Examining the factors that influence medication administration errors and the reporting of these among mental health nurses in the hospital setting: a systematic review

Abstract

A medication administration error is defined as ‘any difference between what the patient received or was supposed to receive and what the prescriber intended in the original order’. Medication administration errors are associated with increased morbidity and mortality. They occur frequently in the mental health setting and pose a serious risk of patient harm. The factors leading to medication administration errors in the mental health care setting is under researched and the potential for mental health services to prevent harm from medication administration error is unknown. The aim of this study was to understand factors that influence medication administration errors, and the reporting of these, among mental health nurses in the mental health hospital setting. A systematic review was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (2015) checklist. A total of 3625 studies were identified, nine of which were included for final review. The CINAHL, Cochrane, EMBASE, Medline, Medline Ovid, Psych Info and PubMed databases were searched, as well as grey literature. Medication administration errors and their reporting are complex, multifaceted and show organisational and individual overlap. Heavy workload, staffing shortages, differing levels of experience, ward dynamics, lack of knowledge, interruptions, communication and patient interaction contributed to the occurrence of medication administration errors. Key factors included rationale on why not to report an error, lack of knowledge regarding how to report, what to report, as well as fear and stigma. Many factors lead to the occurrence of a medication administration error or why they are not reported. More education is needed to help reduce medication administration errors. Further research may understand the behavioural patterns of mental health nurses and at-risk behaviour. This may help identify adequate interventions to reduce the risk of medication administration errors in this setting.