No-Blame Medication Administration Error Reporting by Nursing Staff at a Teaching Hospital in Australia

Abstract

The medication administration error rate on a surgical ward in an Australian teaching hospital was determined using a “no-blame” self-reporting method. The self-reported error rate using the existing ward stock (WS) drug distribution system was determined over a 23-day period. After the ward underwent a number of interventions designed using failure mode and effects analysis (FMEA), a method of systems analysis employed to assess a process and identify problem areas that might lead to errors, the “no-blame” self-reported error rate was again assessed, over a 31-day period. The no-blame aspect of the study was emphasised during all education sessions prior to the study commencing. All reports, made on a simple form designed specifically for the study, were reviewed and collated by a pharmacist in a non-punitive manner. During the WS phase of the study, 182 errors were reported, compared with 170 in the FMEA phase. The error rate was 3.3 per cent of doses administered for the WS system and 2.3 per cent for the FMEA system. The difference between the two phases was found to be significant (P<0.001). These results show an error rate less than that previously found using a direct observation technique. However, used in conjunction with the disguised-observer technique, the no-blame self-reporting method may be a useful part of a continuous error detection process in hospitals.