B. This study used cross-sectional design and may tend to under-select individuals who have been exposed. This is known as "late-look bias." The possibility of nurses recalling MAEs over their careers may result in reporting of, or remembering information that is not accurate.

C. The instrument developed by authors used expert validity, but more research is needed to determine the construction validity and use the appropriate interventions to decrease MAEs (Lin & Ma).

9.

Research questions

Rather than a hypothesis, the Lin and Ma (2009) study was guided by the following research questions:

A. What is the self-reported incidence of MAEs throughout a nurse's career in Taiwan?

B. What is the willingness of nurses to report MAEs?

C. What factors are related to nurses' willingness to report MAEs?

The first research question, though, differs from the authors' stated purpose which was to "explore the prevalence of MAEs and the willingness of nurses to report them," suggesting that they may not completely understand the important differences between the terms "prevalence" and "incidence," an oversight that may have also fundamentally affected the interpretation of their findings.

10.

Operational definitions

The authors do not provide a list of definitions of key terms used in their study, bu they do operationalize the term "medication administration errors" (MAEs) as referring to "medication errors that occur during the process of administering a drug. This usually involves a nursing action in which the patient receives or is supposed to receive a medication" (Lin & Ma, 2009, p. 239).

11.

Setting

The setting for the research was appropriate for the purposes of the study. In this regard, the setting was southern Taiwan wherein participants were working at 14 hospitals (differentiated by hospital funding: public, which included five city hospitals, one veterans general hospital, and two armed forces general hospitals; three private hospitals; and three nonprofit medical centers) that were situated in the university region in southern Taiwan (Lin & Ma, 2009).

12.

Design

The Lin and Ma (2009) study used a cross-sectional design which was regarded as appropriate for their research goals.

13.

Sampling methods

The sampling method used by Lin and Ma (2009) was convenience sampling, comprised of respondents attending bachelor's degree programs at a university in southern Taiwan who were employed at 14 different hospitals in the region. The quality of the researchers' findings, though, could be improved by incorporating a randomization element in future studies (Neuman, 2003). Of the 650 surveys distributed, 605 respondents returned the instruments in time for inclusion in the study's data analysis, representing a 93.1% response rate, which is regarded as being a superior response rate (Neuman, 2003). The exclusion criteria used by the researchers included current employment in one of the following positions:

A. Supervisory position;

B. Advanced practice nurse; or,

C. Dean of a department (Lin & Ma).

All of the respondents were females with registered nurse degree; the respondents had a mean age of 29.35 years and almost 60% (59.8%) had graduated from a junior college (Lin & Ma).

14.

Data collection

The researchers used the following data collection instruments which were considered appropriate for the purposes of the study:

A. A custom-designed MAEs Unwillingness to Report Scale. The unwillingness to report MAEs scale was developed by Lin and Ma based on empirical observations, professional experience and their critical review of the literature. According to Lin and Ma, "This scale contains 11 items related to the reasons nurses do not want to report the MAEs. The instrument measures dichotomized answers about the reasons for unwillingness to report errors (yes: indicated nurses agreed with the reason and therefore did not want to report; no: meant the inverse of yes). Content validity was based on a comprehensive literature review, conducted by nine experts" (2009, p. 239).

B. Medication Errors Etiology Questionnaire, and,

The Personal Features Questionnaire.
Following the slight modification of the willingness to report questionnaire through the sole addition of the question, "When medication errors occur, should they be reported to the department?," the researchers conducted a pilot test consisting of 20 registered nurses to evaluate the respondents' comprehension levels and the amount of time that was typically required to complete the instrument (which was determined to be about 20 minutes). The researchers provide support for their assertion that their modified custom survey instrument was reliable and valid, but do not provide any specific evidence of this for review. Notwithstanding this omission, based on the results of their pilot test, the researchers deemed their instruments satisfactory and the surveys were thereafter distributed as described in the sampling methods section above. Following completion of the survey distribution, the survey instruments were returned to the researchers' mailbox in an unspecified location.

The data collected and analyzed showed that an overwhelming majority (87.7%) of the surveyed nurses reported a willingness to report MAEs, but only provided that there were no adverse consequences involved; however, Lin and Ma did identify some differences in nurses' levels of willingness to report such medication administration errors with respect to their job position, nursing grade, type of hospital, and hospital funding type, leading them to conclude that, "This study demonstrates that reporting of MAEs should be anonymous and without negative consequences in order to monitor and guide improvements in hospital medication systems" (Lin & Ma, 2009, p. 244). This conclusion, though, appears to fly in the face of common sense. After all, if one or two nurses are committing 99% of the medication errors on a nursing unit, it would just make good sense to identify these practitioners so that corrective actions -- of whatever type -- could be taken as quickly as possible. Indeed, the data collected by Lin and Ma may indicate that nurses would prefer anonymity to avoid accountability, but so doubtless so too would countless other professionals, including educators, accountants, politicians, and virtually every other profession as well. The healthcare setting is not like most other professions either. For instance, if a pizza restaurant fails to add pepperoni, lives will not be at stake. Certainly, this is not to trivialize other professions, but it is to highlight the fact that in healthcare, like the military or law enforcement, lives are at stake and there is no room for allowing repeated medication administration errors to continue to occur because the practitioners responsible for them remain unknown. Although something must first be measured in order to improve it, measuring medication administration errors without identifying their source is an overly simplistic approach that ignores the bottom-line cause of many errors in the first place -- the same individual or individuals who may need further training or remedial education in order to avoid the significant adverse clinical outcomes that can results from many types of medication administration errors.

15.

Ethical considerations

The authors report that their study had been approved by their institutional review board, all respondents were assured that their participation in the research project was completely voluntary and their anonymity was assured. The researchers deemed return of the completed survey as sufficient informed consent, but did not specifically obtain an informed consent form from each respondent nor did they describe any protections of the data they used during the analysis process.