HOSPITAL ERRORS AND THEIR CONSEQUENCES AT URMIA SHAHID MOTAHARI HOSPITAL IN 2022 AND 2023 AND PROPOSING PREVENTIVE STRATEGIES: A DESCRIPTIVE SURVEY STUDY

Salamatbakhsh, Maryam; Hosseinzadegan, Fariba; Salehzadeh, Mahsa; Mohammadpour, Yousef

doi:10.61186/unmf.22.5.379

Volume 22, Issue 5 (8-2024) Nursing and Midwifery Journal 2024, 22(5): 379-388 | Back to browse issues page

‎ 10.61186/unmf.22.5.379

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Salamatbakhsh M, Hosseinzadegan F, Salehzadeh M, Mohammadpour Y. HOSPITAL ERRORS AND THEIR CONSEQUENCES AT URMIA SHAHID MOTAHARI HOSPITAL IN 2022 AND 2023 AND PROPOSING PREVENTIVE STRATEGIES: A DESCRIPTIVE SURVEY STUDY. Nursing and Midwifery Journal 2024; 22 (5) :379-388
URL: http://unmf.umsu.ac.ir/article-1-5112-en.html

HOSPITAL ERRORS AND THEIR CONSEQUENCES AT URMIA SHAHID MOTAHARI HOSPITAL IN 2022 AND 2023 AND PROPOSING PREVENTIVE STRATEGIES: A DESCRIPTIVE SURVEY STUDY

Maryam Salamatbakhsh¹

, Fariba Hosseinzadegan ^*²

, Mahsa Salehzadeh¹

, Yousef Mohammadpour³

1- Msc, Nursing, Faculty of Nursing and Midwifery, Urmia University of Medical Sciences, Iran
2- Assistant Professor of Nursing, School of Nursing and Midwifery, Urmia University of Medical Sciences, Urmia, Iran , F.HOSSEINZADEGAN62@YAHOO.COM
3- Assistant Professor of Medical Education, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran.

Abstract: (914 Views)

Background & Aim: Today, the quality and quantity of medical services provided in hospitals is heavily influenced by the accuracy and reliability of medical care and related supplies. In many cases, the absence of essential medicines and medical supplies or errors in their use can lead patients to question the value of other services and their treatment's effectiveness. Thus, the study aimed to compare hospital errors and related outcomes in 2022 and 2023 and present preventive solutions. Thus, the present study was conducted to compare the types and rates of hospital errors and their related outcomes in 2022 and 2023 and to present interventional preventive solutions.
Materials & Methods: In this descriptive-survey study, all recorded errors in the hospital during the first quarter of 2022 and 2023, including medication errors, instrumental errors, and associated consequences, were analyzed and compared. Preventive and corrective solutions were suggested based on the opinions of the management and medical staff to reduce and eliminate errors. Data were collected through a checklist and analyzed using SPSS software version 20.
Results: The results showed that in both years, the most common type of error was medication prescription to the patient and medication calculations during prescription. Overall, there was a statistically significant difference between the types of hospital errors in the two years (p=0.001). In 2022, the highest error consequence occurred in the fourth quarter and included temporary complications and time waste, while in 2023, the highest consequence occurred in the first quarter and included temporary complications and delays in the diagnosis and treatment process. In both years, the number of deaths was the least frequent error consequence. A significant difference was observed in error consequences between the two years (p=0.013). Additionally, most errors occurred during the evening and night shifts, while the fewest errors occurred during the morning shift. A significant difference was observed in the types of errors among the three work shifts (p=0.023).
Conclusion: The results suggest that nursing managers and educational supervisors should plan and implement in-service training programs and create educational booklets and posters to improve nurses' pharmaceutical knowledge in this field.

Keywords: Descriptive Survey Study, Hospital, Hospital Error, Medical Error, Patient Safety, Prevention

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Type of Study: Research | Subject: پرستاری

References

1. Uitvlugt EB, Janssen MJ, Siegert CE, Kneepkens EL, van den Bemt BJ, van den Bemt PM, et al. Medication-related hospital readmissions within 30 days of discharge: prevalence, preventability, type of medication errors and risk factors. Front Pharmacol 2021;12:567424. [PMID: 33927612] [DOI:10.3389/fphar.2021.567424] [PMCID: PMC8077030]

2. Alqenae FA, Steinke D, Keers RN. Prevalence and nature of medication errors and medication-related harm following discharge from hospital to community settings: a systematic review. Drug Safety 2020;43:517-37. [DOI:10.1007/s40264-020-00918-3]

3. Kennedy GA, Pedram S, Sanzone S. Improving safety outcomes through medical error reduction via virtual reality-based clinical skills training. Saf Sci 2023;165:106200. [PMID: 32125666] [DOI:10.1016/j.ssci.2023.106200]

4. Marune AEMS. Legal responsibility of foreign doctors who commit medical malpractice in Indonesia. Sci Midwifery 2024;12(1):137-47. [Google Scholar:]

5. Bell T, Sprajcer M, Flenady T, Sahay A. Fatigue in nurses and medication administration errors: A scoping review. J Clin Nurs 2023;32(17-18):5445-60. [PMID: 36707921] [DOI:10.1111/jocn.16620]

6. Garnier A, Vanherp R, Bonnabry P, Bouchoud L. Use of simulation for education in hospital pharmaceutical technologies: a systematic review. Eur J Hosp Pharmacy 2023;30(2):70-6. [PMID: 34949651] [DOI:10.1136/ejhpharm-2021-003034] [PMCID: PMC9986932]

7. Rezaeian S, Ahmadzadeh J. Assessment of food habits and their association with cardiovascular risk factors in employees. Int J Collab Res Intern Med Publ Health 2012;4(4):339. [URL:]

8. Fathizadeh H, Mousavi S-S, Gharibi Z, Rezaeipour H, Biojmajd A-R. Prevalence of medication errors and its related factors in Iranian nurses: an updated systematic review and meta-analysis. BMC Nurs 2024;23(1):175. [In Persian]. [URL:] [DOI:10.1186/s12912-024-01836-w]

9. Lee ES, Louey S, Bushby N, Levkovich B. Reducing medication errors on emergency department discharge: Evaluation of a collaborative pharmacist‐medical officer discharge prescription planning model in a tertiary hospital emergency short stay unit. Emerg Med Australas 2024. [PMID: 38476040] [DOI:10.1111/1742-6723.14400]

10. Mobaraki K, Salamatbakhsh M, Ahmadzadeh J. Standard expected years of life lost as a neglected index for calculating the burden of premature mortality due to Middle East respiratory syndrome. Health secur 2019;17(5):407-9. [PMID: 31593510] [DOI:10.1089/hs.2019.0074]

11. Sheervalilou R, Ahmadzadeh J, Alavi S, Mobaraki K, Sargazi S, Shirvaliloo M, et al. Evaluation of diagnostic modalities for SARS-Cov-2: A review study. Epidemiol Health Syst J 2021;8(3):129-37. [URL:] [DOI:10.34172/ijer.2021.24]

12. De Oliveira Jr GS, Castro-Alves LJ, Kendall MC, McCarthy R. Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials. J Patient Saf 2021;17(5):375-80. [PMID: 28671909] [DOI:10.1097/PTS.0000000000000283]

13. Trockel MT, Menon NK, Rowe SG, Stewart MT, Smith R, Lu M, et al. Assessment of physician sleep and wellness, burnout, and clinically significant medical errors. JAMA Netw Open 2020;3(12):e2028111-e. [PMID: 33284339] [DOI:10.1001/jamanetworkopen.2020.28111]

14. Yan S, Wang J, Yin X, Lv C, Wu J, Jiang N, et al. Rates of perceived medical errors and its correlation with work-related factors and personal distress among emergency physicians in China: a national cross-sectional study. Emerg Med J 2023;40(5):320-5. [PMID: 36351780] [DOI:10.1136/emermed-2021-212041]

15. Tangye SG, Al-Herz W, Bousfiha A, Cunningham-Rundles C, Franco JL, Holland SM, et al. The ever-increasing array of novel inborn errors of immunity: an interim update by the IUIS committee. J Clin Immunol 2021;41:666-79. [PMID: 33598806] [DOI:10.1007/s10875-021-00980-1] [PMCID: PMC7889474]

16. Richens JG, Lee CM, Johri S. Improving the accuracy of medical diagnosis with causal machine learning. Nat Commun 2020;11(1):3923. [PMID: 32782264] [DOI:10.1038/s41467-020-17419-7 https://doi.org/10.1038/s41467-020-18310-1] [PMCID: PMC7419549]

17. Zhang J, Wu J, Qiu Y, Song A, Li W, Li X, et al. Intelligent speech technologies for transcription, disease diagnosis, and medical equipment interactive control in smart hospitals: A review. Comput Biol Med 2023;153:106517. [PMID: 36623438] [DOI:10.1016/j.compbiomed.2022.106517] [PMCID: PMC9814440]

18. La Fata C, Adelfio L, Micale R, La Scalia G. Human error contribution to accidents in the manufacturing sector: A structured approach to evaluate the interdependence among performance shaping factors. Saf Sci 2023;161:106067. [URL:] [DOI:10.1016/j.ssci.2023.106067]

19. Hüner B, Derksen C, Schmiedhofer M, Lippke S, Riedmüller S, Janni W, et al. Reducing preventable adverse events in obstetrics by improving interprofessional communication skills-Results of an intervention study. BMC Pregnancy Childbirth 2023;23(1):55. [PMID: 36690974] [DOI:10.1186/s12884-022-05304-8]

20. Manias E, Kusljic S, Wu A. Interventions to reduce medication errors in adult medical and surgical settings: a systematic review. her Adv Drug Saf 2020;11:2042098620968309. [PMID: 33240478] [DOI:10.1177/2042098620968309] [PMCID: PMC7672746]

21. Abukhader I, Abukhader K. Effect of medication safety education program on intensive care nurses' knowledge regarding medication errors. J Biosci Med 2020;8(06):135. [URL:] [DOI:10.4236/jbm.2020.86013]

22. Alrabadi N, Shawagfeh S, Haddad R, Mukattash T, Abuhammad S, Al-rabadi D, et al. Medication errors: a focus on nursing practice. J Pharmac Health Serv Res 2021;12(1):78-86. [URL:] [DOI:10.1093/jphsr/rmaa025]

23. Salar A, Kiani F, Rezaee N. Preventing the medication errors in hospitals: a qualitative study. Int J Afr Nurs Sci 2020;13:100235. [URL:] [DOI:10.1016/j.ijans.2020.100235]

24. Yousef A, Abu Farha R, Da'meh K. Medication administration errors: causes and reporting behaviours from nurses perspectives. Int J Clin Pract 2021;75(10):e14541. [PMID: 34132004] [DOI:10.1111/ijcp.14541]

25. Dadras E, Baghaei R, Sharifi H, Sayyadi H. Relationship Between Pharmaceutical Knowledge and Probability of Medication Errors Among Nurses: A Cross-sectional Study in the Northwest of Iran in 2020. Health Scope 2022;11(1). [URL:] [DOI:10.5812/jhealthscope.112269]

26. Aljuaid M, Alajman N, Alsafadi A, Alnajjar F, Alshaikh M. Medication error during the day and night shift on weekdays and weekends: A single teaching hospital experience in Riyadh, Saudi Arabia. Risk Manag Healthc Policy 2021:2571-8. [PMID: 34188568] [DOI:10.2147/RMHP.S311638] [PMCID: PMC8232963]

27. Bani Issa W, Abdul Rahman H, Albluwi N, Samsudin AR, Abraham S, Saqan R, et al. Morning and evening salivary melatonin, sleepiness and chronotype: A comparative study of nurses on fixed day and rotating night shifts. J Adv Nurs 2020;76(12):3372-84. [PMID: 32969092] [DOI:10.1111/jan.14530]

28. Imes CC, Tucker SJ, Trinkoff AM, Chasens ER, Weinstein SM, Dunbar-Jacob J, et al. Wake-up call: night shifts adversely affect nurse health and retention, patient and public safety, and costs. Nurs Admin Q 2023;47(4):E38-E53. [PMID: 37643236] [DOI:10.1097/NAQ.0000000000000595]