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Read the attached Qualitative Research Study. After reading the article, please appraise this study. Use table 7.1 in your book to guide you in your appraisal. What are the strengths and weakness you found in this study?
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pharmacy
Article
Exploration of Nurses’ Knowledge, Attitudes,
and Perceived Barriers towards Medication
Error Reporting in a Tertiary Health Care
Facility: A Qualitative Approach
Eman Ali Dyab 1 , Ramadan Mohamed Elkalmi 2 , Siti Halimah Bux 3 and
Shazia Qasim Jamshed 3, *
1
2
3
*
Department of Pharmaceutics, Faculty of Pharmacy, Tripoli University,
Tripoli 42300, Libya; eman_diab2008@yahoo.com
Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi Mara,
Puncak Alam 42300, Malaysia; edriph@gmail.com
Department of Pharmacy Practice, Kulliyyah of Pharmacy, International Islamic University Malaysia,
Kuantan 25200, Malaysia; sitihalimah@iium.edu.my
Correspondence: shazia_jamshed@iium.edu.my; Tel.: +601-7470-3692
Received: 15 September 2018; Accepted: 2 November 2018; Published: 5 November 2018
Abstract: Medication error reporting (MER) is an effective way used to identify the causes of
Medication Errors (MEs) and to prevent repeating them in future. The underreporting of MEs
is a challenge generally in all MER systems. The current research aimed to explore nurses’ knowledge
on MER by determining their attitudes towards reporting and studying the implicated barriers
and facilitators. A total of 23 nurses were interviewed using a semi-structured interview guide.
The saturation point was attained after 21 interviews. All the interviews were tape-recorded and
transcribed verbatim, and analysed using inductive thematic analysis. Four major themes and
17 sub-themes were identified. Almost all the interviewees were aware about the existence of the
MER system. They showed a positive attitude towards MER. The main barriers for MER were the
impacts of time and workload, fear of investigation, impacts on the job, and negative reactions
from the person in charge. The nurses were knowledgeable about MER but there was uncertainty
towards reporting harmless MEs, thus indicating the need for an educational program to highlight
the benefits of near-miss reporting. To improve participation strategies, a blameless reporting culture,
reporting anonymously, and a simplified MER process should be considered.
Keywords: medication error reporting; nurses’ attitudes; qualitative study; barriers; medication error
1. Introduction
The main principle of giving medication to the patient is to serve them in order to restore his/her
health without any harm [1]. Adverse events and medical errors are the main issues threatening
the patient’s safety, and are awkward predicaments in nearly all healthcare systems [2]. The World
Health Organization (WHO estimated that millions of people suffer injuries directly attributed to
medical care, and many are preventable [3], although prevalence in developing countries is reported
to be higher than developed nations [4]. In Southeast Asian countries, the reported administration
error rates ranged from 15.2% to 88.6% [5]. In Taiwan, a study mentioned that the overall rate of the
medical incidents ranged from 30% to 47.6%, and most of them were related to MEs [6]. In a Malaysian
study, Johari et al. reported 2572 reported cases of ME in 2009 [7]. The prevalence of ME among
geriatric patients was 25.17% [8] whereas in paediatrics this figure was 11.7% [9]. A recently published
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www.mdpi.com/journal/pharmacy
Pharmacy 2018, 6, 120
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four-year retrospective study reported that the total number of paper-based ME reports submitted
to the National Medication Error Reporting system (NMER) was 17,357, but only 0.3% of MEs were
in the administration stage [10]. The percentage in the administration stage is very low, representing
paper-based reports only (excluding online submitted MEs reports) collected by the NMER system,
as well as the effect of underreporting. The annual estimated cost of MEs in Malaysia was estimated to
be 111,924 Malaysian Ringgit (MYR) [10]. Clinically, MEs can have small to severe consequences for
patients. It was reported that the total number of MEs in the administering stage was 166, where 1%
had fatal consequences, 20% were serious, 32% were significant, and 46% were nonsignificant [11].
The identification of trends and patterns of MEs were the main reasons for establishing a ME
reporting system [12]. The effectiveness of all these systems depend on their ability to document
the occurred MEs. Establishing guidelines for medical error reporting (MER) is not enough, as the
healthcare practitioners (reporters) play a vital role in the MER process. The healthcare practitioners’
knowledge about MER, their attitudes toward reporting MEs, and perceived barriers toward MER are
important factors which determined the success of MER systems. Health care professionals in general
and nurses in particular are responsible for MER. It has been reported that the MEs are underreported
in all countries. Nurses’ knowledge and attitudes as well as barriers and facilitators toward MER
among nurses in Malaysia are little-studied issues and warrant investigation.
This study is intended to attain deeper insight into the knowledge and attitudes held by Malaysian
nurse practitioners towards the ME concept and MER process, as well as to investigate the barriers
which prevent nurses from reporting their MEs.
1.
2.
3.
4.
What do nurses know about the ME and MER system?
What are the nurses’ attitudes toward MER?
What are the barriers which could hinder nurses from reporting their MEs?
What are the factors which could facilitate MER among nurses?
2. Methods
2.1. Study Design and Setting
The study was conducted after getting approval from both the Medical Research Ethics
Committee Ministry of Health Malaysia (NMRR-15-2485-24709) and the International Islamic
University of Malaysia Research Ethics Committee (IREC 446). Use of a qualitative method (in-depth
interviews) provides flexibility and efficiency in collecting data related to personal feelings, attitudes,
and experiences [13] and hence, these methods are used for the exploration of the participants’
experiences towards medication error reporting. The individual interview method was chosen over
focus group discussions because of privacy, suitability, and comfort zone issues for shy and hesitant
participants [14]. This gives liberty to the participants to elaborate his/her answers without distractions
from others [14]. The current research was executed in a tertiary healthcare facility of Kuantan city,
Pahang, Malaysia.
2.2. Participants
The target study population was nurses practicing in different units of the hospital. No specific
inclusion and exclusion criteria were applied, and thus all nurses were eligible to participate in
the current research. The participants were recruited by using convenience and snowball sampling
technique. The snowball method helps to recruit hidden subjects which cannot be easily found [15].
The first participant was a nurse from the medical unit and was given information on the details of
the research along with an assurance of confidentiality and anonymity. After her acceptance she was
asked to fill in demographics form and sign the consent form. The interviews were recorded by using
Audio Recording Titanium Software® version 8.5.5 (AATSystems, Kent, UK), and notes were taken
during the interviews. After finishing the first interview, the interviewee was asked to nominate the
Pharmacy 2018, 6, 120
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next participant. Thus, she made a referral to the next nurse, with the same pattern for the subsequent
interviews. Thus, a chain referral technique followed throughout the research study. The number
of participants was determined once the saturation point was achieved. The saturation point occurs
when no new concepts and themes emerge [14,16,17]. Two extra interviews were conducted to confirm
the saturation point. The field supervisor also helped in recruitment process. Participation was
simply on a voluntary basis, and they were informed that anytime during the course of research they
could withdraw. Moreover, they were assured that their confidentiality and anonymity would be
maintained. Only the research team had access to records. The purpose of the study was explained
to each participant before the interviews commenced and therefore, all the participants were asked
to sign an “informed consent form” followed by the addition of their demographic characteristics.
A total of 23 nurses were interviewed.
2.3. Procedure and Interview Process
In-depth interview sessions were conducted using a semi-structured interview guide in June 2015.
This guide was developed on the basis of prior published studies related to MER among health care
professionals [18–20]. The purpose of using this guide was to make sure that all important issues
about the topic were covered in the interviews [13,21]. The medium of communication during the
interview was primarily English, followed by a couple of interviews being conducted in Bahasa
Malayu i.e., the native language of participants. The field supervisor agreed to work as a research
assistant and a translator and assisted the nurses who could not understand the English language. As a
result, participants who expressed their thoughts in the Bahasa Malayu language were also included.
Each interview lasted for about 30–45 min. Venue was chosen as per proximity to nurses’ working units,
their preference of level of comfort/privacy, and the level of noisiness. Places such as the library private
room, the seminar room, and nurses’ rooms were selected as the venue for interviews. The discussion
was focused on several major issues; the nurses’ knowledge, experiences, and perceptions about ME
and MER, exploring their attitudes towards MER, comprehending the factors which might prevent
the nurses from reporting their MEs, and those factors which would promote MER among nurses.
Probing questions were asked to provoke more details from interviewees [13,21].
2.4. Data Analysis
The data analysis was performed using the inductive thematic analysis approach. The participants’
approved transcripts (transcribed verbatim) were coded as (N1, N2, . . . , N23). The process is illustrated
in Figure 1. The analysis followed a cyclic pattern, where it started by familiarization stage, generation
of initial codes stage and revision stage to refine the emerged codes [22,23]. The transcripts were
analysed again by another researcher to validate the resulted themes [22], and a third person’s opinion
was sought to resolve any disagreement between the previous analyses [24,25].
The current research followed an established criterion for maintaining quality in qualitative
research and thus follow the standards of Guba and Lincoln [26] for generating credibility,
transferability, dependability, and confirmability. For strengthening the credibility of the research there
was a continuous interaction with the participants, with checking of interpretations against interview
transcripts. A review with the participants was undertaken. Contrary to quantitative research, the aim
of qualitative is not generalizability but to observe and execute transferability. Therefore, a detailed
description of the participants’ experiences helped the researchers identify the patterns of social
relationships in reporting MEs and as well as the cultural backgrounds of the participants who reported
hesitancy in reporting. For dependability purposes, external audit criteria were put in place, and a
researcher not involved directly in research helped in the evaluation of interpretation and conclusions
with respect to the data collected. For establishing confirmability, not only a conformability audit (as
mentioned above) but also triangulation and reflexivity were maintained. In terms of establishing
triangulation, both methodological triangulation (i.e., the research followed the quantitative design
after qualitative inquiry) and analyst triangulation (i.e., using different analysts to review the findings)
Pharmacy 2018, 6, 120
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were maintained,
whereas
forREVIEW
reflexivity, a reflexive note-sheet was used to record the methodological
Pharmacy 2018,
6, x FOR PEER
4 of 14
parameters and logistics involved. Interviewees were female (n = 22); of Malay race (n = 22); holding a
note-sheet was used to record the methodological parameters and logistics involved. Interviewees
diploma (n = 21). The nursing diploma is a 3-year course in Malaysia and on its successful completion
were female (n = 22); of Malay race (n = 22); holding a diploma (n = 21). The nursing diploma is a 3one can register
with
Board
Malaysia
work asone
a staff
nurse. with
All participants
year course
in Nursing
Malaysia and
on its
successfuland
completion
can register
Nursing Boardwere full
time employees.
Half
of
the
participants
(n
=
12)
have
working
experience
of
than 11 years.
Malaysia and work as a staff nurse. All participants were full time employees. Half of themore
participants
(n
=
12)
have
working
experience
of
more
than
11
years.
Slightly
more
than
three-quarters
the the prior
Slightly more than three-quarters of the participants (n = 18) had not reported any MEs of
over
participants (n =18) had not reported any MEs over the prior 12 months. The interviewees were
12 months. The interviewees were attached to different units in the hospital such as intensive care units
attached to different units in the hospital such as intensive care units (ICUs), medical units, critical
(ICUs), medical
units, critical cardiac units (CCUs), accident and emergency unit (A&Es), orthopaedic
cardiac units (CCUs), accident and emergency unit (A&Es), orthopaedic units, neonatal intensive
units, neonatal
intensive
care
units
(NICUs),
units.
The demographic
characteristics
of
care units
(NICUs),
and
paediatric
units.and
Thepaediatric
demographic
characteristics
of participants
are
presented
in Table 1. in Table 1.
participants
are presented
1. The study
process
flowchart.(I)
(I)transcription
transcription step,
(II) (II)
datadata
analysis
step, (III)
analysts’
Figure 1.Figure
The study
process
flowchart.
step,
analysis
step,
(III) analysts’
triangulation
(two researchers
performed
analysis
and person
third person
resolved
any
triangulation
method method
(two researchers
performed
analysis
and third
resolved
any disagreement),
disagreement), and (IV) final result.
and (IV) final result.
3. Results
Table 1. Interviewees socio-demographic characteristics (n = 23).
Four major themes and 17 sub-themes were emerged: knowledge about MER, attitudes toward
Characteristic
Number (n = 23)
Percentage (%)
MER, barriers toward MER, and facilitators to improve MER process. Figure 2 represents the
Female
22
95.7
emerged themes
Genderand categories.
Male
Race
Characteristic
Age
1
Malay
Table 1. Interviewees socio-demographic
characteristics (n22= 23).
Chines
1
Gender
Race
≤30
30–40
Female
41–50Male
51≥
Malay
Education level
Diploma
Chines
Bachelor
Experience in years
Age
≤5
6–1030–40
≥11 41–50
≤30
Practice site
51≥
Medical unit
a
ICUDiploma
b
CCU
Bachelor
A&Ec
Orthopaedic unit
NICU d
Paediatric unit
Number of reports in the last 12 months
Never report
≥1
Education level
Number (n
6 = 23)
2214
12
1
22
21
1
2
6
5
14 6
2 12
14
21 9
22
3
2
1
2
18
5
4.3
95.7
4.3
Percentage
(%)
26.1
95.7 60.9
4.3 8.7
4.3
95.7
91.3
4.3
8.7
26.1
21.7
60.9 26.1
8.7 52.2
4.3 17.4
91.3 39.1
8.7 8.7
13
8.7
4.3
8.7
78.3
21.7
(a ) Intensive care unit. (b ) Critical cardiac unit. (c ) Accident and emergency unit. (d ) Neonatal intensive care unit.
Medical unit
4
17.4
ICU a
9
39.1
b
2
8.7
CCU
Practice site
A&Ec
3
13
Orthopaedic unit
2
8.7 5 of 14
Pharmacy 2018, 6, 120
NICU d
1
4.3
Paediatric unit
2
8.7
3. Results
Never report
18
78.3
Number of reports in the last 12 months
≥1
5
21.7 toward
Four major themes and 17 sub-themes were emerged:
knowledge about
MER, attitudes
Intensive
care unit.
(b) Critical
cardiac unit.
(c) Accident
andprocess.
emergency
unit. 2(d)represents
Neonatal intensive
MER,(a)barriers
toward
MER,
and facilitators
to improve
MER
Figure
the emerged
careand
unit.categories.
themes
Emergent themes and sub-themes. MER:
MER: medical error reporting.
Figure 2. Emergent
3.1. Knowledge about MER
3.1.1. Concept of ME
The nurses were asked about their understanding of the ME concept. Almost all of them correctly
understood the concept of ME. Moreover, they linked its meaning to five/seven rights, while others
just gave simple and general answers like “giving incorrect medication to the patient”.
“Medication error is an error when giving medication including dosage and also the type of medication,
make sure to follow the 7Rs practice in the hospital.” (N1)
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“Medication error is when something unwanted occurs such as wrong medication is given to the
patient.” (N7)
“Medication error means giving wrong medication to the patient, which includes wrong dose,
wrong route, and wrong documentation.” (N13)
3.1.2. The Existence of a System for MER and the Importance of MER
All the interviewees were aware about the existence of MER system and the importance of MER.
They stated that data collected by MER can be used as an indication of the quality of health service
provided to the patient. It can be used to improve this service by carrying out root-cause analysis
for the MEs reports, and the reported data can be utilized for learning purposes. In other words,
ME reports can be used as good resources to help nurses in avoiding repeating the same errors again
in future.
“Yes, we have a system for medication error reporting [ . . . ] And, it is very important because it
involves the quality of service which is being given to the patient and it is very important to monitor
ME.” (N1)
“It is important because we want to improve the way of delivering care and serving the patient.
To learn from reports, where and which thing can be done. So we have more information about what
has been done and their consequences.” (N3)
“It is important because we want to detect what is ME and to prevent it from happening again.” (N7)
“Normally, we do root-cause analysis to find out when and how this happened. Sometimes it comes
from the wrong prescription like wrong dose or wrong route or wrong frequency and then we find out
how that happen and try to tackle.” (N5)
“It is to guide our practice [ . . . ] Not add more error to this collection [ . . . ] To avoid ME in future
[ . . . ] It is considered as a good resource.” (N4)
3.1.3. The Availability and Confidentiality of the Reporting Form
The majority of interviewed nurses claimed that during their practice, they did not report MEs,
since until the time of interviews they did not commit any error. As a result, most of them did not see
the reporting form and some of them had seen it but they did not remember its content.
“The reporting form is available in the pharmacy department.” (N5)
“I have not seen the reporting form before. Because, so far, I did not make any error.” (N8)
The nurses were asked about their opinions on the reporting form.
“I have seen it; it is easy to fill, it does not need modification or re-designation.” (N1)
“The report is not too detailed like describing everything, but it underlines or highlights when the
medication was given to the patient.” (N3)
3.2. Attitude of Nurses toward ME Reporting
The nurses were asked about their attitudes toward ME reporting. The majority of the participants
had a positive attitude toward reporting of MEs, whether these MEs caused a serious side effect to the
patient or not. The other group had uncertain attitudes and they tended to report the MEs which led
to harm to the patient only.
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3.2.1. Positive Attitude
The majority of nurses claimed that they report all encountered MEs immediately. They reported
them irrespective to their seriousness or the level of patient’s harm due to the error.
“Nothing affects my decision to report, once the error occurs it should be reported.” (N4)
“It is not a matter of choice.” (N7)
“Once I detect an error, I cannot just ignore it, and I straightforward report it […] We must make a
report also because this is ME, and we must report whether it is serious or not.” (N2)
“Here in A and E department, it does not matter if the error is big, mild, or small, it must be reported.” (N8)
3.2.2. Uncertain Attitude toward ME Reporting
During the discussion with the participants about their attitude toward MER, some participants
showed uncertain attitudes towards MER. They would report MEs only based on another factor such
as the severity of the ME or route of administration, or when they received a direct request form the
person in-charge.
“If the error caused big and serious complication I have to report.” (N17)
“Based on the patient, I will see the effect on the patient first. My first concern is the patient, I will
not report unless something happens to the patient. In this case, the doctor gives antidote and then
there is an investigation and eventually, they will revert to me.” (N9)
One nurse related the medication error reporting to the dosage form of administered medicine.
He believes that errors are serious when the medication given by the intravenous route, and this
type of error should be reported, while those resulting from oral or topical administration should not
be reported.
“Based on the route of administration IV it should be reported.” (N18)
One nurse insisted that she reports only if the person in charge requests her to fill the
reporting form.
“I just inform the sister and the doctor, and let them choose to fill the form or not but as for investigation,
I will come and join them” (N13)
Before reporting, the nurses think of the problems that will be faced after reporting their errors.
This has a high effect on their decision to report or not.
“Some nurses, at first, they think about what happen and the problems associated with reporting,
so they do not report.” (N12)
3.2.3. Reporting of Others’ Errors
Some of the interviewees stated that they do not have any problems in reporting MEs committed
by other staff. They believe that the reporting of MEs is better for both the nurses and also for the
patient, whether the MEs have been committed by themselves or by other health care professionals.
While the other group insisted that everyone is responsible for reporting his/her own initiated MEs.
“I will report if other staff nurse made a mistake.” (N1)
“I will report errors committed by others because this is in the best interest of the patient, and also it
would help things go smooth in the future, for example, patient allergy . . . ” (N3)
“If I made a mistake I would inform, also if others from my colleagues made a mistake, I would still
inform.” (N6)
“No, I report only my errors. If my colleagues made mistakes, I would just advise her to report, but I
will not report her error.” (N8)
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3.3. Barriers towards Medication Error Reporting
There are many barriers towards MER which were mentioned by the interviewees. These barriers
are heavy workload, lack of time, tiredness, embarrassment due to reactions of peers and family,
and fear of disciplinary action.
3.3.1. Lack of Time
The main barrier for MER mentioned by the interviewees was time. They considered that the ME
reporting is a time consuming process. As described by the participants, the problem is not the time
needed to fill the MER form. The problem appears after filling the MER form when the investigation
takes place in order to discuss the causes which led to the ME.
“We will be exposed to so many questions [ . . . ] long time [ . . . ] time to discuss the ME that was
reported [ . . . ] investigations take time. No other problems, just that it takes time to report and then
questions from pharmacist or doctors. We do not have time for reporting. It is a long story and takes
much time.” (N4)
“Sometimes, I decide not to report. Because, if there is an investigation we have to be presented, as you
know it will take a long time and we will be all inconvenient.” (N9)
3.3.2. Tiredness
The nurses are responsible for inpatient care, this responsibility requires them to accomplish
many physical activities. Performing these activities make nurses tired, when they are exhausted,
a low number of ME reports will be received from them.
“Sometimes, we are tired. Once we are tired we decide not to report.” (N4)
3.3.3. Embarrassment
The post-embarrassment feeling has been pinpointed by interviewees as another barrier toward
MER. As a result, they tend to hide their MEs and never report them.
“Facing the embarrassment from my family and friends is tough. They will blame us.” (N4)
“They (family and friends) understand because these are not things that a person does on purpose.
But facing them still difficult.” (N9)
3.3.4. Fear
Fear from the legal problems has been addressed by the interviewees as a barrier towards MER.
“I fear from legal problems and disciplinary actions from the hospital.” (N8)
“Sometimes, I do not want to get into issues, I do not want people to come to ask me for investigation
later.” (N2)
The effect of reporting on the personal job record is another factor which might prevent nurses
from reporting.
“If I report this will affect my record because everything will be recorded in my personal record.” (N9)
“Fearing others, especially the investigation, because in Malaysia all errors must be reported to your
job record and they do disciplinary action.” (N4)
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3.3.5. Negative Reaction from Sister In-Charge
The response of managers toward nurses who report their MEs were important factors which
prevented nurses from reporting their MEs. It has been noticed that most of the interviewees insisted
that receiving a negative reaction from senior nurses is a normal response when the MEs occur. As they
always tend to blame and scold the nurses if they commit MEs. They believe that guidance is the main
role of senior nurses during their practices, not blaming the nurses.
“The sister will monitor me more.” (N8)
“Negative reaction from sister and matron [ . . . ] they must not punish the staff, they must guide the
staff and follow the staff and ensure that the stuff follows the standards.” (N4)
3.3.6. The Confidentiality of the Reporting Form
The reporting form which is used to report ME is a strict confidential form. Filling this type of the
reporting requires the reporter’s details such as name, signature and contact details. Some nurses did
not report their MEs because of this issue and they wish if they can report by using an anonymous
reporting form. Consequently, the number of reports will increase by use of anonymous MER forms.
“I prefer to fill anonymous form [ . . . ] Because I feel shy and would not work further. Also, I would
feel sorry for the patient. So, I prefer to fill the form without names.” (N2)
“I prefer to fill the anonymous form as it is good for us. If mistakes have been done, the news of
medication errors should be displayed without names being mentioned. In the future, if the people
know that this person made a mistake, people would decide not to deal with this person again. This will
damage the confidence of the nurse. In the future, they will not report and there will be no chance to
learn from the mistakes.” (N6)
“Off course, if no names mentioned the number of reports will increase.” (N8)
3.3.7. Absence of Effective Feedback
The lack of feedback from the hospital managers:
“No one goes through all the errors and give me a feedback.” (N7)
“I did not receive any feedback for my ME report.” (19)
3.4. Facilitators to Improve ME Reporting
The nurses were asked about the factors which could encourage them towards MER. Their main
concern revolved around removing the blaming culture. They believed that if no one scolded them
about their errors they would definitely report their errors.
“Remove the blaming culture. The matron and sister in charge should guide the staff not blame them.” (N4)
“Tell the matron that if any person is involved in a medication error, she shall not be scolded.” (N7)
Another factor which was addressed by the interviewees was getting encouragement from others
toward MER. Regarding this, there were two different opinions: first, some nurses insisted that they
did not need any encouragement from others because they thought the MER is an integral part of their
responsibility; on the contrary, other nurses welcomed encouragement by other health practitioners
such as a doctor, matron, or even their colleagues.
“There is no need to encourage us because this is our duty.” (N12)
“The sister in charge encouraged me to report.” (N9)
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“Actually, among us, we as nurses encourage each other to report errors; also the sister in charge
encourages us to do that.” (N8)
Few nurses highlighted the incentives as an effective way to encourage nurses to be more
meticulous to report MEs.
“Giving monetary rewards to the nurses.” (N3)
The confidentiality of the reporting form is an important factor, some of them preferred to fill
anonymously to avoid the embarrassment and being reprimanded by the authorities.
“I prefer to fill the form with no names and it is better not to include names.” (N2)
“I think as long as they can ensure the confidentiality of the person who reported, we will feel safe.”
(N9)
4. Discussion
This is an exploratory study intended to investigate the knowledge and attitude of nurses towards
MER. The current research is also anticipated to address the barriers and facilitators towards MER
among nurses, attached to different medical wards in the hospital.
The interviewed nurses reflected on the basic knowledge of concept of ME and MER.
They reported awareness about the presence of ME reporting system, guidelines, and the importance
of the MER. This might be attributed to the frequent talk sessions and training courses such as the
continuing nursing education program (CNE), in addition to the encouragement from the nurse
leaders (head nurses, supervisors and directors). This finding is consistent with the previous studies
conducted in Malaysia [7,27]. Wei and his colleagues reported that the Malaysian nurses had baseline
knowledge regarding MEs, whereas Johari et al. reported that Malaysian nurses had good knowledge
level regarding medication administration safety. However, most of the interviewees were not familiar
with the content of the ME reporting form due to their lack of contact. The low involvement of nurses
toward MER was not related to the lack of knowledge about the MER or due to the lack of information
about the process of incidents reporting, as reported in previous studies [28,29]. Handler and his
colleagues. reported that the lack of information on how to report ME among nurses as a barrier for
MER and this needs an immediate action and should be on higher priority towards improving MER
among nurses.
The willingness of nurses to report MEs has great impact on MER practices. Respondents had two
contradictory attitudes toward MER. Positive attitudes towards reporting all MEs are found to be in
accordance with what has been stated in Malaysian medication error guidelines [30], while an uncertain
attitude was also stated where participants were keen to report major errors only. In this case, the minor
errors and near-miss errors most likely will not be reported, in line with the previous studies [31–34].
Martowirono et al. reported that the MEs with minor consequences were lesser reported. Reporting of
near-miss errors gives valuable lessons without harming the patient [35]. In such situations, a seminar
discussion with the experienced nurse managers about benefits of near-miss error reporting can be a
useful tool to improve near-miss reporting rate among nurses.
The current research revealed that most nurses have positive attitudes toward ME reporting.
However, factors such as lack of time for reporting, lack of reporting culture without being blamed,
lack of effective feedback, and fear are considered as main reasons for underreporting problems among
the participants. These findings were consistent with the study conducted in Taiwan [36] where fear
was cited as the fundamental projecting factor in underreporting.
Despite the positive attitude of nurses towards the MER, they revealed that they did not report
MEs due to barriers like paucity of time, already in accordance with the studies done in Taiwan and
Canada [6,37]. Lack of time could be a reflection of heavy workload, as in many instances a limited
number of nurses take care of many patients. On the other hand, lack of reporting can be related to
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the MER process, which starts informally by informing the doctor, pharmacist, and the nurse director,
a
