Literature Review: Cause Factor Analysis and an Effort to prevent Medication Administration Error (MAE) at Hospital

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Innes Rizma Brigitta
Inge Dhamanti

Abstract

The high number of medical errors, especially in medication administration errors (MAE) in the last few decades that have occurred in hospitals in developed and developing countries makes patient safety an important issue. This requires the hospital to take steps that prioritize patient safety by focusing on preventive measures, so as to reduce the risk of an MAE. The writing of this article of literature review aims to explain the determinants of MAE in hospitals and their prevention efforts through preventive measures, so that patient safety standards in hospitals (zero defects) can be achieved. The design of the article search in this literature study was carried out through Google scholar, JAKI, and PSNet with the keywords of patient safety incident, medication administration error, contributing factor of MAEs, and determinant factor of MAEs. Based on 13 articles that have been obtained in accordance with the criteria, there are 38 determinant factors in MAE which are grouped into three categories, namely ineffective communication factors, work environment factors, and human factors. Various preventive efforts that can be done to prevent MAEs include: implementing crew resource management, clarifying the chain of command, using the communication form of SBAR, designing an ergonomic workplace, implementing Patient Advocacy Reporting System (PARS), providing training and education for health workers, and setting work schedules that do not exceed workload. Implementation of effective MAE preventive measures can reduce the number of MAEs in the hospital directly.

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How to Cite
Brigitta, I. R., & Dhamanti, I. (2020). Literature Review: Cause Factor Analysis and an Effort to prevent Medication Administration Error (MAE) at Hospital. Unnes Journal of Public Health, 9(2), 98-107. https://doi.org/10.15294/ujph.v9i2.36470

References

REFERENCES
Alemu, W., Belachew, T. & Yimam, I. 2017. Medication administration errors and contributing factors: A cross sectional study in two public hospitals in Southern Ethiopia. International Journal of Africa Nursing Sciences. 7(September): 68–74. doi: 10.1016/j.ijans.2017.09.001.
Ayorinde, M. O. and Alabi, P. I. 2019. Perception and contributing factors to medication administration errors among nurses in Nigeria. International Journal of Africa Nursing Sciences, 11(May): 100153. doi: 10.1016/j.ijans.2019.100153.
Baraki, Z., et al. 2018. Medication administration error and contributing factors among pediatric inpatient in public hospitals of Tigray, northern Ethiopia. BMC Pediatrics, 18(1): 1–8. doi: 10.1186/s12887-018-1294-5.
Battles, J. et al. 2017. Advances in Patient Safety and Medical Liability. AHRQ Publication No. 17-0017. Rocville, MD: Agency for Healthcare Research and Quality
Budihardjo, V. S. 2017. Faktor Perawat Terhadap Kejadian Medication Administration Error di Instalasi Rawat Inap. Jurnal Administrasi Kesehatan Indonesia, 5(1): 52–61. doi: 10.20473/jaki.v5i1.2017.52-61
Carayon, P., Alvarado, C. J. & Hundt, A.S. 2007. Work design and patient safety. Theoretical Issues in Ergonomics Science, 8(5): 395–428. doi: 10.1080/14639220701193157.
Delgado, M.C.M., et al. 2015. Analysis of contributing factors associated to related patients safety incidents in Intensive Care Medicine. Medicina Intensiva Journal (English Edition), 39(5): 263–271. doi: 10.1016/j.medine.2015.05.001.
Department of Health of the Republic of Indonesia. 2008. Panduan Nasional Keselamatan Pasien Rumah Sakit. Departemen Kesehatan Republik Indonesia. Jakarta: Department of Health of the Republic of Indonesia.
Dietrich, M. & Norman, L. 2017. Nurses’ Perceived Skills and Attitudes About Updated Safety Concepts: Impact on Medication Administration Errors and Practices. Journal of Nursing Care Quality, 32(3): 226–233. doi: 10.1097/NCQ.0000000000000226.
Elasrag, G.A.E. & Abu-Snieneh, H.M. 2020. Nurses’ perception of factors contributing to medication administration errors. International Journal of Research in Pharmaceutical Sciences, 11(1): 44–56. doi: 10.26452/ijrps.v11i1.1781.
Emanuel, L. et al. 2008. What Exactly Is Patient Safety?. Advances in Patient Safety: New Directions and Alternative Approaches, 1(Assessment): 1–18. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21249863.
Feleke, S.A., Mulatu, M.A. & Yesmaw, Y.S. 2015. Medication administration error: Magnitude and associated factors among nurses in Ethiopia. BMC Nursing, 14(1): 1–8. doi: 10.1186/s12912-015-0099-1.
Girma, B. & Feleke, Y. 2010. Medication administration errors involving paediatric in-patients in a hospital in Ethiopia. Tropical Journal of Pharmaceutical Research, 9(4): 401–407. doi: 10.4314/tjpr.v9i4.58942.
Handayani, T.W. 2017 Faktor Penyebab Medication Error di RSU Anutapura. Jurnal Pengembangan Sumber Daya Insani, 02(2): 224–229. doi: 10.26618/perspektif.v2i2.1285
Hara, J.K.O., et al. 2018. What can patients tell us about the quality and safety of hospital care? Findings from a UK multicentre survey study. BMJ Quality and Safety, 27: 673–682. doi: 10.1136/bmjqs-2017-006974.
Hastuti, A.P., Nursalam & Triharini, M. 2014. Preventing Medication Error Based on Knowledge Management Against Adverse Event. Jurnal Ners, 12(1): 133–141. doi: 10.20473/jn.v12i1.2297
Hayden, E.M., Wong, A.H., Ackerman, J., Sande, M.K., Lei, C., Kobayashi, L., et al. 2018. Human factors and simulation in emergency medicine. Academic Emergency Medicine, 25(2): 221-229. https://doi.org/10.1111/acem.13315.
Hines, S., Kynoch, K. & Khalil, H. 2018. Effectiveness of interventions to prevent medication errors. JBI Database of Systematic Reviews and Implementation Reports, 16(2): 291–296. doi: 10.11124/jbisrir-2017-003481.
Hunt, C. M. 2010. Patient Safety is Enhanced by Teamwork. Pennsylvania Patient Safety Advisory, 7(2): 14–17. available at: http://www.patientsafetyauthority.org
Johnson, M. et al. 2017. The impact of interruptions on medication errors in hospitals: an observational study of nurses. Journal of Nursing Management, 25(7): 498–507. doi: 10.1111/jonm.12486.
Keers, R.N. et al. 2015. Understanding the causes of intravenous medication administration errors in hospitals: A qualitative critical incident study. BMJ Open, 5(3): 1–10. doi: 10.1136/bmjopen-2014-005948.
Kumar K.S.A. & Venkateswarlu, K.R.A. 2011. A Study of medication administration errors in a tertiary care hospital. Indian Journal of Pharmacy Practice, 4(2): 37–42. doi:10.5530/ijopp
Leber, M., Carillo, C.J.D., Cassano, A.T., et al. 2018. ASHP guidelines on the prevention of medication errors in hospitals. Am J Health Syst Pharm, 75: 1493-1517. doi: 10.2146/ajhp170811
Levinson, D.R. 2011. Adverse Events in Hospitals: National Incidence Among Medicare Beneficaries. Washington DC: Department of Health & Human Services USA.
Lindquist, D.G. 2009. Improving Patient Safety Using Crew Resource Management Principles Taught Via Medical Simulation. Prescriptions for excellence in health care newsletter supplement, 1(7): 5. Available at: http://jdc.jefferson.edu/pehc/vol1/iss7/5.
Link, Terri. 2018. Guideline Implementation: Team Communication. AORN Journal, 102(2): 165–174. doi: 10.1002/aorn.12300.
Mansah, M., Hons, B.N., et al. 2014. Older Folks in Hospitals: The Contributing Factors and Recommendations for Incident Prevention. Journal of Patient Safety, 10(3): 146–153. doi: 10.1097/PTS.0b013e31829954fd
Manser, T. 2009. Teamwork and patient safety in dynamic domains of healthcare: A review of the literature. Acta Anaesthesiologica Scandinavica, 53(2): 143–151. doi: 10.1111/j.1399-6576.2008.01717.x.
Mattson, M. & Hellgren, J. 2015. Leader communication approaches and patient safety: An integrated model. Journal of Safety Research, 53: 53–62. doi: 10.1016/j.jsr.2015.03.008.
Mckoin, S. et al. 2010. Chain of Command: When Disruptive Behavior Affects Communication and Teamwork. Pennsylvania Patient Safety Advisory, 7(2): 4–14. available at: http://www.patientsafetyauthority.org
McKoin, S., et al. 2010. Building a culture of operating room safety using crew resource management. Pennsylvania Patient Safety Advisory, 7(2): 1–3. Available at: http://www.patientsafetyauthority.org.
Mekonnen, A.B., et al. 2018. Adverse Drug Events and Medication Errors in African Hospitals: A Systematic Review. Drugs - Real World Outcomes, 5(1): 1–24. doi: 10.1007/s40801-017-0125-6.
Oludeyi, O. S. 2015. A review of literature on work environment and work commitment: Implication for future research in citadels of learning. Journal of Human Resource Management, 18: 32–46.
Parry, A.M., Barriball, K.L. & While, A.E. 2015. International Journal of Nursing Studies Factors contributing to Registered Nurse medication administration error: A narrative review. International Journal of Nursing Studies, 52(1): 403–420. doi: 10.1016/j.ijnurstu.2014.07.003.
Patel, I. & Balkrishnan, R. 2010. ‘Medication error management around the globe: An overview. Indian Journal of Pharmaceutical Sciences, 72(5): 539–545. doi: 10.4103/0250-474X.78518.
Saghafi, F. & Zargarzadeh, A.H. 2014. Medication error detection in two major teaching hospitals: What are the types of errors? Journal of Research in Medical Sciences, 19(7): 617–623.
Sahlström, M. 2018. Patient participation in patient safety — An exploration of promoting factors. Journal Nursing Management, 27: 1–9. doi: 10.1111/jonm.12651.
Sarfati, L., et al. 2019. Human-simulation-based learning to prevent medication error: A systematic review. Journal of Evaluation in Clinical Practice, 25(1): 11–20. doi: 10.1111/jep.12883.
Scanlon, M.C. & Karsh, B. 2010. Value of human factors to medication and patient safety in the intensive care unit. Critical Care Med, 38(6): 90–96. doi: 10.1097/CCM.0b013e3181dd8de2.
Tehewy, M. et al. 2016. Medication Administration Errors in a University Hospital. Journal of Patient Safety, 12(1): 34–39.
Thomas, L. et al. 2017. Impact of Interruptions, Distractions, and Cognitive Load on Procedure Failures and Medication Administration Errors. Journal of Nursing Care Quality, 32(4):309-317. doi: 10.1097/NCQ.0000000000000256.
Timmons, S., et al. 2014. Implementing human factors in clinical practice. Emergency Medicine Journal, 32(5):368-72. doi: 10.1136/emermed-2013-203203.
Undang-Undang Republik Indonesia no 44 tahun 2009, Tentang Rumah Sakit. [Law of the Republic of Indonesia No. 44 of 2009]
Weinger, M.B. & Gaba, D.M. 2014. Human Factors Engineering in Patient Safety. Anesthesiology, Vol. 120(4): 801–806. doi: 10.1097/ALN.0000000000000144
Westbrook, J.I., et al. 2011. Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience. BMJ Quality and Safety, 20(12): 1027–1034. doi: 10.1136/bmjqs-2011-000089.