medical negligence in India: urgent call for comprehensive data, tort reforms, and cultural transformation to revitalize healthcare system. Med J Dr DY Patil Vidyapeeth. 2024;17(2):259-61. DOI: https://doi.org/10.4103/mjdrdypu.mjdrdypu_601_23
Savva G, Papastavrou E, Charalambous A, Vryonides S, Merkouris A. Exploring nurses’ perceptions of medication error risk factors: findings from a sequential qualitative study. Glob Qual Nurs Res. 2022;9:23333936221094857. DOI: https://doi.org/10.1177/23333936221094857
Ciapponi A, Fernandez Nievas SE, Seijo M, Rodríguez MB, Vietto V, et al. Reducing medication errors for adults in hospital settings. Cochrane Database Syst Rev. 2021;2021(11). DOI: https://doi.org/10.1002/14651858.CD009985.pub2
Billstein-Leber M, Carrillo CJD, Cassano AT, Moline K, Robertson JJ. ASHP Guidelines on Preventing Medication Errors in Hospitals. Am J Health-Syst Pharm. 2018;75(19):1493-517. DOI: https://doi.org/10.2146/ajhp170811
Grissinger M. The five rights: a destination without a map. Pharm Ther. 2010;35(10):542.
Wang HF, Jin JF, Feng XQ, Huang X, Zhu LL, Zhao XY, et al. Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: a trend analysis during the journey to Joint Commission International accreditation and in the post-accreditation era. Ther Clin Risk Manage; 2015: 393-406. DOI: https://doi.org/10.2147/TCRM.S79238
Ibarra-Pérez R, Puértolas-Balint F, Lozano-Cruz E, Zamora-Gómez SE, Castro-Pastrana LI. Intravenous administration errors intercepted by smart infusion technology in an adult intensive care unit. J Patient Saf. 2021;17(6):430-6. DOI: https://doi.org/10.1097/PTS.0000000000000374