International Journal for Quality in Health Care, 2015, 27(4), 276–283 doi: 10.1093/intqhc/mzv036 Advance Access Publication Date: 8 June 2015 Article

Article

Perceptions regarding medication administration errors among hospital staff nurses of South Korea MI-AE YOU1, MI-HYEON CHOE2, GEUN-OK PARK2, SANG-HEE KIM2, and YOUN-JUNG SON3 1

College of Nursing, Ajou University, Suwon, South Korea, 2Soonchunhyang University Hospital, Cheonan, South Korea, and 3Department of Nursing, Soonchunhyang University, Cheonan, South Korea

Address reprint requests to: Youn-Jung Son, Department of Nursing, Soonchunhyang University, Soon Chunhyang 6 Gil 31, Dongnam-gu, Cheonan 330-100, South Korea. Tel: +82-41-570-2487; Fax: +82-41-570-2497; E-mail: [email protected] or [email protected] Accepted 4 May 2015

Abstract Objective: To identify reasons for medication administration errors (MAEs) and why they are unreported, and estimate the percentage of MAEs actually reported among hospital nurses. Design: A cross-sectional survey design. Setting: Three university hospitals in three South Korean provinces. Participants: A total of 312 hospital staff nurses were included in this study. Main outcome: Medication administration errors. Results: Actual MAEs were experienced by 217 nurses (69.6%) during their clinical career, whereas 149 nurses (47.8%) perceived that MAEs only occur less than 20% rate. MAEs occurred mostly during intravenous (IV) administrations. Nurses perceived that the most common reasons for MAEs were inadequate number of nurses in each working shift (4.88 ± 1.05) and administering drugs with similar names or labels (4.49 ± 0.94). The most prevalent reasons for unreported MAEs included fears of being blamed (4.36 ± 1.10) and having too much emphasis on MAEs as a measure of nursing care quality (4.32 ± 1.02). The three most frequent errors perceived by nurses for non-IV related MAEs included administering medications to the incorrect patients and incorrect medication doses and drug choices. The three most frequent IV related MAEs included incorrect infusion rates, patients and medication doses. Conclusions: Nurse-staffing adequacy could be helpful to prevent MAEs among nurses as well ongoing education, and training regarding safe medication administration using the problem-based simulation education. In addition, encouraging nurses to identify and report work related errors in a non-punitive milieu will increase error reporting. Key words: hospitals, medication errors, nurses, patient safety

Introduction Patent safety has long been a major concern for health care professionals and its significance has expanded with the increasing need for hospital accreditation [1, 2]. Medication errors have been identified as the most common type of errors affecting patient safety and the most common single preventable cause of adverse events [3].

Although preventing the mediation errors in patient safety is very important, there are no structured guidelines or policies available for disclosing medication errors to the patients in South Korea. Therefore, it is also necessary to develop strategies to improve medication safety [4]. Medication errors are multidisciplinary in nature and include prescribing, dispensing and administration errors that result in incorrect

© The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved

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Medication administration errors • Medication Errors medications, administration routes, doses, inappropriate continuation of medications, omission of doses or administering medications to patients despite knowing that they are allergic to the medication [3]. Nurses are intimately involved in and ultimately responsible for the delivery of medication [5]. The medication administration process is a daily component of nursing practice and is often viewed as a routine and basic nursing task. Nurses spend up to 40% of their work time on medication administration [6]. However, nurses often practice under suboptimal organizational conditions in terms of staffing, organization of work and the work environment [7]. The medication administration errors (MAEs) rate varies because of the differences in the definitions of MAE, error categories, departments, medication distribution system and countries. In a systematic review of 45 studies, it was revealed that the prevalence of medication errors was 2–75% in studies that included a generic definition of medication errors [8]. Tissot et al. [9] observed MAEs during a period of 20 days in two departments at a university hospital; the medication error rate was 14.9%, and dose errors (i.e. omission, unauthorized or incorrect dose) were the most frequent types of errors (41%), followed by incorrect time (26%) and rate errors (19%). The overall nonintravenous (IV) and IV related MAE rates in hospitals in the United Kingdom were 5.6 and 35%, respectively [10]. Studies related to medication errors in South Korea are limited compared to other countries because most hospitals are reluctant to report medication errors. Recently, Kim et al. reported that 63.6% of nurses with a minimum of 1 year clinical experience were involved in medication errors more than once in the past month and only 28.3% of them reported the medication errors formally. Kim et al. [1] used the survey questionnaire that was developed by the researcher through literature review and they have no process of evaluating the validity and reliability. Oh and Yoon studied the rate of perception and experience in medication errors in targeted new nurses with less than 1 year clinical experience [11]. Average perception rate of nurses in 22 items about medication errors was 86.7%. Experience rate of medication errors among nurses was 23 and 46.3% out of those reported the medication errors. In South Korea, there are approximately 2800 hospitals including 44 tertiary hospitals [12]. Under the Healthcare Accreditation Program launched in 2010 [13], hospitals have introduced hospital-wide incident-reporting systems to meet the requirement of implementing patient safety-reporting systems. Nevertheless, no official statistics on the scale and magnitude of mediation errors in South Korea are available [4]. Reporting of errors is essential for developing strategies to prevent and reduce medication errors because the health care community can learn from previous mistakes. However, nurses are reluctant to report medication errors because of fears of blame. In addition, most hospitals are reluctant to reveal incident reports of medication errors because of potential damage to the hospitals’ reputation. Therefore, it is very difficult to obtain useful and accurate data about medication errors. More importantly, preventing medication errors depends on precise reporting, and it is important to evaluate the reasons staff nurses avoid error reporting [14, 15]. Therefore, there is a need to identify the perceptions of nurses regarding MAEs and prepare strategies to enhance patient safety. A proper understanding of why MAEs occur and why they are often unreported and the extent to which errors are actually reported is the first step towards preventing MAEs. The purpose of this study was to identify and describe reasons for MAEs and why they are often unreported, and to determine the incidence of reported non-IV and IV related MAEs by hospital staff nurses in South Korea.

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Methods Study design This study was a cross-sectional survey conducted by self-reported questionnaires.

Participants The study sample was comprised of nurses working at the three Soonchunhyang University affiliated general hospitals with in a 780–840 bed in Seoul, Bucheon and Cheonan city, South Korea. Nurses who have been working in these three hospitals take charge of 15–20 patients per duty, respectively. The number of participants from each hospital were 100 (A hospital), 100 (B hospital) and 112 (C hospital). Inclusion criteria were the registered nurses (RNs) who provided direct patient care and had been employed for more than one year. The RNs in higher positions, such as administrators of nursing departments, and male nurses were excluded from the study for the following reason: few male nurses exist in South Korea. Furthermore, the manager position of each job category was also excluded because we only wanted to evaluate employees who contact and provide care to the patients directly. A total of 350 subjects participated in the study. Finally, 312 nurses were included in this study because 38 subjects did not complete the questionnaires.

Measures To investigate the nurses’ perception of MAE, we used the MAE selfreported questionnaire developed by Wakefield et al. [16]. After approval from the MAEs questionnaires developer, the questionnaires were initially translated into Korean and then back-translated into English. To improve content validity, we consulted two faculty nurses and five head nurses with actual content validity more than 0.85; the questions were modified as a pilot test for 20 nurses. The questionnaires consisted of three sections; (i) 29 items regarding reasons for the occurrence of MAEs; (ii) 16 items regarding reasons for why MAEs are unreported and (iii) 20 items regarding the percentage of actually reported non-IV and IV related MAEs (9 and 11 items, respectively). For the first two sections, each item was evaluated with a 6-point Likert scale (i.e. 1 = strongly disagree; 6 = strongly agree). To score the survey, means and standard deviation can be calculated for individual items for the first two sections of survey [16]. Cronbach’s alpha was 0.95 in this study. For the third section, each item were asked ‘Have you ever experience each type of medication errors?’ and were dichotomous question ‘yes’ or ‘no’.

Data collection After receiving approval from the institutional research board (IRB-2012-91), data were collected between January and February 2013. After hospital selection, the self-administered questionnaire package was provided to the participants. The package included an introductory letter, informed consent form, the questionnaire and a reply envelope with return postage prepaid. Informed consent and the completed questionnaire were obtained from each participant using separate envelopes. Given the sensitive topic of this study, the main concern was to gain participants willingness and trust so that they would provide faithful information about the medication errors in which they have been involved. The researcher informed the participants that access to the surveys would be tightly controlled by the researchers and no names of hospitals or persons would not be revealed in any manner for their confidentiality.

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Data analysis Data were analyzed by descriptive statistics (frequency, percentages, means and standard deviation) using SPSS for windows 18.0 (SPSS Inc., Chicago, IL, USA).

Results General characteristics of hospital staff nurses A total of 312 nurses were included in this study. The mean age was 29 years (standard deviation [SD] = 5.48 years); 197 (63.2%) nurses were under 29 years; 135 (43.3%) had completed college or graduate education. The mean years of total clinical experience was about 5.93 years (SD = 13.55 years); 122 (39.1%) nurses were working at the medical unit. The number of nurses reported that they experienced MAEs during their clinical career was 217 (69.6%). A total of 182 (58.3%) nurses reported that the most frequent routes of MAEs were made by IV administrations (Table 1).

Nurses’ perceptions regarding reasons for MAEs The most common reason for MAEs according to the nurses was inadequate number of staff nurses in each working shift (4.88 ± 1.05). The second most common reason for MAEs was administering a drug with a similar name or label as another drug (4.49 ± 0.94) and a drug that appeared similar to another drug (4.44 ± 1.03). However, errors made in the medication Kardex (medication Kadex is illegible) (2.72 ± 1.09), and medication orders not transcribed to the Kardex correctly (2.77 ± 1.06) were the least common reasons for MAEs (Table 2).

Nurses’ perceptions about reasons for unreported MAEs The most common reason for unreported MAEs was the fear of being blamed if something happened to the patients (4.36 ± 1.10). The second most common reason was having too much emphasis on MAEs as a measure of the quality of care (4.32 ± 1.02). However, the least common reasons for MAEs were the idea that expecting medications to be administered exactly as ordered is unrealistic (2.39 ± 1.17) and nurses not recognizing that an error has occurred (2.54 ± 1.15; Table 3).

Perceived non-intravenous and intravenous related MAEs The highest prevalent non-IV related MAEs included drugs administered to the wrong patient (63.5%), drugs administered as a wrong dose (62.5%) and an incorrect drug choice (61.9%). The highest prevalent IV related MAEs included medications administered with an incorrect infusion rate (66.0%), drugs given to the incorrect patient (60.3%) and drugs administered at an incorrect dose (59.3%). The least prevalent non-IV and IV related medication errors included administering a medication that was known to be allergic to a patient (31.4 and 34.3%, respectively) and those relating to poor communication between nurses and doctors (32.4 and 34.3%; Tables 4 and 5, respectively).

Discussion Preventing MAEs represents a central focus of hospital quality improvement and risk management initiatives. The administration of medication is predominantly the responsibility of nurses and an important part of nursing practice that affects patient safety and quality

Table 1 General characteristics of subjects (N = 312) Characteristics

n (%)

Age (years) ≤24 54 (17.3) 25–29 143 (45.9) 30–34 65 (20.8) ≥35 50 (16.0) Education level Diploma 177 (56.7) Above college 135 (43.3) Unit type Medical 122 (39.1) Surgical 92 (29.5) ICU/ER 51 (16.3) Pediatrics/Obstetrics 47 (15.1) Nursing experience in current unit (years) 1–2 135 (43.3) 3–4 108 (34.6) ≥5 69 (22.1) Total clinical career (years) 1–2 119 (38.1) 3–4 111 (35.6) Experience of MAEs Yes 217 (69.6) No 95 (30.4) Routes of MAEs Intravenous 182 (58.3) Oral 58 (18.6) Subcutaneous 48 (15.4) Intramuscular and others 24 (7.7) Frequency of received education for medication errors 1–2 110 (35.3) 3–4 89 (28.5) ≥5 113 (36.2) Perceived rate of reporting for MAEs 0–20% 149 (47.8) 21–30% 66 (21.2) 31–40% 39 (12.5) 41–50% 14 (4.5) 51–60% 15 (4.8) 61–70% 8 (2.6) 71–80% 8 (2.6) 81–90% 8 (2.6) 91–100% 5 (1.6)

Mean ± SD 29.22 ± 5.48

3.67 ± 12.75

5.93 ± 13.55

of health care services. Education regarding the administration of medications is provided for nurses to prevent medication errors at hospitals because nurses are positioned at the final stage to prevent medication errors before administering medications to patients. Therefore, finding the causes and solutions to MAEs should be a top priority for any health system. In the present study, 69.6% of nurses reported that they experienced MAEs during their career. A direct comparison of results needs to be done with caution because of the differences in subject characteristics, such as period of clinical career, working unit, recall period of experienced errors and definitions of MAEs. This result was lower compared to another study in which 92.6% of Korean nurses were reported to experience MAEs during 3 months [17] and higher than the 32.4% French nurses that observed a medication error during 1 week [9]. Cheragi et al. [18] reported that 64.6% of Iran nurses to have experiences of medication errors during 3 months. Nurses in South Korea tend to work long hours and are relatively

Medication administration errors • Medication Errors

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Table 2 Reasons for the occurrence of MAEs (N = 312) Items

1. Similar drug names or labels 2. Different medications look alike. 3. Similar drug paking 4. Physicians’ medication orders are not legible. 5. Physicians’ medication orders are not clear. 6. Physicians change orders frequently. 7. Abbreviations are used instead of writing the orders out completely. 8. Verbal orders are used instead of written orders 9. Pharmacy delivers incorrect doses to this unit. 10. Pharmacy does not prepare the medicines correctly. 11. Pharmacy does not label the medicines correctly. 12. Pharmacists are not available 24 h a day. 13. Frequent substitution of drugs (i.e. cheaper generic for brand names). 14. Poor communication between nurses and physicians. 15. Many medications on multiple patients 16. Insufficient knowledge and information on new medications 17. On this unit, there is no easy way to look up information on medications. 18. Nurses on this unit have limited knowledge about medications. 19. Distractions by other patients, co-workers or events on the unit 20. When scheduled medications are delayed, nurses do not communicate the time when the next dose is due. 21. Failure to adhere to policy and procedure documents 22. Heavy workload in the ward 23. Inadequate number of staffs in each working shift 24. All medications for one team of patients cannot be passed within an accepted time frame. 25. Medication orders are not transcribed to the Kardex correctly. 26. Errors are made in the Medication Kardex. 27. Equipment malfunctions or is not set correctly (e.g. IV pump). 28. Nurse is unaware of a known allergy. 29. Patients are off the ward for other care.

Strongly agree n(%)

Moderately agree n(%)

Slightly agree n(%)

37(11.9) 41(13.1) 32(10.3) 11(3.5) 15(4.8) 18(5.8) 19(6.1)

121(38.8) 116(37.2) 103(33) 39(12.5) 56(17.9) 54(17.3) 52(16.7)

127(40.7) 115(36.9) 116(37.2) 86(27.6) 107(34.3) 122(39.1) 119(38.1)

48(15.4)

94(30.1)

9(2.9)

Moderately disagree n(%)

Strongly disagree n(%)

Mean ± SD

15(4.8) 23(7.4) 34(10.9) 79(25.3) 80(25.6) 83(26.6) 79(25.3)

9(2.9) 13(4.2) 21(6.7) 54(17.3) 35(11.2) 29(9.3) 29(9.3)

3(1.0) 4(1.3) 6(1.9) 43(13.8) 19(6.1) 6(1.9) 14(4.5)

4.49 ± 0.94 4.44 ± 1.03 4.24 ± 1.11 3.18 ± 1.33 3.61 ± 1.22 3.78 ± 1.08 3.71 ± 1.17

113(36.2)

35(11.2)

14(4.5)

8(2.6)

4.33 ± 1.16

33(10.6)

136(43.6)

86(27.6)

40(12.8)

8(2.6)

3.55 ± 1.02

6(1.9)

20(6.4)

92(29.5)

111(35.6)

63(20.2)

20(6.4)

3.15 ± 1.08

7(2.2)

23(7.4)

90(28.8)

104(33.3)

64(20.5)

24(7.7)

3.14 ± 1.13

12(3.8) 15(4.8)

31(9.9) 35(11.2)

68(21.8) 114(36.5)

75(24.0) 100(32.1)

53(17.0) 39(12.5)

73(23.4) 9(2.9)

2.89 ± 1.43 3.55 ± 1.09

17(5.4)

50(16.0)

127(40.7)

84(26.9)

31(9.9)

3(1.0)

3.77 ± 1.04

29(9.3) 16(5.1)

98(31.4) 53(17.0)

127(40.7) 135(43.3)

39(12.5) 73(23.4)

19(6.1) 31(9.9)

0(0) 4(1.3)

4.25 ± 0.99 3.80 ± 1.42

9(2.9)

25(8.0)

72(23.1)

111(35.6)

68(21.8)

27(8.7)

3.09 ± 1.17

8(2.6)

26(8.3)

108(34.6)

92(29.5)

65(20.8)

13(4.2)

3.30 ± 1.09

38(12.2)

100(32.1)

115(36.9)

40(12.8)

15(4.8)

4(1.3)

4.30 ± 1.08

8(2.6)

18(5.8)

81(26.0)

94(30.1)

90(28.8)

21(6.7)

3.03 ± 1.13

5(1.6)

15(4.8)

71(22.8)

98(31.4)

89(28.5)

34(10.9)

2.87 ± 1.13

47(15.1) 103(33.0)

89(28.5) 107(34.3)

106(34.0) 73(23.4)

32(10.3) 19(6.1)

34(10.9) 9(2.9)

4(1.3) 1(0.3)

4.23 ± 1.22 4.88 ± 1.05

3(1.0)

43(13.8)

122(39.1)

70(22.4)

58(18.6)

16(5.1)

3.41 ± 1.12

3(1.0)

12(3.8)

57(18.3)

114(36.5)

91(29.2)

35(11.2)

2.77 ± 1.06

2(0.6) 1(0.3)

12(3.8) 27(8.7)

63(20.2) 86(27.6)

98(31.4) 91(29.2)

95(30.4) 81(26.0)

42(13.5) 26(8.3)

2.72 ± 1.09 3.03 ± 1.12

4(1.3) 3(1.0)

28(9.0) 35(11.2)

108(34.6) 143(45.8)

95(30.4) 60(19.2)

60(19.2) 41(13.1)

17(5.4) 30(9.6)

3.26 ± 1.08 3.39 ± 1.17

young. According to the Organization for Economic Cooperation and Development (OECD) data, actual working hours in South Korea in 2012 were the 3rd longest among the OECD countries [19]. In addition, while the average age of employed RNs in the US was 45.5 in 2008 [20], the average age of employed RNs in South Korea was 34.6 in 2006 [21]. Due to these differences in working conditions and demographic characteristics, there would be differences in risk factors of MAE compared to other countries. In our study, 47.8% nurses perceived that MAEs occur less than 20% at actual clinical field, in our study. Joolaee et al. [14] reported

Slightly disgree n(%)

that the average number of self-reported medication error cases by each nurse was 19.5 cases, and an error was reported per 1.3 cases on average. There is a gap between the nurses’ perceived knowledge and his or her actual knowledge about medication errors; therefore, nurses require specific information regarding what constitutes medication errors [15]. The voluntary nature of the self-reporting method has been shown to underestimate the actual MAEs occurrences [10, 14]. Actual MAEs occurrence data can only be used to identify problems and develop solutions provided that they are a true reflection of the type and number

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Table 3 Reasons for unreported MAEs (N = 312) Items

Strongly agree n(%)

30. Nurses do not agree with hospital’s definition of a medication error. 31. Nurses do not recognize an error occurred. 32. Filling out an incident report for a medication error takes too much time. 33. Too long and time consuming reporting 34. Medication error is not clearly defined. 35. No need to report if no patient is harmed 36. Nurses believe other nurses will think they are incompetent 37. Patient or family might develop a negative attitude 38. The expectation that medications be given exactly as ordered is unrealistic. 39. Nurses fear reprimand from doctor. 40. Nurses fear adverse consequences from reporting medication errors. 41. The response by nursing administration does not match the severity of the error. 42. Nurses could be blamed if something happens to the patient 43. No positive feedback is given for passing medications correctly. 44. Too much emphasis is placed on medication errors as a measure of the quality of nursing care provided. 45. Nursing administration focuses on the personal rather than looking at the systems

Moderately agree n(%)

Slightly agree n(%)

Slightly disgree n(%)

Moderately disagree n(%)

Strongly disagree n(%)

Mean ± SD

2(0.6)

17(5.4)

48(15.4)

102(32.7)

87(27.9)

56(17.9)

2.64 ± 1.14

0(0) 1(0.3)

17(5.4) 40(12.8)

49(15.7) 102(32.7)

83(26.6) 99(31.7)

98(31.4) 43(13.8)

65(20.8) 27(8.7)

2.54 ± 1.15 3.28 ± 1.13

3(1.0) 1(0.3) 4(1.3) 8(2.6)

15(4.8) 12(3.8) 20(6.4) 47(15.1)

65(20.8) 70(22.4) 63(20.2) 126(40.4)

108(34.6) 97(31.1) 90(28.8) 72(23.1)

78(25.0) 72(23.1) 78(25.0) 33(10.6)

43(13.8) 60(19.2) 57(18.3) 26(8.3)

2.81 ± 1.12 2.70 ± 1.15 2.75 ± 1.22 3.51 ± 1.19

13(4.2)

54(17.3)

114(36.5)

69(22.1)

37(11.9)

25(8.0)

3.56 ± 1.25

2(0.6)

13(4.2)

40(12.8)

77(24.7)

97(31.1)

83(26.6)

2.39 ± 1.17

9(2.9) 24(7.7)

52(16.7) 82(26.3)

130(41.7) 125(40.1)

71(22.8) 46(14.7)

28(9.0) 21(6.7)

22(7.1) 14(4.5)

3.61 ± 1.16 4.00 ± 1.18

4(1.3)

27(8.7)

96(30.8)

103(33.0)

57(18.3)

25(8.0)

3.18 ± 1.12

106(34)

118(37.8)

28(9.0)

10(3.2)

9(2.9)

4.36 ± 1.10

41(13.1) 17(5.4)

71(22.8)

119(38.1)

76(24.4)

17(5.4)

12(3.8)

3.87 ± 1.11

5(1.6)

9(2.9)

40(12.8)

117(37.5)

109(34.9)

32(10.3)

4.32 ± 1.02

25(8.0)

72(23.1)

130(41.7)

58(18.6)

16(5.1)

11(3.5)

4.10 ± 1.12

Table 4 Type of error reported for Non-IV medication (N = 312)

Table 5 Type of error reported for IV medication (N = 312)

Rank

Types of medication errors

Number of errors (%)a

Rank

Types of medication errors

Number of errors (%)a

1 2 3 4 5 6 7

Drugs given to the wrong patient Drugs given wrong dose Wrong choice of drug Drugs given at wrong administration time Medication omitted Drugs given by the wrong route Medication administered after the order discontinued Poor communication between nurses and doctors Given to patient with a known allergy

198 (63.5) 195 (62.5) 193 (61.9) 190 (60.9) 181 (58.0) 144 (46.2) 138 (44.2) 101 (32.4)

1 2 3 4 5 6 7 8 9

206 (66.0) 188 (60.3) 185 (59.3) 180 (57.7) 178 (57.0) 176 (56.4) 158 (50.6) 154 (39.4) 135 (43.2)

98 (31.4)

10

Wrong infusion rate Drugs given to the wrong patient Drugs given wrong dose Wrong choice of drug Wrong choice mixed fluid Drugs given at wrong administration time Drugs given by the wrong route Medications omitted Medication administered after the order discontinued Poor communication between nurses and doctors Given to patient with a known allergy

8 9

a Sums exceed totals because of multiple errors within the same non-IV medication.

11

110 (35.2) 107 (34.3)

a Sums exceed totals because of multiple errors within the same IV medication.

of MAEs that actually happen [10]. Accuracy can only be improved in an environment that encourages and supports the reporting of medication errors. Therefore, a simple and easy-to-use reporting system should be implemented to encourage reporting and access to available systems for safety information [15]. To further increase MAEs reporting, health care providers should know that first, reporting without penalty leads to improving safety and second, errors are primarily

the product of flaws in the organization [22]. In addition, effective communication and collaboration between healthcare providers, such as open communications, error reporting and team accountability among healthcare providers, should be facilitated and considered as a rule.

Medication administration errors • Medication Errors In the present study, nurses perceived that the most common reason for MAEs was inadequate number of staff nurses at each working shift. Employing adequate number of staff is a necessary condition for safe patient care [7]. Increased nurse workload can result in more MAEs by nurses [1, 9, 14, 15]. Kang et al. [4] examined the relationship between nurse-perceived patient adverse events and nurse practice environment. This study showed that nurse-staffing adequacy was correlated with medication errors. However, this finding was inconsistent with the finding that there was no significant relationship between RN staffing levels, measured by the number of RN hours per patient day, and medication errors [3]. Appropriate nurse staffing by employing new personnel or moderating the working hours and eliminating irrelevant tasks can be beneficial for improving the working conditions of the nursing personnel and the overall quality of health care service [23]. In the OECD countries, there was an average of 9.1 nurses per 1000 people and an average of 4.8 nurses per capita in South Korea [24]. South Korea is concerned about shortage of nurses and having a higher ratio of nurses per patient. Therefore, there is a need to analyze work conditions, improve health care systems, and create a culture where patients’ safety is a priority. Staffing alone will not deliver the positive results of a supportive health care environment [25]. Therefore, nurses should allocate time during the beginning of their shift to examine the medication list, refer to the patient records and to read the original order. Appropriate environmental design takes error prevention into account and plays a critical role in preventing errors [26]. Furthermore, safe and positive work environments should include a supportive manager, collegial relationships with physicians, sufficient resources, staff development and opportunities to be involved in decision-making processes. The second and third common causes of MAEs involved medication names that appeared or sounded similar to other medications. Mrayyan et al. [27] supported this finding and suggested that the information on labels and packaging of medications can confuse health care personnel if it is not prominently placed (i.e. small font size), which may lead to poor readability. Furthermore, medications with similar names can lead to errors associated with verbal prescriptions. For these reasons, the Joint Commission published a list of drugs that appear or sounded similar, which were considered the most problematic medication names across health care settings [28]. Accordingly, medications should be delivered in a standardized package and labeling to reduce nurses’ confusion because there are many varieties of medication packaging, forms, doses and preparations that might lead to MAEs. Nurses are front-line health care staff who recognize and report MAEs. Therefore, they are responsible for their errors and immediate remedial actions should be implemented to prevent any complications [2]. The Hospital policy in South Korea is that all medication errors should be reported on an incident form that is sent to and collated by the responsible senior nurse manager. According to the nurses in our study, the barriers to reporting MAEs were fear of being blamed if something happens to the patient, having too much emphasis placed on MAEs as a measure of the quality of nursing care provided, fear of adverse consequences and having the nursing administrations focus on the individual as a potential cause of error. This finding supported the results of previous studies regarding the reasons for unreported MAEs [1, 14]. Researchers emphasized that a supportive practice environment needs to be more effective and create a blame-free culture to encourage nurses to report errors [3, 27]. Luk et al. [2] interviewed 14 nurses involved in medication errors that were recorded in incident reports and found that the nurses experienced fairness and were

281 respected by senior nursing staff during the investigation of those incidents. Therefore, nurse managers should have a positive attitude toward the reporting of medication errors by nurses and create a no-blame culture. Medication errors can only be reported freely in an atmosphere free of blame for nurses, which enables the proper utilization of these reported errors as learning opportunities [29]. In the present study, the most common non-IV related MAEs included administering the medication to the wrong patient, followed by administering incorrect medication doses and the incorrect choice of drugs. Similarly, the most common IV related MAEs included incorrect medication infusion rates, followed by administering medications to the incorrect patient, incorrect medication doses and incorrect drug choice. In both non-IV and IV related MAEs, medications administered to a patient with a known allergy to that medication and poor communication between nurses and doctors were less common. Indeed, staff nurses are at risk of committing MAEs because they do not have enough time to follow the five rights (right patient, time, dose, drug and route) of medication administration [30]. Accurate administration of medications is a critical task, but administering the wrong medication or dose is a ubiquitous nursing problem. Recently, there is increasing evidence of successful strategies that improve the safety of the medication management system [26], including standardized medication charts, prescriber decision support, individualized administration systems and clinical pharmacy services. The awareness of risks and errors in the medication system by all staff nurses, and their ability to identify errors and take appropriate action is paramount in improving patient safety and reducing harm [9, 10]. In our study, IV was the most common route of MAEs with baseline participants’ characteristics, which was reported by 182 nurses (58.3%). Medication errors of IV administration have accounted for 49–69.7% of MAEs in previous studies [1, 31]. IV administrationrelated MAEs result in the most serious health outcomes [10] because of their greater complexity and the multiple steps required in their preparation, administration and monitoring [31]. Kim et al. [1] reported medication errors occurred during IV administration. According to the study of Oh and Yoon [11], majority of MAEs were IV related errors as like influx in to an IV set, crystal occurring in an IV line, wrong injection site and wrong IV infusion rate. To prevent non-IV and IV related MAEs reported in our study, nurses have to check the patients’ record before preparing and administering medication. It is important that medication management is addressed in the education and training of nurses, including both nursing student preparations for practice and in the continuing education of nurses. Recently, Korean Hospital Nurse Association (KHNA) published guideline for education of new nurses in 2010 and revised in 2014. The guideline includes a flow chart of medication administration such as confirm the prescription, preparation administration and precautions. Also, since 2006, the Korean Accreditation Board of Nursing (KABON) has been accredited nursing education programs with the goal of determining if nursing education has received a level capable of producing nurses who can fulfill their social responsibilities [32]. Traditionally, clinical practice education has been structured as practical experience occurring in a real-world environment [4]. Nursing educators face many challenges ensuring that students have the knowledge and abilities to safely administer medications to patients. The simulation for medical and healthcare applications has recently been employed in our country in medical and nursing colleges for students’ educational purposes. Simulated experiences help learners attain the desired knowledge, demonstrate competence in skills, develop communication skills and increase self-confidence [33]. In

282 addition, the use of standardized patient simulation in providing education for preventing medication errors is helpful in a clinical setting. The present study had several limitations. First, we used a convenience sampling method for nurses who were working at three university hospitals, which cannot be generalized to other nurses. Second, the focus of this study was the perception about MAEs, which may be different from the actual experiences of MAEs among nurses. Future studies with large samples are recommended to identify the perceptions regarding MAEs according to hospital characteristics in a variety of settings and to identify the rate of MAEs using direct observations and multiple sources. Despite these limitations, we addressed the reasons for MAEs by staff nurses, which have been limited in previous studies in South Korea. Furthermore, the results of this study can be used as fundamental data for developing programs for preventing MAEs in hospitals. Until now, there is no national consensus among nursing schools about standardized patient safety education in Korea. We need to standardize patient safety curriculum in which the essential competencies of patient safety are integrated as learning outcomes. Also, various teaching strategies such as simulation should be developed to improve students’ patient safety competencies. Furthermore, the nursing school curriculum and hospitals’ continuing education programs should emphasize concepts related to medication administration.

Conclusion In conclusion, nurses had experienced a higher rate of MAEs compared to the rate of reported MAEs that they perceived. Furthermore, the main reason for MAEs as perceived by the nurses was inadequate staffing level; nurses did not report MAEs because of a fear of being blamed. A number of technology strategies have been implemented to decrease the number of medication errors including computerized physician order entry, automated medication administration records and bar coding administration; but even with the use of these technologies, errors continue to occur. Health care leaders need to consider not only technology capital investments but also human capital as a strategy to keep patients safe. Namely, administering medications to hospitalized patients is not a simple task; it requires thorough knowledge of every medication that is administered to patients. Therefore, qualified RN should be more appropriately assigned to patients. In addition, we should try to create a blame-free culture to encourage reporting the errors.

Funding This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIP) (NRF-2012R1A2A2A01047560) and Soonchunhyang University Research Fund, 2014.

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