Potential Medication Error Reporting: Nurses' Perceptions, Attitudes and Conflicts

2.50
Hdl Handle:
http://hdl.handle.net/10755/157792
Type:
Presentation
Title:
Potential Medication Error Reporting: Nurses' Perceptions, Attitudes and Conflicts
Abstract:
Potential Medication Error Reporting: Nurses' Perceptions, Attitudes and Conflicts
Conference Sponsor:Western Institute of Nursing
Conference Year:2009
Author:Magilvy, J. Kathy, RN, PhD, FAAN
P.I. Institution Name:University of Colorado Denver, College of Nursing
Title:Professor & Associate Dean
Contact Address:13120 East 19th Avenue Box C288-2, Aurora, CO, 80045, USA
Contact Telephone:303-724-8507
Co-Authors:Gaya Carlton, PhD, RN, Professor
Purpose/Aims:  Current research in medication error (ME) reporting has focused on retrospective analysis of reported errors and the underreporting issues that hinder resolution of error occurrence.  Understanding nurses' perceptions concerning reporting of potential medication errors (PMEs) may enlighten and influence change in the reporting process.  The purpose of this study was to describe nurses' feelings toward reporting of PMEs in an attempt to better understand reporting issues and lessen ME occurrence in the future through sharing of ways errors were discovered and prevented. Rationale/Background:  Prevention of MEs relies on adequate and accurate information concerning their occurrence.  Using existing incident reports to identify incidence of ME and potential causes is difficult given the under-reporting and the questions concerning validity and reliability of the data.  Reporting systems rely on nurses to recognize and report errors; however, many errors are unrecognized and reporting behaviors vary widely among nurses depending on nurse perception of what constitutes error, fear, guilt, and the burdensome nature of reporting.  Changing nurses' perceptions about incident reporting coupled with administrative shift to a systems approach to errors would allow for greater analysis and further research toward preventable actions.  Fundamental to the success of decreasing MEs is a change in understanding of how errors occur. Methods:  A narrative inquiry research design using a purposive sampling strategy was used to elicit nurses? stories of near miss medication errors and their perceptions concerning reporting of such errors.  In-depth audio-taped interviews were conducted with 14 registered nurses.  Transcribed data were analyzed using narrative inquiry techniques to identify essential elements of their stories. Results:  Nurses? feelings toward reporting of PMEs often mirrored those experienced by nurses reporting actual MEs.  Most nurse participants in this study felt the reporting of PMEs was just as important as reporting actual errors citing patient safety as a positive outcome.  Tracking and trending PMEs had the potential to identify and correct ME problems, build a data base for future use, identify why a PME happened, identify number of "near misses" and identify efficient systems to catch errors.  Nurses verbalized the importance of sharing information with the intent to prevent future ME occurrence.  Nurse participant's negative feelings toward reporting included punitive issues concerning management and administration's handling of incident reports and the cumbersome nature of reporting as a whole.  Nurses' perceptions of reporting PMEs brought to the forefront reasons why potential errors should be reported but why nurses will resist implementation of such a reporting system.  This information may enlighten management and administration as to available uncaptured information concerning "near misses" that may improve patient safety along with barriers to implementation of such a reporting system. Implications:  Implications for nursing should focus on information sharing of near miss MEs through no fault potential error reporting and celebration of error discovery. Administrators must continue progress toward a culture of safety where frontline nurses and management are committed to safety, are safety conscious and freely report concerns.  Nurses should feel their voices are heard and be rewarded by nursing management with positive feedback and recognition for contributing to patient safety through discovering potential medication errors, reporting triggers, or identifying potential threats to safety.
Repository Posting Date:
26-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Western Institute of Nursing

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titlePotential Medication Error Reporting: Nurses' Perceptions, Attitudes and Conflictsen_GB
dc.identifier.urihttp://hdl.handle.net/10755/157792-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Potential Medication Error Reporting: Nurses' Perceptions, Attitudes and Conflicts</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Western Institute of Nursing</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2009</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Magilvy, J. Kathy, RN, PhD, FAAN</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">University of Colorado Denver, College of Nursing</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Professor &amp; Associate Dean</td></tr><tr class="item-address"><td class="label">Contact Address:</td><td class="value">13120 East 19th Avenue Box C288-2, Aurora, CO, 80045, USA</td></tr><tr class="item-phone"><td class="label">Contact Telephone:</td><td class="value">303-724-8507</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">Kathy.Magilvy@ucdenver.edu</td></tr><tr class="item-co-authors"><td class="label">Co-Authors:</td><td class="value">Gaya Carlton, PhD, RN, Professor</td></tr><tr><td colspan="2" class="item-abstract">Purpose/Aims: &nbsp;Current research in medication error (ME) reporting has focused on retrospective analysis of reported errors and the underreporting issues that hinder resolution of error occurrence.&nbsp; Understanding nurses' perceptions concerning reporting of potential medication errors (PMEs) may enlighten and influence change in the reporting process.&nbsp; The purpose of this study was to describe nurses' feelings toward reporting of PMEs in an attempt to better understand reporting issues and lessen ME occurrence in the future through sharing of ways errors were discovered and prevented.&nbsp;Rationale/Background: &nbsp;Prevention of MEs relies on adequate and accurate information concerning their occurrence. &nbsp;Using existing incident reports to identify incidence of ME and potential causes is difficult given the under-reporting and the questions concerning validity and reliability of the data. &nbsp;Reporting systems rely on nurses to recognize and report errors; however, many errors are unrecognized and reporting behaviors vary widely among nurses depending on nurse perception of what constitutes error, fear, guilt, and the burdensome nature of reporting.&nbsp; Changing nurses' perceptions about incident reporting coupled with administrative shift to a systems approach to errors would allow for greater analysis and further research toward preventable actions.&nbsp; Fundamental to the success of decreasing MEs is a change in understanding of how errors occur. Methods: &nbsp;A narrative inquiry research design using a purposive sampling strategy was used to elicit nurses? stories of near miss medication errors and their perceptions concerning reporting of such errors.&nbsp; In-depth audio-taped interviews were conducted with 14 registered nurses.&nbsp; Transcribed data were analyzed using narrative inquiry techniques to identify essential elements of their stories. Results: &nbsp;Nurses? feelings toward reporting of PMEs often mirrored those experienced by nurses reporting actual MEs. &nbsp;Most nurse participants in this study felt the reporting of PMEs was just as important as reporting actual errors citing patient safety as a positive outcome. &nbsp;Tracking and trending PMEs had the potential to identify and correct ME problems, build a data base for future use, identify why a PME happened, identify number of &quot;near misses&quot; and identify efficient systems to catch errors. &nbsp;Nurses verbalized the importance of sharing information with the intent to prevent future ME occurrence.&nbsp; Nurse participant's negative feelings toward reporting included punitive issues concerning management and administration's handling of incident reports and the cumbersome nature of reporting as a whole. &nbsp;Nurses' perceptions of reporting PMEs brought to the forefront reasons why potential errors should be reported but why nurses will resist implementation of such a reporting system. &nbsp;This information may enlighten management and administration as to available uncaptured information concerning &quot;near misses&quot; that may improve patient safety along with barriers to implementation of such a reporting system.&nbsp;Implications: &nbsp;Implications for nursing should focus on information sharing of near miss MEs through no fault potential error reporting and celebration of error discovery. Administrators must continue progress toward a culture of safety where frontline nurses and management are committed to safety, are safety conscious and freely report concerns.&nbsp; Nurses should feel their voices are heard and be rewarded by nursing management with positive feedback and recognition for contributing to patient safety through discovering potential medication errors, reporting triggers, or identifying potential threats to safety.</td></tr></table>en_GB
dc.date.available2011-10-26T20:12:33Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-26T20:12:33Z-
dc.description.sponsorshipWestern Institute of Nursingen_GB
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