What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff
| Autor: | Keers, Richard N., Plácido, Madalena, Bennett, Karen, Clayton, Kristen, Brown, Petra, Ashcroft, Darren M. |
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| Jazyk: | angličtina |
| Rok vydání: | 2018 |
| Předmět: |
Adult
Hospitals Psychiatric Male Health Knowledge Attitudes Practice Medication Systems Hospital Patients National Health Programs Health Care Providers Nursing Administration lcsh:Medicine Nurses Workload Nursing Staff Hospital Nursing Science Risk Factors Mental Health and Psychiatry Medicine and Health Sciences Antipsychotics Humans Medication Errors Oral Administration Medical Personnel lcsh:Science Routes of Administration Qualitative Research Aged Pharmacology Inpatients Risk Management Mental Disorders lcsh:R Drugs Health Care Professions England People and Places lcsh:Q Population Groupings Female Clinical Competence Patient Safety Research Article |
| Zdroj: | PLoS ONE PLoS ONE, Vol 13, Iss 10, p e0206233 (2018) Keers, R N, Plácido, M, Bennett, K, Clayton, K, Brown, P & Ashcroft, D M 2018, ' What causes medication administration errors in a mental health hospital? A qualitative study with nursing staff ', PLoS ONE, vol. 13, no. 10, e0206233 . https://doi.org/10.1371/journal.pone.0206233 |
| ISSN: | 1932-6203 |
| DOI: | 10.1371/journal.pone.0206233 |
| Popis: | ObjectiveMedication administration errors (MAEs) are a common risk to patient safety in mental health hospitals, but an absence of in-depth studies to understand the underlying causes of these errors limits the development of effective remedial interventions. This study aimed to investigate the causes of MAEs affecting inpatients in a mental health National Health Service (NHS) hospital in the North West of England.MethodsRegistered and student mental health nurses working in inpatient psychiatric units were identified using a combination of direct advertisement and incident reports and invited to participate in semi-structured interviews utilising the critical incident technique. Interviews were designed to capture the participants’ experiences of inpatient MAEs. All interviews were transcribed verbatim and subject to framework analysis to illuminate the underlying active failures, error/violation-provoking conditions and latent failures according to Reason’s model of accident causation.ResultsA total of 20 participants described 26 MAEs (including 5 near misses) during the interviews. The majority of MAEs were skill-based slips and lapses (n = 16) or mistakes (n = 5), and were caused by a variety of interconnecting error/violation-provoking conditions relating to the patient, medicines used, medicines administration task, health care team, individual nurse and working environment. Some of these local conditions had origins in wider organisational latent failures. Recurrent and influential themes included inadequate staffing levels, unbalanced staff skill mix, interruptions/distractions, concerns with how the medicines administration task was approached and problems with communication.ConclusionsTo our knowledge this is the first published in-depth qualitative study to investigate the underlying causes of specific MAEs in a mental health hospital. Our findings revealed that MAEs may arise due to multiple interacting error and violation provoking conditions and latent ‘system’ failures, which emphasises the complexity of this everyday task facing practitioners in clinical practice. Future research should focus on developing and testing interventions which address key local and wider organisational ‘systems’ failures to reduce error. |
| Databáze: | OpenAIRE |
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