Investigating the administration of medication in a private healthcare facility: identifying the most common medication administration error.

Abstract

Background: Medication errors are an ongoing global problem for which there is limited South African data. Most medication errors have been shown to occur during the prescribing and administration of medication, with medication administration errors being the type of medication error least likely to be caught before reaching the patient. A study was conducted in one ward in a South African private healthcare facility to investigate the administration of medication in order to identify the most common medication administration error. The potentially serious effects of medication administration errors for the patient, as well as limited South African data on the topic show the significance of this study. Aim: Identification of the most common medication administration error in the selected ward. Method: Medication administration was observed over 16 consecutive days in one ward in a private healthcare facility in KwaZulu-Natal, South Africa. Allowing medication errors to occur for observation was considered unethical. Observer intervened in cases of potential errors before the error reached the patient. These potential errors were counted as near-misses. Nurses who administered medication in the ward also filled out a questionnaire to obtain their views on medication administration errors. Sampling was by convenience for both elements of the study. Results: A near-miss rate of 10.65% (n=56) including wrong time near-misses. The most common type of near-miss was wrong dose (33.93%, n=20). Discussion/Conclusion: The most common type of near-miss was wrong dose mainly due to ineffective communication between members of the healthcare team, which provides direction for educational efforts to improve system safety and thereby reduce near-miss rate. Recommendations: A bigger study involving more sites is required. Improved communication is required especially between pharmacists and nurses administering medication by communicating changes on prescriptions to nurses and providing medication information.