Root Cause Analysis of Medication Administration Error by Nursing Staff at a Number of Medical Institutes in Riyadh

Background: Medication errors genuinely influence patient safety, staying cost in hospital and which included: abbreviations were used instead of writing the orders out completely, overall 60.5% of the times nurses were pulled between teams. Third reason, overall 45.3% of the times the errors were associated with pharmacy when they did not prepare\label the medication correctly, and clinical pharmacist did not give education workshops to the nurses. Documentation issues were the fourth reason, 39.5% of the times nurses were interrupted while administering medication to perform other duties and nurses on the same unit did not adhere to the approved medication administration procedure. Conclusion: The data of the current study suggested the ranking of five reasons or root causes of why medication errors happened. These are medication package, system related, pharmacy related, documentation-transcription reason and physician-nurse related respectively. Furthermore, clinical pharmacists must thrive to improve the nurses' knowledge of how these factors will lead to critical errors and help them discover strategies to prevent these errors from happening.


INTRODUCTION
These days, more than twenty thousand medications are consumed worldwide; the wrong utilization can cause extreme dangers and risks to the patients. The right technique for medication administration, which is important duty of nurses, appears to be crucial for safety of the patients. These includes, giving correct medication to the correct patient at the perfect time and at an appropriate dose through the execution with the correct technique, and the right recording concerning how the medications have to to be administered to the patients-is very critical. Nurses have an exceptionally critical obligation in keeping medicine blunders from occurring since they assume the primary part in medication administration [1].
Nurses have a role in the last but crucial steps in the medication administration procedure. The time spent by nurses on each shift to manage topics related with drugs comes up to 40% of their working time. Therefore, it is more probable for forefront healthcare professional of the drug procedure (nurses) to be rebuked for when medication errors happened. In fact, nurses are at the ′′sharp end′′ of this procedure [2]. Drug mistakes have a lot of undesired results, including mortality, prolonged hospitalization period, lose of quality of care, and increased treatment costs. It also hurts the trust of the patients and their families in the healthcare system. Moreover, drug mistakes initiates stress and clashes among nurses, accordingly diminishing the execution of healthcare forces [3].
Patient safety, as one of the key segments of healthcare quality is defined as "the prevention of harm to patients during medical care "Drug mistakes are among the most dangerous errors which affect patient safety and are known as one of the most common medical errors. Guaranteeing patient safety obscured medical errors are components of health services. For therapeutic establishments to give proper health administrations, it is important to satisfy these key prerequisites of patient safety. Medication administration error stands out amongst the most widely recognized mistakes in the medication errors procedure and occurs when an error happens between the medications got by the patient and the medication expected by the prescriber. For example, a study from United Kingdom's national patient agency revealed that of different types of medication errors which occurs, nearly 50% can be attributed to administration mistake contrasted with 18 % for dispensing, and 16% for prescribing [4].

Drug
administration is considered as fundamental capacity for nurses, and that nurses competency and following rules of medication administration is a guarantee for patients' safety and quality of nursing care. Medication administration is center task for nurses at every day [5].
Patient safety is a worldwide concern and is a test confronting health care system today. Medication administration is regularly done under disordered and upsetting conditions and is most likely the heights hazard activity a nurse performs. Accordingly, nurses should be mindful of their legal and expert responsibility with respect to medication management. Medication administration requires broad information and expertise to perform correctly [6].
Reporting errors is essential to prevent them. It decreases the adverse effect of errors and adequately maintains a strategic distance from future errors that can cause patient harm.
additionally, reporting will decrease the personal suffering and the costs (EAE 2015). To have the capacity to make error free or low and to have enhanced safety in medicinal establishments, it is important to inspect the factors related with the nurses themselves and their work environment [7].
Correct use of medication is vital part in producing the needed and expected effect from medication. The clinical pharmacist is an important member of the health team. He ensures the correct drug information in related to nurses. This information includes the medication names, correct administration and its related data. The clinical pharmacist plays an important role in decreasing errors related to medical and subsequences positively effecting the patients care [8].
The role of clinical pharmacists of taking care of hospitalized patients has evolved over time, with expanded emphasis on collaborative care and patient interaction. Clinical pharmacists have the relevant background in therapeutics and give complete medication management to patients and provider including the nurses.
Studies demonstrate that the incorporation of the clinical pharmacists in the intensive care unit decrease mortality and adverse events enhances clinical outcomes and decrease hospital cost.
This study aims to investigate the factors associated with nurses' medication errors in a number of medical institutes (Ministry of Health) and the role of clinical pharmacist around these errors. Outcome of study will give an idea about the factors which affect medication errors among nurse staff and such factors will guide practitioners to prevent such errors in the future, and will help improve the patient safety, too.

Study Design, Site of the Study and Instruments Used
Prospective, Observational -cross sectional study was carried out in 2017 during the period from July to December, at a number of medical institutes in KSA (six months). The Inclusion criteria for the study participants were Health care professionals target were (Nurses) who were working in the Ministry of Health during study time either male or female and also dealing with the patient directly in the wards of the hospital. Exclusion criteria was any medical experts other than nurses, nurses not working in ministry of health and any nurse who had not to be dealing with the patient directly in the wards of the hospital.

Data Collection and Sample Size
According to calculation of sample size by (www.raosoft.com) and the confidence level was 90% our target nurses were N=171 nurses from a total 457 nurses.
Questionnaires were distributed to participants, and all the 171 respondents were enrolled in the study.

Data Analysis
Data analyses had been performed using Statistical Package for the Social Sciences (SPSS/PC+, version 24) where P value less than 0.05 was considered significant.

Root Cause Analysis of Medication Errors
Regarding Root Cause Analysis of errors, the analysis showed that the most commonly reported Root Cause Analysis of medication error is:" Different medications look alike" (86%, n=147), followed by " pulled between teams and from other units (79.5%, n=136) and "The names of many medications are similar" (79.4%, n=129) the lowest reported factors are "Nurses on this unit do not adhere to the approved medication administration procedure" (23.4%, n=40), followed by "Equipment malfunctions or is not set correctly" (33.3, n=57), and "Physicians change orders frequently" (33.9, n=58) as seen in (  3)

Root Cause Analysis of Medication Errors by Nationality
Two-way cross-tabulation showed that Saudi nurses are more likely to agree that the most association factors are "Nurses on this unit have limited knowledge about medications" and "Nurses are interrupted while administering medications to perform other duties". Fisher's exact test showed that this association was statistically significant (p<0.05) ( Table  Although non-Saudi nurses are more likely to agree on the majority of factors, no statistically significant association was found between them and nationality (p>0.05).
The most reported factors associated with medication error reported by Saudis and Saudis are "Different medications look alike" (85.9% and 86% respectively), followed by "Nurses are pulled between teams and from other units" (78.2% and 80.6% respectively) and "The names of many medications are similar" (73.1% and 77.4% respectively) reported factors by Saudis are " change orders frequently" (25.6%, n=20), followed by "Equipment malfunctions or is not set correctly" (28.2%, n=22) and "Nurses on this unit do not adhere to the approved medication administration procedure" (28.2%, n=22).
On the other hand, the lowest reported factor by non-Saudis are "Nurses on this unit do not adhere to the approved medication administration procedure" (19.4%, n=18), followed by "Nurses on this unit have limited knowledge about medications" (26.9%, n=25) and "Nurse is unaware of a known allergy" (29%, n=27).

Root Cause Analysis of Medication
Root Cause Analysis of medication errors, the analysis showed that the most Root Cause Analysis of Different medications look " (86%, n=147), followed by "Nurses are pulled between teams and from other units" ames of many medications are similar" (79.4%, n=129), while Nurses on this unit do not adhere to the approved medication " (23.4%, n=40), Equipment malfunctions or is not set Physicians change " (33.9, n=58) as seen in (Table

Root Cause Analysis of Medication
tabulation showed that Saudi nurses are more likely to agree that the most Nurses on this unit have limited knowledge about medications" and "Nurses are interrupted while administering medications to perform other duties". Fisher's exact test showed that this association was statistically significant (p<0.05) ( Table 4).
Saudi nurses are more likely to agree on the majority of factors, no statistically significant association was found between them The most reported factors associated with medication error reported by Saudis and non-Different medications look alike" (85.9% and 86% respectively), followed by "Nurses are pulled between teams and from other units" (78.2% and 80.6% respectively) and "The names of many medications are similar" (73.1% and 77.4% respectively). The lowest reported factors by Saudis are "Physicians change orders frequently" (25.6%, n=20), followed by "Equipment malfunctions or is not set correctly" (28.2%, n=22) and "Nurses on this unit do not adhere to the approved medication cedure" (28.2%, n=22).
On the other hand, the lowest reported factor by Saudis are "Nurses on this unit do not adhere to the approved medication administration procedure" (19.4%, n=18), followed by "Nurses on this unit have limited dications" (26.9%, n=25) and "Nurse is unaware of a known allergy" (29%,

Root Cause Analysis of Medication Errors by Educational Level
Two-way cross-tabulation showed that bachelor degree holders are more likely to agree on the majority of the contributing factors. However, Fisher's exact test showed no statistically significant association between any of the factors and educational level (p>0.05) ( Table 5).
The most reported factors associated with medication error reported by diploma and bachelor degree holders are "Different medications look alike" (91% and 80.5% respectively), followed by "Nurses are pulled between teams and from other units" (78.7%, and 80.5% respectively) and "The names of many medications are similar" (75.3% and 75.6% respectively). The lowest reported factors by diploma holders are "Nurses on this unit do not adhere to the approved medication administration procedure" (20.2), followed by "Equipment malfunctions or is not set correctly" (29.2) and "Physicians change orders frequently" (29.2).
On the other hand, the lowest reported factor by bachelor holder are "Nurses on this unit do not adhere to the approved medication administration procedure" (26.8%), followed by "Nurse is unaware of a known allergy" (34.1%) and "Nurses on this unit have limited knowledge about medications" (36.6%). Fig. 4 and Table 6 represent perception of participants for why medication errors occur. Accordingly the ranking of the five average values of causes stated that the medication package reason (82.7%) was perceived as the most important factor for reasons of medication error, followed by the system factors (60.5%), pharmacy factors (45.3%), and documentationtranscription factors (39.5%). Physician-Nurse factors (38.9%) was perceived as the least reason of medication error.

DISCUSSION
In this study, the outcomes of factors analyzed to five root causes of why medication errors happen that were recognized in the survey. These root causes were classified as medication packaging reasons, system related, pharmacy related, documentation-transcription reasons and physician-nurse reasons.
Medication packaging associated with two reasons, which are different medication look alike, and the names of many medications are similar. System associated with two reasons: abbreviations are used instead of writing orders completely and nurses are pulled between teams and from other duties. The third group is pharmacy, which includes: pharmacy dose not prepare\label the medication correctly and pharmacists do not give education workshop [9]. The documentation group comes with: nurses are interrupted while administering medication to perform other duties and nurses on this unit do not adhere to the approved medication administration procedure. The last group was physician\nurse which includes five reason: physician order not clear\legible, physician change order frequently, nurses on this unit have limited knowledge about medication, equipment malfunction or it is not set correctly, nurse is unaware of a known allergy and poor communication between physician and nurses.
In the present study, the first group of reasons why medication errors may happen was associated medication package reason, which further includes: different medication look alike and the names of many medication were similar. However, it was difficult to recognize medication when it has been removed from its original packaging and it is very simple to confuse it with other medication, thus, good label design will ensure safety due to avoiding the confusion with other medications [8].
The second group of reasons why medication errors happen was associated with the system and includes: abbreviations were used instead of writing the orders out completely and nurses were pulled between team and from other duties. This result was similar to what was reported by in contrast [9] reported that the second factor is the physician\nurse communication.
The present study showed that the pharmacy role was the third affecting group which includes: pharmacy did not prepare\label the medication correctly and pharmacist did not give education workshop and ideally the pharmacists should collaborate with the prescriber in developing and monitoring the therapeutic plan to produce defined therapeutic outcomes for the patients [5] reported in his study similar result and outcomes to the present one, in exception, the authors reported it as the major contributor, not the third as in this study.
The present study illustrates the participants' perceived Documentation issue was the fourth affecting reason of medication errors and these include: nurses were interrupted while administering medication to perform other duties and nurses on this unit did not adhere to the approved medication administration procedure [1]. These finding may be due to nurses missed what is written on documents and the nurses sometimes have difficult time to know some words especially if the team from different region and work experience also had an impact [10] reported a similar line of results as in this study, in exception, the author reported it as the major contributor, not the fourth as in this study.
Outcomes of this study indicate that the physician-nurse issue classified as the fifth and last group of why medication errors happened which includes: physician medication order were not legible\clear, physician change order frequently, nurses on this unit have limited knowledge about medication, equipment malfunction or it was not set correctly. Nurses were unaware of a known allergy and poor communication between nurses and physician. This finding was consistent with Dumo who reported that poor nurse\physician relationship may lead to medication errors, because the physician did not respect or care to listen to nursing perspective on patient care that lead to misunderstanding and conflict between physician and nurses [8][9][10].

CONCLUSION
In conclusion, the data of this study suggested the ranking of five reasons of why medication errors happen: medication package reason, system related, pharmacy related, documentation-transcription reason and physician-nurse reason respectively. Medication errors may happen in all medical fields and to reduce these errors the prescriber who decided the prescription and the pharmacist who dispensed the medication and the nurse who is at the last step of this process to give the medication to the patient must   The clinical pharmacist plays an important role in reducing medication errors and adverse drug reaction. The rounds taken by the clinical team give a good outcome against medication errors by intervention and detecting the errors and by giving full information about the medication to the healthcare professionals. The role played by them by educating the staff nurse about the medication counseling the medication to the patient [11-In conclusion, the data of this study suggested the ranking of five reasons of why medication errors happen: medication package reason, system related, pharmacy related, transcription reason and nurse reason respectively. Medication errors may happen in all medical fields and to reduce these errors the prescriber who decided the prescription and the pharmacist who dispensed the medication and the nurse who is at the last step of this process to give the medication to the patient must cooperate together to avoid these errors thus, all the medical field staff play a critical role in preventing these errors. Additionally its must improve the nurses' knowledge of how these factors will lead to critical errors and help them to discover strategies to prevent these errors from happening by a clinical pharmacist because the clinical pharmacist play an important role in reducing the errors by active intervention. The limitation of the study can be observed that since it was limited only to the nurses who were working in two Ministry of Health hospitals and dealing with patient directly in wards and other health care providers (physician and pharmacist) were not included in the study.

CONSENT AND ETHICAL APPROVAL
Study was approved by Riyadh C Dentistry and Pharmacy in 2017 by the number FPGRP/43639008/177. Participant's information was kept confidential. All the policies and procedures of the hospitals systems we visited it for collecting the data was respected. As per international standard or university standard, respondents' written consent has been collected and preserved by the author(s).
; Article no. JPRI.70283 together to avoid these errors thus, all the medical field staff play a critical role in preventing these errors. Additionally its must improve the nurses' knowledge of how these factors will lead to critical errors and help them to discover ategies to prevent these errors from happening by a clinical pharmacist because the clinical pharmacist play an important role in reducing the errors by active intervention. The limitation of the study can be observed that since nurses who were working in two Ministry of Health hospitals and dealing with patient directly in wards and other health care providers (physician and pharmacist)

ETHICAL APPROVAL
Study was approved by Riyadh Colleges of Dentistry and Pharmacy in 2017 by the number FPGRP/43639008/177. Participant's information was kept confidential. All the policies and procedures of the hospitals systems we visited it for collecting the data was respected. As per standard or university standard, respondents' written consent has been collected