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KMID : 0381219870190020156
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Journal of RIMSK
1987 Volume.19 No. 2 p.156 ~ p.173
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A Study of Hospital Medication Errors
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Abstract
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The present study was intended to examine the frequency and cause of medication errors to protect patients´ health and life by establishing effective measures to prevent medication errors, and to collect baseline data for improving nursing service.
Data were collected through questionnaire survey.
Subjects served for the study consisted of 420 nurses in Korea, sampled from three university hospital nurse group, using random sampling method. The actual number of cases put into the analyses was 372.
Data were analyzed by computer, using SPSS program. Statistical methods employed were Chi square and percentage analyses.
Results of the study were as follows:
1) In regard to the age distribution of the subjects, 47.3 percent of nurses were at the age of 24 to 26 years, 21. 1 percent at the age of 27 to 29, 19.4 percent at the age of 21 to 23, 12. 1 percent at the of 30 or more. The average age of the subjects was 25.8. On marital status, 89.0 percent were not married and 11.0 percent were married.
2) According to nurse service department, 30.1 percent of nurses were working at the special ward involving all department patients and emergency room, 21.0 percent at the internal medicine ward, 13.2 percent at the orthopedic surgery, 11.6 percent at the neurosurgery etc.
3) In considering the level of education, 76.9 percent of the subjects graduated from technical nurse college, 22.8 percent graduated from nurse college, and 0.3 percent were postgraduates.
4) In the nursing service career, 68.3 percent had worked from one to five years, averaging 3 years and 4 months.
5) The scores of individual with medication errors ranged from 5 points to 48 points.
Individual average scores of medication errors were 12.6 points. In regard to score distribution of medication errors, 45.4 percent had scores from 11 to 20, 44. 1 percent from 1 to 10 points, 8. 9 percent from 21 to 30, 1. 1 percent from 31 to 40, and 0. 5 percent more than .40 points. Most of them were within the scores of 20.
6) In the number of medication errors during her clinical service in hospital, 54.8 percent had experienced one time error, 29.6 percent two times, and 15.6 percent three times or more.
7) With regard to the type of medication errors, 23.7 percent of errors were with wrong time, 18.8 percent with omission of medication, 17.7 percent with wrong dose, 15.9 percent with unordered medication and 10.5 percent with incorrect IV solution etc.
8) In regard to errors of administration route, 46.5 percent were administered orally, 27.1 percent intravenously and 21.5 percent intramuscularly etc.
9) As regards errors of the type of drug/IV solution administered, 39. 0 percent of errors were with antibiotics, 15. 1 percent with antiphlogistics and analgesics, 10. 5 percent with IV solution, 7. 0 percent with antacids, 3.8 percent with anti psychotic agents, etc.
10) In reporting the errors, 68.3 percent were reported to the head nurses or supervisors, while 31.7 percent not reported. In considering time report initiated, 65.1 percent were reported within 30 minutes, 21.7 percent between 30 minutes and one hour, 8.2 percent between one and six hours, and 5.1 percent after six hours.
11) In errors by shift, 49.7 percent of errors made on the 7:30-15:30 shift, 31.5 percent from the 14:30-22:30 shift, and 17.2 percent from 22:30-7:30 shift. It also showed that there was a significant relationship between the frequency of medication errors and shift. In other words, there were a lot of errors in daytime shift.
12) In considering causes of medication errors in percentages, 23.6 percent resulted from -the misread or misinterpreted medicine card, 11.6 percent from medicine to wrong patient, 10.8 percent from delay in receiving from pharmacy, 9.9 percent from Doctor´s order misunderstood or confusing, 9.7 percent from transcription error, and 9.1 percent from nurse miscalculated or mismeasured etc. In other words, A lot of errors resulted from primary incomplete or confusing medicine card.
13) In regard to medication errors according to the type of order, 59. 9 percent of errors
were made from written order, 27.1 percent from verbal, and 10.8 percent from telephone. 14) In 92.5 percent of the patients involved in the medication errors, there was no change in condition, while 7.5 percent changed in condition.
On the basis of the above results, our suggestions were present below.
1) This study showed that medication error rates among teaching hospital were relatively higher. Therefore, it needs to establish the effective measures to prevent medication -errors. Accordingly we recommend that unit dose systems to Korean hospital will be adopted.
2) We suggest that disciplinary action for medication errors will be established. If suggesting an example of disciplinary action based on results of this study, accumulating points from 1 to 10 will result in a verbal counseling session by unit supervisor, from 11 to
20 will require a verbal counseling session with the unit supervisor and a referral to Staff Development for Medication Review Class, from 21 to 30 will require a verbal counseling session and written corrective action by the unit supervisor and he/she will also asked to write a paper with the direct correlation to the error or errors made, and return it to the unit supervisor, from 31 to 40 will require a verbal counseling session and a written statement by the unit supervisor; in addition, she/he will be required to have all medication transcription and administration of meds checked with another RN for 2 days, from 41 to 50 will require that she/he be given a 3 day suspension without pay, and accumulating points greater than 50 subjects the nurse to consideration for termination of employment. However, the disciplinary action will be required to adopt different action pertinent to each hospital situation. Therefore, it is most important to develop the tool for evaluating medication errors.
3) It was revealed in this study that 31.7 percent after medication errors were not reported. We, therefore, emphasize that it is necessary to establish a reward mechanism for encouraging the nurse to acknowledge and report the error, based on the principle that early detection and intervention allows potentially for the reversal or neutralization of ill effects.
4) It will be necessary to lay in the supply of man power in daytime shift because there occurred higher percentages of medication errors in 7:30-15:30 shift.
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