Nurses' identification and reporting of medication errors

To investigate hospital nurses' involvement in the identification and reporting of medication errors in Turkey.

Medication safety is an international priority, and medication error identification and reporting are essential for patient safety.

A descriptive survey design consistent with the STROBE guidelines was used.

The participants were 135 nurses employed in a university hospital in Turkey. The survey instrument included 18 sample cases and respondents identified whether errors had been made and how they should be reported. Descriptive statistics were analysed using the chi-square and Fisher's exact tests.

The sample case of "Patient given 10 mg morphine sulphate instead of 1.0 mg of morphine sulphate" was defined as a medication error by 97% of respondents, whereas the sample case of "Omitting oral/IV antibiotics because of the need to take the patient out for X-rays for 3 hr" was defined as a medication error by only 32.1%. It was found that eight sample cases (omitting antibiotics, diluting norodol drops with saline, giving aspirin preprandially, injecting clexane before colonoscopy, giving an analgesic at the nurse's discretion, dispensing undiluted morphine, preparing dobutamine instead of dopamine and administering enteral nutrition intravenously) were assessed as errors and reported, although there were significant statistical differences between the identification and reporting of these errors.

Nurses are able to identify medication errors, but are reluctant to report them. Fear of the consequences was the main reason given for not reporting medication errors. When errors are reported, it is likely to be to physicians.

The development of a commonly agreed definition of a medication error, along with clear and robust reporting mechanisms, would be a positive step towards increasing patient safety. Staff reporting medication errors should be supported, not punished, and the information provided used to improve the system.