Research Raw

Nursing documentation is the record of nursing care that is planned and delivered to
individual clients by qualified nurses or other caregivers under the direction of a qualified nurse.[1] It
contains information in accordance with the steps of the nursing process. Nursing documentation is
the principal clinical information source to meet legal and professional requirements,[2] and one of the
most significant components in nursing care. Quality nursing documentation plays a vital role in the
delivery of quality nursing care services through supporting better communication between different
care team members to facilitate continuity of care and safety of the clients.
Purposes[edit]
 A written record of the history, treatment, care, and response of the client while under the care of
a health care provider.
 A guide for reimbursement of care costs.
 Evidence of care in a court of law. A legal record that can be used as evidence of events that
occurred or treatments given.
 Show the use of the nursing process. It contains observations by the nurses about the client's
condition, care, and treatment delivered.
 Provides data for quality assurance studies and shows progress toward expected outcomes.
Documentation of the nursing process[edit]

See also: Nursing process
The internationally accepted nursing process consists of five steps: assessment, nursing
problem/diagnosis, goal, intervention and evaluation.[3] Nursing process model provides the
theoretical framework for nursing documentation. A nurse can follow this model to assess the clinical
situation of a client and record a constructive document for nursing communication.
Content[edit]
Nursing documentation mainly consists of a client's background information or nursing history
referred as admission form, numerous assessment forms, nursing care plan and progress notes.
These documents record the client's data captured at the relevant stages of the nursing
process.[4] The following sections describe the concept, aim, possible structure and content of these
nursing documents using the example of nursing documentation in Australian residential aged
care homes.
Admission[edit]
An admission form is a fundamental record in nursing documentation. It documents a client's status,
reasons why the client is being admitted, and the initial instructions for that client's care.[5] The form
is completed by a nurse when a client is admitted to a health care facility.
The admission form provides the basic information to establish foundations for further nursing
assessment. It usually contains the general data about a client, such as name, gender, age, birth
date, address, contact, identification information (ID) and some situational descriptions about
marriage, work or other background information. Based on the different nursing care provider's
requirements, this form may also record family history, past medical history, history of present
illness, and allergies (see Figure 1).
Assessment[edit]
The documentation of nursing assessment is the recording of the process about how a judgment
was made and its related factors, in addition to the result of the judgment. It makes the process of
nursing assessment visible through what is presented in the documentation content.[6]
During nursing assessment, a nurse systematically collects, verifies, analyses and communicates a
health care client's information to derive a nursing diagnosis and plan individualized nursing care for
the client.[7] Complete and accurate nursing assessment determines the accuracy of the other stages
of the nursing process.[8]
The nursing documents may contain a number of assessment forms. In an assessment form, a
licensed Registered Nurse records the client's information, such as physiological, psychological,
sociological, and spiritual status (see Figure 2). The accuracy and completeness of nursing
assessment determine the accuracy of care planning in the nursing process.[9]
Nursing care plan[edit]

The nursing care plan (NCP) is a clinical document recording the nursing process, which is a
systematic method of planning and providing care to clients.[8] It was originally developed in hospitals
to guide nursing students or junior nurses in providing care to client; however, the format was task-
oriented rather than nursing-process-based.[10] Nowadays, the NCP is widely used in nursing in
various clinical and educational settings as a tool to direct individualized nursing care for
clients.[11][12][13][14]
The nurses make nursing care plans based on the assessments they have completed previously
with a client. There are many ways of structuring nursing care plans in correspondence with the
different needs of nursing care in different nursing specialties. For example, a nursing care plan in
an Australian residential aged care home may be structured with several sections under each care
domain such as pain, mobility, lifestyle, nutrition and continence. The information is recorded in free-
text style, and various terms are used singly or in combination to name each of the four sections in
the formats that are used by a facility during a particular period (Figure 3).
Figure 2-2. A sample nursing assessment form for an Australian residential aged care home
Figure 3-3. An example of a nursing care plan in an Australian residential aged care home
Progress notes[edit]
A progress note is the record of nursing actions and observations in the nursing care process.[15] It
helps nurses to monitor and control the course of nursing care.
Figure 3-1. An example of a nursing care plan in an Australian residential aged care home.
Generally, nurses record information with a common format. Nurses are likely to record details about
a client's clinical status or achievements during the course of the nursing care.
Recording format[edit]
Paper-based nursing documentation[edit]
The paper-based nursing documentation has been in place for decades. Client's data are recorded
in paper documents. The information in these documents needs to be integrated for sense-making in
a nursing decision.
Electronic nursing documentation[edit]

Electronic nursing documentation is an electronic format of nursing documentation an increasingly
used by nurses. Electronic nursing documentation systems have been implemented in health care
organizations to bring in the benefits of increasing access to more complete, accurate and up-to-
date data and reducing redundancy, improving communication and care service delivery.[16]
Comparison of the quality of paper-based and electronic

documentation[edit]
Electronic nursing documentation systems are able to produce somewhat better quality data in
comparison with paper-based systems, in certain respects depending on the characteristics of the
systems and the practice of the various study settings. The common benefits of electronic
documentation systems include the improvement of comprehensiveness in documenting the nursing
process, the use of standardized language and the recording of specific items about particular client
issues and relevance of the message. In addition, electronic systems can improve legibility, dating
and signing in nursing records.
For the documentation of nursing assessment, the electronic systems significantly increased the
quantity and comprehensiveness of documented assessment forms in each record. In regard to the
NCP, the electronic standardized NCPs were graded with a higher total quality score than its paper-
based counterpart. In addition, in comparison with the paper-based documentation systems, the
electronic systems, due to their automatic functions, were able to improve the format, structure and
process features of documentation quality such as legibility, signing, dating, crossing out error and
space with a single line and resident identification on every page.
Paper-based documentation has been found to be inferior in comparison with electronic
documentation. This is caused by the inherent nature of paper being difficult to update, time-
consuming in a recording. Thus, the records are often incomplete, illegible, repetitive and missing
signatures.[17]
Figure 3-2. An example of a nursing care plan in an Australian residential aged care home
Electronic nursing documentation systems have the potential to improve the quality of
documentation structure and format, process and content in comparison with paper-based
documentation, as demonstrated in a comparative study of electronic and paper-based nursing
admission forms.[18] However, improvement in documentation quality is not necessarily to be brought
about by the introduction of electronic nursing documentation system to replace paper-based
documentation. For example, Wang et al.[18] that although the electronic nursing assessment form
contained more documented assessment forms, which covered a wider range of resident care
needs, they did not perform better than the previous [null paper-based assessment forms according
to] the quality criteria of [null completeness] and timeliness. Therefore, further work on the usage of
the electronic documentation systems may focus on improving form design and usage. There is also
a need for improvement in compliance with standards in order to better meet the clients' care needs.
Quality of nursing documentation[edit]

A study by the National Client Safety Agency (NPSA)[19] found that poor standards of documentation
were a contributory factor in the failure to detect clients who were clinically deteriorating. Nurses are
responsible for maintaining accurate records of the care they provide and are accountable if
information is incomplete and inaccurate.[20] Thus, a quality standard is required for recording of
nursing documentation.
The quality of nursing documentation is a multidimensional concept. Its two key elements are its
characteristics and the requirements that they fulfil. The systematic review of nursing documentation
audit studies in different settings[21] identified the following relevant quality characteristics of nursing
documentation:
 Quality of documentation structure and format: relates to constructive features and physical
presentation of records such as quantity, completeness, legibility, readability, redundancy and
the use of abbreviations.
 Quality of documentation process: the procedural issues of capturing client data such as nurse's
signature and designation, date, chronological order, timeliness, regularity of documentation and
concordance between documentation and reality.
 Quality of documentation content: refers to the message from data about a care process. It is
concerned with the comprehensiveness, appropriateness and the relationship of the five steps
of the nursing process. The care issue recorded at each step is also considered
Standardized nursing terminology[edit]

North American Nursing Diagnosis Association (NANDA) nursing diagnosis:
NANDA International (formerly the North American Nursing Diagnosis Association) is a professional
organization of nurses standardized nursing terminology that was officially founded in 1982 and
develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing
diagnoses.
Nursing intervention classification (NIC):
The Nursing Interventions Classification (NIC) is a care classification system which describes the
activities that nurses perform as a part of the planning phase of the nursing process associated with
the creation of a nursing care plan.
Nursing outcome classification (NOC):
The Nursing Outcomes Classification (NOC) is a classification system which describes client
outcomes sensitive to nursing intervention.
The Omaha System:
The Omaha System is a standardized health care terminology consisting of an assessment
component (Problem Classification Scheme), a care plan/services component (Intervention
Scheme), and an evaluation component (Problem Rating Scale for Outcomes).
International Classification for Nursing Practice (ICNP):
The International Classification for Nursing Practice (ICNP) is a collaborative project under the
auspices of the International Council of Nurses. The ICNP provides a structured and defined
vocabulary as well as a classification for nursing and a framework into which existing vocabularies
and classifications can be cross-mapped to enable comparison of nursing data.[22]
Structured documentation[edit]
Structured documentation takes the form of pre-printed guidelines for specific aspects of care and
can, therefore, focus nursing care upon diagnoses, treatment aims, client outcomes and evaluations
of care.[23] It can improve client care by replacing the practice of vague, narrative style entries by
nurses with cohesive and accurate information determined by the format of the care plan.[24] The
clarity of the recorded information also facilitates clinical auditing and evaluation of documentation
practices through.[25] Therefore, the introduction of structured documentation and care plans are seen
as a means by which nurses can raise standards of record-keeping practice.[26]
References[edit]
1. Jump up^ Urquhart C, Currell R, Grant MJ. Hardiker NR. Nursing record systems: Effects on nursing
practice and healthcare outcomes. Cochrane Data- base of Systematic Reviews 2009; (1): 1–66.
2. Jump up^ Daskein R,Moyle W, Creedy D.Aged-care nurses' knowledge of nursing documentation: An
Australian perspective. Journal of Clinical Nursing 2009; 18: 2087–2095.
3. Jump up^ Björvell C,Thorell-Ekstrand I.Wredling R.Development of an audit instrument for nursing
care plans in the client record. Quality in Health Care 2000; 9: 6–13.
4. Jump up^ Blair, W., & Smith, B. (n.d). Nursing documentation: Frameworks and barriers.
Contemporary Nurse, 41(2), 160-168.
5. Jump up^ "General Info". Archived from the original on 12 March 2009. Retrieved 2009-04-03
6. Jump up^ Oroviogoicoechea C., Elliott B. & Watson S. (2008) Review: evaluating information systems
in nursing. Journal of Clinical Nursing 17, 567–575.
7. Jump up^ Crisp J., Taylor C., Potter PA. & Perry A.G. (2005) POTTER and PERRY'S fundamentals of
nursing (2nd ed). Elsevier Australia.
8. ^ Jump up to:a b White L. (2002) Documentation and the Nursing Process. Delmar Learning, Clifton
Park, NY
9. Jump up^ L. White, Documentation and the Nursing Process, Delmar Learning, Clifton Park, NY,
2002.
10. Jump up^ Greenwood D. (1996) Nursing care plans: issues and solutions. Nursing Management
27(3), 33-40.
11. Jump up^ Neilson T., Peet M., Ledsham R. & Poole J. (1996) Does the nursing care plan help in the
management of psychiatric risk? Journal of Advanced Nursing 24,1201-1206 Daly J.M., Buckwalter K.
& Maas M. (2002) Written and computerized care plans. Journal of Gerontological Nursing 28(9), 14–
23. Björvell C., Thorell-Ekstrand I. & Wredling R. (2000) Development of an audit instrument for
nursing care plans in the patient record. Quality in Health Care 9, 6-13. Kern C.S., Bush K.L. &
McCleish J.M. (2006) Mind-mapped care plans: integrating an innovative educational tool as an
alternative to traditional care plans. Journal of Nursing Education 45(4), 112-119.
12. Jump up^ Daly J.M., Buckwalter K. & Maas M. (2002) Written and computerized care plans. Journal
of Gerontological Nursing 28(9), 14–23.
13. Jump up^ Björvell C., Thorell-Ekstrand I. & Wredling R. (2000) Development of an audit instrument for
nursing care plans in the patient record. Quality in Health Care 9, 6-13.
14. Jump up^ Kern C.S., Bush K.L. & McCleish J.M. (2006) Mind-mapped care plans: integrating an
innovative educational tool as an alternative to traditional care plans. Journal of Nursing Education
45(4), 112-119.
15. Jump up^ "UW Internal Medicine Residency Program". Retrieved 2009-04-10
16. Jump up^ Zhang Y, Yu P, Shen J. The benefits of introducing electronic health records in residential
aged care facilities:A multiple case study. Interna- tional Journal of Medical Informatics 2012; 81: 690–
704.
17. Jump up^ Ammenwerth E,Eichstadter R,Haux R et al.A randomized evaluation of a computer-based
nursing documentation system. Method Inform Med 2001; 40: 61–68.
18. ^ Jump up to:a b Wang, N., Yu, P., & Hailey, D. (2012). Description and comparison of quality of
electronic versus paper-based resident admission forms in Australian aged care facilities. International
Journal of Medical Informatics, doi:10.1016/j.ijmedinf.2012.11.011
19. Jump up^ National Clients Safety Agency (2007) Recognising and responding appropriately to early
signs of deterioration in hospital clients. NPSA, London. http://tinyurl.com/yk8ao5x (Accessed 20
November 2011)
20. Jump up^ Owen K (2005) Documentation in nursing practice. Nurs Stand 19(32): 48–9
21. Jump up^ Wang N, Hailey D, Yu P. Quality of nursing documentation and approaches to its
evaluation: A mixed-method systematic review.Journal of Advanced Nursing 2011; 67: 1858–1875.
22. Jump up^ Wake, M., & Coenen, A. (1998). Nursing diagnosis in the international classification for
nursing practice (icnp). International Journal of Nursing Knowledge, 5(4), 335.
23. Jump up^ Dahm M, Wadensten B (2008) Nurses' experiences of and opinions about using
standardised care plans in electronic health records; a questionnaire study. J Clin Nurs 17(16): 2137–
45
24. Jump up^ Irvine K, Tracey M, Scott A, Hyde A, Butler M, MacNeela P (2006) Discursive practices in
the documentation of client assessments. Journal of Advanced Nursing 53(2): 151–9
25. Jump up^ Saranto K, Kinnunen U (2009) Evaluating nursing documentation-research designs and
methods: systematic review. J Adv Nurs 65(3): 464–76
26. Jump up^ Law L, Akroyd K, Burke L (2010) Improving nursing documentation and record-keeping in
stoma care. Br J Nurs 19(21): 1328
and these criteria may include such conditions as multi -trauma, drug overdose, post-
operative major vascular surgery, cardio-pulmonary arrest and sepsis. The
current process of documentation involvesnumerous and separate charts.
Definitions of Documentation:
•
Documentation is any written or electronically generated information about a client
that describesthe care or service to the client
•
Documentation is the key - If it is not written it did not happen
•
The term documentation” is used in this publication to mean any written or electronically
generatedinformation about a client that describes the care or service provided to that client.
“Client” refers toindividuals, families, groups, populations or entire communities who require
nursing expertise
•
Documentation is the written evidence of the interactions between
a n d a m o n g h e a l t h c a r e professionals, patients and their families, and h
e a l t h c a r e o r g a n i z a t i o n s ; t h e a d m i n i s t r a t i o n procedures, treatments, and patient
education; and the results or patient’s responses to them
•
Documentation includes all aspects of the nursing process as well as
the contributions of all other health team members to the patient’s care
•
Nursing Documentation is that part of the clinical record written by nurses and is
the total writteninformation concerning patient’s health status, nursing needs, nursing care,
and response to nursingcare. Key components of nursing documentation includes assessments,
nursing diagnoses, plannedcare, nursing interventions, patient teaching, patient out come, and
interdisciplinary communication
•
Nursing Documentation comprises of all written and/or computerized recordings of
relevant datamade by nurses to document care given or to communicate information
relevant to the care of a particular client/patient. Other supporting documentation includes:
Policies/Procedures/Protocols
Rosters
Incident Reports
Performance Appraisals/Assessments
Personnel Files
Computer Generated Data
Dependency Studies
Research Data
Documents required for health finding purposes

•
Temporary media, such as audio taped or video taped handovers, should not be
considered as asubstitute for full and proper documentation in client/patient records
Purposes of Documentations:
•
Professional accountability
•
Professional responsibility
•
Quality assurance
•
Patient client’s teaching
•
Education
•
Research
•
Reimbursement
•
Prevention of missing something in care
•
Prevention doubling or duplication in care
•
Monitoring
•
Communicate information accurately, effectively and in a timely fashion
•
Financial billing
•
Assessment
•
Auditing
•
Legal record
•
Legal and practice standards and protection
•
Who else depends on the information in the record?
o
Medical records and Coding department
o
Billing and finance
o
Internal and External quality monitoring
o
Insurance companies and Attorneys
o
Secondary users of varying sophistication.
Legal and ethical issues
What may be obvious at the time needs to be explicitly stated for later reference (hours,days,
years later)
Need to reflect complexity of medical services provided
Language does matter - Accuracy and specificity are essential

Reason for Documentation:
•
To facilitate communication:
Through documentation, nurses communicate to other nurses and c a r e p r o v i d e r s
their assessments about the status of clients, and nursing interventions
t h a t a r e carried out the results. Documentation of this information increases the
likelihood that the
clientw i l l r e c e i v e c o n s i s t e n t a n d i n f o r m e d c a r e o r s e r v i c e . A c c u r a t e d o c u m
e n t a t i o n d e c r e a s e s t h e potential for miscommunication and errors. However
documentation is most often done by nurses
and care providers, there are situations where client(s) and family (ies) may document
observationsand / or care provided in order to communicate with members of the health care
team
•
To promote good Nursing care
: Documentation encourages nurses to assess client progress anddetermine which
interventions are effective and ineffective, and identify and document changes tothe plan of
care as needed. Documentation can be a valuable source of data for making
decisionsabout finding and resource management as well as facilitating nursing
research, all of which havethe potential to improve the quality of nursing practice
and client care. Individual nurses can useoutcome information or information from a
critical incident to reflect on their practice and to makenecessary changes based on evidence
•
To meet professional and legal standards: Documentation is a valuable method for
demonstratingt h a t , w i t h i n t h e n u r s e -
c l i e n t r e l a t i o n s h i p , t h e n u r s e h a s a p p l i e d n u r s i n g k n o w l e d g e , s k i l l s a n d jud
gment according to professional standards. The nurse’s documentation may be used as
evidencei n l e g a l p r o c e e d i n g s s u c h a s l a w s u i t s , c o r o n e r s ’ i n q u e s t s , a n d d i s c i
p l i n a r y h e a r i n g s t h r o u g h professional regulatory bodies. In a court of law, the client’s
health record serves as the legal recordof the care or service provided. Nursing care and
the documentation of that care will be measuredaccording to the standard of a reasonable
and prudent nurse with similar education and experiencein a similar situation.
Out patients perception and satisfection regarding out patient services at national institute
of neurosciences hospital,Dhaka
Perceptions regarding medication administration errors among hospital staff nurses of South
Korea
Mi-Ae You Mi-Hyeon Choe Geun-Ok Park Sang-Hee Kim Youn-Jung Son
International Journal for Quality in Health Care, Volume 27, Issue 4, 1 August 2015, Pages
276–283, https://doi.org/10.1093/intqhc/mzv036
Published:
08 June 2015
Article history
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Abstract
Objective
To identify reasons for medication administration errors (MAEs) and why they are unreported,
and estimate the percentage of MAEs actually reported among hospital nurses.
Design
A cross-sectional survey design.
Setting
Three university hospitals in three South Korean provinces.
Participants
A total of 312 hospital staff nurses were included in this study.
Main outcome
Medication administration errors.
Results
Actual MAEs were experienced by 217 nurses (69.6%) during their clinical career, whereas 149
nurses (47.8%) perceived that MAEs only occur less than 20% rate. MAEs occurred mostly
during intravenous (IV) administrations. Nurses perceived that the most common reasons for
MAEs were inadequate number of nurses in each working shift (4.88 ± 1.05) and administering
drugs with similar names or labels (4.49 ± 0.94). The most prevalent reasons for unreported
MAEs included fears of being blamed (4.36 ± 1.10) and having too much emphasis on MAEs as
a measure of nursing care quality (4.32 ± 1.02). The three most frequent errors perceived by
nurses for non-IV related MAEs included administering medications to the incorrect patients and
incorrect medication doses and drug choices. The three most frequent IV related MAEs included
incorrect infusion rates, patients and medication doses.
Conclusions
Nurse-staffing adequacy could be helpful to prevent MAEs among nurses as well ongoing
education, and training regarding safe medication administration using the problem-based
simulation education. In addition, encouraging nurses to identify and report work related errors
in a non-punitive milieu will increase error reporting.
hospitals, medication errors, nurses, patient safety
Topic:
 nurses
 perception
 personnel, hospital
 drug administration error
 south korea
Issue Section:
Papers
Introduction
Patent safety has long been a major concern for health care professionals and its significance has
expanded with the increasing need for hospital accreditation [1, 2]. Medication errors have been
identified as the most common type of errors affecting patient safety and the most common
single preventable cause of adverse events [3]. Although preventing the mediation errors in
patient safety is very important, there are no structured guidelines or policies available for
disclosing medication errors to the patients in South Korea. Therefore, it is also necessary to
develop strategies to improve medication safety [4].
Medication errors are multidisciplinary in nature and include prescribing, dispensing and
administration errors that result in incorrect medications, administration routes, doses,
inappropriate continuation of medications, omission of doses or administering medications to
patients despite knowing that they are allergic to the medication [3]. Nurses are intimately
involved in and ultimately responsible for the delivery of medication [5]. The medication
administration process is a daily component of nursing practice and is often viewed as a routine
and basic nursing task. Nurses spend up to 40% of their work time on medication administration
[6]. However, nurses often practice under suboptimal organizational conditions in terms of
staffing, organization of work and the work environment [7].
The medication administration errors (MAEs) rate varies because of the differences in the
definitions of MAE, error categories, departments, medication distribution system and countries.
In a systematic review of 45 studies, it was revealed that the prevalence of medication errors was
2–75% in studies that included a generic definition of medication errors [8]. Tissot et al.[9]
observed MAEs during a period of 20 days in two departments at a university hospital; the
medication error rate was 14.9%, and dose errors (i.e. omission, unauthorized or incorrect dose)
were the most frequent types of errors (41%), followed by incorrect time (26%) and rate errors
(19%). The overall non-intravenous (IV) and IV related MAE rates in hospitals in the United
Kingdom were 5.6 and 35%, respectively [10]. Studies related to medication errors in South
Korea are limited compared to other countries because most hospitals are reluctant to report
medication errors. Recently, Kim et al. reported that 63.6% of nurses with a minimum of 1 year
clinical experience were involved in medication errors more than once in the past month and
only 28.3% of them reported the medication errors formally. Kim et al. [1] used the survey
questionnaire that was developed by the researcher through literature review and they have no
process of evaluating the validity and reliability. Oh and Yoon studied the rate of perception and
experience in medication errors in targeted new nurses with less than 1 year clinical experience
[11]. Average perception rate of nurses in 22 items about medication errors was 86.7%.
Experience rate of medication errors among nurses was 23 and 46.3% out of those reported the
medication errors. In South Korea, there are approximately 2800 hospitals including 44 tertiary
hospitals [12]. Under the Healthcare Accreditation Program launched in 2010 [13], hospitals
have introduced hospital-wide incident-reporting systems to meet the requirement of
implementing patient safety-reporting systems. Nevertheless, no official statistics on the scale
and magnitude of mediation errors in South Korea are available [4].
Reporting of errors is essential for developing strategies to prevent and reduce medication errors
because the health care community can learn from previous mistakes. However, nurses are
reluctant to report medication errors because of fears of blame. In addition, most hospitals are
reluctant to reveal incident reports of medication errors because of potential damage to the
hospitals' reputation. Therefore, it is very difficult to obtain useful and accurate data about
medication errors. More importantly, preventing medication errors depends on precise reporting,
and it is important to evaluate the reasons staff nurses avoid error reporting [14, 15]. Therefore,
there is a need to identify the perceptions of nurses regarding MAEs and prepare strategies to
enhance patient safety. A proper understanding of why MAEs occur and why they are often
unreported and the extent to which errors are actually reported is the first step towards
preventing MAEs. The purpose of this study was to identify and describe reasons for MAEs and
why they are often unreported, and to determine the incidence of reported non-IV and IV related
MAEs by hospital staff nurses in South Korea.
Methods
Study design
This study was a cross-sectional survey conducted by self-reported questionnaires.
Participants
The study sample was comprised of nurses working at the three Soonchunhyang University
affiliated general hospitals with in a 780–840 bed in Seoul, Bucheon and Cheonan city, South
Korea. Nurses who have been working in these three hospitals take charge of 15–20 patients per
duty, respectively. The number of participants from each hospital were 100 (A hospital), 100 (B
hospital) and 112 (C hospital).
Inclusion criteria were the registered nurses (RNs) who provided direct patient care and had been
employed for more than one year. The RNs in higher positions, such as administrators of nursing
departments, and male nurses were excluded from the study for the following reason: few male
nurses exist in South Korea. Furthermore, the manager position of each job category was also
excluded because we only wanted to evaluate employees who contact and provide care to the
patients directly. A total of 350 subjects participated in the study. Finally, 312 nurses were
included in this study because 38 subjects did not complete the questionnaires.
Measures
To investigate the nurses' perception of MAE, we used the MAE self-reported questionnaire
developed by Wakefield et al. [16]. After approval from the MAEs questionnaires developer, the
questionnaires were initially translated into Korean and then back-translated into English. To
improve content validity, we consulted two faculty nurses and five head nurses with actual
content validity more than 0.85; the questions were modified as a pilot test for 20 nurses. The
questionnaires consisted of three sections; (i) 29 items regarding reasons for the occurrence of
MAEs; (ii) 16 items regarding reasons for why MAEs are unreported and (iii) 20 items regarding
the percentage of actually reported non-IV and IV related MAEs (9 and 11 items, respectively).
For the first two sections, each item was evaluated with a 6-point Likert scale (i.e. 1 = strongly
disagree; 6 = strongly agree). To score the survey, means and standard deviation can be
calculated for individual items for the first two sections of survey [16]. Cronbach's alpha was
0.95 in this study. For the third section, each item were asked ‘Have you ever experience each
type of medication errors?’ and were dichotomous question ‘yes’ or ‘no’.
Data collection
After receiving approval from the institutional research board (IRB-2012-91), data were
collected between January and February 2013. After hospital selection, the self-administered
questionnaire package was provided to the participants. The package included an introductory
letter, informed consent form, the questionnaire and a reply envelope with return postage
prepaid. Informed consent and the completed questionnaire were obtained from each participant
using separate envelopes. Given the sensitive topic of this study, the main concern was to gain
participants willingness and trust so that they would provide faithful information about the
medication errors in which they have been involved. The researcher informed the participants
that access to the surveys would be tightly controlled by the researchers and no names of
hospitals or persons would not be revealed in any manner for their confidentiality.
Data analysis
Data were analyzed by descriptive statistics (frequency, percentages, means and standard
deviation) using SPSS for windows 18.0 (SPSS Inc., Chicago, IL, USA).
Results
General characteristics of hospital staff nurses
A total of 312 nurses were included in this study. The mean age was 29 years (standard deviation
[SD] = 5.48 years); 197 (63.2%) nurses were under 29 years; 135 (43.3%) had completed college
or graduate education. The mean years of total clinical experience was about 5.93 years (SD =
13.55 years); 122 (39.1%) nurses were working at the medical unit. The number of nurses
reported that they experienced MAEs during their clinical career was 217 (69.6%). A total of 182
(58.3%) nurses reported that the most frequent routes of MAEs were made by IV administrations
(Table 1).
Table 1
General characteristics of subjects (N = 312)
Characteristics n (%) Mean ± SD
Age (years) 29.22 ± 5.48
≤24 54 (17.3)
25–29 143 (45.9)
30–34 65 (20.8)
≥35 50 (16.0)
Education level
Diploma 177 (56.7)
Above college 135 (43.3)
Unit type
Medical 122 (39.1)
Surgical 92 (29.5)
ICU/ER 51 (16.3)
Pediatrics/Obstetrics 47 (15.1)
Nursing experience in current unit (years) 3.67 ± 12.75
1–2 135 (43.3)

3–4 108 (34.6)
≥5 69 (22.1)
Total clinical career (years) 5.93 ± 13.55
1–2 119 (38.1)
3–4 111 (35.6)
Experience of MAEs
Yes 217 (69.6)
No 95 (30.4)
Routes of MAEs
Intravenous 182 (58.3)
Oral 58 (18.6)
Subcutaneous 48 (15.4)
Intramuscular and others 24 (7.7)
Frequency of received education for medication errors
1–2 110 (35.3)
3–4 89 (28.5)
≥5 113 (36.2)
Perceived rate of reporting for MAEs
0–20% 149 (47.8)

21–30% 66 (21.2)
31–40% 39 (12.5)
41–50% 14 (4.5)
51–60% 15 (4.8)
61–70% 8 (2.6)
71–80% 8 (2.6)
81–90% 8 (2.6)
91–100% 5 (1.6)
View Large
Nurses' perceptions regarding reasons for MAEs
The most common reason for MAEs according to the nurses was inadequate number of staff
nurses in each working shift (4.88 ± 1.05). The second most common reason for MAEs was
administering a drug with a similar name or label as another drug (4.49 ± 0.94) and a drug that
appeared similar to another drug (4.44 ± 1.03). However, errors made in the medication Kardex
(medication Kadex is illegible) (2.72 ± 1.09), and medication orders not transcribed to the
Kardex correctly (2.77 ± 1.06) were the least common reasons for MAEs (Table 2).
Table 2
Reasons for the occurrence of MAEs (N = 312)
Strongl
Moderate y
Strongly Moderate Slightly Slightly ly disagre
agree ly agree agree disgree disagree e Mea
n±
Items n(%) n(%) n(%) n(%) n(%) n(%) SD
Strongl
Moderate y
n±
Items n(%) n(%) n(%) n(%) n(%) n(%) SD
1. Similar 4.49
drug names 121(38.8) 127(40.7 ±
or labels 37(11.9) ) 15(4.8) 9(2.9) 3(1.0) 0.94
2. Different 4.44
medications 116(37.2) 115(36.9 ±
look alike. 41(13.1) ) 23(7.4) 13(4.2) 4(1.3) 1.03
4.24
3. Similar 116(37.2 ±
drug paking 32(10.3) 103(33) ) 34(10.9) 21(6.7) 6(1.9) 1.11
4. Physicians'
medication 3.18
orders are 43(13.8 ±
not legible. 11(3.5) 39(12.5) 86(27.6) 79(25.3) 54(17.3) ) 1.33
5. Physicians'
medication 3.61
orders are 107(34.3 ±
not clear. 15(4.8) 56(17.9) ) 80(25.6) 35(11.2) 19(6.1) 1.22
6. Physicians
change 3.78
orders 122(39.1 ±
frequently. 18(5.8) 54(17.3) ) 83(26.6) 29(9.3) 6(1.9) 1.08
7.
Abbreviation
s are used
instead of 3.71
writing the 119(38.1 ±
orders out 19(6.1) 52(16.7) ) 79(25.3) 29(9.3) 14(4.5) 1.17
Strongl
Moderate y
n±
Items n(%) n(%) n(%) n(%) n(%) n(%) SD
completely.
8. Verbal
orders are
used instead 4.33
of written 113(36.2 ±
orders 48(15.4) 94(30.1) ) 35(11.2) 14(4.5) 8(2.6) 1.16
9. Pharmacy
delivers
incorrect 3.55
doses to this 136(43.6 ±
unit. 9(2.9) 33(10.6) ) 86(27.6) 40(12.8) 8(2.6) 1.02
10.
Pharmacy
does not
prepare the 3.15
medicines 111(35.6 ±
correctly. 6(1.9) 20(6.4) 92(29.5) ) 63(20.2) 20(6.4) 1.08
11.
Pharmacy
does not
label the 3.14
medicines 104(33.3 ±
correctly. 7(2.2) 23(7.4) 90(28.8) ) 64(20.5) 24(7.7) 1.13
12.
Pharmacists
are not 2.89
available 24 73(23.4 ±
h a day. 12(3.8) 31(9.9) 68(21.8) 75(24.0) 53(17.0) ) 1.43
Strongl
Moderate y
n±
Items n(%) n(%) n(%) n(%) n(%) n(%) SD
13. Frequent
substitution
of drugs (i.e.
cheaper
generic for 3.55
brand 114(36.5 100(32.1 ±
names). 15(4.8) 35(11.2) ) ) 39(12.5) 9(2.9) 1.09
14. Poor
communicati
on between 3.77
nurses and 127(40.7 ±
physicians. 17(5.4) 50(16.0) ) 84(26.9) 31(9.9) 3(1.0) 1.04
15. Many
medications 4.25
on multiple 127(40.7 ±
patients 29(9.3) 98(31.4) ) 39(12.5) 19(6.1) 0(0) 0.99
16.
Insufficient
knowledge
and
information 3.80
on new 135(43.3 ±
medications 16(5.1) 53(17.0) ) 73(23.4) 31(9.9) 4(1.3) 1.42
17. On this
unit, there is
no easy way
to look up 3.09
information 111(35.6 ±
on 9(2.9) 25(8.0) 72(23.1) ) 68(21.8) 27(8.7) 1.17
Strongl
Moderate y
n±
Items n(%) n(%) n(%) n(%) n(%) n(%) SD
medications.
18. Nurses
on this unit
have limited
knowledge 3.30
about 108(34.6 ±
medications. 8(2.6) 26(8.3) ) 92(29.5) 65(20.8) 13(4.2) 1.09
19.
Distractions
by other
patients, co-
workers or 4.30
events on the 100(32.1) 115(36.9 ±
unit 38(12.2) ) 40(12.8) 15(4.8) 4(1.3) 1.08
20. When
scheduled
medications
are delayed,
nurses do not
communicate
the time
when the 3.03
next dose is ±
due. 8(2.6) 18(5.8) 81(26.0) 94(30.1) 90(28.8) 21(6.7) 1.13
21. Failure to
adhere to
policy and 2.87
procedure 34(10.9 ±
documents 5(1.6) 15(4.8) 71(22.8) 98(31.4) 89(28.5) ) 1.13
Strongl
Moderate y
n±
Items n(%) n(%) n(%) n(%) n(%) n(%) SD
22. Heavy 4.23

workload in 106(34.0 ±
the ward 47(15.1) 89(28.5) ) 32(10.3) 34(10.9) 4(1.3) 1.22
23.
Inadequate
number of
staffs in each 4.88
working 103(33.0 107(34.3) ±
shift ) 73(23.4) 19(6.1) 9(2.9) 1(0.3) 1.05
24. All
medications
for one team
of patients
cannot be
passed within 3.41
an accepted 122(39.1 ±
time frame. 3(1.0) 43(13.8) ) 70(22.4) 58(18.6) 16(5.1) 1.12
25.
Medication
orders are
not
transcribed to 2.77
the Kardex 114(36.5 35(11.2 ±
correctly. 3(1.0) 12(3.8) 57(18.3) ) 91(29.2) ) 1.06
26. Errors are

made in the 2.72
Medication 42(13.5 ±
Kardex. 2(0.6) 12(3.8) 63(20.2) 98(31.4) 95(30.4) ) 1.09
Strongl
Moderate y
n±
Items n(%) n(%) n(%) n(%) n(%) n(%) SD
27.
Equipment
malfunctions
or is not set
correctly 3.03
(e.g. IV ±
pump). 1(0.3) 27(8.7) 86(27.6) 91(29.2) 81(26.0) 26(8.3) 1.12
28. Nurse is
unaware of a 3.26
known 108(34.6 ±
allergy. 4(1.3) 28(9.0) ) 95(30.4) 60(19.2) 17(5.4) 1.08
29. Patients
are off the 3.39
ward for 143(45.8 ±
other care. 3(1.0) 35(11.2) ) 60(19.2) 41(13.1) 30(9.6) 1.17
View Large
Nurses' perceptions about reasons for unreported MAEs
The most common reason for unreported MAEs was the fear of being blamed if something
happened to the patients (4.36 ± 1.10). The second most common reason was having too much
emphasis on MAEs as a measure of the quality of care (4.32 ± 1.02). However, the least common
reasons for MAEs were the idea that expecting medications to be administered exactly as ordered
is unrealistic (2.39 ± 1.17) and nurses not recognizing that an error has occurred (2.54 ± 1.15;
Table 3).
Table 3
Reasons for unreported MAEs (N = 312)
Strongl
Moderatel y
Strongl Moderatel Slightly Slightly y disagre
y agree y agree agree disgree disagree e Mea
n±
Items n(%) n(%) n(%) n(%) n(%) n(%) SD
30. Nurses
do not agree
with
hospital's
definition of 2.64
a medication 102(32.7 56(17.9 ±
error. 2(0.6) 17(5.4) 48(15.4) ) 87(27.9) ) 1.14
31. Nurses
do not
recognize an 2.54
error 65(20.8 ±
occurred. 0(0) 17(5.4) 49(15.7) 83(26.6) 98(31.4) ) 1.15
32. Filling
out an
incident
report for a
medication
error takes 3.28
too much 102(32.7 ±
time. 1(0.3) 40(12.8) ) 99(31.7) 43(13.8) 27(8.7) 1.13
33. Too long

and time 2.81
consuming 108(34.6 43(13.8 ±
reporting 3(1.0) 15(4.8) 65(20.8) ) 78(25.0) ) 1.12
34.
Medication
error is not 2.70
clearly 60(19.2 ±
defined. 1(0.3) 12(3.8) 70(22.4) 97(31.1) 72(23.1) ) 1.15
Strongl
Moderatel y
n±
Items n(%) n(%) n(%) n(%) n(%) n(%) SD
35. No need
to report if 2.75
no patient is 57(18.3 ±
harmed 4(1.3) 20(6.4) 63(20.2) 90(28.8) 78(25.0) ) 1.22
36. Nurses
believe other
nurses will
think they 3.51
are 126(40.4 ±
incompetent 8(2.6) 47(15.1) ) 72(23.1) 33(10.6) 26(8.3) 1.19
37. Patient
or family
might
develop a 3.56
negative 114(36.5 ±
attitude 13(4.2) 54(17.3) ) 69(22.1) 37(11.9) 25(8.0) 1.25
38. The
expectation
that
medications
be given
exactly as 2.39
ordered is 83(26.6 ±
unrealistic. 2(0.6) 13(4.2) 40(12.8) 77(24.7) 97(31.1) ) 1.17
39. Nurses
fear
reprimand 3.61
from 130(41.7 ±
doctor. 9(2.9) 52(16.7) ) 71(22.8) 28(9.0) 22(7.1) 1.16
Strongl
Moderatel y
n±
Items n(%) n(%) n(%) n(%) n(%) n(%) SD
40. Nurses
fear adverse
consequence
s from
reporting 4.00
medication 125(40.1 ±
errors. 24(7.7) 82(26.3) ) 46(14.7) 21(6.7) 14(4.5) 1.18
41. The
response by
nursing
administrati
on does not
match the 3.18
severity of 103(33.0 ±
the error. 4(1.3) 27(8.7) 96(30.8) ) 57(18.3) 25(8.0) 1.12
42. Nurses
could be
blamed if
something 4.36
happens to 41(13.1 118(37.8 ±
the patient ) 106(34) ) 28(9.0) 10(3.2) 9(2.9) 1.10
43. No
positive
feedback is
given for
passing 3.87
medications 119(38.1 ±
correctly. 17(5.4) 71(22.8) ) 76(24.4) 17(5.4) 12(3.8) 1.11
44. Too 5(1.6) 9(2.9) 40(12.8) 117(37.5 109(34.9) 32(10.3 4.32

Strongl
Moderatel y
n±
Items n(%) n(%) n(%) n(%) n(%) n(%) SD
much ) ) ±
emphasis is 1.02
placed on
medication
errors as a
measure of
the quality
of nursing
care
provided.
45. Nursing
administrati
on focuses
on the
personal
rather than 4.10
looking at 130(41.7 ±
the systems 25(8.0) 72(23.1) ) 58(18.6) 16(5.1) 11(3.5) 1.12
View Large
Perceived non-intravenous and intravenous related MAEs
The highest prevalent non-IV related MAEs included drugs administered to the wrong patient
(63.5%), drugs administered as a wrong dose (62.5%) and an incorrect drug choice (61.9%). The
highest prevalent IV related MAEs included medications administered with an incorrect infusion
rate (66.0%), drugs given to the incorrect patient (60.3%) and drugs administered at an incorrect
dose (59.3%). The least prevalent non-IV and IV related medication errors included
administering a medication that was known to be allergic to a patient (31.4 and 34.3%,
respectively) and those relating to poor communication between nurses and doctors (32.4 and
34.3%; Tables 4 and 5, respectively).
Table 4
Type of error reported for Non-IV medication (N = 312)
Rank Types of medication errors Number of errors (%)a
1 Drugs given to the wrong patient 198 (63.5)
2 Drugs given wrong dose 195 (62.5)
3 Wrong choice of drug 193 (61.9)
4 Drugs given at wrong administration time 190 (60.9)
5 Medication omitted 181 (58.0)
6 Drugs given by the wrong route 144 (46.2)
7 Medication administered after the order discontinued 138 (44.2)
8 Poor communication between nurses and doctors 101 (32.4)
9 Given to patient with a known allergy 98 (31.4)

aSums exceed totals because of multiple errors within the same non-IV medication.
View Large
Table 5
Type of error reported for IV medication (N = 312)
1 Wrong infusion rate 206 (66.0)
2 Drugs given to the wrong patient 188 (60.3)
3 Drugs given wrong dose 185 (59.3)
4 Wrong choice of drug 180 (57.7)
5 Wrong choice mixed fluid 178 (57.0)

6 Drugs given at wrong administration time 176 (56.4)
7 Drugs given by the wrong route 158 (50.6)
8 Medications omitted 154 (39.4)
9 Medication administered after the order discontinued 135 (43.2)
10 Poor communication between nurses and doctors 110 (35.2)
11 Given to patient with a known allergy 107 (34.3)

aSums exceed totals because of multiple errors within the same IV medication.
View Large
Discussion
Preventing MAEs represents a central focus of hospital quality improvement and risk
management initiatives. The administration of medication is predominantly the responsibility of
nurses and an important part of nursing practice that affects patient safety and quality of health
care services. Education regarding the administration of medications is provided for nurses to
prevent medication errors at hospitals because nurses are positioned at the final stage to prevent
medication errors before administering medications to patients. Therefore, finding the causes and
solutions to MAEs should be a top priority for any health system.
In the present study, 69.6% of nurses reported that they experienced MAEs during their career. A
direct comparison of results needs to be done with caution because of the differences in subject
characteristics, such as period of clinical career, working unit, recall period of experienced errors
and definitions of MAEs. This result was lower compared to another study in which 92.6% of
Korean nurses were reported to experience MAEs during 3 months [17] and higher than the
32.4% French nurses that observed a medication error during 1 week [9]. Cheragi et al. [18]
reported that 64.6% of Iran nurses to have experiences of medication errors during 3 months.
Nurses in South Korea tend to work long hours and are relatively young. According to the
Organization for Economic Cooperation and Development (OECD) data, actual working hours in
South Korea in 2012 were the 3rd longest among the OECD countries [19]. In addition, while the
average age of employed RNs in the US was 45.5 in 2008 [20], the average age of employed
RNs in South Korea was 34.6 in 2006 [21]. Due to these differences in working conditions and
demographic characteristics, there would be differences in risk factors of MAE compared to
other countries.
In our study, 47.8% nurses perceived that MAEs occur less than 20% at actual clinical field, in
our study. Joolaee et al. [14] reported that the average number of self-reported medication error
cases by each nurse was 19.5 cases, and an error was reported per 1.3 cases on average. There is
a gap between the nurses' perceived knowledge and his or her actual knowledge about
medication errors; therefore, nurses require specific information regarding what constitutes
medication errors [15].
The voluntary nature of the self-reporting method has been shown to underestimate the actual
MAEs occurrences [10, 14]. Actual MAEs occurrence data can only be used to identify problems
and develop solutions provided that they are a true reflection of the type and number of MAEs
that actually happen [10]. Accuracy can only be improved in an environment that encourages and
supports the reporting of medication errors. Therefore, a simple and easy-to-use reporting system
should be implemented to encourage reporting and access to available systems for safety
information [15]. To further increase MAEs reporting, health care providers should know that
first, reporting without penalty leads to improving safety and second, errors are primarily the
product of flaws in the organization [22]. In addition, effective communication and collaboration
between healthcare providers, such as open communications, error reporting and team
accountability among healthcare providers, should be facilitated and considered as a rule.
In the present study, nurses perceived that the most common reason for MAEs was inadequate
number of staff nurses at each working shift. Employing adequate number of staff is a necessary
condition for safe patient care [7]. Increased nurse workload can result in more MAEs by nurses
[1, 9, 14, 15]. Kang et al. [4] examined the relationship between nurse-perceived patient adverse
events and nurse practice environment. This study showed that nurse-staffing adequacy was
correlated with medication errors. However, this finding was inconsistent with the finding that
there was no significant relationship between RN staffing levels, measured by the number of RN
hours per patient day, and medication errors [3]. Appropriate nurse staffing by employing new
personnel or moderating the working hours and eliminating irrelevant tasks can be beneficial for
improving the working conditions of the nursing personnel and the overall quality of health care
service [23]. In the OECD countries, there was an average of 9.1 nurses per 1000 people and an
average of 4.8 nurses per capita in South Korea [24]. South Korea is concerned about shortage of
nurses and having a higher ratio of nurses per patient. Therefore, there is a need to analyze work
conditions, improve health care systems, and create a culture where patients' safety is a priority.
Staffing alone will not deliver the positive results of a supportive health care environment [25].
Therefore, nurses should allocate time during the beginning of their shift to examine the
medication list, refer to the patient records and to read the original order. Appropriate
environmental design takes error prevention into account and plays a critical role in preventing
errors [26]. Furthermore, safe and positive work environments should include a supportive
manager, collegial relationships with physicians, sufficient resources, staff development and
opportunities to be involved in decision-making processes.
The second and third common causes of MAEs involved medication names that appeared or
sounded similar to other medications. Mrayyan et al. [27] supported this finding and suggested
that the information on labels and packaging of medications can confuse health care personnel if
it is not prominently placed (i.e. small font size), which may lead to poor readability.
Furthermore, medications with similar names can lead to errors associated with verbal
prescriptions. For these reasons, the Joint Commission published a list of drugs that appear or
sounded similar, which were considered the most problematic medication names across health
care settings [28]. Accordingly, medications should be delivered in a standardized package and
labeling to reduce nurses' confusion because there are many varieties of medication packaging,
forms, doses and preparations that might lead to MAEs.
Nurses are front-line health care staff who recognize and report MAEs. Therefore, they are
responsible for their errors and immediate remedial actions should be implemented to prevent
any complications [2]. The Hospital policy in South Korea is that all medication errors should be
reported on an incident form that is sent to and collated by the responsible senior nurse manager.
According to the nurses in our study, the barriers to reporting MAEs were fear of being blamed if
something happens to the patient, having too much emphasis placed on MAEs as a measure of
the quality of nursing care provided, fear of adverse consequences and having the nursing
administrations focus on the individual as a potential cause of error. This finding supported the
results of previous studies regarding the reasons for unreported MAEs [1, 14]. Researchers
emphasized that a supportive practice environment needs to be more effective and create a
blame-free culture to encourage nurses to report errors [3, 27]. Luk et al. [2] interviewed 14
nurses involved in medication errors that were recorded in incident reports and found that the
nurses experienced fairness and were respected by senior nursing staff during the investigation of
those incidents. Therefore, nurse managers should have a positive attitude toward the reporting
of medication errors by nurses and create a no-blame culture. Medication errors can only be
reported freely in an atmosphere free of blame for nurses, which enables the proper utilization of
these reported errors as learning opportunities [29].
In the present study, the most common non-IV related MAEs included administering the
medication to the wrong patient, followed by administering incorrect medication doses and the
incorrect choice of drugs. Similarly, the most common IV related MAEs included incorrect
medication infusion rates, followed by administering medications to the incorrect patient,
incorrect medication doses and incorrect drug choice. In both non-IV and IV related MAEs,
medications administered to a patient with a known allergy to that medication and poor
communication between nurses and doctors were less common. Indeed, staff nurses are at risk of
committing MAEs because they do not have enough time to follow the five rights (right patient,
time, dose, drug and route) of medication administration [30]. Accurate administration of
medications is a critical task, but administering the wrong medication or dose is a ubiquitous
nursing problem. Recently, there is increasing evidence of successful strategies that improve the
safety of the medication management system [26], including standardized medication charts,
prescriber decision support, individualized administration systems and clinical pharmacy
services. The awareness of risks and errors in the medication system by all staff nurses, and their
ability to identify errors and take appropriate action is paramount in improving patient safety and
reducing harm [9, 10].
In our study, IV was the most common route of MAEs with baseline participants' characteristics,
which was reported by 182 nurses (58.3%). Medication errors of IV administration have
accounted for 49–69.7% of MAEs in previous studies [1, 31]. IV administration-related MAEs
result in the most serious health outcomes [10] because of their greater complexity and the
multiple steps required in their preparation, administration and monitoring [31]. Kim et al. [1]
reported medication errors occurred during IV administration. According to the study of Oh and
Yoon [11], majority of MAEs were IV related errors as like influx in to an IV set, crystal
occurring in an IV line, wrong injection site and wrong IV infusion rate. To prevent non-IV and
IV related MAEs reported in our study, nurses have to check the patients' record before preparing
and administering medication. It is important that medication management is addressed in the
education and training of nurses, including both nursing student preparations for practice and in
the continuing education of nurses. Recently, Korean Hospital Nurse Association (KHNA)
published guideline for education of new nurses in 2010 and revised in 2014. The guideline
includes a flow chart of medication administration such as confirm the prescription, preparation
administration and precautions. Also, since 2006, the Korean Accreditation Board of Nursing
(KABON) has been accredited nursing education programs with the goal of determining if
nursing education has received a level capable of producing nurses who can fulfill their social
responsibilities [32]. Traditionally, clinical practice education has been structured as practical
experience occurring in a real-world environment [4]. Nursing educators face many challenges
ensuring that students have the knowledge and abilities to safely administer medications to
patients. The simulation for medical and healthcare applications has recently been employed in
our country in medical and nursing colleges for students' educational purposes. Simulated
experiences help learners attain the desired knowledge, demonstrate competence in skills,
develop communication skills and increase self-confidence [33]. In addition, the use of
standardized patient simulation in providing education for preventing medication errors is
helpful in a clinical setting.
The present study had several limitations. First, we used a convenience sampling method for
nurses who were working at three university hospitals, which cannot be generalized to other
nurses. Second, the focus of this study was the perception about MAEs, which may be different
from the actual experiences of MAEs among nurses. Future studies with large samples are
recommended to identify the perceptions regarding MAEs according to hospital characteristics in
a variety of settings and to identify the rate of MAEs using direct observations and multiple
sources. Despite these limitations, we addressed the reasons for MAEs by staff nurses, which
have been limited in previous studies in South Korea. Furthermore, the results of this study can
be used as fundamental data for developing programs for preventing MAEs in hospitals.
Until now, there is no national consensus among nursing schools about standardized patient
safety education in Korea. We need to standardize patient safety curriculum in which the
essential competencies of patient safety are integrated as learning outcomes. Also, various
teaching strategies such as simulation should be developed to improve students' patient safety
competencies. Furthermore, the nursing school curriculum and hospitals' continuing education
programs should emphasize concepts related to medication administration.
Conclusion
In conclusion, nurses had experienced a higher rate of MAEs compared to the rate of reported
MAEs that they perceived. Furthermore, the main reason for MAEs as perceived by the nurses
was inadequate staffing level; nurses did not report MAEs because of a fear of being blamed. A
number of technology strategies have been implemented to decrease the number of medication
errors including computerized physician order entry, automated medication administration
records and bar coding administration; but even with the use of these technologies, errors
continue to occur. Health care leaders need to consider not only technology capital investments
but also human capital as a strategy to keep patients safe. Namely, administering medications to
hospitalized patients is not a simple task; it requires thorough knowledge of every medication
that is administered to patients. Therefore, qualified RN should be more appropriately assigned
to patients. In addition, we should try to create a blame-free culture to encourage reporting the
errors.
Funding
This work was supported by the National Research Foundation of Korea (NRF) grant funded by
the Korean government (MSIP) (NRF-2012R1A2A2A01047560) and Soonchunhyang
University Research Fund, 2014.
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© The Author 2015. Published by Oxford University Press in association with the International
Society for Quality in Health Care; all rights reserved
Knowledge, Attitude, and Practice towards Medication Errors and Adverse Drug Reaction
Reporting among Medical Students Maryam Aghakouchakzadeh1 , Mandana Izadpanah2*, Ali
Yadegari3 1 School of Pharmacy, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
2 Department of Clinical Pharmacy, School of Pharmacy, Ahvaz Jundishapur University of
Medical Sciences, Ahvaz, Iran. 3 Food and Drug Department, Arak University of Medical
Sciences, Arak, Iran. Received: 2015-04-23, Revised: 2015-07-14, Accept: 2015-07-28,
Published: 2015-08-01 ARTICLE INFO Article type: Original article Keywords: Medication Errors
Adverse Drug Reaction Reporting Systems Knowledge Attitude Practice Introduction Medication
errors are one of the most common types of medical error (1,2) which can threaten the
patient’s health (3,4). Medication errors are defined as any preventable event that may cause
by an inappropriate medication usage and lead to an adverse drug event in patients (4).
Medication errors can occur at broadly diverse steps, including prescribing, transcribing,
dispensing and administration (3-5) so medication errors were significantly decreased with
computerized physician order entry (CPOE) than with hand-written prescribing (HWP) (5). It is
estimated that medication errors cost for the * Corresponding Author: Dr Mandana Izadpanah
Address: Department of Clinical Pharmacy, School of Pharmacy, Ahvaz Jundishapur University
of Medical Sciences, Golestan blvd., Ahvaz 61357- 33184, Iran. Tel:+986113738378, Fax:
+986113738381 Email: izadpanah.m@ajums.ac.ir ABSTRACT Background: The most common
types of medical error are medication errors (MEs) which defined as any preventable event that
may be caused by an inappropriate medication usage and lead to an adverse drug reaction
(ADR) event in patients. In recent years, different approaches have been proposed to reduce
MEs, one of which is reported ADRs. The present study was designed to assess the Knowledge,
Attitude and Practice (KAP) of medical students towards MEs and ADRs reporting. Methods:
The study population was 40 students of fourth-year of medicine. The validated 12-item
questionnaire included subsequently 4 questions, 5 items and the final 3 questions related to
the knowledge, attitude, and practice that was given to each participant before and after of the
interactive workshop. Results: Demographic features of the participants have no significant
difference. Mean of age participants was 23.18 years and 23 of the students were female.
Medicine students had a poor KAP towards MEs. Only 8% of respondents had general
knowledge about MEs and 50% of students believed MEs are inevitable events, less than 20% of
them were acquainted with 5 rules of prescribing. Students had good knowledge and attitude,
but poor practice towards ADRs reporting. 55% of participants were aware of their
responsibility of ADRs reporting, but only 5% of respondents were acquainted with ADRs the
reporting method and the ADR center in the hospitals. Conclusion: The educational
intervention, alteration in medical student’s curriculum, and hold the interactive clerkship for
health care professionals can improve the KAP towards ADRs reporting and diminish of the
preventable medication errors. J Pharm Care 2015;3(3-4):49-53. jpc.tums.ac.ir ► Please cite
this paper as: Aghakouchakzadeh M, Izadpanah M, Yadegari A. Knowledge, Attitude, and
Practice towards Medication Errors and Adverse Drug Reaction Reporting among Medical
Students. J Pharm Care 2015;3(3-4):49-53. 50 jpc.tums.ac.ir August 2015;3(3-4)
Aghakouchakzadeh et al. National Health Service (NHS) are about £500 million in hospitalized
patients each year (3, 6). In recent years, several approaches have been proposed to detect and
reduce the incidence of medication errors that reporting of ADRs is one of them. The reporting
system is a quality improvement in high-risk industries, especially in hospitals. The reporting
system is not designed to determine error rates. Though it is a safety improvement method
which takes advantage of the astute perceptions of workers, including the primary care
clinicians and office staff during the treatment process to detect problems which may modify
the systems, policies, and procedures, and consequently the safety and quality improvement
methods (4, 7). Yellow cards are one of the reporting tools in adverse drug reaction reporting
systems. Investigations demonstrated an adverse drug reaction is an important clinical issue,
which can be entered the high cost of NHS and serious ADRs can be a resulted in death (8, 9).
According to the World Health Organization (WHO), pharmacovigilance has been defined as the
science and activities relating to the detection, assessment, understanding and prevention of
adverse effects or any other drug-related problem (10). Post-marketing ADRs is one of the
concerns on health issues and require the cooperation of all healthcare for ADRs reporting.
Spontaneous reporting of ADRs on the yellow cards is a fundamental of pharmacovigilance and
important in maintaining patient safety, but reporting of serious ADRs rarely exceeds 10% (11).
Based on the varied investigations, knowledge, attitude and practice (KAP) of the pharmacist,
physicians and nurses are the important factors on their functions for event reporting (11-13).
This function depends on the understanding the importance of their role in the emergence of
ADRs and also reporting event for reduction of side effects and medication errors. Methods
This study was a cross-sectional and Interventional, before-and-after-type survey, which held
an interactive workshop for medical students of Arak University of medical sciences in April
2016. The data collection tool was a validated 12-item questionnaire that included two parts:
Pharmacovigilance and medication errors. The standard questionnaire of the European
Pharmacovigilance research group and the previous studies were used for Pharmacovigilance
questions (13- 15) and medication error questions were prepared as a valid- reliable
questionnaire. After the description of the questionnaire, the validity of the questionnaire was
asses by Content validity ratio (CVR) and Content validity index (CVI) using a sample consist of
10 randomly selected professors acquainted with respective issues. For measuring, CVR
members of the questionnaire were asked to rate each item as “essential,” “useful, but not
essential,” or “not necessary”. Then, CVR was calculated to indicate whether the item was
relevant. CVI Members of these also were asked to rate each item in terms of relevancy, clarity,
and simplicity, which these were on a Likert scale from 1 to 4 (16). Test- retest reliability of
questionnaire involves administering the same measures to the same groups of test-takers,
including 20 students selected randomly from the fifth year, under the same conditions on two
different time with two week intervals. Cronbach’s alpha was used for assessing the internal
consistency reliability (17). The validated 12-item questionnaire that distributed included 4
questions were related to knowledge, 5 items to attitude and the final 3 questions to the
practice that were given to each participant before and after of the clerkship course. Interactive
clerkship for the 4th academic year of medical students was compulsory and the part of the
curriculum for them in Arak University of medical sciences and the certificate of this clerkship
was necessary to enter the internship period for the medical students, so the presence of this
group of students was indispensable in the clerkship interactive. Knowledge questions were
designed as multiple choices, that 2 point considered for these questions as follows 0-ponit for
incorrect answers and 1-ponit for correct answers. Knowledge questions included the general
concept of pharmacovigilance, and medication errors, the cause of medication errors and the
acquaintance of adverse drug reaction reporting system. Attitude questions were developed on
a five-point Likert scale ranging from ‘strongly disagree’ to ‘strongly agree’. The design of
practice question was included multiple choi August 2015;3(3-4) jpc.tums.ac.ir 51
Aghakouchakzadeh et al. Table 1. Student’s knowledge about medication errors and ADRs.
Response (%) Issues Pre test Post test 8.11 26.47 Medication errors 55.26 58.82 ADRs while
55% of students were aware of their responsibility of ADRs reporting and the types of ADRs
which should be reported. No statistically significant differences were found between the
knowledge of ADRs in pre and post samples of the clerkship course, but educational
intervention significantly increased (p < 0.01) knowledge of medication errors. In other words,
knowledge of participants about ADRs reporting and pharmacovigilance have been better.
Students were asked about their attitudes toward the importance of their presence in
decreasing medication errors and their role in ADR reporting. Although several options were
considered for evaluation student’s attitude toward medication errors and ADRs, but due to the
large number of items only of the average percent of “strongly agree” with “partially agree”
were reported (Table 2). Of those responding, 78.38% felt that ADR reporting was a
professional obligation for all health care professionals, and generally, the respondents had a
good attitude towards ADRs reporting. While 50% of students stated that medication errors are
inevitable events. Also, approximately all of the respondents believed that the medication
errors would increase health system costs, before and after the clerkship course, the 78.95 %
and 97.14% of student agreed with the educational intervention and an interactive clerkship to
decrease the medication errors and conscious approach to adverse drug events. The results of
practice questions showed that despite the sufficient knowledge in ADRs reporting issue, only
5% of them were acquainted with ADRs reporting method and the ADR registering center in the
hospitals, ultimately their approach with different cases have significant differences before and
after the clerkship course (p < 0.001). For evaluation of students’ practice, they were asked
about the 5 rules of prescribing, which may reduce the medication error events. The results of
the study revealed despite the preconception, less than 20 percent of participants were familiar
with the 5 rules of prescriptions. The percentage of practice issue is displayed in Table 3.
Discussion All of the health care professionals can play an important role in the decreasing of
medication errors (1, 2). Other studies described the medication errors reduced following the
introduction of CPOE. Other methods such as ADRs reporting can also play an important role in
the prevention of medication error occurrence (4, 5, 7, 15). Our results show medical students
had a poor KAP towards medication errors and they didn’t aware about their important role in
decreasing medication error events. Wendy’s study showed that a patient safety and medical
curriculum can affect the knowledge, attitudes, and practice of second-year medical students
and proposed a necessary curriculum for medical students, including Table 2. Student’s attitude
toward medication errors and ADRs reporting. Questions Strongly agree and partially agree (%)
Pre test Post test All of the health care have responsibility in relation to preventing the
occurrence of adverse effects of drugs. 78.38 100 Most of the medication errors are inevitable
and non-avoidable. 48.65 35.29 The medication errors play a critical role in increased health
system costs. 94.12 94.29 Educational interventions and training courses can reduce
medication errors and consciously approach to with adverse drug events. 78.95 97.14 More
studies and the using of modern methods for drugs information are essential for increasing of
scientific and practical skills. 81.58 97.14 52 jpc.tums.ac.ir August 2015;3(3-4)
Aghakouchakzadeh et al. Care Medication Error and Adverse Drug Event Reporting System--
MEADERS. Ann Fam Med 2010;8(6):517-25. 5. Shulman R, Singer M, Goldstone J, Bellingan G.
Medication errors: a prospective cohort study of hand-written and computerised physician
order entry in the intensive care unit. Crit Care 2005;9(5):R516-R21. 6. Ridley SA, Booth SA,
Thompson CM, the Intensive Care Society’s Working Group on Adverse I. Prescription errors in
UK critical care units. Anaesthesia 2004;59(12):1193-200. 7. Joolaee S, Hajibabaee F, Peyrovi H,
Haghani H, Bahrani N. The relationship between incidence and report of medication errors and
working conditions. Int Nurs Rev 2011;58(1):37-44. 8. Lazarou J, Pomeranz BH, Corey PN.
Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective
studies. JAMA 1998;279(15):1200-5. 9. Millar JS. Consultations owing to adverse drug reactions
in a single practice. Br J Gen Pract 2001;51(463):130-1. 10. Organization WH. A practical
handbook on the pharmacovigilance of antimalarial medicines: World Health Organization;
2008. 11. Green CF, Mottram DR, Rowe PH, Pirmohamed M. Attitudes and knowledge of
hospital pharmacists to adverse drug reaction reporting. Brit J Clin Pharmacol 2001;51(1):81-6.
12. Hasford J, Goettler M, Munter K-H, Müller-Oerlinghausen B. Physicians’ knowledge and
attitudes regarding the spontaneous reporting system for adverse drug reactions. J Clin
Epidemiol 2002;55(9):945-50. 13. Salehifar E, Ala S, Gholami K. Knowledge, attitude and
performance of pharmacists and nurses in Mazandaran province, Iran regarding adverse drug
reaction and its reporting, 2005. Journal of Mazandaran University of Medical Sciences
2007;16(56):115-25. 14. Vessal G, Mardani Z, Mollai M. Knowledge, attitudes, and perceptions
of pharmacists to adverse drug reaction reporting in Iran. Pharm World Sci 2009;31(2):183-7.
15. Etminani M, Mousavi S, Rakhshan A, Assarian M, Kuti L, Eslami K. Adverse drug reactions:
knowledge, attitude and practice of pharmacy students. J Pharm Care 2013;1(4):145-8. 16.
Hariri FZ, Moghaddam-Banaem L, Bazi SS, Malehi AS, Montazeri A. The Iranian version of the
Premenstrual Symptoms Screening Tool (PSST): a validation study. Arch Womens Ment Health
2013;16(6):531-7. 17. Deniz MS, Alsaffar AA. Assessing the Validity and Reliability of a
Questionnaire on Dietary Fibre-related Knowledge in a Turkish Student Population. J Health
Popul Nutr 2013;31(4):497-503. 18. Madigosky WS, Headrick LA, Nelson K, Cox KR, Anderson T.
Changing and sustaining medical students’ knowledge, skills, and attitudes about patient safety
and medical fallibility. Acad Med 2006;81(1):94-101. 19. Patey R, Flin R, Cuthbertson BH, et al.
Patient safety: helping medical students understand error in healthcare. Qual Saf Health Care
2007;16(4):256-9. 20. Halbach JL, Sullivan LL. Teaching medical students about medical errors
and patient safety: evaluation of a required curriculum. Acad Med 2005;80(6):600-6. 21. Fadare
JO, Enwere OO, Afolabi A, Chedi B, Musa A. Knowledge, attitude and practice of adverse drug
reaction reporting among healthcare workers in a tertiary centre in Northern Nigeria. Trop J
Pharm Res 2011;10(3):235-42. patient safety overview, error reporting, system vs. human
approach, safety tools, and ethics/disclosure, that several them held based on lecture or
interactive clerkship (18). Other studies confirm the importance of awareness of patient safety
and medical error by using an experiential curriculum (19, 20). On the other hand, our findings
described medicine students were conscious of their responsibility of ADRs reporting and the
proper attitude towards it while acquainting of ADRs reporting method and the ADR center in
the hospitals were at the lowest level. Palaian and colleagues illustrated the healthcare
professionals had a poor KAP towards ADRs and pharmacovigilance and among of participants
had not reported even a single ADR to the pharmacovigilance center (21). Enwere et al.
described despite the better knowledge of ADR among doctors, the rate of reporting was low
(22).Other studies emphasized education and training are the most recognized means of
improving ADR reporting (23, 24). Therefore, our advice is the alternation in the medicine
student’s curriculum and appropriate training can improve the KAP of ADRs reporting and
medication errors. This leads to the identification of ADRs and the causing of medication errors.
In conclusion, educational intervention and presentation the interactive workshop for health
care professionals to report ADRs can be a critical factor for the improvement of health care
practice and diminish of the preventable medication errors. References Table 3. Student’s
attitude toward medication errors and ADRs reporting. Questions Pretest (%) Posttest (%) What
is your reaction upon observation of a side effect? The best function : Report to ADR center in
the hospitals 5.26 58.82 Do you attend in correct and complete prescription? The best function
: Yes 91.18 94.74 Do you assist 5 rules of prescriptions? The best function : Yes (They wrote
correct and complete) 18.42 44.12 1. Mrayyan MT, Shishani K, Al-Faouri I. Rate, causes and
reporting of medication errors in Jordan: nurses’ perspectives. J Nurs Manag 2007;15(6):659-
70. 2. Vazin A, Delfani S. Medication errors in an internal intensive care unit of a large teaching
hospital: a direct observation study. Acta Med Iran 2012;50(6):425-32. 3. Sanghera IS, Franklin
BD, Dhillon S. The attitudes and beliefs of healthcare professionals on the causes and reporting
of medication errors in a UK Intensive care unit. Anaesthesia 2007;62(1):53-61. 4. Hickner J,
Zafar A, Kuo GM, et al. Field Test Results of a New Ambulatory August 2015;3(3-4) jpc.tums.ac.ir
53 Aghakouchakzadeh et al. 22. Okezie EO, Olufunmilayo F. Adverse drug reactions reporting by
physicians in Ibadan, Nigeria. Pharmacoepidemiol Drug Saf 2008;17(5):517-22. 23. Herdeiro MT,
Figueiras A, Polónia J, Gestal-Otero JJ. Physicians’ Attitudes and Adverse Drug Reaction
Reporting. Drug Saf 2005; 28(9):825-33. 24. Oshikoya KA, Awobusuyi JO. Perceptions of doctors
to adverse drug reaction reporting in a teaching hospital in Lagos, Nigeria. BMC Clin

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Nursing documentation is the record of nursing care that is planned and delivered to

Documentation of the nursing process[edit]

Nursing care plan[edit]

Electronic nursing documentation[edit]

Comparison of the quality of paper-based and electronic

Quality of nursing documentation[edit]

Standardized nursing terminology[edit]

Computer Generated Data

Documents required for health finding purposes

Legal and ethical issues

Need to reflect complexity of medical services provided

Language does matter - Accuracy and specificity are essential

This study was a cross-sectional survey conducted by self-reported questionnaires.

General characteristics of hospital staff nurses

Characteristics n (%) Mean ± SD

Age (years) 29.22 ± 5.48

25–29 143 (45.9)

Diploma 177 (56.7)

Above college 135 (43.3)

Medical 122 (39.1)

Nursing experience in current unit (years) 3.67 ± 12.75

1–2 135 (43.3)

3–4 108 (34.6)

Total clinical career (years) 5.93 ± 13.55

1–2 119 (38.1)

3–4 111 (35.6)

Yes 217 (69.6)

Intravenous 182 (58.3)

Intramuscular and others 24 (7.7)

Frequency of received education for medication errors

1–2 110 (35.3)

Perceived rate of reporting for MAEs

0–20% 149 (47.8)

Nurses' perceptions regarding reasons for MAEs

22. Heavy 4.23

26. Errors are

Nurses' perceptions about reasons for unreported MAEs

33. Too long

44. Too 5(1.6) 9(2.9) 40(12.8) 117(37.5 109(34.9) 32(10.3 4.32

Perceived non-intravenous and intravenous related MAEs

Rank Types of medication errors Number of errors (%)a

1 Drugs given to the wrong patient 198 (63.5)

2 Drugs given wrong dose 195 (62.5)

3 Wrong choice of drug 193 (61.9)

4 Drugs given at wrong administration time 190 (60.9)

5 Medication omitted 181 (58.0)

6 Drugs given by the wrong route 144 (46.2)

7 Medication administered after the order discontinued 138 (44.2)

8 Poor communication between nurses and doctors 101 (32.4)

9 Given to patient with a known allergy 98 (31.4)

Rank Types of medication errors Number of errors (%)a

1 Wrong infusion rate 206 (66.0)

2 Drugs given to the wrong patient 188 (60.3)

3 Drugs given wrong dose 185 (59.3)

4 Wrong choice of drug 180 (57.7)

5 Wrong choice mixed fluid 178 (57.0)

6 Drugs given at wrong administration time 176 (56.4)

7 Drugs given by the wrong route 158 (50.6)

8 Medications omitted 154 (39.4)

9 Medication administered after the order discontinued 135 (43.2)

10 Poor communication between nurses and doctors 110 (35.2)

11 Given to patient with a known allergy 107 (34.3)

Nursing management of medication errors

Observational study of potential risk factors of medication administration errors