El uso ético o fair use

Feng-Tzu Huang

School of Nursing, Midwifery and Social Work, University of Manchester

Background

Medication safety has recently become an important healthcare priority worldwide (Runciman et al. 2003; Department of Health UK 2004; Department of Health, Taiwan 2005; IOM 2006; JCAHO 2006). According to the available evidence, the incidence and cost of medication errors and harmful events is high. A major study in USA, using observation to identify medication errors in 36 health care settings, showed that nearly one in every five doses in hospital settings is an error (n=3216) (Barker et al. 2002). In the United Kingdom, according to the Department of Health (2004), the actual incidence of medication errors is unknown because of low reporting rates and lack of a national incident reporting system. Between 10% and 20% of all adverse events are reported as medication errors consistently. In NHS hospitals medication errors and the ensuing cost are estimated at between £200 and £400 million per year.

Definition of Terms

There is no consensus definition of medication safety terms in the literature (Grandhi et al. 2000; Cousins 2005; Yu et al. 2005). A study based on a search of 160 websites associated with medication safety organisations, examined the terms used to describe medication errors currently in use. It identified twenty-five different terms with 119 definitions (Yu et al. 2005). In addition, the Department of Health UK (2004) also pointed out that it did not differentiate between errors and adverse drug reactions in either the published studies or in the World Health Organisation’s International Statistical Classification of Disease and Related Health Problems (ICD-10).

After comparing the relevant literature and Internet resources, the common terms used in the context of medication safety are summarized in Box 1 along with their conceptual definitions and general meanings. Furthermore, the terms for medication errors, adverse drug errors, and adverse drug reactions are related. Figure 1 illustrates this relationship between medication errors and adverse drug events (Grandhi et al. 2000; Morimoto et al. 2004; IOM, 2006).

Box 1 The Common Terms Related to Medication Safety

An error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve a plan (IOM 2000). Furthermore, an error may be an act of commission or an act of omission (IOM 2004).

A medication error is defined as any error occurring at any step of the medication use process, including ordering, transcribing, dispensing, administrating and monitoring (Bates et al. 1995; Morimoto et al. 2004).

An adverse drug event, often abbreviated as ADE, is defined as any injuries caused by medications (Bates et al. 1995; Leape et al. 1991). An injury includes physical harms (for example, a rash), mental harm (for example, confusion), or loss of function (for example, inability to drive).

An adverse drug reaction is defined as an unintended noxious response to a drug, which occurred at normal dose use in man for prophylaxis or the treatment of disease (WHO 1975).

Near miss: any incident that had the potential to cause harm but was prevented, resulting in no harm to patients (NPSA 2004b).

Figure 1. Relationships between medication errors and adverse drugs events. (Adapted from Grandhi et al. 2000; Morimoto et al. 2004)

Medication errors are the broadest category. Some medication errors have little potential for harmful consequences; others are either potential or preventable adverse drug events (Grandhi et al. 2000; Morimoto et al. 2004). The occurrence of medication errors is higher than that for adverse drug events (Bates et al. 1995); only a small proportion of medication errors cause adverse drug events (Bates et al. 1995). Adverse drug events (ADE) can be either preventable (e.g. a wrong dose leads to injury) or non-preventable (e.g. an allergic reaction in a patient not known to be allergic) depending on what injuries occurred (Grandhi et al. 2000; Morimoto et al. 2004). A preventable ADE is indicated as a serious type of medication error (IOM 2006).

The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP 1995) consisting of 22 American national organizations approved the working definition of medication errors giving a more comprehensive, detailed definition (See Box 2). The purpose of this working definition is to offer a research focus and guidance for the type of information to collect (De Vaus 2002). Within this definition, the nature and causes of medication errors are included.

Non-preventable ADEs. ADEs Potential ADEs Medication errors Preventable ADEs

Box 2 The Working Definition of Medication Errors

The functional meaning of “medication error” was defined by the NCC MERP (1995) as follows:

“A medication error is 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. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use” (p.1).

The researchers state that definitions are crucial to the study of medication errors (Grandhi et al. 2000) because of the analysis of incidence data and the development of error prevention strategies (Yu et al. 2005). In addition, the Department of Health UK (2004) states that it is crucial for error reporting programmes to distinguish between adverse events resulting from medication errors and those occurring during correct medication usage. Therefore, the multiplicity of terms for medication errors, including definitions and functional meanings, urgently need to be standardised (IOM 2004; Yu et al. 2005).

The Role of Medication Error Reporting

In order to minimise the risk to patient safety involving medicines, successful incident reporting is indicated as an effective approach to medication error reduction (Anderson and Webster 2001; Wachter 2004; Department of Health Taiwan 2006; Giles et al. 2006) because identification of medication errors is recognised as a significant first step towards medication safety (Grandhi et al. 2000; Anderson and Webster, 2001; Morimoto et al. 2004; Preston 2004). The origins of incident reporting are high-risk industries, such as aviation and nuclear power plants (Barach and Small 2000; Helmreich 2000; Reason 2000). The primary purpose of incident reporting is to learn from errors in order to prevent a recurrence and to deliver safer health care to patients (Leap 2002).

There has been a growing interest in incident reporting in healthcare systems globally (Giles et al. 2006), including Taiwan. Incident reporting systems have been established in many advanced countries (See Table 1).

Table 1 Current Reporting Systems Worldwide

Year Reporting System Organisations Country

1995 Sentinel Event Reporting System Joint Commission on Accreditation of Healthcare Organisations (JCAHO).

America

1998 Australia Incident Monitoring System (AIMS)

Australia Patient Safety Foundation (APSF)

Australia 2000 Patient safety reporting system

(PSRS)

Department of Veteran Affair (VA)

America 2001 National reporting and learning

system (NRLS)

National Patient Safety Agency (NPSA)

Britain 2001 Canadian Coalition on

Medication Incident Reporting and Prevention System

(CMIRPS)

A coalition of health and consumer organisations

2004 Taiwan Patient-Safety Reporting System (TPR)

Department of Health Taiwan

Not stated

Medication Error Reporting Programme

Institute for Safe Medication Practice (ISMP) and U.S. Pharmacopeia (USP).

America

Not stated

MedMARx U.S. Pharmacopeia (USP). America

Data are summarised according to the website by APSF (no date), Department of Health Taiwan (2005), Health Canada (2004), JCAHO (2005), NPSA (no date), U.S. Pharmacopeia (no date), and US Veteran Affairs (2006).

Although it has been recognised that voluntary reporting only detects a small proportion of medication errors and cannot be used to measure the actual frequency of errors (Flynn et al. 2002), the role of medication error reporting is still significant. Voluntary reporting can collect information on errors and adverse events, as well as enhance learning and improvement through the analysis of epidemiological data (Leap 2002; Shaw et al. 2005; Giles et al. 2006). Voluntary reporting is useful for Root-Cause Analysis and for trend analysis of medication errors, for example medications involved, doses, forms, and routes. Additionally, a large database can aid trend analysis (Flynn et al. 2002; IOM 2006). Moreover, voluntary reporting provides a stimulus for change. A good reporting system can help healthcare professionals be aware of major hazards and is also important to the monitoring process for preventing errors (Leap 2002; IOM 2006).

The Challenge

The existing literature emphasises the importance of reporting all errors and incidents in the administration of medication, including near-misses (Anderson and Webster 2001; NMC 2004; IOM 2006). In America, The IOM (2006) recommended that medication error- reporting should be facilitated aggressively by all stakeholders that shape the environment of healthcare delivery, including legislators, regulators, accreditors, payers and patient safety organisations. In Britain, since 2004 The Nursing and Midwifery Council (NMC), the Professional Nursing Regulatory Body, has clearly indicated that all errors in the administration of medicines must be reported to managers or employers in “The Guidelines for the Administration of Medicines”.

However, the major challenge to voluntary reporting is the low reporting rate (Grandhi et al. 2000; Department of Health UK 2004). The Department of Health Report (2004), ‘Building a safer NHS for patients. Improving medication safety’ uses the ‘tip of the iceberg’ analogy (See Figure 2) to illustrate the problem of low reporting, where the majority of medication errors remain unknown.

Figure 2: The Iceberg of Medication Errors (Adapted from Department of Health UK, 2004)

Low reporting of medication errors could be potentially harmful to patients and the provision of standard care (NMC 2004). After reviewing the current research literature the IOM (2006) identified that a large gap exists in the understanding of incident rates, costs and prevention strategies for medication errors; however, some data are ten years old (Bates et al. 1997). Furthermore, the development of medication error prevention strategies requires a better understanding of error occurrences, costs and consequences (IOM 2006). Moreover, the IOM (2006) costs of medication errors may be underestimated since the current understanding of the costs of medication errors is drawn from preventable adverse drug events (IOM 2006). The Taiwan Context

Little literature discussed the issue of medication error reporting and strategies to promote reporting in the author’s country, Taiwan. The issue of medication errors has not been an open topic for discussion and education in Taiwan. Later, two serious medication errors that occurred in 2002 (See Box 3) had shown that hospital administrators focused on the “person” who made an error (Chiu et al. 2004) and who therefore must be ‘incompetent’ (Lee et al. 2004). It is evident that nobody has discussed medication errors unless they have resulted in a critical incident.

Box 3 Outline of Two Critical Incidents in Taiwan

• At the end of 2002, a registered nurse mistakenly injected a muscle relaxant rather than Hepatitis B vaccine to seven newborn babies in a Women and Children hospital. One baby died immediately and six babies suffered brain damaged after receiving cardiopulmonary resuscitation (Chen 2003).

• Two weeks later, diabetic medications were dispensed instead of antihistamine agents to more than one hundred and twenty patients in a clinic. One child died and many patients were affected because of the use of the wrong drug (Department of Health Taiwan 2005).

Additionally, the education for preventing medication errors and adverse drug events was still limited to the “five-rights” principle (Chen 2003). The “five-rights” in the process of medication administration mean the right time, the right dose, the right route, the right medicine and the right patient (Chen 2003). For example, in the author’s five-year nursing diploma programme in the 90’s and a recent three-year bachelor’s degree in nursing education, the “five- rights” principle has been the only method addressed for medication safety. Additionally, in the author’s four years clinical practice in two organisations, medication errors did occur and the issue of medication safety was not included in in-service education.

These two serious medication errors raised public, healthcare and government awareness regarding the safety of medication treatment. A Taiwan Patient-Safety Reporting System, which is a national, anonymous and voluntary electronic reporting system, was established in 2004 (See Table 1); the national launch was scheduled for 2006 after the testing stage (Department of Health Taiwan 2006). Medication safety has become one of Taiwan’s major healthcare delivery goals since 2004 (Department of Health Taiwan 2005).

However, medication safety cannot be achieved by the incident reporting system alone since error reporting is crucial to the process of error management (Lawton and Parker 2002). Expert opinions suggest that under-reporting may occur for a number of reasons (Department of Health UK 2004; IOM 2006). In order to achieve medication safety, there is a need to bridge the knowledge gap of costs, occurrence and prevention strategies of medication errors by producing a large database in Taiwan. Evidence suggests that the role of medication error reporting is crucial in the identification, trend analysis and prevention of medication errors. Review Aims

This review examined the evidence about nurses’ perceptions of medication error reporting. Nurses play a key role in facilitating medication safety. Armitage and Knapman, (2003) claim that nurses spend 40% of their time administering medications. Nurses also carry out the last two steps in the complex process of drug administration: administering and monitoring. Hence, it is essential for researchers and policy makers to gain greater insight into the nurses’ perceptions and feelings towards medication error reporting as these may affect patient safety involving medication usage. As little is known regarding medication error and reporting in Taiwan; the following review will analyse the issue of medication error reporting using evidence from Western countries. Thus, the review of nurses’ perceptions of medication error reporting would help to provide information relevant to improving medication safety.

In order to locate the best available evidence, the strategies of using electronic databases and reference lists (Timmins and McCabe 2005) were applied to ensure systematic, thorough and comprehensive searches. Firstly, several electronic databases were used. The purpose of using multiple databases was to increase coverage, as databases have strengths in different areas. (Muir Gray 2001). In order to identify relevant studies, the year of search was not set. Secondly, once a relevant study was identified, the reference list was examined in order to gain more understanding of the topic (Timmins and McCabe 2005).

For identifying relevant studies in Western countries, three electronic databases were used including MEDLINE (United States National Library of Medicine Database) from 1966, EMBASE (Expcerpta Medical Database) from 1980 and CINAHL (Cumulative Index to Nursing and Allied Health) from 1982. In terms of Taiwanese studies, three electronic systems were searched. The first database was the Electronic Theses and Dissertations System which is a national electronic database, which collects theses and dissertations in Taiwan since 1956 (National Central Library 2005). The second was the READncl Service System, a national electronic database containing published Taiwanese journals since 1991 (National Central Library 2004). The third was the Chinese Electronic Periodical Service (CEPS), covering all journals written in Mandarin and those published in Mainland China, Hong Kong and Taiwan since 1991 (Airiti Company 2006).

The key search terms employed to identify studies included: medication administration, drug administration, medication safety, medication errors, patient safety, medication administration errors, drug administration errors, knowledge, incident reporting, voluntary reporting, self-reporting, error prevention, quality improvement, perception, blame, nurses, nursing staff, registered nurses, culture, organisational culture, attitude to change, attitude to risk and finally attitude of health personnel. The differences between British and American spellings were also noticed. Furthermore, key terms were utilized in both single and combined searches.

Findings Search Results

In total, 217 studies were found. Regarding the Western studies, only studies written in English were recruited. Studies were screened for relevance by reading the abstracts. If their focus was the reporting of medication or administration errors among staff nurses, the study was selected. A total of 13 studies were selected for this review. The studies were drawn from Australia, Taiwan, the United Kingdom and the United States of America.

Review of the Selected Studies

The characteristics of each study are listed in Appendix 1. Seven out of thirteen studies were designed as quantitative research using the survey approach (Osborne et al. 1999; Wakefield et al. 1999; Blegen et al. 2004; Mayo and Duncan 2004; Stratton et al. 2004; Hsu 2005; Shih et al. 2005). Another three studies were qualitative research (Hand and Barber 2000; Jeffe et al. 2004; Kingston et al. 2004). The other three studies used mixed methods i.e. they adopted both qualitative and quantitative methods (Gladstone 1995; Walker and Lowe 1998; Handler et al. 2004). Gladstone (1995) used a document review and interviews to gain additional data. Handler et al. (2004) supplemented their quantitative data with observation, semi-structured interviews and document review. Walker and Lowe (1998) conducted focus groups to obtain the perceptions of staff nurses.

Seven studies were from the United States of America, including five surveys, one mixed- method approach and one qualitative study. Four studies used questionnaires to survey nurses’ perceived proportion of medication error reporting, knowledge regarding what constituted medication errors and when to report them, perceptions regarding reporting and the reasons for under-reporting. Osborne et al. (1999) conducted a small study (n=57) exploring nurses’ perceptions and reporting of medication errors in one hospital by convenience sampling. A large-scale study was conducted by Mayo and Duncan (2004) exploring registered nurses (n=983) across 16 acute care hospitals in Southern California by simple random sampling. The study by Stratton et al. (2004), which was a pilot study prior to the study by Blegen et al. (2004), surveyed acute care registered nurses (n=227) and paediatric registered nurses (n=57) across 11 hospitals in two states. These were sampled by convenience sampling. Next, Blegen et al. (2004) conducted an American nationwide study survey of registered nurses (n=1105) across 25 acute care hospitals; the sampling strategy was not stated in the published journal.

Only one survey, by Wakefield et al. (1999), examined potential barriers to medication error reporting among nurses (n=1428) by convenience sampling across 29 acute care hospitals in Iowa State, USA. Only Handler et al. (2004) adopted the mixed-method approach to study the processes of medication administration and error reporting among registered nurses (n=20) working in one long-term care setting through observing, interviewing and a questionnaire survey. They also reviewed medication error documents. Only Jeffe et al. (2004) conducted a qualitative study using convenience sampling and focus groups to explore the views of 30 doctors, 49 staff nurses and 10 nurse managers across 20 academic and community hospitals serving adult and/or paediatric patients in the St. Louis metropolitan area.

Two studies from the United Kingdom were included. Gladstone’s (1995) study, the earliest study in this review, adopted a combination approach to examine the common issues underlying medication errors and reporting in one district general hospital. Incident report documents were analysed (n=79), staff nurses were surveyed (n=81) by stratified sampling and nurses who made errors were interviewed (n=14) by convenience sampling. Hand and Barber (2000) conducted a qualitative study through interviews (n=17) to explore nurses’ attitudes and beliefs about medication errors in one London teaching hospital.

Two studies from Australia were included. Walker and Lowe (1998) surveyed and interviewed staff nurses’ beliefs (n=43) concerning medication error reporting after the introduction of a new medication incident reporting system in one hospital. Its sampling strategy was not stated. Kingston et al. (2004) conducted a qualitative study exploring 14 medical and 19 nursing staff across three tertiary metropolitan public hospitals by purposive sampling and focus groups.

Two studies have been included from Taiwan; both were surveys. The study by Hsu (2005) adopted the questionnaire of Mayo and Duncan (2004) to survey registered nurses (n=1352) in one medical centre and one regional hospital by convenience sampling. The study by Shih et al. (2005), a Taiwanese nationwide study by stratified sampling (n=2579), surveyed the current incident reporting systems in all Taiwanese hospital settings (n=327) and healthcare professionals’ perceptions of the willingness to practise incident reporting, including medication errors, and the barriers against it.Nearly half of the participants (n=1287, 49.9%) were registered nurses.

Most studies explored the perceived proportions of medication error reporting and knowledge regarding what constituted medication errors and when to report them. Perceptions among registered nurses regarding reporting and the reasons for under-reporting were also examined. There was little exploration of barriers to medication errors. Additionally, eight of thirteen studies were published in the past two years: 2004 and 2005, indicating that the issue of medication errors has been paid much more attention in recent years.

Data Summary

After appraising the thirteen studies, the following themes were identified as factors affecting