Barriers to the reporting of medication administration errors and near misses: an interview study of nurses at a psychiatric hospital.

C. Haw; J. Stubbs; G. L. Dickens

Study

Barriers to the reporting of medication administration errors and near misses: an interview study of nurses at a psychiatric hospital.

May 14, 2014

Haw C, Stubbs J, Dickens GL. J Psychiatr Ment Health Nurs. 2014;21(9):797-805.

View more articles from the same authors.

Researchers interviewed mental health nurses to determine perceived obstacles to reporting medication administration errors or near misses. Many factors were identified, including insufficient knowledge, fear of consequences, or burden of work associated with reporting. These have also been cited as reasons for under-reporting of errors in prior nursing studies.

PubMed citation

Available at

Related Resources From the Same Author(s)

An observational study of medication administration errors in old-age psychiatric inpatients.

July 4, 2007

A review of medication administration errors reported in a large psychiatric hospital in the United Kingdom.

January 4, 2006

Prescription errors in psychiatry - a multi-centre study.

September 6, 2006

Improving reporting of outpatient pediatric medical errors.

January 30, 2005

Exploring the causes of COPD misdiagnosis in primary care: a mixed methods study.

April 10, 2024

Impact of the initial response to COVID-19 on long-term care for people with intellectual disability: an interrupted time series analysis of incident reports.

October 14, 2020

Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum?

April 5, 2006

Testing process errors and their harms and consequences reported from family medicine practices: a study of the American Academy of Family Physicians National Research Network.

June 11, 2008

The economic consequences of medical injuries: implications for a no-fault insurance plan.

March 6, 2005

Patient safety systems in the primary health care of diabetes—a story of missed opportunities?

November 17, 2010

Impact of the introduction of electronic prescribing on staff perceptions of patient safety and organizational culture.

June 28, 2017

Relationship between patient complaints and surgical complications.

February 15, 2006

Analysing potential harm in Australian general practice: an incident-monitoring study.

March 27, 2005

Do faculty and resident physicians discuss their medical errors?

October 15, 2008

Effects of shift length on quality of patient care and health provider outcomes: systematic review.

June 10, 2009

Supporting doctors as healthcare quality and safety advocates: recommendations from the Association of Surgeons in Training (ASiT).

July 25, 2018

A case of adverse drug reaction induced by dispensing error.

November 7, 2012

Medication prescribing and monitoring errors in primary care: a report from the Practice Partner Research Network.

November 17, 2010

Patient safety in emergency medical services: a systematic review of the literature.

December 21, 2011

A comparison of voluntarily reported medication errors in intensive care and general care units.

March 24, 2010

Preventable errors in organ transplantation: an emerging patient safety issue?

July 11, 2012

Medical error and human factors engineering: where are we now?

January 25, 2006

Overestimation of clinical diagnostic performance caused by low necropsy rates.

December 14, 2005

A reduction in cardiac arrests and duration of clinical instability after implementation of a paediatric rapid response system.

December 16, 2009

Functional health literacy and understanding of medications at discharge.

July 16, 2008

Perceptions of preventable medical errors in Alberta, Canada.

January 30, 2008

Disclosure of medical error to parents and paediatric patients: assessment of parents' attitudes and influencing factors.

April 21, 2010

Motivational influences on anaesthetists' use of practice guidelines.

May 13, 2009

Longitudinal evaluation of a programme for safety culture change in a mental health service.

January 13, 2021

Effectiveness of a graduate medical education program for improving medical event reporting attitude and behavior.

October 12, 2005

Applicability of Healthcare Failure Mode and Effects Analysis to healthcare epidemiology: evaluation of the sterilization and use of surgical instruments.

September 21, 2005

What defines a high-performing health system: a systematic review.

September 6, 2017

Underdiagnosis of dementia: an observational study of patterns in diagnosis and awareness in US older adults.

April 11, 2018

Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study.

January 30, 2005

Clinicians' perceptions of medication errors with opioids in cancer and palliative care services: a priority setting report.

May 30, 2018

Active surveillance using electronic triggers to detect adverse events in hospitalized patients.

June 14, 2006

Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems.

January 28, 2015

The science of human factors: separating fact from fiction.

May 22, 2013

The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II.

March 27, 2005

Learning from malpractice claims about negligent, adverse events in primary care in the United States.

March 6, 2005

Survey of medication documentation at hospital discharge: implications for patient safety and continuity of care.

April 30, 2008

Agreement between patient-reported symptoms and their documentation in the medical record.

August 27, 2008

Development and measurement of perioperative patient safety indicators.

March 18, 2015

Awareness with recall during general anaesthesia: a prospective observational evaluation of 4001 patients.

August 20, 2008

Can aviation-based team training elicit sustainable behavioral change?

January 6, 2010

Human factors engineering in healthcare systems: the problem of human error and accident management.

January 21, 2009

Extraneous tissue a potential source for diagnostic error in surgical pathology.

January 4, 2012

SIMMEON-Prep study: SIMulation of Medication Errors in ONcology: prevention of antineoplastic preparation errors.

December 17, 2014

Clinical diagnoses vs. autopsy findings in early deceased septic patients in the intensive care: a retrospective cohort study.

July 28, 2021

A preliminary taxonomy of medical errors in family practice.

March 6, 2005

The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.

May 26, 2010

Physician practice patterns resemble ACGME duty hours.

July 8, 2009

A systematic review of interventions to follow-up test results pending at discharge.

February 7, 2018

Minimizing errors of omission: Behavioural rEenforcement of Heparin to Avert Venous Emboli: The BEHAVE Study.

March 8, 2006

Mitigation of patient harm from testing errors in family medicine offices: a report from the American Academy of Family Physicians National Research Network.

June 11, 2008

Identification and characterization of adverse drug events in primary care.

October 11, 2017

The SAGES Fundamental Use of Surgical Energy program (FUSE): history, development, and purpose.

February 14, 2018

More to teamwork than knowledge, skill and attitude.

September 1, 2010

Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality.

March 27, 2005

Developing and implementing new safe practices: voluntary adoption through statewide collaboratives.

August 16, 2006

The vanishing nonforensic autopsy.

March 12, 2008

Medication prescribing errors in a teaching hospital.

March 6, 2005

Improving acceptance of computerized prescribing alerts in ambulatory care.

November 9, 2005

Adapting cognitive task analysis to investigate clinical decision making and medication safety incidents.

September 18, 2019

Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room.

June 14, 2006

Involvement of parents in critical incidents in a neonatal-paediatric intensive care unit.

December 16, 2009

Using computerized virtual cases to explore diagnostic error in practicing physicians.

February 13, 2019

Measuring patient safety climate: a review of surveys.

October 12, 2005

Computerized surveillance of adverse drug events in hospital patients.

March 27, 2005

Discrepant perceptions of communication, teamwork and situation awareness among surgical team members.

March 23, 2011

A simulation design for research evaluating safety innovations in anaesthesia.

January 28, 2009

Exploring the causes of adverse events in hospitals and potential prevention strategies.

February 24, 2010

Lack of association between intraoperative handoff of care and postoperative complications: a retrospective observational study.

November 6, 2019

Improving team information sharing with a structured call-out in anaesthetic emergencies: a randomized controlled trial.

March 12, 2014

Cluster randomized trial to evaluate the impact of team training on surgical outcomes.

October 5, 2016

Anatomy of a patient safety event: a pediatric patient safety taxonomy.

December 21, 2005

Weekend and night outcomes in a statewide trauma system.

April 13, 2011

Communication failures in the operating room: an observational classification of recurrent types and effects.

March 6, 2005

Implementing a 48 h EWTD-compliant rota for junior doctors in the UK does not compromise patients' safety: assessor-blind pilot comparison.

February 25, 2009

Patient safety and quality improvement education: a cross-sectional study of medical students' preferences and attitudes.

April 24, 2013

Failure to follow medication changes made at hospital discharge is associated with adverse events in 30 days.

June 17, 2020

Standardization of compounded oral liquids for pediatric patients in Michigan.

August 31, 2016

Resident participation does not affect surgical outcomes, despite introduction of new techniques.

September 22, 2010

Paper- and computer-based workarounds to electronic health record use at three benchmark institutions.

April 3, 2013

The prevalence of wrong level surgery among spine surgeons.

January 30, 2008

Patient safety attitudes of paediatric trainee physicians.

January 6, 2010

Examining the diagnostic justification abilities of fourth-year medical students.

November 7, 2012

Root-cause analysis: swatting at mosquitoes versus draining the swamp.

March 22, 2017

The 100,000 Lives Campaign: crystallizing standards of care for hospitals.

November 23, 2005

Systems analysis of adverse drug events.

March 27, 2005

Comparison of potential risk factors for medication errors with and without patient harm.

August 18, 2010

Unrealized potential and residual consequences of electronic prescribing on pharmacy workflow in the outpatient pharmacy.

July 9, 2014

Voluntary medical incident reporting tool to improve physician reporting of medical errors in an emergency department.

February 17, 2016

Feedback from incident reporting: information and action to improve patient safety.

March 11, 2009

Inter- and intra-rater reliability for classification of medication related events in paediatric inpatients.

June 21, 2006

Protocol-based computer reminders, the quality of care and the non-perfectability of man.

November 22, 2006

The critical incident technique.

March 27, 2005

Undertaking risk and relational work to manage vulnerability: acute medical patients' involvement in patient safety in the NHS.

March 15, 2023

Assessing patient safety culture in hospitals across countries.

May 15, 2013

Can the aviation industry be useful in teaching oncology about safety?

December 6, 2017

Related Resources

Discharge from Mental Health Care: Making it Safe and Patient-centred.

April 17, 2024

Should dignity preservation be a precondition for safety and a design priority for healing in inpatient psychiatry spaces?

April 10, 2024

Exploring safety culture within inpatient mental health units: the results from participant observation across three mental health services.

April 3, 2024

WebM&M Cases

Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation

March 27, 2024

Implementing and evaluating patient-focused safety technology on adult acute mental health wards.

March 13, 2024

Anticipating patient safety events in psychiatric care.

February 7, 2024

Supporting carers to improve patient safety and maintain their well-being in transitions from mental health hospitals to the community: a prioritisation nominal group technique.

August 16, 2023

Why stigma matters in addressing alcohol harm.

August 9, 2023

Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency department.

July 26, 2023

WebM&M Cases

The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.

June 14, 2023

Analysis of reported suicide safety events among veterans who received treatment through Department of Veterans Affairs-contracted community care.

May 24, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Care Delivery within Community Mental Health Teams.

April 5, 2023

WebM&M Cases

Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities.

March 29, 2023

Few hospitals are willing to bear the cost of providing psychiatric care for kids.

March 22, 2023

Use of complete medication history to identify and correct transitions-of-care medication errors at psychiatric hospital admission.

February 15, 2023

Conceptual and practical challenges associated with understanding patient safety within community-based mental health services.

December 7, 2022

Influencing a culture of quality and safety through huddles.

November 9, 2022

Patients who die by suicide: a study of treatment patterns and patient safety incidents in Norway.

November 9, 2022

Spreading a strategy to prevent suicide after psychiatric hospitalization: results of a quality improvement spread initiative.

October 5, 2022

Addressing Burnout in the Behavioral Health Workforce through Organizational Strategies.

September 14, 2022

Developing and aligning a safety event taxonomy for inpatient psychiatry.

July 13, 2022

Is it time for the mental health field to consider unplanned discharge a key metric of patient safety?

May 4, 2022

Factors associated with workplace violence among healthcare workers in an academic medical center.

April 27, 2022

Investigating the impact of cognitive bias in nursing documentation on decision-making and judgement.

April 20, 2022

To what extent are patients involved in researching safety in acute mental healthcare?

April 6, 2022

Annual Perspective

Annual Perspective: Psychological Safety of Healthcare Staff

March 31, 2022

Patient safety and mental health-a growing quality gap in Canada.

October 6, 2021

Influence of organizational climate and clinician morale on seclusion and physical restraint use in inpatient psychiatric units.

September 1, 2021

Analysis of suicides reported as adverse events in psychiatry resulted in nine quality improvement initiatives.

July 21, 2021

See More About The Topic

Psychiatric Facilities

Nurses

Nurse Managers

Quality and Safety Professionals

Mental Health Care (Psychiatry and Clinical Psychology)

Barriers to the reporting of medication administration errors and near misses: an interview study of nurses at a psychiatric hospital.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Barriers to the reporting of medication administration errors and near misses: an interview study of nurses at a psychiatric hospital.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site