Critique of Nurse MAE Reporting Study in Southern Taiwan

Introduction and Study Overview

Medication administration errors (MAEs) represent an ongoing threat to the quality of nursing services, but their causes are multifaceted and differ from individual to individual as well as from healthcare facility to healthcare facility. The purpose of the cross-sectional study by Lin and Ma (2009) — involving a survey of a convenience sample of 605 respondents from 14 tertiary healthcare facilities in southern Taiwan — was to examine the prevalence of MAEs and the willingness of nurses to report them. As their data collection instruments, these researchers used a modified structured questionnaire, an MAEs Unwillingness to Report Scale, a Medication Errors Etiology Questionnaire, and a Personal Features Questionnaire.

The researchers determined that more than two-thirds (66.9%) of the nurse respondents had personal experience with MAEs during their professional careers, and the majority reported a willingness to report the MAEs they encountered (Lin & Ma, 2009). According to Lin and Ma, "The key factor contributing to the nurses' willingness to report MAEs was working in a private or nonprofit hospital" (2009, p. 244). Based on their results, Lin and Ma conclude that MAE reporting should be anonymous and that there should be no adverse consequences associated with reporting, in order to help ensure that the process is properly overseen, meaningfully administered, and results in improvements to patient outcomes.

The study notes that Lin is employed in the Nursing Department of a university and is a PhD candidate at the College of Nursing in Kaohsiung, Taiwan; her collaborator, Ma, is the Section Coordinator at the Cancer Center, Chi Mei Medical Center, Liou Ying Branch, Tainan, Taiwan. Lin holds an RN and MSN, and Ma is an RN. The purpose of the study was to explore the prevalence of MAEs and the willingness of nurses to report them.

Research Credentials, Purpose, and Problem Statement

The problem addressed by Lin and Ma concerned the need to reduce medication errors in general, and medication administration errors in particular, among nursing professionals working in southern Taiwan. According to the authors, current levels of MAEs are inordinately high — "MAEs made by nurses in Taiwan are not unusual" (Lin & Ma, 2009, p. 243) — with correspondingly high social and economic costs. For instance, Lin and Ma report that "In the United States, medication errors account for an estimated 7,000 deaths per year. In addition, an average of 400,000 preventable drug-related injuries occur each year in hospitals, 800,000 occur in long-term care settings, and 530,000 occur in outpatient clinics in the United States. These incidents account for extra medical costs amounting to $3.5 billion annually" (p. 237).

It is axiomatic that in order to improve something, it must first be measured. Improving the reporting of medication administration errors therefore represents the first step toward addressing the problem. As Wakefield, Uden-Holman, and Wakefield (2005) point out, "Analysis of medication errors can lead to system improvement and reduced risk only if the errors are detected, reported, and used to design better patient-care practices and systems" (p. 37). This same point is emphasized by Lin and Ma (2009), who report that "Reporting medication errors is fundamental to gathering information on such incidents, helps health professionals learn how to improve the medication-use process, and prevents or minimizes future incidents" (p. 238).

Although virtually anyone — including patients and families — is in a position to report medication errors (Gebhart, 2008), clinicians are on the front line of care delivery and are therefore primarily responsible for identifying and reporting medication errors of all types. In order for effective and timely corrective actions to be taken, clinicians must be willing to report medication errors irrespective of their severity or origin. In this regard, Wakefield et al. emphasize that "Voluntary medication error reporting systems rely on the ability and willingness of individual physicians, pharmacists, and nurses to detect and report errors as part of their routine practice. Because of the central role nurses play in medication administration, it is important to understand their perceptions of the medication error reporting process" (2005, p. 37). It was precisely this problem that the Lin and Ma (2009) study examined.

To their credit, Lin and Ma (2009) present a comprehensive review of the relevant literature, including peer-reviewed studies, scholarly sources, online resources from accrediting organizations such as the Joint Commission on the Accreditation of Healthcare Organizations, and governmental resources, with roughly one-third of the sources dating from the previous five years.

The literature review provides background and an overview of the problems under consideration from a wider perspective, including the most common types of medication administration errors and how these errors are typically made by nursing professionals. According to Lin and Ma, among the most common types of medication errors is the medication administration error, which can be either an act of omission or an act of commission. Commission errors occur when one or more of the so-called "six Rs" or "six rights" — giving the right medication in the right dose at the right time via the right route to the right patient with the right documentation — are violated. Omission errors, by contrast, occur when prescribed medications are not administered at all (Lin & Ma, 2009).

With respect to MAE reporting regimens, Lin and Ma suggest that the procedures in place in Taiwan are comparable to those used elsewhere, differing only in that the reporting medium remains paper-based. According to the authors, "In Taiwan, most hospitals' medication administration errors are reported on a standard paper form. On this form, the reporting nurse describes the error and any contributing factors" (2009, p. 239). Completed medication error reports are then typically sent to the unit head nurse, then to the supervisor, and ultimately to the nursing department director, who is responsible for acting on the report (Lin & Ma, 2009). The type of action taken depends on the nature and severity of the error, but disciplinary measures generally include:

Literature Review and Conceptual Framework

A. Some type of punishment (i.e., a lost opportunity for promotion or a pay cut); B. Assigning official responsibility; C. Requiring the nurse responsible for the error to undertake additional training; or D. Correcting faults inherent in the environment (Lin & Ma, 2009, p. 239).

Clearly, identifying the responsible clinician is necessary for the majority of these corrective actions to be implemented.

The conceptual framework used by Lin and Ma (2009) held that in order to properly identify opportunities for improving medication administration error rates, errors must first be reported and then trended to determine the types of errors being experienced and their sources. Achieving this level of consistent reporting requires a framework in which healthcare practitioners can report errors without fear of recrimination, either personal or professional. The researchers note, however, that this framework had certain limitations, including the following:

A. The study's findings are limited by the selection of samples from southern Taiwan. The convenience sample consisted exclusively of nurses, which may have introduced sampling bias, since other healthcare providers — such as physicians, pharmacists, and technicians — also contribute to MAEs. The study therefore needs to be corroborated by replication across all national facilities using random sampling.

B. The cross-sectional design may tend to under-select individuals who have been exposed to the phenomenon under study, a phenomenon known as "late-look bias." The possibility that nurses were recalling MAEs over the course of their careers may have resulted in inaccurate reporting or memory distortion.

C. The instrument developed by the authors relied on expert validity, but further research is needed to establish construct validity and to identify appropriate interventions to decrease MAEs (Lin & Ma, 2009).