Good/Bad Research Article/Clinical Background

The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems

Abbas Al Mutair , Saad Alhumaid, Abbas Shamsan, Abdul Rehman Zia Zaidi, Mohammed Al Mohaini,

Alya Al Mutairi, Ali A. Rabaan, Mansour Awad and Awad Al-Omari

Special Issue PROTAC—From Bench to Bed

Edited by

Dr. Deyao Li and Dr. Ke li

Review

https://doi.org/10.3390/medicines8090046

medicines

Review

The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems

Abbas Al Mutair 1,2,3,* , Saad Alhumaid 4 , Abbas Shamsan 5, Abdul Rehman Zia Zaidi 5,6 ,

Mohammed Al Mohaini 7,8 , Alya Al Mutairi 9 , Ali A. Rabaan 10,11, Mansour Awad 12 and Awad Al-Omari 5,6

���������� �������

Citation: Mutair, A.A.; Alhumaid, S.;

Shamsan, A.; Zaidi, A.R.Z.; Mohaini,

M.A.; Al Mutairi, A.; Rabaan, A.A.;

Awad, M.; Al-Omari, A. The Effective

Strategies to Avoid Medication Errors

and Improving Reporting Systems.

Medicines 2021, 8, 46. https://

doi.org/10.3390/medicines8090046

Academic Editor: William Cho

Received: 5 August 2021

Accepted: 25 August 2021

Published: 27 August 2021

Publisher’s Note: MDPI stays neutral

with regard to jurisdictional claims in

published maps and institutional affil-

iations.

Copyright: © 2021 by the authors.

Licensee MDPI, Basel, Switzerland.

This article is an open access article

distributed under the terms and

conditions of the Creative Commons

Attribution (CC BY) license (https://

creativecommons.org/licenses/by/

4.0/).

1 Research Center, Almoosa Specialist Hospital, Al-Ahsa 36342, Saudi Arabia 2 College of Nursing, Princess Norah Bint Abdulrahman University, Riyadh 12214, Saudi Arabia 3 School of Nursing, University of Wollongong, Wollongong, NSW 2522, Australia 4 Administration of Pharmaceutical Care, Al-Ahsa Health Cluster, Ministry of Health,

Al-Ahsa 36342, Saudi Arabia; [email protected] 5 Research Center, Dr. Sulaiman Al Habib Medical Group, Riyadh 12214, Saudi Arabia;

[email protected] (A.S.); [email protected] (A.R.Z.Z.);

[email protected] (A.A.-O.) 6 College of Medicine, Alfaisal University, Riyadh 12214, Saudi Arabia 7 Basic Sciences Department, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for

Health Sciences, Alhasa 31982, Saudi Arabia; [email protected] 8 Basic Sciences Department, College of Applied Medical Sciences, King Abdullah International Medical

Research Center, Alhasa 31982, Saudi Arabia 9 Department of Mathematics, Faculty of Science, Taibah University, Medina 54321, Saudi Arabia;

[email protected] 10 Microbiology Department, Johns Hopkins Aramco Healthcare, Alhasa 31982, Saudi Arabia;

[email protected] 11 Department of Public Health and Nutrition, The University of Haipur, Haripur 22610, Pakistan 12 Commitment Administration, General Directorate of Health Affairs, Ministry of Health,

Medina 54321, Saudi Arabia; [email protected]

* Correspondence: [email protected]

Abstract: Background: Population-based studies from several countries have constantly shown

excessively high rates of medication errors and avoidable deaths. An efficient medication error

reporting system is the backbone of reliable practice and a measure of progress towards achieving

safety. Improvement efforts and system changes of medication error reporting systems should be

targeted towards reductions in the likelihood of injury to future patients. However, the aim of this

review is to provide a summary of medication errors reporting culture, incidence reporting systems,

creating effective reporting methods, analysis of medication error reports, and recommendations

to improve medication errors reporting systems. Methods: Electronic databases (PubMed, Ovid,

EBSCOhost, EMBASE, and ProQuest) were examined from 1 January 1998 to 30 June 2020. 180 articles

were found and 60 papers were ultimately included in the review. Data were mined by two reviewers

and verified by two other reviewers. The search yielded 684 articles, which were then reduced

to 60 after the deletion of duplicates via vetting of titles, abstracts, and full-text papers. Results:

Studies were principally from the United States of America and the United Kingdom. Limited

studies were from Canada, Australia, New Zealand, Korea, Japan, Greece, France, Saudi Arabia,

and Egypt. Detection, measurement, and analysis of medication errors require an active rather

than a passive approach. Efforts are needed to encourage medication error reporting, including

involving staff in opportunities for improvement and the determination of root cause(s). The National

Coordinating Council for Medication Error Reporting and Prevention taxonomy is a classification

system to describe and analyze the details around individual medication error events. Conclusion: A

successful medication error reporting program should be safe for the reporter, result in constructive

and useful recommendations and effective changes while being inclusive of everyone and supported

with required resources. Health organizations need to adopt an effectual reporting environment for

the medication use process in order to advance into a sounder practice.

Medicines 2021, 8, 46. https://doi.org/10.3390/medicines8090046 https://www.mdpi.com/journal/medicines

Medicines 2021, 8, 46 2 of 12

Keywords: medical errors; medication error; improve; medication error reporting program; health

care professional; patients; health organizations

1. Introduction

Medical errors are described as unintentional mistakes either by omission or commis- sion. Medical errors are classified into an error of execution or an error of planning, which are explained as the unsuccessful process of deliberate action or utilization of an improper plan to attain a goal, respectively, or by deviating from the process of care that may po- tentially cause harm to the patient [1]. In 2008, the US Department of Health and Human Services Office reported 180,000 deaths by medical errors among hospitalized patients [1]. A high percentage of medical errors is attributed to medications that account for almost 1.5 million victims of medical errors every year [2]. The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.” These events can be linked to procedures, healthcare commodities, professional practice, along with systems consisting of prescription, order communication, dispensing, monitoring, product labeling, distribution, compounding, administration, nomenclature and packaging, education, and use. These events can be linked to healthcare commodi- ties, procedures, professional practice, along with systems started with nomenclature and packaging, storing and distributing, prescribing, transcribing, documenting, reviewing, preparing (or compounding), product labeling, educating, dispensing, and ended with drug administration and monitoring [3]. Medication errors significantly impact the well- being of individuals, organizations, and healthcare systems. According to an NCCMERP report, medication errors are ranked the sixth cause of mortality in the United States, with 5–10% of the reported medication errors classified as harmful [3]. Recently, medication errors have become a challenge facing healthcare systems and are directly linked to hospital mortality and morbidity rates [4]. Specifically, medication errors cause adverse effects on hospitalized patients and weaken the public’s confidence in the healthcare system and the healthcare services being provided [5]. In addition, medication errors negatively impact clinical outcomes such as length of stay (LOS), incurring substantial costs of about USD 2000-2500 per patient [2,6]. Another issue is the high proportion of underreporting of med- ication errors (estimated to be 50–60%) across healthcare organizations that is attributed to the lack of medical recording systems in many hospitals [2]. Therefore, different prevention programs were implemented to monitor errors targeting triggers and/or influencing factors of medication errors [7–10] through using carefully formulated establishment-wide report- ing systems to find the likely sources of medication errors [11]. Although the reporting of medication errors offers usable data for identifying areas of improvement with regard to patient safety, the advancement of patient safety is impeded and the lack of formal reporting is well recognized [12]. A variety of standards at the institutional level and a higher level of government exist for designing an effective medication error reporting system [12]. Simultaneously, the transformation of medication error reporting systems is required to facilitate easily preventable mistakes and their often-severe aftereffects [12]. Thus, understanding what hinders reporting could eventually result in superior patient care [12]. Whilst plentiful reports have studied the contributing factors [7–10], rates of prescription errors, and adverse events [13–15], insufficient researches have analyzed the characteristics of successful medication error reporting systems.

2. Material and Methods

2.1. Aims and Objectives

In order to give basic details about the medication error reporting culture, incidence reporting systems, effective reporting method(s), analysis of medication error reports,

Medicines 2021, 8, 46 3 of 12

and also suggest recommendations to improve medication errors reporting systems, we conducted a review of currently available literature evidence.

2.2. Search Strategy

A total number of five electronic databases (PubMed, Ovid, EBSCOhost, Embase.com, and ProQuest) were methodically searched for articles using components derived from the subsequent subject headings and keywords: characteristics, effective, error, improve, medication, report, reporting, successful, system. Furthermore, we searched citations from relevant papers to select additional studies. The search remained limited to English language journals published between January 1998 and June 2020.

2.3. Inclusion and Exclusion Criteria

Readily accessible peer-reviewed, full-text articles in the English language, primary research publications of any design (quantitative and qualitative studies: observational cohort or case-control studies, clinical trials, cross-sectional and systematic reviews) were included. We looked for studies that reported medication error reporting culture, incident reporting systems, creation of effective reporting methods, analysis of medication error reports, and recommendations to enhance medication error reporting systems. The studies identified in the search were manually evaluated for applicability in this article. We also included limited articles that concentrated on medical—not medication errors and nursing practice errors. We eliminated conference papers, editorials, letters to the editor, organizational reports, opinion papers, and case reports.

2.4. Data Extraction and Analysis

Two reviewers (AA and SA) individually vetted titles with abstracts followed by a full article review, where any doubt remained. Disagreements between two reviewers after full-text vetting were resolved via unanimity by a third reviewer (AS) and a fourth reviewer (ARZ). The data extraction involved evidence in each relevant selected article on medi- cation error reporting systems, reporting culture, creating an effective reporting method, analysis of medication error reports, and/or recommendations to improve medication errors reporting systems. To examine the literature, a narrative synthesis was performed due to the variety of instruments and reported data. A narrative synthesis is characterized by the textual methodology that delivers a trustworthy tale of the findings from the selected literature [16]. Additionally eligible studies were appraised using critical appraisal tools. The appraisal consists of 10 items that assess the methodological quality of a study and determines the extent to which a study has addressed the possibility of bias in its design, conduct, and analysis. The results of the appraisal have been taken into full account and used to inform the synthesis and interpretation of the results of the recommendations.

3. Results and Discussion

Overall, we screened 5 literature databases and identified 684 articles. A total of 384 duplicated articles were excluded from the review. Then, 300 articles evaluated for possible inclusion using title and abstract. 180 articles were selected for full-text vetting, resulting in the 60 articles comprising the narrative review (Figure 1). An estimated 120 articles were omitted after full-text screening (reasons: conference papers, editorials, letters to the editor, organizational reports, opinion papers, and case reports = 80, not relevant to hospital settings = 17, focused on an error concerning a specific medication or associated with a specific medical condition = 14, or study with no relative data = 9). Articles were published from 1998 to 2020 with a summit of papers between 2006 and 2014. Articles largely came from the United States and the United Kingdom, with fewer studies from Canada, Australia, New Zealand, Korea, Japan, Greece, France, Saudi Arabia, and Egypt.

Medicines 2021, 8, 46 4 of 12

Figure 1. Flowchart.

3.1. Reporting Culture

A system for reporting medical errors can lead to future detection of the possibility of a medical error occurring [17,18]. However, patient safety is not developing fast enough to face future challenges in healthcare [19]. In the past, medical errors were rarely disclosed; nowadays, however, failing to disclose an error in the hospital is considered a violation of the code of ethics and leads to litigation [17,20]. Nevertheless, do all healthcare providers divulge medical errors? The decision of disclosing a medical error by a healthcare provider is problematic [17]. Fein and others discussed the most effective factors that influence decisions on disclosing a medical error, which fall into four categories; provider elements, patient elements, error elements, and institutional culture [17–21]. There is an absence of reporting medical errors in the medical field and factors influencing motivation to report medical errors have been investigated in several countries. Around 16–20% of nurses fail to report incidences [22–25] because they fear being terminated by employers. Some healthcare providers fail to report an incident because of a lack of management feed- back [22,25,26], unsupportive colleagues [26], lack of time [25], and lack of knowledge [27]. In order to realize the development in such an area, cultural changes have to be made; feeling safe to report a medical error and learning from past mistakes are crucial factors that might improve patient safety [19,28]. One of the controversial problems in reporting systems is whether reports should be mandatory or voluntary. Mandatory reports might lead to litigations [29] and may destroy the doctor-patient relationship, which can lead health care providers to practice “defensive medicine” [29,30]. Ethically and professionally, healthcare providers should not be obligated to report medical errors. Voluntary reporting

Medicines 2021, 8, 46 5 of 12

is beneficial for medical learning and promotes a culture of safety. On the other hand, mandatory reports have shown the effectiveness of participation in reporting medical errors. For example, in Denmark the reporting rate is 50% compared to 1% in Australia, where the reporting is voluntary [19]. England has changed its policy of reporting from voluntary to mandatory, and if there is a failure to notify the error, the medical Trust may face the consequence of a £4000 penalty. To have organizational accountability and to im- prove patients’ safety and effective prevention systems, the two reports “To Err is Human” and “An Organization with a Memory” both suggested the utilization of a compulsory reporting system in harmful accidents [19,30].

3.2. Incidence Reporting Systems

Incidence Reporting Systems (IRSs) have been known to minimize incidences in air flights; hypothetically, it would also decrease the medical errors in the healthcare sys- tems [31]. Nowadays, medical error reporting systems are widely used. The New Zealand Pharmacovigilance Centre (NZPhvC) is the national center responsible for monitoring adverse reactions to medications in New Zealand, through the Centre for Adverse Reac- tions Monitoring (CARM) [32]. In Australia, the Advanced Incident Monitoring System (AIMS) was implemented around 2005 [31], and the National Reporting and Learning System (NRLS) is used since 2003 in the United Kingdom [31]. Additionally, in Ireland, the National Adverse Event Management System (NAEMS) (formally known as STARS web IRS) was implemented and has been in use since 2004 [31]. Several years back in the United States, the Medical Event Reporting System for Transfusion Medicine (MERS-TM) and United States Pharmacopeia’s MEDMARX Reporting System were introduced. The differ- ent systems the United States has launched can be represented as a high level of knowledge in reporting systems [33,34]. There are two kinds of reporting systems, voluntary and mandatory. The most significant systems are designed after the Aviation Safety Report System (ASRS) which is run by NASA for the Federal Aviation Administration; the system is voluntary and anonymous [35]. Several voluntary systems are being modeled after the Aviation Safety Report System (ASRS) such as, the Veterans Administration Patient Safety Reporting System (PSRS) [36], the Institute for Safe Medical Practice (ISMP) which is de- signed for medical error reporting [37], and Data Watch which is established by the United States Food and Drug Administration (US FDA) for documenting of contrary occasions stemming from medicines and therapeutic devices [38]. The Canadian Medication Incident Reporting and Prevention System (CMIRPS), which is involved in nationwide preventable medication error occurrences and reporting, was established by Health Canada, ISMP Canada, and the Canadian Institute for Health Information (CIHI) [39]. Furthermore, in Egypt, neonatal intensive care units (NICUs) utilize the Egyptian Neonatal Safety Training Network (ENSTN), which can be used confidentially and anonymously to report medical errors [40]. In Saudi Arabia, the National Pharmacovigilance Center (NPC) was established by the Saudi Food and Drug Authority (SFDA) to monitor for surveillance of the safety matters of medications and it plays a vital role in the identification of adverse drug reac- tions (ADRs), their evaluation and prevention [41]. Many countries such as Greece [42], Korea [43], Japan [44], and France [45] have adopted similar systems which have shown substantial positive benefits [46–49].

3.3. Creating an Effective Reporting Method

Creating an effective multiple-phase reporting method to lower medication errors can act to identify the baseline rates of prescription errors. Hence, this can enable a recognition of the major types of medication errors and thereby assist in risk-reduction through the application of various preventive measures [50]. A successful strategy to prevent and detect drug-related problems may involve three stages: pre-intervention phase, intervention phase, and post-intervention phase [51]. The pre-intervention phase reinforces voluntary medication error reporting in the healthcare facility by healthcare professionals utilizing standardized forms. Reports must be continuously monitored, reviewed, and documented

Medicines 2021, 8, 46 6 of 12

on a daily basis throughout the pre-intervention phase [51]. During the pre-intervention phase, medication handling stages are monitored, patient records will be reviewed, and all procedures will be documented. The incident(s) and types of medication error(s) within the healthcare facility will be identified. Quantitative and qualitative analyses of the collected reports should be carried out during the intervention phase [50,51]. Multiple quantitative and qualitative data analyses can be applied here based on the data available, such as quantitative root-cause analysis or qualitative content analysis. Root factors that contribute to prescription errors that have caused or have had the possibility to cause harm “near miss” to the patient can thus be realized [50]. The intervention phase is an integral corrective phase as it should consist of training programs for the targeted healthcare providers [51]. Training programs should be directed towards the identification of medication errors, causation, the harm inflicted, and the importance of effective communication to promote patient safety parameters within the healthcare facility. The post-intervention phase ought to embrace continuous monitoring after the intervention corrective phase [51]. It should also emphasize the re-collecting of data and comparing it with the pre-intervention data. This phase studies the adherence of staff to voluntarily report the incidents of medication errors. The incident is then reported nationally through the organization’s system or online electronic-form.

4. Analysis of Medication Error Reports

NCCMERP has developed a medication error taxonomy tool to aid healthcare workers and organizations characterize, trace, and analyze medication errors in a standardized, methodical approach [52]. The taxonomy is useful for developing a medication error database and designing an error reporting or data collection form. Healthcare organizations should build systems and procedures to accumulate ample information required to inspect and report medication errors at the time the events occur (ideally, all the elements identified in the taxonomy). One key component of the taxonomy, which categorizes an error in accordance with the severity of the outcome on a scale from A to I, is the NCCMERP medication index [52]. Factors such as whether the error got to the patient and if the patient was affected by the error and to what level, are considered by the index. The use of the NCCMERP medication error-index is encouraged in all healthcare delivery settings [52].

5. Recommendations to Improve Medication Errors Reporting Systems

Every medical institution should aim towards implementing methodologies whereby patients are not put at risk due to medication errors. Healthcare organizations should proactively eliminate these by investigating errors that have both occurred and those that may potentially occur. This way, it is possible to identify methods by which the consumption of medicines is incorrectly reported and thus mitigating the health risks patients are exposed to. A consistent organizational framework is needed to monitor and measure medication safety. Encouraging reporting, monitoring, and open discussion of medication errors is key in establishing a culture of safety. The system will improve with more data entries; these can be from existing errors already known, ones that may have been missed earlier, and even other miscellaneous errors. The following (Table 1) depicts a list of necessary factors that should be considered based on the findings explored by other academics [53–63].

5.1. Blame-Free or Non-Punitive Culture

A system that can properly evaluate and rectify errors needs to be non-punitive if is to provide meaningful, applicable data [53]. There should be a system where blame is not assigned to those experiencing the errors or those that annotate them. Priorities of an effective medication error reporting system need to target pre-emptive and retroactive actions as opposed to placing blame on an individual. Corrective actions can prevent an incident recurrence, mitigate prescription errors, and enhance the long-term well-being of patients, thus improving their quality of care [54].

Medicines 2021, 8, 46 7 of 12

Table 1. Characteristics of Successful Reporting Systems.

Non-punitive No punishment for the reporter as a result of error reporting.

Anonymous The reporter is not identified by name.

Responsive Recommendations are disseminated and changes implemented when possible.

Inclusiveness Engaging everyone (prescriber, pharmacist, nurse, allied health professionals, patient, and family).

Accountability Holding an individual accountable for continuing unsafe practices.

Supportive environment Utilize preventive strategies (e.g. information technology) and increase comfort level by considering

system design changes.

Summary review Analyze summary of medication error information on a quarterly, semi-annual, or annual basis.

System-oriented Focusing on the context and external environment in which an organization operates.

Expert analysis Understanding the circumstances under which incidents occur and recognizing defects.

Psychological safety The reporter is able to report without fear of negative consequences of self-ima

Collepals.com Plagiarism Free Papers

Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.

Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS

Why Hire Collepals.com writers to do your paper?

Quality- We are experienced and have access to ample research materials.

We write plagiarism Free Content

Confidential- We never share or sell your personal information to third parties.

Support-Chat with us today! We are always waiting to answer all your questions.