Medication administration error is defined as- any difference between what the patients received or supposed to receive and what the prescriber planned in the original order. Any error in the prescribing, dispensing, or administration of a drug [1]. Medication error is any preventable drug incident leading to inappropriate medication use or patient harm. More than one million serious medication errors happen annually estimated by experts in prescribing, dispensing, or administering of drug, irrespective of which lead to adverse consequences [2].

Feleke et al., [1], expressed that medication administration error occurs in 5 to 20 % of all drug administrations, at least 1.5 million about 4000,000 patients suffering from preventable adverse event per year. The errors involved of 42 % dose omissions or 50 % wrong time administration. The National Patient Safety Agency of UK revealed that, medication administration error is common in hospitals and this occurs in 50 % of all drug medication administrations. All of medication administrations the error rate ranges from 9.4 to 80 % in East Africa. In Jimma, Ethiopia the prevalence of medication administration error within the intensive care unit (ICU) and pediatric ward of 51.8 and 90.8 %. Anderson & Townsend [3], revealed that in the United States more than 7,000 deaths occur annually due to medication error.

Each year in the USA an average of 450,000 are preventable medication errors [4]. According to Ehsani et al., [5], thousands of people die in America every year and near 77 million dollars of financial expenses relating to medication side effects in a year. Causes of inappropriate use of medicines, drug side effects, failure to take appropriate medicine and inappropriate administration of medicine. Medication  error of  nurses  can  lead to unsuccessful and imperfect, legal problems and increase of term and cost of treatment, damage to the professional reputation and mistrust of patients and the health care society [5]. Medication error occurred due to the effect of systematic issues, patient factors, doctor factors and nurse factors [6]. The significant reasons of medication error are: 

• Personal causes such as stress, exhaustion, absentmindedness or forgetfulness, error in administration of commands, reduced attention to details, lack of satisfaction with job and workplace, deficiency of dutifulness or work consciousness

• Predisposing reasons are shortage of educated personnel, extreme overtime, long working days, busy environmental setting, provision of intensive care etc

• Causes concerning to knowledge and awareness such as lack of experience or knowledge about medications or patient’s condition and incorrect mathematical calculations 

Medication error problems and sources are multidisciplinary and multi factorial e.g. lack of knowledge, substandard performances and mental lapses, or defects or failures in systems errors are occur. By both experienced and inexperienced staff, including physicians, pharmacists, nurses, clerical staff, administrators, pharmaceutical manufacturers, patients and their caregivers and others medication errors may be committed [7]. 

Medication error is the most common preventable cause of adverse drug events which adversely effects on patient safety but several studies on medication error have been undertaken in developed countries and very little is known about medication error in Bangladesh. In the context of Bangladesh researcher have not found any study regarding medication error confidence on patient safety at medical university hospital in Bangladesh. As a consequence, the researcher would like to explore nurses’ knowledge regarding medication error at a tertiary hospital in Bangladesh. This study will help the nursing administrator as well as nurse manager to identify the level of nurse’s knowledge regarding medication error and gain knowledge to improve confidence level in their practice during providing medication to the patient.

Study Design

A descriptive-correlation study was conducted to identify nurses’ knowledge regarding medication error and related factors.

Study Participants

The sample in this study was nurses who were working in general surgery, general medicine, CCU, cardiac medicine and ICU of BSMUU hospital who met the inclusion criteria and participants were recruited by convenience sampling technique. The sample size estimated by computer software analysis and the minimum sample was 108. For calculating sample size researcher used, accepted minimum level of significance (α) of 0.05, an expected power of 0.80 (1- β) and an estimated population effect size of 0.30 (γ). However, researcher expected about 20% of non-response rate (22), which were 130. Therefore, 130 questionnaires were distributed and 108 were collected. The response rate was 83%.

Inclusion Criteria

• Nurses who have diploma in nursing, midwifery and others equivalent educational qualification

• Having at least one-year service experience in nursing at this hospital

• Nurses who were willing to participate in this study

Data Collection Instruments

Researcher developed a self-administered questionnaire consisting of demographic characteristics, job-related characteristics and knowledge related questionnaire regarding medication error. The questionnaire was pilot-tested with 12 nurses to check the field testing before data collection. Part I. Demographic characteristics of nurses' including age, gender, religion, level of education, service experience, monthly income and marital status. Part II. Job-related characteristics of nurses'. It consists of 5 items. Part III. Level of nurses’ knowledge regarding medication error. It consists of 30 items on knowledge were assessed by two options (Correct/incorrect) to indicate nurses' knowledge regarding medication error. Nurses who correctly answered on 30 items classified as high knowledgeable and those getting scores below 30 were considered as low knowledgeable. Correct answer was scored one and incorrect answer was scored zero. Scores were reversed for incorrect answer. Possible scores were ranges from 0-30. In this study, researcher found moderate level of knowledge score 18.74 out of 30regarding medication error. Three experts were examined the nurses' knowledge regarding medication error questionnaire including one expert from K. C. University, South Korea, one expert from faculty of nursing management at NIANER and a nursing superintendent who has knowledge regarding nursing research with hospital management and administration. Cronbach’s alpha coefficient for the instrument was .90, which is acceptable.

Data Collection Methods

Ethical Consideration: This thesis proposal approved by the Institutional Review Board (IRB) of NIANER and BSMMU, Dhaka, Bangladesh. IRB clearance No. is NIANER/2017-33. The data collection period was 13th February 2018 to 3rd March 2018.

Data Collection Procedure

Permission for data collection obtained from the Director of Bangabandhu Sheikh Mujib Medical University Hospital, Nursing Superintendent and Chairman or Head of the Department, In-charge of selected ward and from the subject. Informed written consent obtained from each nurse prior to interview being conducted. Nurses' informed that, participation in this study were entirely voluntary and without any obligation. The nurses' can abstain themselves from the study at any time and they should wish to do so with no disadvantage. Nurses' also informed that strict confidentiality will be maintained at all times. All of the data and information stored in a way, which not be disclosed to anybody else except the researcher only. All answer script kept in confidential and maintained privacy about nurses' information.

Data Analysis

Data was analyzed by using statistical Package for social sciences (SPSS) version 23. Demographic characteristics, job-related characteristics and level of nurses’ knowledge regarding medication error was analyzed by using frequencies, percentage, mean and standard deviation. Two sample t-test, ANOVA and Pearson correlation were used to examine the relationship among the demographic characteristics, job-related characteristics and level of nurses’ knowledge regarding medication error.

Demographic Characteristics of Nurses'

The nurses age ranged from 25 to 39 years and the majority 64 (59.3%) were within the age 25-29 years, average service experience 7.34 years and monthly income ranged from 27000 to 90000. Most of the nurses were female 94.4%, 75.0% Muslim. Most nurses 75.0% held diploma in nursing and 70.4% were married (Table 1).

Table 1: Demographic Characteristics of Nurses' (n=108)

Job-Related Characteristics of Nurses'

Working at ICU 32%, CCU 25.9%, cardiology 22.2%, general medicine 10.2% and general surgery 9.3%. Regarding the question on “times of making medication error”, 82.4% answered ‘never’. “What things you need to prevent medication error in the hospital?" 79.6% provided “check the medication order”. “Following which policy the ward has?” 70.4% provided “supervision for proper record keeping”. “Continuing education program is important for prevention of medication error?” 71.3% were strongly agreed (Table 2).

Table 2: Job-Related Characteristics of Nurses' (n = 108)

Level of Nurses’ Knowledge Regarding Medication Error 

The average knowledge score regarding medication error was 18.74. 75.9% on “Cause permanently disability or death”, 90.7% on “It should be reported to the patient”, 86.1% on “It should be reported to patient’s family”, 95.4% on “Improved system is necessary in drug administration and management”, 95.4% on "Training and education program is important for nurses" and 85.2% on “Most errors are not important to report” (Table 3).

Table 3: Level of Nurses’ Knowledge Regarding Medication Error: (n = 108)

Relationship Between Characteristics of Nurses’ and Knowledge Regarding Medication Error

In Table 4, older (r= 0.266, p= 0.005), BSN (t = -11.169, p = 0.000), longer service (r = 0.199, p = 0.039) and high monthly income (r = 0.525, p = 0.000) were significantly related to nurses’ knowledge regarding medication error.

Table 4: Relationship Between Characteristics of Nurses’ and Knowledge Regarding Medication Error

Relationship Between Nurses’ Knowledge Regarding Medication Error and Job-Related Characteristics

In Table 5, there were no significant relationship between nurses’ knowledge regarding medication error and job-related characteristics. ANOVA (Analysis of Variance Analysis) was used to examine the relationship between nurses’ knowledge score with nurses' 'Working ward' (F = 0.278), the probability value (p = 0.891). In this case, General medicine and Cardiac medicine nurses' have more knowledge (mean = 19.73) and (mean = 19.25) compare to the General surgery (mean = 18.70), ICU (mean = 18.50) and CCU (mean = 18.29) nurses'. But the result is not statistically significant. The two-sample t-test was used to examine the relationship between nurses’ knowledge score with ‘Times of making medication error’ (t = 0.686), the probability value (p = 0.494). In this case, nurses' who reported that ‘Sometimes’ (mean = 19.42) made medication error they have slightly more knowledge score than who reported that ‘Never’ (mean = 18.60) made medication error. But the result is not statistically significant. ANOVA (Analysis of Variance Analysis) was used to examine the relationship between nurses’ knowledge score with ‘What things you need to prevent medication error in the hospital?’. In this case, nurses' who answered ‘Identifies the purpose of drug use’ they have more knowledge score (mean = 20.33) than who answered ‘Check patient name before giving medication’ (mean = 17.79) and ‘Check the medication order’ (mean = 18.90). But the result is not statistically significant. 

Table 5: Relationship Between Nurses’ Knowledge Regarding Medication Error and Job-Related Characteristics

The two-sample t-test was used to examine the relationship between nurses’ knowledge score with ‘Continuing education program is important for prevention of medication error?’. Here, nurses' who reported ‘Strongly Agree’ have slightly more knowledge score (mean = 18.90) than who reported ‘Agree’ (mean = 18.35). However, the result is not statistically significant (Table 5).

Medication errors are such a factor through which patient safety can be at risk anytime. Although, in whole, other health professionals (physicians, pharmacists) also contribute in the medication procedure, nurses have a dynamic role in the management of patients’ medication. The examination of medication errors in the clinical nursing practice is vital, since serious patient maltreatment is potential. Moreover, medication errors are a burden for the hospital organization and the health professionals as well [8].

This study shows significant statistical relation between total knowledge score and nurses' age. This finding was not similar to any study. A study was conducted to assess the magnitude and associated factors of medication administration errors among nurses found, age of the nurses and working experience were significantly associated with medication administration error. This can be described by the fact that medication administration is one of the nurses' practices that progresses with age and experience. In addition, nurses with more age and work experience have more knowledge and skills related to medication administration [1].

The result of this study revealed that the mean value (23.81±2.039) of B. Sc Nurses was higher as compared with mean value (17.05±4.153) of Diploma Nurses. This finding was higher than that study conducted in Ajman, UAE by Johnson & Thomas [9]. The mean value of their knowledge was 14.2±2.8 among BSN as compared with the 56% of graduate nurses, whose mean knowledge score revealed was 15.1±2.6.

Upon seeing the knowledge regarding medication errors and the service experience was significantly high. The study conducted in Ajman UAE by Johnson & Thomas [9], among the knowledge regarding medication errors and the number of years of experience, about 35% had a clinical experience of 8 years and above, whose mean knowledge score was found 14.25. This is followed by 22.9% in 2-4 years with the mean score of 14.66. Out of 22.4% nurses with clinical experience of 4-6 years also had a mean knowledge score 14.89, followed by 12.9% with an experience of 6-8 years also had a mean knowledge score 14.63. In my study, highly significant relationship of total knowledge score with nurses’ monthly income which was not similar to any other study. However, the results showed that nurses who had higher monthly income, had less contribution in medication error.

Accordingly, nurses of 50.9% mentioned knowledge lacking regarding medication administration and dose calculation, nurses 90.7% mentioned fear of blame as well as decreasing of professional reputation and of getting punishment, nurses 64.8% mentioned interruption during medication pass with incomplete and unclear medication order, nurses 56.5% mentioned that shortage of nursing staff and heavy work load, hand writing treatment order are associated in producing medication errors. Hosseinzadeh et al., [10], recommended, the most significant reasons for medication errors as shortages of nursing staff, nursing burn-out and high workload. Eshani et al., found, 72.7% of the nurses never reported these errors. The rate of reporting medication errors among nurses was far less than the medication errors they had made. Feleke et al., [1], found, interruption of the nurse at the time of medication administration contributes to medication administration error. This finding is consistent with the study done in Sydney, Australia Westbrook et al., [11]. This can be explained by the fact that, since medication preparation and administration need concentration, interruptions during these activities leads to cognitive failures among nurses in relation to working memory and attentiveness.

In addition, taking for arranged that education is a fundamental part of nurses’ career and since the acknowledgement of the contributing factors to medication errors has been attained in a several degrees, it is authoritative to implement respective educational strategies to hinder errors’ arrival or increase their appropriate management [12].

The confidentiality of demographic information data was ensured and all identifiable data were eliminated, the participants may have provided incorrect answers to the questions as a result of fear of disclosure, blame as well as decreasing of professional reputation which can be considered as the limitation of the study which may reduce the credibility of the findings, as well as the generalizability of the findings to a larger population since it was carried out in a specific region. Other limitations were identified as: 

• A convenience sample there might have been a selection bias that diminish the generalizability of the findings. Therefore, future studies should use random subjects

• The sample size of 108 was relatively small which may limite the generalizability of the study findings 

• Majority of the participants were female, thus did not find any difference between male and female nurses knowledge regarding medication administration error

It can be concluded that the significantly low knowledge regarding medication error among diploma nurses. The knowledge is the matters toward safe administration of medication and most of the nurses strongly agree to continue education program for prevention of medication error. Adequately educate nurses to manage interruptions and prioritize according to individual patient needs, through critical thinking, analysis and assessment of each individual situation. Researcher recommend increasing the number of nursing staff, adjusting the workload of the nurses and intensive regular retraining programs should be held for nursing staff aiming to improve nurses’ pharmacological information, encourage nurses to report medical errors to minimize the errors rates and encourage hospital managers to respond to errors in a positive ethical and logical manner in order to enhance patient safety. Future study should be conducted in the reduction of medication error.

Acknowledgment

All admiration and decent gratefulness to Almighty Allah at the beginning for his immerses loveliness and mercy which dynamic me to get strengthening all the time during the whole period of progress of this dissertation.

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