Root Cause Analysis of Medication Administration Error by Nursing Staff at a Number of Medical Institutes in Riyadh

Background: Medication errors genuinely influence patient safety, staying cost in hospital and integrity of nursing job, because the nurses play a specific part in managing the medication for the patients. The present study was done with the aim to investigate factors associated with nurses’ medication errors in a number of medical institutes (Ministry of Health) and the role of clinical pharmacist in these errors.

Methodology: The present study was a cross-sectional study based on standardized questionnaire which was designed and distributed to the target nurses in a number of medical institutes (Ministry of Health). The target number was (171) which was achieved depending on the calculation of sample size after the questionnaires was gathered; data was subjected to descriptive and inferential statistics.

Results: The highest mean score of error was obtained in the factor related to medication packaging reason, which includes that different medications look alike, and the names of at least 60 medications were similar by 82.7%. The second group of reasons was system associated, which included: abbreviations were used instead of writing the orders out completely, overall 60.5% of the times nurses were pulled between teams. Third reason, overall 45.3% of the times the errors were associated with pharmacy when they did not prepare\label the medication correctly, and clinical pharmacist did not give education workshops to the nurses. Documentation issues were the fourth reason, 39.5% of the times nurses were interrupted while administering medication to perform other duties and nurses on the same unit did not adhere to the approved medication administration procedure.

Conclusion: The data of the current study suggested the ranking of five reasons or root causes of why medication errors happened. These are medication package, system related, pharmacy related, documentation-transcription reason and physician-nurse related respectively. Furthermore, clinical pharmacists must thrive to improve the nurses' knowledge of how these factors will lead to critical errors and help them discover strategies to prevent these errors from happening.