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. 2024 Jan-Mar;39(1):51-57.
doi: 10.1097/NCQ.0000000000000720. Epub 2023 May 9.

Medication Safety Event Reporting: Factors That Contribute to Safety Events During Times of Organizational Stress

Tara N Cohen  1 , Carl T Berdahl, Bernice L Coleman, Edward G Seferian, Andrew J Henreid, Donna W Leang, Teryl K Nuckols
Affiliations

Medication Safety Event Reporting: Factors That Contribute to Safety Events During Times of Organizational Stress

Tara N Cohen et al. J Nurs Care Qual. 2024 Jan-Mar.

Abstract

Background: Incident reports submitted during times of organizational stress may reveal unique insights.

Purpose: To understand the insights conveyed in hospital incident reports about how work system factors affected medication safety during a coronavirus disease-2019 (COVID-19) surge.

Methods: We randomly selected 100 medication safety incident reports from an academic medical center (December 2020 to January 2021), identified near misses and errors, and classified contributing work system factors using the Human Factors Analysis and Classification System-Healthcare.

Results: Among 35 near misses/errors, incident reports described contributing factors (mean 1.3/report) involving skill-based errors (n = 20), communication (n = 8), and tools/technology (n = 4). Reporters linked 7 events to COVID-19.

Conclusions: Skill-based errors were the most common contributing factors for medication safety events during a COVID-19 surge. Reporters rarely deemed events to be related to COVID-19, despite the tremendous strain of the surge on nurses. Future efforts to improve the utility of incident reports should emphasize the importance of describing work system factors.

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Conflict of interest statement

The authors declare no conflict of interest.

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References

    1. Organization WH. Medication without harm. 2017. Accessed January 1, 2022. https://www.who.int/initiatives/medication-without-harm
    1. Manias E, Street M, Lowe G, Low JK, Gray K, Botti M. Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: a retrospective clinical audit. BMC Health Serv Res. 2021;21(1):1025. doi: 10.1186/s12913-021-07033-8 - DOI - PMC - PubMed
    1. Ferner RE, Aronson JK. Clarification of terminology in medication errors: definitions and classification. Drug Saf. 2006;29(11):1011–1022.doi: 10.2165/00002018-200629110-00001 - DOI - PubMed
    1. Marvanova M, Henkel PJ. Collaborating on medication errors in nursing. Clin Teach. 2018;15(2):163–168. doi: 10.1111/tct.12655 - DOI - PubMed
    1. Nuckols TK, Bell DS, Paddock SM, Hilborne LH. Contributing factors identified by hospital incident report narratives. Qual Saf Health Care. 2008;17(5):368–372. doi: 10.1136/qshc.2007.023721 - DOI - PubMed