Non-punitive Medication Error Reporting
Appraised by Students: Kennedie Boehm SN, Lauren Moug SN, Kalcey Schneider SN, Kendra Zins SN
NDSU School of Nursing Bismarck
Clinical Question: Does a non-punitive environment influence the reporting of medication errors?
Articles:
Farag, A., Blegen M., Gedney-Lose A., Lose D., and Perkhounkova Y. (2017). Voluntary medication error reporting by ED nurses: examining the association with work environment and social capital. Journal of Emergency Nursing, 43(3), 246-254.
Grant, M., & Larsen, G. (2007). Effect of an anonymous reporting system on near-miss and harmful medical error reporting in a pediatric intensive care unit. Journal of Nursing Care Quality, 22(3), 213-221.DOI: 10.1097/01.NCQ.0000277777.35395.e0
Potylycki, M. J., Kimmel, S. R., Ritter, M., Capuano, T., Gross, L., Riegel-Gross, K., & Panik, A. (2006). Nonpunitive medication error reporting. The Journal of Nursing Administration, 36(7), 370-376.
Yung, H., Yu, S., Chu, C., Hou, I., & Tang, F. (2016). Nurses' attitudes and perceived barriers to the reporting of medication administration errors. Journal of Nursing Management, 24(5), 580-588.
Synthesis of Evidence:
Four articles were reviewed as evidence in this report. All four of the studies were quantitative studies.
Farag, Blegen, Gedney-Lose, Lose, and Perkhounkova (2017) conducted a cross-sectional descriptive correlation study. The purpose of this study was to examine the relationship among work environment (including nurse manager leadership style and safety climate), social capital (including warmth and belonging to relationships and organizational trust), and nurses’ willingness to report medication errors. Data was collected using a questionnaire. The questionnaire included leadership styles (transformational and transitional), safety culture, safety climate (manager’s actions supporting safety, team work, communication openness, error feedback and communication about errors, organizational learning, non-punitive response to errors), and social capital (warmth and belonging, organizational trust). A convenience sample of emergency nurses working full time, part time, or as needed, and from 5 hospitals (3 community and 2 critical access) affiliated with one Midwestern health care system, was used. Seventy-one completed and usable surveys were mailed back and chosen. Results found that nurses’ willingness to report medication errors decreased as years of experience increased, willingness to report errors increased when they received more feedback about errors and when their managers used transactional leadership style.
Grant and Larsen (2007) conducted a prospective study. This study was conducted over 18 months, in a 32-bed combined medical and surgical PICU in a university-affiliated tertiary care facility. The intervention was implementing a new patient safety reporting system that was anonymous compared to the old one that was not anonymous. It was found that during the 18-month study 1,119 Patient Safety Reports were submitted versus 590 PICU traditional event reports. It was found the anonymous Patient Safety Reports captured more medication errors than thenon-anonymous reporting. Focusing on system changes and care processes rather than individual failure lends to increase medication error reporting.
A study by Potylycki et al. (2006)conducted a pretest and posttest and interventions study. The goal of this study was to identify underlying practices and attitudes on medication error incidences and how the practices of reporting were occurring. Baseline data was collected with a 45-question survey that was administered to all healthcare workers who are both involved in indirect and direct patient care with the authority to order, fill, and/or administer medications to patients. The questions focused on situations in which the staff would or would not report their medication errors, how errors were perceived and reprimanded, and their attitudes and beliefs on when to report errors. The pretest was used to craft an intervention of non-punitive error reporting programs. Results of the surveys found that errors with more serious outcomes will be reported more often than that of a less serious nature. The biggest barrier to medication error reporting was the perception that it carries the risks of disciplinary action. With this information, a non-punitive medication error reporting policy and educational training was implemented. After this was implemented a new questionnaire with the same 45-questions plus 3 new questions were given to staff. The findings after implementation were that staff were much more likely to report errors and learn from them when disciplinary actions were not the focus.
Yung, Yu, Chu, Hou, and Tang (2016) conducted a cross-sectional descriptive study. This study was done to explore the attitudes and perceived barriers to reporting medication administration errors and to understand the characteristic of and nurses’ feelings about error reporting. A three-part questionnaire was prepared. Part one was aimed at understanding nurses’ attitudes towards the reporting of medication administration errors (MAEs). Part two was aimed at understanding the barriers that nurses perceived to reporting MAEs. Part three was aimed at analyzing known MAEs in order to understand the actual reporting situations. The target participants were nurses who worked at one large teaching hospital (>2900 beds). Previous research demonstrated that intensive care unit (ICU), medical, surgical, pediatric and mixed wards had higher rates of MAEs, so nursing staff and nursing leaders (head nurses, supervisors and directors) working in those wards were set as our inclusion criteria and invited to participate. This study included 306 nurses. Results found that nurses’ attitudes towards medication administration error reporting were inclined towards positive. Our research found that nearly 90% (88.9%) of errors had been unofficially, orally reported, mainly to head nurses. Nurses were more comfortable and willing to report MAEs orally than by way of written documentation. It demonstrated that 88.9% of medication administration errors were reported orally, whereas 19.0% were reported through the hospital internet system. Self-recrimination was the common feeling of nurses after the commission of a medication administration error. Nurses articulate many barriers for being unwilling to report medication errors, but fear is the most prominent. It was found that nursing staff possessed more negative attitudes and perceived more barriers than nursing leaders. Previous research has found that young nurses were disinclined to report, perceived more reporting barriers and showed more negative responses to error reporting than senior nurses. Also, senior nurses have been found to be more likely to know how to access a form, to know what to do with it and to have experience of filling one out (Evans et al. 2006).
Conclusion:
Non-punitive error reporting policies foster an environment with less fear and increased incidence of learning from mistakes. The above evidence addresses error reporting in a non-punitive matter and shows a positive trend towards attitudes and incidences of reporting when a policy of this nature is implemented.
Implications for Nursing Practice:
There is evidence that a policy of medication error reporting with non-punitive repercussions creates a positive working environment. When staff feel more comfortable with reporting the errors that are made, the errors can be used for educational purposes and help others learn to not make the same mistakes.