Improving patient safety through identifying barriers to reporting medication errors among nurses: an integrative review

Background: The aim of the third WHO challenge released in 2017 was to attain a global commitment to lessen the severity and to prevent medication-related harm by 50% within the next ve years. To achieve this goal, comprehensive identication of barriers to reporting medication errors is imperative. Objective: This review aimed to identify studies that investigated barriers to reporting medication administration errors among nurses, systematically summarize the ndings to make recommendations for improving error reporting, and for future investigation. review Review methods: PubMed, Web of Science, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) including Google scholar were searched to identify published studies on barriers to medication error reporting from January 2016 to December 2020. The reviewers independently assessed the quality of all the included studies using the Mixed Methods Appraisal Tool (MMAT) version 2018. Results: Of the 10937 articles reviewed, 14 studies were included. The main themes and subthemes identied after the integration of results from qualitative and quantitative studies were; organizational barriers (inadequate reporting systems, management behavior, and unclear denition of medication error), and professional and individual barriers (fear of management/colleagues/lawsuit, individual reasons and inadequate knowledge of errors). Conclusion: It is not expected that nurses will freely report medication errors in a fearful, punitive, and blaming culture. Providing an enabling environment void of punitive measures and blame culture is imperative for nurses to report medication errors. To minimize the burden on nurses reporting medication errors, an effective, non-time consuming, and uncomplicated anonymous system is required. An open feedback system for motivating or rewarding nurses for reporting medication errors is imperative and will therefore increase the rate of error reporting. Policymakers, managers, and nurses should agree on a uniform denition of what constitutes medication error to enhance nurses' ability to report.


Introduction
Improving patient safety remains an ongoing global health challenge for more than two decades after the beginning of the new wave of attention by the United States (US) Institute of Medicine (IOM) in 1999 report "To err is human" [1][2][3][4]. According to the National Coordinating Council for Medication Error Reporting and Prevention, medication error is de ned as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer" [5]. In March 2017, the World Health Organization (WHO), released an article called "Medication Without Harm, WHO Global Patient Safety Challenge", to gear up the process of change to reduce the impact of patient harm associated with unsafe medication practices by health care practitioners [6]. The aim of the third WHO challenge released in 2017 was to attain a global commitment, involvement, and prevention strategies to lessen the severity and to prevent medication-related harm by 50% within the next ve years [6][7][8]. One of the 10 leading causes of disability and deaths in the world is the occurrence of adverse events arising due to errors [9]. In developed countries, approximately one in every 10 patients suffers harm while receiving care [10,11] in the hospital with 50% of them being preventable [9]. It is also estimated that each year, 134 million adverse effects occur in hospitals within developing countries resulting in 2.6 million deaths due to unsafe care.
Medication error reporting is a major issue in the health care system and may become indispensable if adequate measures are not taken to ensure an enabling environment in reporting medication errors. Reporting medication administration errors would help identify potential patient harm and risk, and provide data for clinicians, managers, and researchers to identify and rectify defective systems. A plethora of studies documents that an organizational culture that encourages the reporting of medication administration error is closely concomitant to patient safety [7,12,13].
Nurses are the largest healthcare workforce in the healthcare sector and the primary caregivers of patients, and play a vital role in the prevention and detection of adverse events in patients [4] because they are directly involved in the administration of the vast majority of the medications ordered in hospitals [12]. Thus, ensuring a culture in which nurses are empowered to report and challenge unsafe medication administration practices, is fundamental to improve safe practice in health facilities [14].
Nurses reporting medication administration errors is crucial as the incidence garnered could be used to analyze the root causes of medication errors which will further allow for the development of complex medication error prevention mechanisms to improve patient safety. One major limitation to patient safety is the failure to report or underreporting of medication errors and the key step to improve this is to identify the barriers to reporting medication errors among nurses.

Objective
This review aimed to identify studies that investigated barriers to reporting medication administration errors among nurses, to systematically summarize the ndings to make recommendations for improving error reporting, and for future investigation.

Methods
An integrative review method based on Whittemore and Kna 's [15] methodological approach was employed to identify primary studies that included 12 quantitative studies, one qualitative study, and one mixed-method study using both qualitative and quantitative designs. The review was guided by the ve steps of Whittemore and Kna 's which fostered a thorough methodological approach focusing on problem identi cation, literature search, data evaluation, data analysis, and presentation of study characteristics [15]. The rst step focused on why this review is important. The second step detailed how the reviewers conducted a robust literature search using the Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines (PRISMA). The third step detailed how the articles were assessed for rigor using the Mixed Method Appraisal Tool (MMAT) version 2018 [16]. The last step involved data analysis and presentation of ndings from the reviewed articles.

Problem Identi cation
The reviewers observed that nurses' inability to report medication administration errors is hindered by multiple organizational and individual barriers. Therefore, the need to systematically synthesize current available studies from a wider international perspective to inform nurses and policymakers on strategies to improve medication administration error reporting and the prevention of patient harm in health facilities.

Literature Search
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework was used for the identi cation and screening of articles [17,18]. A deep search of electronic databases included; PubMed, Web of Science, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). Articles published between January 2016 to December 2020 were included. To determine the correct search parameters the Population Intervention Comparison Outcome (PICO) framework was used. Nurses were the population for this review, the intervention was reporting medication administration error, there was no comparison and the Outcome was barriers to reporting medication error. The following keywords and combinations were used: medication error*/medicine error*/drug error*; report*/disclosure; nurs*. The search yielded 10937 articles. Citations for the articles were imported into Endnote X9 (version 1.19.6) reference manager for screening, removal of duplicates, and storage. Additional articles (n=3) were searched from Google Scholar and manually tracing relevant literature from the list of references in the included studies.
A total of 7840 non-duplicate articles were screened by title and abstract using the standard integrative review process (inclusion and exclusion criteria). Following the title and abstract screening, 28 articles were included. Of the remaining 28 sources, 14 articles were excluded following full-text review. The reviewers scheduled a meeting to agree on the nalized articles and any discrepancies were resolved through discussions. Finally, a total of 14 studies were included in the review. Figure 1 displays the PRISMA diagram.

Inclusion and exclusion criteria
Inclusion criteria Studies published from January 2016 to December 2020.
Studies focused on barriers to reporting mediation errors among nurses in hospitals.

Exclusion criteria
Studies not published in the English language.
Studies focused on barriers to reporting medication errors among other health professionals but not nurses.

Data evaluation and analysis
The reviewers independently assessed the quality of all the included studies using the Mixed Methods Appraisal Tool (MMAT) version 2018 [16]. The MMAT tool evaluates the appropriateness of the study aim, study design, methodology, recruitment of participants, data collection, analysis of data, presentation of results, discussions by authors, and conclusions. The studies were rated as high, moderate, and low in quality. The researcher did not assign the overall quality score as it was not recommended by Hong et al. [16].
For data analysis, a matrix was developed to extract relevant information from the studies which included; information about the authors, study aim, study design, sample size and characteristics, key ndings concerning barriers to reporting medication errors. A convergent synthesis design was adopted to integrate results from qualitative, quantitative, and mixed-method studies and transformed them into qualitative ndings [19]. A thematic approach was used to synthesize key ndings emerging from the literature in relation to barriers to reporting medication errors among nurses, which were read thoroughly and coded. Codes were reviewed and similar codes were categorized to form descriptive themes. The descriptive themes were assessed to generate meaning beyond the original data leading to the development of new, interpretive analytical themes. The reviewers synthesized the data independently, discrepancies were discussed and consensus built before nalizing the overarching themes and subthemes. Nurses are concerned about patients or families developing a negative attitude towards them with a loss of con dence in their nursing abilities.
Nurses are concerned about facing lawsuits or legal action by patients or family. Nurses felt they might be seen as criminals when they report medication errors.

Results
Before we initialized the qualitative synthesis, the researchers sorted out the most occurring or common barriers to reporting medication errors among the included studies. The researchers then quanti ed the barriers by presenting them in frequencies and rank-ordered them from the most to the least occurring. We believe this will give a clearer picture of the main issues serving us impediments in reporting medication errors among nurses. If these bottlenecks identi ed are given much attention by policymakers and other relevant stakeholders it will go a long way to improve patient safety.

Study characteristics
The study approaches used were mainly quantitative descriptive cross-sectional (12), mixed-method (1), and qualitative study explorative design (1). The cumulative sample size comprised 3,299 nurses. The sample size for the quantitative studies ranged from 135 to 548 and the qualitative study involved 23 nurses. Three studies were conducted in Iran [25,28,32] and Saudi Arabia [12,22,31], and a study each in Malaysia [23], Jordan [20], South Korea [21], Taiwan [24], United States [29], Ethiopia [26], Pakistan [27] and Turkey [30]. Two studies utilized a theoretical or conceptual framework. The Theoretical Domains Framework model was utilized by Alrabadi et al. [20] and the Theory of Planned Behavior was utilized by Shahzadi et al. [27] (See Table 1). During the data analysis two major themes and ve subthemes regarding barriers to medication errors reporting emerged. The two major themes included organizational barriers and professional/behavior-related barriers to reporting medication error as shown in table 2.

Organizational barriers
Organizational barriers were categorized into three subthemes of barriers to medication error reporting; reporting system, de nitions of medication error, and management behavior.

Reporting system
The researchers identi ed in the studies that there was no clear or proper medication error reporting system [27] therefore making the process of reporting cumbersome, especially the use of the medication incidence reporting which served as a major barrier to underreporting [20]. Some studies documented that medication error reporting consumed much time [21,27,[29][30][31] whiles Dyab et al. [23] reported lack of time, tiredness, and heavy workload as barriers to reporting medication errors. Rutledge et al. [29] revealed that the forms used to report medication errors are long which posed as a barrier to reporting medication errors.
De nitions of medication error It was indicated in some studies that because there was no precise de nition of medication error within the hospital [26,28,[30][31][32], there were disagreements regarding the de nition of medication error and what should constitute a reporting event [22,26,30,31].

Management behavior
Several studies revealed that reporting medication administration errors may result in punitive actions by management or negative consequence [12, 21-23, 25, 26, 29, 31, 32] thereby creating fear among nurses [21,23,25,26,29]. Also, a negative response from the hospital administration was identi ed by Shahzadi et al. [27] as a key deterrent to reporting medication errors by nurses. Nurses indicated in several studies that they were not given feedback after reporting medication administration error [12, 21-23, 25, 30] which contributed to underreporting or not barrier medication errors. The researchers also observed that the nursing administration focuses on the individual rather than using the systems approach to solve the problems [12,22,25,28,31] which served as a major barrier to reporting medication error. Nurses indicated that too much emphasis is placed on medication errors as a measure of the quality of nursing care [22,28,31] therefore impeding error reporting. Nurses fear being blamed by management [23,24,29,31] for reporting medication errors. Lack of con dentiality in management in reporting medication errors [23].

Professional and behavioral barriers
Under the professional behavioral barriers two subthemes were identi ed; personal reasons, and knowledge of error.

Individual reasons/lawsuit
Personal reasons such as criticism from colleagues or other professionals was a barrier to medication error reporting [21,30] because they felt they will be embarrassed or discriminated against if they report medication administration errors [23]. Nurses personally felt they could be blamed [29] if something negative happens to the patient [22] so they were not encouraged to report medication errors. Nurses feared that reporting medication errors will negatively impact their job records [23] or they might lose their job [20,30] which served as an impediment to reporting medication errors. Nurses without reporting experience on medication error reporting were a barrier [24]. A tag on their professional identity or fear of being labeled as incompetent and an inadequate nurse [24] was also identi ed as a barrier to medication error reporting. One major key factor impeding medication error reporting in some studies was the fear of legal actions against nurses by patients or their families [12,21,25,29]. Forgetting to report medication errors was another individual barrier [32].

Knowledge of error/unawareness of error
Inadequate knowledge of nurses about what constitutes medication error [20] leads to underreporting. Nurses did not see the gravity of the medication error to warrant reporting [20,27,31]. The inability of nurses to identify that an error has occurred hindered reporting of medication errors [20,24,27]. Medication administration errors that occurred without patient harm did not warrant reporting [24]. Unawareness of the occurrence of medication errors [30] also leads to nurses not reporting medication errors.

Discussion
This study reviewed and synthesized results of studies from different countries ranging from low-middle-, and highincome countries, therefore, the ndings from this review can be vital for the global healthcare communities to improve patient safety as it remains one of the biggest global challenges in healthcare. The majority of the studies included in this review were rated as strong, and moderate inferring that the evidence produced from this integrative review has a strong and justi ed conclusion, meaning that implications can be drawn for nursing research and practice. Also, this study aligns with the WHO `Global Patient Safety Challenge' emphasizing the promotion and improvement of patient safety actions to reduce severe, preventable medication-related harm by 50% in the next ve years [8]. To develop an effective and robust intervention to improve patient safety, medication administration error reporting is essential and grounded through the identi cation of barriers based on the consideration of behavioral change theories [33]. This information garnered from the key clinical practicing professionals will go a long way to inform policy, healthcare organizations, and other stakeholders on measures to mitigate these barriers and improve patient safety within our healthcare settings across the globe.
The current review found organizational barriers to be the most prominent barrier for nurses not reporting/underreporting medication administration errors. Barriers such as lack of proper reporting systems, no clear de nition of medication administration errors (MAEs), and punitive actions against nurses after reporting MAE were identi ed as organizational barriers to reporting MAEs. Many MAEs go unreported due to the lack of reporting systems or lack of proper reporting systems. It is imperative to know that if there are no proper reporting systems for MAEs in health facilities then nurses will nd it di cult to duly report errors. Therefore, an established system for reporting medication errors in hospitals is important to improving patient safety measures. Established good reporting systems are avenues for collecting vital and su cient information about MAEs from different reporters. This information gathered will help reporters understand the factors that in uence errors and will therefore subsequently help to prevent their recurrence [34]. Generally, it is observed that nurses' failure to report medication errors is related to the aftermath consequences they may suffer after reporting depending on the severity of the incidence of injury [35]. It is observed that some health practitioners fail to report errors due to the intense follow-up investigations on persons that commit these errors rather than the system. Nurses believe that reporting errors negatively impact their future job appraisals and professional development due to the punitive actions taken against them. Non-punitive actions against health care professionals who report errors are recommended to improve patient safety care [35][36][37]. Several studies have documented that health professionals who are rewarded and motivated for reporting errors during healthcare are encouraged to further improve on their reporting behavior which subsequently improves patient safety in the organization [36,37]. It is also noted that many organizations have been challenged to provide an environment that is free and safe to admit errors and to understand why they occur void of reprisal and punishment [38].
Criminal prosecution of health-care professionals in the line of duty remains an astonishing event. Over the years the number of healthcare professionals facing legal actions continues to increase [39] indicating that health care professionals should take strong actions to address these issues. This review revealed that nurses were afraid to report medication errors due to possible lawsuits and lack of con dentiality or anonymity in the reporting system. When designing a reporting system, anonymity has been considered to be an important factor [37] because an anonymous system means a non-punitive reporting culture [40] and no traceable follow-up procedures after reporting medication incidents [41]. An anonymous medication error reporting system could help to overcome these barriers of not reporting. A study by Hurley and Berghahn [39] reported two cases in which nurses were prosecuted for criminal negligence related to medication administration errors. In order to enhance medication error reporting, addressing systemic issues and problems in the institutions but not the individual is imperative.
Inadequate knowledge of nurses about what constitutes medication error [20] and their inability to identify medication error necessitating error reporting [20,24,27] were barriers to error reporting. Nurses' knowledge of medication error reporting is an important factor that determines the success of the medication reporting system [23]. It has been recommended that a blend of formal educational seminars (patient safety lectures), and informal educational sessions (lunchtime educational sessions or an online tutorial on using a new reporting system) could improve error reporting [36]. Therefore, Organizations should develop educational interventional programs tailored toward continuous professional education of nurses on medication errors reporting systems to improve medication safety. As some studies have found a strong correlation between healthcare workers attending patient safety training workshops and the increased rate of error reporting [36,42].

Limitations
This review had several limitations. First, 12 of the studies included in this review were clustered in Asia (Iran, Saudi Arabia, Jordan, South Korea, Taiwan, Iraq, Turkey, Malaysia, and Pakistan) one each in the United State and Ethiopia.
These countries captured in this review are not su cient for the entire world. Second, this study included only published articles in English which might have excluded relevant evidence published in other languages. Finally, authors may have unintentionally omitted relevant studies from this review although extensive database and hand searches were conducted. Nonetheless, this study provides a comprehensive insight into barriers to reporting medication errors among nurses. The ndings can also inform policy decision-making in order to improve patient safety through reporting medication errors.

Conclusion
Providing an enabling environment void of punitive measures and blame culture is imperative for nurses to report medication errors. The institutionalization of a proper reporting system for medication error reporting provides an avenue to gather data for root cause analysis of errors. This will further enhance a systems approach in dealing with the problems and issues with medication errors without focusing on the individual. It is not expected that nurses will freely report medication errors in a fearful, punitive, and blaming culture. To minimize the burden on nurses reporting medication errors, an effective, non-time consuming, and uncomplicated anonymous system is required. Continuous professional education on medication error reporting systems would improve nurses' knowledge and skill in the handling of errors when they occur and will therefore bridge the barrier of underreporting. An open feedback system for motivating or rewarding nurses for reporting medication errors is imperative and will therefore increase the rate of error reporting.
Policymakers, managers, and Nurses should agree on a uniform de nition of what constitutes medication error to enhance nurses' ability to report.