Barriers to medication administration error reporting in a tertiary hospital in Lebanon

Abstract

Objective

The aim of this study is to identify the key barriers that prevent medication administration errors (MAEs) from being reported by nurses in Lebanese hospitals.

Methods

A quantitative cross-sectional study was conducted at Hotel-Dieu de France Hospital using a self-administered questionnaire. A total of 275 responses were recorded and analysed using the IBM SPSS software V.23.0.

Results

Our study showed that ‘Fear’ and ‘Administrative response’ present the two main types of barriers to MAE reporting with a frequency of 62.9% and 60.7%, respectively, with more than half of our nurses confirming it (52.7%). The significant administrative barriers are: No positive feedback if medications were given correctly, too much emphasis being placed on MAE and the focus by the nursing administration on the individual rather than looking at the systems as a potential cause of the MAE whereas the significant fear barriers are the chances of suing the nurse if MAE is reported, the fear of adverse consequences of MAE reporting, the blame of nurses if something happens to the patient as a result of the MAE. No significant association was found between the barriers and demographic factors such as age, gender, experience and attending the training and orientation programmes.

Conclusion

The findings highlight the need for targeted strategies to address these types of barriers. Anonymous error reporting, fostering a culture of transparency and adopting a non-punitive reporting system are approaches that can be implemented for optimal performance improvement, enhanced safety and healthcare quality and reduced wasting of the hospitals’ financial resources.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• The evidence from published studies suggests that nurses often under-report errors due to the culture of blame and punishment, fear of disciplinary actions and managerial factors. No similar data is available in Lebanon.

WHAT THIS STUDY ADDS

• ‘Fear’ and ‘Administrative response’ present the two main types of barriers to medication administration error (MAE) reporting with a frequency of 62.9% and 60.7%, respectively.

• No significant association was found between these types of barriers and demographic factors, notably the nurses’ years of experience.

• In this study, 15.9% consider that MAEs should not be reported if they do not cause any harm or if they are intercepted and adjusted before reaching the patient.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Anonymous error reporting, fostering a culture of transparency and adopting a non-punitive reporting system are approaches that can be implemented for enhanced safety and healthcare quality.

Introduction

Medication errors (MEs) can have a major impact on the safety and quality of healthcare received by patients. In addition, it can be an added burden draining the hospital’s financial resources.^{1 2} Nevertheless, studies have shown that more than half of errors can be averted.^{3 4} The National Coordinating Council for Medication Error Reporting and Prevention defined a ME 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 health care professional, patient, or consumer’.^5(p4) As stated by the WHO, the most frequent errors occur during the medication administration phase in hospitals⁶ which consists of up to 40% of nursing tasks⁷ and is potentially hazardous.⁸

A multinational systematic review found that medication administration errors (MAEs) remain a common threat to patient safety, with a prevalence of 19.6% (8.6–28.3%).⁹ A systematic review reporting MEs in hospitals in the Middle East showed that it remains prevalent; 10% across all studies.¹⁰ The incidence of medical errors in Lebanon is still unknown,¹¹ although Lebanon was considered second in reporting MEs among Middle Eastern countries.¹² Reporting is a crucial step to system improvement by analysing MAEs, detecting trends and designing better patient care practices and systems.¹³

The evidence from published studies suggests that nurses often under-report errors^{14 15} Identifying and understanding the barriers to MAEs reporting is key to implementing a successful intervention. Different types of barriers were identified among nurses; culture of blame and punishment, fear of disciplinary actions, managerial factors, variations in how errors are defined and effort required to report MAEs.16,19 To our knowledge, studies that address the barriers to MAE reporting are scarce in Lebanon.

The aim of this study is to provide a compendium of information on the key barriers that prevent MAEs from being reported by nurses in Lebanese hospitals.

Materials and methods

Study design

An institution-based quantitative cross-sectional study was conducted at Hotel-Dieu de France Hospital (HDF) during the month of November 2023. It is a non-profit university hospital and research centre founded in 1922 in Beirut. HDF has become a model for excellence in the region, with more than 400 beds, 170 physicians, 400 nurses, 12 operating rooms and 150 000 admissions per year. It is one of the three leading Lebanese hospitals. Inclusion criteria: All nurses working at HDF Hospital regardless of the ward in which they work and regardless of their position. Exclusion criteria: Nurses who were on annual leave, maternity leave, seriously ill and attending external training courses off-site at the time of the data collection were excluded.

Data collection and used instruments

Data was collected using a hard copy self-administered questionnaire distributed to all the nurses working at HDF during that time (420 nurses). The duration of the data collection was 1 month; with one follow-up email sent to all the nursing staff after 2 weeks of questionnaire distribution to encourage participation and improve the response rate.

The first part of this survey instrument consists of the sociodemographic characteristics of the participants.

The second part was developed based on a single part of a validated questionnaire developed by Wakefield et al.²⁰ The permission from the author was obtained. It consists of a 6-point Likert scale (score from 1=strongly disagree to 6=strongly agree) based on 16 barriers, assessing the reasons why MAEs are not reported. These barriers were grouped into four types namely disagree with definition, reporting effort, fear and administrative response. The range of total score is from 16 to 96, with the higher score indicating more barriers to MAE reporting.

The third and final part was included to gather information on previous experiences with MAEs, reporting it, MAE’s theoretical/practical learning and nurses’ knowledge concerning the reporting system in the hospital.

The questionnaire was translated into French by a certified public translator and then back-translated into English by a bilingual professor who had majored in English. These two versions were reviewed by one of the authors and minor revisions were made to minimise confusion and improve clarity. Before gathering data, a pilot study was conducted on a small number of nurses to assess the tool’s applicability and viability.

The psychometric properties of the Medication Administration Error Reporting Survey developed by Wakefield et al were tested through confirmatory factor analysis. On the basis of the construct and criterion-related validity tests and subscale reliability with Cronbach’s alpha ranging from 0.69 to 0.76, this instrument was demonstrated to be valid and reliable. This instrument was used in various studies.^{14 21 22}

Statistical analysis

Data analysis was done using the IBM SPSS statistical software V.23.0. Descriptive statistics summarised the participants’ characteristics. Mean with SD were calculated for each type of barrier. One sample ‘t-test’ was applied to the 16 barriers, the overall barrier and the four different types of barriers for reporting MAEs with a neutral test value=3.5. Bivariate analysis with χ² test was performed to determine the factors associated with the different types of barriers and differences between groups (age, educational level, years of professional experience, years of work at HDF, position at work).

Results

Participants characteristics

The sample consisted of 420 nurses working at HDF at the time of the study, from which 20 were excluded. A total of 275 nurses completed the questionnaire with a 68.8% response rate; 88.4% were female, 39.4% were younger than 25 years old and 15.6% were 45 years or older (table 1) . All the nurses had a bachelor’s degree in nursing, 27.6% had a university diploma and 17.4% held a master’s degree. As for nursing working experience, 20% of nurses had experience of less than a year, more than 55% had up to 20 years of experience while 22.5% had more than 20 years of experience. The mean of work experience (in years) was 11.22 with SD 10.7889, with a maximum of 43 professional years (n=2 nurses). The mean of work experience at HDF wass 9.69 years with SD 10.72 and a maximum of 43 professional years (n=1).

Table 1. Demographic characteristics of the sample (n=275).

Variable	Category	Frequency (percentage %)
Gender	Male	32 (11.6)
	Female	241 (88.4)
Age	25 years old or less	106 (39.4)
	26–35 years old	68 (25.3)
	36–45 years old	53 (19.7)
	More than 45 years old	42 (15.6)
Unit they currently work in	Maternity	17 (6.2)
	Psychiatry	4 (1.5)
	Surgical ward	39 (14.2)
	Day surgery unit	4 (1.5)
	Internal medicine ward	56 (20.4)
	Paediatric ward	22 (8)
	Intensive care unit	44 (16)
	Emergency room	21 (7.6)
	Operating room	9 (3.3)
	Other	50 (18.2)
Educational level	BSc	148 (53.8)
	BSc + University Diploma	74 (26.9)
	MSc	46 (16.7)
	MSc + University Diploma	2 (0.7)
Years of experience as RN	1 year or less	55 (20.2)
	Up to 5 years	63 (23.2)
	Up to 10 years	40 (14.7)
	Up to 20 years	52 (19.1)
	More than 20 years	62 (22.8)
Years of experience at this hospital	1 year or less	73 (27.3)
	Up to 5 years	65 (24.3)
	Up to 10 years	37 (13.9)
	Up to 20 years	38 (14.2)
	More than 20 years	54 (20.2)

BScBachelor of ScienceMScMasters of ScienceRNregistered nurse

Barriers to MAE reporting

Administrative response was the most perceived type of barrier (mean 3.95—SD 1.14) followed by fear (mean 3.94—SD 1.27) with an overall barrier’s mean of 3.33 and SD of 0.9 (table 2). In addition, 62.9% of our nurses considered ‘Fear’ an important type of barrier, with a score above 3.5 and 60.7% gave ‘Administrative response’ a score above 3.5, with more than half of them (52.7%), considering both fear and administrative response as a significant type of barrier to MAE reporting. Comparing the frequency of ‘fear’ and ‘administrative response’ between the different age groups, educational level, years of professional experience, years of work at HDF and position at work showed no significant difference using χ² test. Each type of barrier was compared with the neutral mean with a significant difference observed for ‘fear’ (0.44; 95% CI (0.28 to 0.59)) and ‘administrative response’ response (0.45; 95% CI (0.31 to 0.59)), confirming the importance of these obstacles for MAE reporting (table 3). Furthermore, 6 barriers were found significantly strong factors preventing MAE reporting (table 4); The fear of blame (0.91; 95% CI (0.72 to 1.1)) and the concentration on MAE to measure the quality of nursing care (0.89; 95% CI (0.7 to 1.08)) present the two major obstacles, followed by the chances of suing the nurse if MAE is reported (0.73; 95% CI (0.53 to 0.93)), no positive feedback if medications were given correctly (0.62; 95% CI (0.39 to 0.84)), the focus by the nursing administration on the individual rather than looking at the systems as a potential cause of the MAE (0.61; 95% CI (0.43 to 0.78)) and the fear of adverse consequences of MAE reporting (0.53; 95% CI (0.34 to 0.72)).

Table 2. Barriers means and SD.

	N	Mean	SD
Disagreementoverdefinition	257	2.4008	1.09459
Nurses do not agree with hospital’s definition of a medication error	265	2.317	1.5068
Nurses do not recognise an error occurred	267	2.307	1.5004
Medication error is not clearly defined	265	2.162	1.3388
Nurses may not think the error is important enough to be reported	266	2.831	1.6636
Reportingeffort	267	2.7615	1.15946
Filling out an incident report for a medication error takes too much time	268	3.716	1.7184
Contacting the physician about a medication error takes too much time	268	2.354	1.4474
The expectation that medications be given exactly as ordered is unrealistic	268	2.243	1.5180
Fear	269	3.9361	1.26965
Nurses believe that other nurses will think they are incompetent if they make medication errors	269	3.465	1.7222
The patient or family might develop a negative attitude toward the nurse or may sue the nurse if a medication error is reported	269	4.230	1.6387
Nurses are afraid the physician will reprimand them for the medication error	272	3.592	1.7092
Nurses fear adverse consequences from reporting medication errors	272	4.026	1.5827
Nurses could be blamed if something happens to the patient as a result of the medication error	271	4.410	1.5911
Administrativeresponse	263	3.9525	1.13880
The response by nursing administration does not match the severity of the error	266	3.218	1.5238
No positive feedback is given for passing medications test correctly	272	4.118	1.8882
Too much emphasis is placed on medication errors as a measure of the quality of nursing care provided	270	4.393	1.6113
When medication errors occur, nursing administration focuses on the individual rather than looking at the systems as a potential cause of the error	271	4.107	1.4781
Overallbarrier	247	3.3320	0.90238

Table 3. One sample t-test results.

	Test value=3.5
	T	df	Sig. (2-tailed)	Mean difference	95% CI of the difference
					Lower	Upper
1. Disagreement over definition	−16.099	256	0.000	−1.09922	−1.2337	−0.9648
2. Reporting effort	−10.407	266	0.000	−0.73845	−0.8782	−0.5987
3. Fear	5.633	268	0.000	0.43606	0.2836	0.5885
4. Administrative response	6.443	262	0.000	0.45247	0.3142	0.5907
5. Overall barrier	−2.926	246	0.004	−0.16802	−0.2811	−0.0549

Table 4. Barriers presenting significant difficulty to MAE reporting.

Barriers	Mean	df	t	Sig. (2-tailed)
1. The patient or family might develop a negative attitude toward the nurse or may sue the nurse if a medication error is reported	0.73	268	7.311	0.000
2. Nurses fear adverse consequences from reporting medication errors	0.53	271	5.478	0.000
3. Nurses could be blamed if something happens to the patient as a result of the medication error	0.91	270	9.411	0.000
4. No positive feedback is given for passing medications correctly	0.62	271	5.395	0.000
5. Too much emphasis is placed on medication errors as a measure of the quality of nursing care provided	0.89	269	9.103	0.000
6. When medication errors occur, nursing administration focuses on the individual rather than looking at the systems as a potential cause of the error	0.61	270	6.760	0.000

Barriers 1, 2 and 3 are listed under ‘Fear’. Barriers 4, 5 and 6 are listed under ‘administrative response’.

MAEmedication administration error

Previous experience with MAE and error reporting

Almost all participants (98.9%) agree that MAEs should be reported but 15.9% consider that MAEs should not be reported if they do not cause any harm or if they are intercepted and adjusted before reaching the patient. Further, 45% of participants have already experienced an MAE and 38.2% reported it. The majority of nurses (97.8%) know about the existing reporting system at the hospital and (95.2%) claimed that their study curriculum in college included material on patient safety and/or quality improvement. The majority 71% of nurses have received an orientation programme related to the hospital’s policy regarding MAE reporting and have attended a training programme related to medication administration.

Almost 67% confirmed that the institution notifies the patients about how to contact the hospital management to report concerns about patient safety and quality of care.

Table 5 highlights all the aforementioned results. Using the χ² test, no significant difference was found between fear/administrative response frequency and the aforementioned factors.

Table 5. Previous experience with MAE and error reporting.

	YES percentage (N)	NO percentage (N)
Do you think MAEs should be reported?	98.9 (269)	1.1 (3)
Do you think MAEs should be reported even when they do not cause any harm to the patient or when they are intercepted and adjusted before reaching the patient?	84.1 (228)	15.9 (43)
Have you ever experienced any medication administration error?	45 (122)	55 (149)
Have you ever reported a medication error?	38.2 (104)	61.8 (168)
Is there a reporting protocol/system in your hospital?	97.8 (266)	2.2 (6)
Has your study curriculum in college included material on patient safety and/or quality improvement?	95.2 (258)	4.8 (13)
Have you ever attended a training programme related to medication administration?	71 (191)	29 (78)
Have you ever received an orientation programme related to the hospital’s policy regarding MAE reporting?	71.2 (193)	28.8 (78)
Does your institution notify the public it serves about how to contact the hospital management to report concerns about patient safety and quality of care such as hanging flyers or handing out brochures or delivering the message orally?	66.9 (180)	33.1 (89)

MAEmedication administration error

Discussion

The main purpose of this study was to assess barriers to MAE reporting by Lebanese nurses and associated factors. Most of the enrolled nurses 88.4% were female, 39.4% were younger than 25 years old and 15.6% were 45 years or older. All participants had a bachelor’s degree in nursing, 20% have a nursing working experience of less than a year and 22.5% have more than 20 years of experience, while the majority (57%) are somewhere in between with a mean of work experience of 11.22 years with SD 10.7889 in comparison to the mean of work experience at HDF which is 9.69 years with SD 10.72.

Our study showed that the top six significant obstacles to MAE reporting from the nurses’ perspective are (1) the chances of suing the nurse if MAE is reported, (2) fear of adverse consequences of MAE reporting, (3) blame of nurses if something happens to the patient as a result of the MAE, (4) no positive feedback if medications were given correctly, (5) too much emphasis being placed on MAE and (6) the focus by the nursing administration on the individual rather than looking at the systems as a potential cause of the MAE. These aforementioned obstacles represent the two main types of barriers to MAE reporting as demonstrated in this study; ‘Fear’ and ‘Administrative response’ with a frequency of 62.9% and 60.7%, respectively, with more than half of our nurses confirming it (52.7%).

This result corroborates the findings of other earlier studies. A study in 2006 aimed to identify the nurses’ perceptions of barriers to reporting MEs and to examine the relationship between the barriers, cultural factors and work environment in Taiwan. Data from 597 nurses showed that the major perceived barrier to reporting MEs was fear followed by administrative barriers.²³ Another study, conducted in 2016 in Saudi Arabia with the aim of identifying the main barriers in reporting MAEs among multicultural registered nurses exploring the relationship between the nurses’ demographic variables and their perception of reporting MAEs, found that administrative response was the main perceived barrier to MAE reporting, followed by fear barriers.²¹ Similar findings were shared by an Egyptian study²² and a Czech study.¹⁴

A systematic review conducted in 2016 with 38 studies included in the synthesis found that organisational barriers in addition to fear and accountability are barriers to reporting MEs.²⁴

Identifying ‘administrative response’ as a main barrier to error reporting reflects that most healthcare organisations are still adopting a traditional approach to healthcare management. The traditional way of management emphasises on who to blame rather than how and why an error occurred.²⁵ A shift to system-based thinking is needed where errors are attributed to poorly designed system structures and processes rather than blaming and punishing the healthcare workers (HCWs).²⁶ Similar findings were reported in a systematic review of error reporting barriers.²⁷ Fear was one of the highest perceived barriers to error reporting in many studies.28,30 It can be more noticeable in certain cultures than others; For example, ‘fear of consequences’ is more prevalent in East Asia and the Middle East compared with the USA.³¹ It can also be more prominent in hospitals with hierarchical structures.³² Some of the sources for fear are not modifiable or predictable, such as the concern over patients’ and their families’ reactions to medical errors. Education and training of the healthcare providers can help overcome that type of fear. On the other hand, modifiable fear which is usually secondary to being blamed for the error or the possibility of losing one’s job, is directly related to the workplace culture.³¹

It is also important to highlight that the similarity of results in different studies from all around the world discloses that nurses’ perception of barriers to MAE reporting is unequivocal, regardless of culture and location. Therefore, the most important barrier to consider for patient safety improvements is modifiable organisational barriers. This requires a redesign of healthcare systems and adjustment of the work environment as proposed by the institute of medicine; supportive leadership and safety culture could enhance staff commitment to safety practices such as ME reporting.³³ There are strategies that healthcare organisations can prioritise to foster a safety culture; The joint commission published in March 2022 the patient safety systems (PS) chapter that provides healthcare organisations with a proactive approach to designing or redesigning a patient-centred system with the aim of improving quality of care and patient safety.³⁴ Empowering healthcare professionals to report errors without fear of retribution, with a prompt and effective addressing of reported errors and providing timely feedback regarding actions taken on patient safety events is key to build a safety culture. Anonymous error reporting promotes as well a culture of open reporting and enhances nurses’ involvement in preventing MEs.^{24 35} Supportive leadership, on the other hand, can be achieved through adopting a non-punitive reporting system³⁶ where errors are viewed as opportunities for learning and improvement. Another important approach is fostering a culture of transparency³⁷ by clearly communicating that the purpose of reporting is to learn from errors, encouraging open discussions about errors or near-misses, sharing lessons learnt and celebrating successful interventions that have improved patient safety. Finally, providing education and training programmes specifically designed for higher staff, including executives, managers and supervisors should also be adopted.³⁴

Our study also assessed the aforementioned barriers with demographic factors such as age, gender, experience and attending the training and orientation programmes. No significant association was found. Similar findings were supported in the Saudi study by Mohammad et al that used the same instrument which is comparable to our study.²¹ In contrast to our work, nurses’ sex and marital status were significantly associated with ME reporting in a study by Jember et al.³⁸ Nurses who have higher qualifications, who are older than 40 and those who have more than 10 years of experience were more likely to report MEs.³⁹ In another study conducted by Alshammari et al, they found that lack of knowledge and training were the main barriers of reporting ME.⁴⁰ The observed discrepancy, could be attributed to the training received on error reporting and the influence of the patient safety culture within a healthcare institution.

In the current study 15.9% consider that MAEs should not be reported if they do not cause any harm or if they are intercepted and adjusted before reaching the patient; referring to near-miss events. Reporting and addressing these events is as important as MAEs since they are more prevalent; According to Wagner et al, near‐miss errors occur approximately 7700 times as often as serious medical accidents⁴¹ and reducing cases of these errors is perceived as effective for preventing medical accidents.⁴² Nurses tend to not report an error especially if it is unharmful or can be hidden.^{43 44} Barriers to ME reporting make it less likely that nurses will report MEs, even more so near-misses. Under-reporting these events hinders valuable data collection and potential adjustment of harmful practices.²⁹ Perhaps the benefits of education and training are perceived to be self-evident, but promoting it has been strongly correlated to an increased rate of error reporting.⁴⁵ In our study, almost all nurses knew about the existing reporting system at the hospital and claimed that their study curriculum in college included material on patient safety and/or quality improvement and 71% of nurses have received an orientation programme related to the hospital’s policy regarding the MAE reporting and have attended a training programme related to medication administration. This is probably the reason why years of experience had no influence on MAE reporting. In addition, it has been demonstrated by other studies that educational interventions can improve HCWs’ knowledge of how to report incidents, promote a non-punitive environment and improve safety culture.46,48 These are considered the main components to creating an enabling environment for nurses to report MAEs, especially when ‘fear’ and ‘administrative response’ are the main reporting barriers.

Finally, 45% of participants have already experienced an MAE and 38.2% reported it, although all participants agreed that MAEs should be reported. The fact that not all those who encountered an error reported it, reflects the impact of the existing barriers to MAE reporting and the need to address these barriers. Some regional studies demonstrated similar results^{28 39} while others had lower reporting rates.^{22 49} Several factors account for the inconsistent reporting of ME across different institutions and regions. These include variations in awareness, reporting systems and organisational culture.

This study has some potential limitations. First, the results cannot be generalised to all Lebanese nurses since the respondents were recruited in only one hospital. Second, the profile of nurses and their knowledge can affect the results. If the study had been conducted in a different hospital where the recruited nurses had not received orientation and training on MEs, the results could have been different.

Conclusion

In this cross-sectional study conducted on Lebanese nurses, the two main types of barriers to MAE reporting were fear and administrative response. These barriers, as presented in this study, exist regardless of geographical location, culture and personal factors (demographic factors, experience, knowledge). The findings highlight the need for targeted strategies to address these types of barriers: (1) A shift from a traditional management approach to system-based thinking where errors are attributed to poorly designed system structures and processes rather than blaming and punishing the HCWs. (2) A patient-centred system that empowers healthcare professionals to anonymously report errors without fear of retribution and that ensures prompt addressing of errors and timely feedback, is essential for fostering a safety culture. (3) A non-punitive reporting system and a culture of transparency where errors are viewed as opportunities for learning and improvement are key to build a supportive leadership. Finally, the present study demonstrates the importance of integrating patient safety study material into college curricula as well as into orientation and training programmes related to the hospital’s policy on MAE reporting, in decreasing the influence of nurses’ years of experience on MAE reporting.

Data availability statement

Data are available upon reasonable request.