Medication Administration Error Reporting Among Nurses: A Descriptive Qualitative Study Open Access

Medication administration errors (MAEs) are any act or event that may lead to inappropriate administration of a prescribed medication to a patient. Medication errors have profound implications for patient safety. Globally, 5% of MAEs result in death, and 50% may be prevented.^[1,2] The National Patient Safety Agency has identified medication errors as a global burden, with administration errors accounting for nearly 50%, dispensing errors for 18%, and 16% being prescribing errors. In the United States, it is estimated that MAEs cause the death of 7000 patients annually.^[3,4] A Society of Actuaries Health Section study used medical claim data to assess the cost of medical errors in the United States.^[5] The study found 6.3 million measurable medical injuries in 2008, costing $19.5 billion. This cost included direct medical costs for inpatient, outpatient, and prescription drug services ($17 billion), indirect medical costs related to increased mortality rate ($1.4 billion), and loss of productivity ($1.1 billion).^[2] One crucial strategy to reduce MAEs is the implementation of error detection, which involves recognizing and reporting errors.^[6,7] Reporting MAEs requires healthcare professionals to acknowledge and report these errors through official channels.

Nurses are expected to administer medication, considering their knowledge of pharmacology and therapeutics. Patient safety has been a significant concern for healthcare professionals and, more importantly, for nurses. Most medication errors occur at the time of administration.^[8] MAEs have been noted and rated as the most common error affecting patient safety and, commonly, the most preventable error in the medical setting. However, underreporting is expected because of blame and adverse consequences, especially for hospital nurses who administer most medications.^[9] Nurses in centralized and hierarchical units may hesitate to report MAEs owing to potential reprisals or negative outcomes.^[10] In an unsupportive environment, nurses may worry about being perceived as incompetent or troublemakers by their colleagues.^[6,7,11] It is worth noting that medication errors can occur among both newly graduated and experienced nurses, as shown in a study where 62.1% of newly graduated nurses and 57.3% of nurses with at least 3 years of experience admitted making at least one error during their careers.^[12]

Medication error reporting is necessary to appreciate the extent and impact of MAEs. Nurses’ ability to detect 86% of medication errors was reported in a descriptive cross-sectional study conducted in a large medical center in southern Taiwan, which found a significance rate of MAE reporting among nurses.^[6] A study conducted in Ethiopia indicated that the proportion of MAE reporting among nurses was 57.4%.^[13] Another study conducted at the University of Gondar Referral Hospital, Ethiopia, revealed that the estimated MAE reporting was 29.1%. The perceived rates of MAE reporting for nonintravenous-related medications ranged from 16.8 to 28.6% and for intravenous-related medications, from 20.6 to 33.4%.^[14]

Several studies have shown a relationship between the mix of nursing staff and medication errors.^[15–18] They found that medication errors decrease as the proportion of registered nurses in the staff mix increases. However, the error rate rises when the proportion of registered nurses exceeds 85% of the staff mix. Nursing shortages have also been identified as contributing to time constraints, affecting MAE reporting.^[15,19] Additionally, individual factors such as lack of knowledge related to medication errors, the perception that fixing an error is easier than reporting it, and uncertainty about which errors should be reported reduce the willingness to report MAEs.^[3,16]

Reason’s model of accident causation suggests that active failures by front-line individuals occur because of error-producing conditions in their work environment.^[20,21] The model proposes that complex systems like hospitals have inherent vulnerabilities that contribute to errors. Despite the interventions and measures put in place by the Ministry of Health of Ghana and its related agencies, such as the Nursing and Midwifery Council of Ghana, to improve patient safety and quality of care, there is a lack of sufficient data, surveys, and research to assess the prevalence of MAE reporting that ensures a patient safety culture. Therefore, this study aims to explore the barriers and facilitators to the reporting behavior for MAEs among nurses in Ghana.

Ethical approval for this study was obtained from the University of Ghana Institutional Review Board. In addition, permission was sought from the hospital management to allow participants (nurses) to access face-to-face interviews for data collection. Nurses’ participation in this study was strictly voluntary. Written informed consent was obtained from all participants. The general aim of the study was explained to the recruited participants before they responded to the questions. Participants were assured of strict confidentiality, with all data anonymized and stored securely to prevent identification. As such, pseudonyms (such as Nurse 1, Nurse 2) were used during transcription, and no personal identifiers were included in the final analysis. To mitigate potential repercussions, participants were informed that the study aimed to understand systemic issues rather than assign individual blame. Additionally, participants were allowed to withdraw at any stage without penalty.

This study used a descriptive qualitative cross-sectional approach. The qualitative approach was chosen to gain in-depth insights from participants on medication error reporting and factors contributing to MAEs.

The study was conducted at a district catholic hospital in the Volta region of Ghana, a general hospital in the Konda community of Kpando Township. The hospital has a 163-bed capacity and an average annual admission of 8480. The population for this study comprised professional nurses, which include registered general nurses, nurse-assistant clinical nurses, ophthalmic nurses, mental health nurses, and nurse practitioners. Using this population for the study is essential because nurses are the professionals who administer medications directly to the patient and are involved in patient care. Nurses directly involved in patient care and who had been employed for more than 6 months were recruited. A purposive sampling technique was used to select nurses that could participate in the study to ensure they directly experienced the phenomena under study, minimizing variability. The sample size of 20 nurses was determined from the principle of data saturation, where no new themes or insights emerged from subsequent interviews. Data saturation was achieved through the iterative process of data collection and analysis. Initially, 20 interviews were conducted, with each session transcribed and analyzed for recurring patterns and themes. As interviews progressed, no new themes or significant insights emerged, indicating that the data had reached saturation. This was confirmed through continuous comparison of new data with previously collected information. The decision to stop data collection was based on the redundancy of responses, with themes and patterns becoming consistent across participants. This ensured that the study captured the full range of perspectives necessary for comprehensive thematic analysis.

Data were primarily collected by using a structured interview guide based on the research objectives. Face-to-face, in-depth interviews were conducted with the assistance of trained research assistants. The interview guide was structured to explore participants’ experiences and perceptions regarding MAEs and their reporting behaviors. It included open-ended questions designed to elicit in-depth responses. Key questions focused on understanding nurses’ knowledge of MAEs, such as “Can you describe what constitutes a medication administration error?” Other questions explored barriers to reporting errors; for example, “What factors prevent you from reporting medication errors?” “How do you perceive the consequences of reporting an error?” Additionally, the guide addressed strategies for minimizing MAEs, such as “What kind of training or support would help you avoid medication errors?” The interviews were audio-recorded, each lasting approximately 30–45 minutes.

The interviews were transcribed and analyzed thematically. The coding of interviewees’ answers followed a systematic thematic analysis approach. First, all audio-recorded interviews were transcribed verbatim to ensure accuracy. The transcripts were read multiple times to familiarize the researchers with the data. Open coding was used to identify initial codes based on recurring words, phrases, and ideas. These codes were then grouped into categories reflecting broader patterns. Axial coding was used to refine categories and explore relationships among them. Finally, selective coding was used to identify overarching themes. Coding was conducted manually and verified independently by two researchers to enhance reliability and reduce subjective bias in interpretation.

The participants were between 20 and 40 years of age, with the majority (65%, n = 13) being women who had worked between 1 and 5 years (Table 1). All the nurses interviewed had basic nursing qualifications, with most having a diploma in nursing.

The study found that all 20 respondents were cognizant of MAEs in their day-to-day work. They were all aware that there is a high likelihood of preventing MAEs if proper directions are given. The following quotes were provided by the participants.

The 10 Rs mentioned are the right patient, time, medication, dose or dosage, and route. Others are right for patient refusal, right to client or patient administration, right assessment, and right evaluation.

The respondents were also asked to describe the types of MAEs that warrant reporting. The MAEs mentioned include prescribing errors, omission errors, wrong time errors, unauthorized drug errors, dose errors, dosage form errors, drug preparation errors, route of administration errors, administration technique errors, deteriorated drug errors, monitoring errors, and compliance errors. Definitions for each type of MAE are presented in Table 2.^[22] The study found that one or more nurses had committed one or more of these errors. A respondent had the following comment:

Identifying the factors that increase the potential of MAEs is needed to address how best to overcome these problems to guarantee patient safety. The findings from the study show that workload, stress and tiredness, staff strength, inability to calculate drug dosage, poor knowledge of some medications, distractions during medication administration, and patient-related factors are the most common factors that contribute to an MAE. Below are comments provided by the respondents:

The study found that some nurses do not report MAEs when they occur; only a few nurses report such errors. For example, one respondent shared:

The study revealed that hospital management and fear of the consequences of reporting errors are significant barriers hindering nurses from reporting MAEs. Respondents echoed this as shared below:

Fear of the consequences of reporting MAEs was a major barrier. The respondents had this to say:

The study revealed the need for a system put in place by management to record medication errors when patients experience them. Despite the high occurrence of medication errors, reporting is often done informally. For instance, errors are mainly discussed verbally without any proper records of such events. However, avenues for patient safety enhancement may be limited without formal written reports on medication errors. The respondents had the following suggestions.

The National Coordinating Council for Medication Error Reporting and Prevention states that a medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm.^[23] Because all respondents were knowledgeable about MAEs, this knowledge may provide a basis on which quality improvement decisions may be implemented, a lack of which may result in poor decision-making. Other studies have identified a knowledge deficit in determining the correct dose and preventing medication errors.^[6,16,17] MAEs may be avoided by giving proper directions; however, some MAEs are related to professional practice, healthcare products, procedures, systems, prescribing, order communication, product labelling, packaging, nomenclature, compounding, dispensing, administration, education, and monitoring.^[23]

Our study findings are also consistent with others that identified system failures or omissions and failure of health professionals themselves as the major contributing factors to MAEs.^[18,24–26] System characteristics such as being understaffed, poor communication, vague authorization, an inadequate system of error information exchange, and an increase in high-risk patients contribute to creating error-prone hospital surroundings, as do workload and staffing levels, factors that have been shown to affect the rate of MAEs.^[20,27,28] Insufficient training and staffing issues have been identified as critical barriers to error reporting, particularly in resource-constrained environments.^[9]

Poor adherence to medicines policy and lack of compliance with prescriptions ordered by medical professionals also may contribute to medication errors.^[17,27] Inadequate knowledge and lack of pharmacology education among nurses are other barriers to effective medication administration.^[18,26] Thus, it is imperative to create a conducive atmosphere to educate nurses on ways and means to reduce medication errors in their day-to-day care of patients.

Although nurses have an obligation to reduce MAEs, our study found that most nurses do not report MAEs when they occur. Another study reported only 20% of MAEs were reported by nurses.^[24] Because patient safety is paramount to the contemporary healthcare delivery framework and a vital indicator of healthcare effectiveness, we sought to identify barriers to MAE reporting. We found that attitudes of hospital management and fear of consequences are significant barriers hindering nurses from reporting MAEs. Nurses are afraid of job threats, legal liability, adverse economic effects, face-saving issues, and other adverse consequences of reporting. Nurses believe that reporting medication errors leads to blaming colleagues instead of the system, subsequent reporting errors, and fear of reprimand and punishment. This finding is consistent with earlier studies, which found that nurses consider positive or negative consequences before reporting MAEs.^[1,6] If hospital management provides a supportive atmosphere for nurses who commit medication errors, then nurses will be at ease in reporting any error they commit when administering medications to patients.

The barriers to MAE reporting identified in this study — fear of punishment, lack of training, and inadequate staffing — interact in complex ways that hinder reporting behaviors. Fear of punishment, including concerns about job loss or legal consequences, creates a climate of silence, particularly when errors are perceived as blameworthy. This fear is exacerbated by inadequate training, which leaves nurses feeling unprepared and insecure in their roles, further contributing to a reluctance to report. Moreover, understaffing and heavy workloads increase stress and fatigue, which lead to more errors, perpetuating a cycle of underreporting. These barriers align with findings from other studies that highlight the influence of organizational culture and fear of reprisal on MAE reporting in various healthcare settings.^[1,7]

Reporting MAEs reduces their adverse effects and effectively assists in avoiding future errors that can harm patients. Reporting also decreases personal suffering and financial costs to both the patient and the nurse. Nurses should be familiar with diverse avenues to reduce the likelihood of not reporting MAEs, including healthy ways of recognizing and accepting medication errors when they occur.

The study further revealed that there are no systems in place for recording medication errors when patients experience them. For best practice, when a nurse on duty commits an MAE, they must create awareness among the other nurses on duty, and the error must be documented and reported to the nursing superior or superior of the facility. It is essential to put the right interventions in place to avoid errors, shield nurses from litigation and unforeseen circumstances, and protect the patient from harm. Such interventions could be educational programs for all nurses.

Given the unique challenges of the Ghanaian healthcare system, the following recommendations are proposed:

1. Strengthening Reporting Systems: Implement a more structured and confidential error reporting system across all healthcare facilities in Ghana. This should involve training nurses on the importance of reporting and ensuring that the system is nonpunitive to alleviate fears of consequences.

2. Continuous Education and Training: Organize regular workshops and in-service training for healthcare staff on the causes and prevention of medication errors. Focus on pharmacology, drug calculations, and proper administration techniques to improve competency.

3. Resource Allocation: Address staffing shortages and heavy workloads, particularly in rural and district hospitals, by increasing the number of healthcare workers and improving shift management to reduce stress and fatigue, which contribute to errors.

4. Policy Development: Develop and enforce national policies that support a nonblaming, nonpunitive culture for reporting errors, modelled on the World Health Organization’s medication safety standards.

5. Leadership and Supportive Environment: Encourage hospital leadership to create a supportive environment where nurses feel safe reporting errors without fear of job loss or retribution, promoting patient safety and a culture of transparency.

This study has limitations. We used a descriptive qualitative cross-sectional study design and did not confirm a definitive cause-and-effect relationship between the variables. The study included only 20 participants, which, although sufficient for achieving data saturation in qualitative research, may limit the generalizability of the findings to other healthcare settings. Data were collected from nurses at a single hospital, which may not reflect the experiences or practices in other hospitals or regions in Ghana. The study excluded other stakeholders, such as pharmacists and physicians, whose perspectives could provide a more holistic understanding of MAE reporting. Further, some participants may wrongly answer questions concerning MAEs and reporting owing to fear of the outcome or social desirability.

The study revealed key barriers to medication error reporting among nurses in Ghana, including fear of punishment, inadequate training, heavy workloads, and the absence of structured, nonpunitive reporting systems. These factors contribute to the significant underreporting of medication errors, limiting opportunities to address systemic issues and improve patient safety. To enhance reporting practices, it is crucial to establish supportive organizational cultures, implement confidential and structured reporting systems, and provide continuous education on error prevention and reporting. Addressing these challenges will not only improve reporting rates but also foster a culture of safety and accountability in Ghanaian healthcare facilities.