Medication Error Reporting Among Nurses in Ghana

Research Article
Medication Administration Error Reporting
Among Nurses: A Descriptive Qualitative Study
Dzidefo Tuvor,
1
Augustine Kumah ,
2
Rebecca Abiti,
1
Stephen Henry Afakorzi,
3
Peter K. Agbemade,
4
Christine Ahiale,
5
Mac Dzodzodzi,
6
Anthony Bless Dogbedo,
7
Adanu Peter Worlasi,
8
Emmanuel Obot,
3
Janet Mawunyo Tornyi,
9
Abdul-Razak Issah,
10
Innocent Dzubey,
9
Deborah Terkperkie Kanamitie
2
1
Nurses Training College, Ho, Ghana
2
Nyaho Medical Centre, Accra, Ghana
3
School of Public Health, University of Port Harcourt, River State, Nigeria
4
St Micheal’s Nursing and Midwifery Training College, Offinso-Kumasi, Ghana
5
Ghana Health Service, Accra, Ghana
6
Department of Health and Wellbeing, Leeds Beckett University, Leeds, UK
7
Consultant, Clinton Health Access Initiative (CHAI), Accra, Ghana
8
Faculty of Science, Eotvos Lorand University, Budapest, Hungary
9
School of Hygiene, Ho, Ghana
10
Department of Health Information Management, College of Health, Yamfo, Ghana
Address correspondence to Augustine Kumah ([e-mail]).
Source of Support: None. Conflict of Interest: None.
Submitted: Jul 20, 2024; First Revision Received: Dec 6, 2024; Accepted: Jan 5, 2025; First Published: Feb 20, 2025.
Tuvor D, Kumah A, Abiti R, et al. Medication administration error reporting among nurses: a descriptive qualitative study. Glob J
Qual Saf Healthc. 2025; XX:XX–XX. DOI: 10.36401/JQSH-24-33.
This work is published under a CC-BY-NC-ND 4.0 International License.
ABSTRACT
Introduction: Nurses are integral to the healthcare delivery team (multidisciplinary team). They are involved and play
vital roles with responsibilities to ensure the quality of healthcare for their patients. The key to those varied roles is the
administration of medication. Depending on the clinical setting, nurses spend up to 40% of their hours on medication
administration and its management processes. They are liable to identify and prevent medication administration errors
(MAEs) and their consequences. This study aimed to explore the barriers and facilitators to the reporting behavior for
MAEs among nurses in Ghana. Methods: A descriptive qualitative cross-sectional study was conducted among
nurses in a district catholic hospital in Ghana. The level of nurses’ knowledge of MAEs, causes of such errors,
barriers to reporting, and strategies for minimizing errors were assessed. Purposive sampling was used to select a
total sample of 20 nurses interviewed face-to-face using an in-depth method. The interviews were recorded,
transcribed, and analyzed thematically. Results: The study found that all nurses are aware of MAEs, which serve
as the basis for decision-making. However, some nurses do not report these errors when they occur. Factors such as
workload, stress and tiredness, staff shortage, difficulty calculating drug dosage, inadequate knowledge about
specific medications, distractions during administration, and patient-related factors were identified as common
causes of MAEs. The study also revealed that hospital management and the potential negative consequences of
reporting errors, such as unpleasant reactions, lawsuits, and loss of a job, are significant barriers to reporting.
Conclusion: Regular training workshops should be conducted to update nurses’ knowledge about the importance
of reporting medication errors, the reporting process, new medications and their administration, to develop a
policy document that promotes a nonblaming, nonpunitive, and supportive learning culture for MAE medic
reporting.
Keywords: medication administration, error reporting, patient safety, nurses, Ghana
INTRODUCTION
Medication administration errors (MAEs) are any act or
event that may lead to inappropriate administration of a
prescribed medication to a patient. Medication errors have
profound implications for patient safety. Globally, 5% of
MAEs result in death, and 50% may be prevented.
[1,2]
The National Patient Safety Agency has identified medica-
tion errors as a global burden, with administration
errors accounting for nearly 50%, dispensing errors for
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18%, and 16% being prescribing errors. In the United
States, it is estimated that MAEs cause the death of 7000
patients annually.
[3,4]
A Society of Actuaries Health Section
study used medical claim data to assess the cost of medical
errors in the United States.
[5]
The study found 6.3 million
measurable medical injuries in 2008, costing $19.5 billion.
This cost included direct medical costs for inpatient, outpa-
tient, and prescription drug services ($17 billion), indirect
medical costs related to increased mortality rate ($1.4 bil-
lion), and loss of productivity ($1.1 billion).
[2]
One cru-
cial strategy to reduce MAEs is the implementation of
error detection, which involves recognizing and report-
ing errors.
[6,7]
Reporting MAEs requires healthcare profes-
sionals to acknowledge and report these errors through
official channels.
Nurses are expected to administer medication, con-
sidering their knowledge of pharmacology and thera-
peutics. Patient safety has been a significant concern for
healthcare professionals and, more importantly, for
nurses. Most medication errors occur at the time of
administration.
[8]
MAEs have been noted and rated as
the most common error affecting patient safety and,
commonly, the most preventable error in the medical
setting. However, underreporting is expected because of
blame and adverse consequences, especially for hospital
nurses who administer most medications.
[9]
Nurses in
centralized and hierarchical units may hesitate to report
MAEs owing to potential reprisals or negative out-
comes.
[10]
In an unsupportive environment, nurses may
worry about being perceived as incompetent or trouble-
makers by their colleagues.
[6,7,11]
It is worth noting that
medication errors can occur among both newly gradu-
ated and experienced nurses, as shown in a study where
62.1% of newly graduated nurses and 57.3% of nurses
with at least 3 years of experience admitted making at
least one error during their careers.
[12]
Medication error reporting is necessary to appreciate
the extent and impact of MAEs. Nurses’ ability to detect
86% of medication errors was reported in a descriptive
cross-sectional study conducted in a large medical cen-
ter in southern Taiwan, which found a significance rate
of MAE reporting among nurses.
[6]
A study conducted
in Ethiopia indicated that the proportion of MAE
reporting among nurses was 57.4%.
[13]
Another study
conducted at the University of Gondar Referral Hospi-
tal, Ethiopia, revealed that the estimated MAE reporting
was 29.1%. The perceived rates of MAE reporting for
nonintravenous-related medications ranged from 16.8
to 28.6% and for intravenous-related medications, from
20.6 to 33.4%.
[14]
Several studies have shown a relationship between
the mix of nursing staff and medication errors.
[15–18]
They found that medication errors decrease as the pro-
portion of registered nurses in the staff mix increases.
However, the error rate rises when the proportion of
registered nurses exceeds 85% of the staff mix. Nursing
shortages have also been identified as contributing to
time constraints, affecting MAE reporting.
[15,19]
Addi-
tionally, individual factors such as lack of knowledge
related to medication errors, the perception that fixing
an error is easier than reporting it, and uncertainty
about which errors should be reported reduce the will-
ingness to report MAEs.
[3,16]
Reason’s model of accident causation suggests that active
failures by front-line individuals occur because of error-pro-
ducing conditions in their work environment.
[20,21]
The
model proposes that complex systems like hospitals have
inherent vulnerabilities that contribute to errors. Despite
the interventions and measures put in place by the Minis-
try of Health of Ghana and its related agencies, such as the
Nursing and Midwifery Council of Ghana, to improve
patient safety and quality of care, there is a lack of suffi-
cient data, surveys, and research to assess the prevalence of
MAE reporting that ensures a patient safety culture. There-
fore, this study aims to explore the barriers and facilitators
to the reporting behavior for MAEs among nurses in
Ghana.
METHODS
Ethical approval for this study was obtained from the
University of Ghana Institutional Review Board. In
addition, permission was sought from the hospital
management to allow participants (nurses) to access
face-to-face interviews for data collection. Nurses’ par-
ticipation in this study was strictly voluntary. Written
informed consent was obtained from all participants.
The general aim of the study was explained to the
recruited participants before they responded to the
questions. Participants were assured of strict confidenti-
ality, with all data anonymized and stored securely to
prevent identification. As such, pseudonyms (such as
Nurse 1, Nurse 2) were used during transcription, and
no personal identifiers were included in the final analy-
sis. To mitigate potential repercussions, participants
were informed that the study aimed to understand sys-
temic issues rather than assign individual blame. Addi-
tionally, participants were allowed to withdraw at any
stage without penalty.
Study Design
This study used a descriptive qualitative cross-sec-
tional approach. The qualitative approach was chosen
to gain in-depth insights from participants on medica-
tion error reporting and factors contributing to MAEs.
Study Population
The study was conducted at a district catholic hospital
in the Volta region of Ghana, a general hospital in the
Konda community of Kpando Township. The hospital
has a 163-bed capacity and an average annual admission
of 8480. The population for this study comprised profes-
sional nurses, which include registered general nurses,
nurse-assistant clinical nurses, ophthalmic nurses, mental
2Tuvor et al: Medication administration error reporting
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health nurses, and nurse practitioners. Using this popula-
tion for the study is essential because nurses are the pro-
fessionals who administer medications directly to the
patient and are involved in patient care. Nurses directly
involved in patient care and who had been employed for
more than 6 months were recruited. A purposive sam-
pling technique was used to select nurses that could par-
ticipate in the study to ensure they directly experienced
the phenomena under study, minimizing variability. The
sample size of 20 nurses was determined from the princi-
ple of data saturation, where no new themes or insights
emerged from subsequent interviews. Data saturation was
achieved through the iterative process of data collection
and analysis. Initially, 20 interviews were conducted, with
each session transcribed and analyzed for recurring pat-
terns and themes. As interviews progressed, no new
themes or significant insights emerged, indicating that
the data had reached saturation. This was confirmed
through continuous comparison of new data with previ-
ously collected information. The decision to stop data col-
lection was based on the redundancy of responses, with
themes and patterns becoming consistent across partici-
pants. This ensured that the study captured the full range
of perspectives necessary for comprehensive thematic
analysis.
Data Collection and Analysis
Data were primarily collected by using a structured inter-
view guide based on the research objectives. Face-to-face,
in-depth interviews were conducted with the assistance
of trained research assistants. The interview guide was
structured to explore participants’ experiences and per-
ceptions regarding MAEs and their reporting behaviors.
It included open-ended questions designed to elicit in-
depth responses. Key questions focused on understand-
ing nurses’ knowledge of MAEs, such as “Can you
describe what constitutes a medication administration
error?”Other questions explored barriers to reporting
errors; for example, “What factors prevent you from
reporting medication errors?”“How do you perceive the
consequences of reporting an error?”Additionally, the
guide addressed strategies for minimizing MAEs, such as
“What kind of training or support would help you avoid
medication errors?”The interviews were audio-recorded,
each lasting approximately 30–45 minutes.
The interviews were transcribed and analyzed the-
matically. The coding of interviewees’ answers fol-
lowed a systematic thematic analysis approach. First,
all audio-recorded interviews were transcribed verba-
tim to ensure accuracy. The transcripts were read mul-
tiple times to familiarize the researchers with the data.
Open coding was used to identify initial codes based
on recurring words, phrases, and ideas. These codes
were then grouped into categories reflecting broader
patterns. Axial coding was used to refine categories
and explore relationships among them. Finally, selec-
tive coding was used to identify overarching themes.
Coding was conducted manually and verified indepen-
dently by two researchers to enhance reliability and
reduce subjective bias in interpretation.
RESULTS
The participants were between 20 and 40 years of age,
with the majority (65%, n¼13) being women who had
worked between 1 and 5 years (Table 1). All the nurses
interviewed had basic nursing qualifications, with most
having a diploma in nursing.
Level of Knowledge on Medication
Administration Errors (MAEs)
The study found that all 20 respondents were cogni-
zant of MAEs in their day-to-day work. They were all
aware that there is a high likelihood of preventing
MAEs if proper directions are given. The following
quotes were provided by the participants.
“As a nurse, an error is committed when you administer the
wrong drug to the right patient or wrong patient, using a
wrong dose and wrong route at the wrong time. For instance, if
a doctor prescribes IV gentamycin to be given in 72 hrs, then
the nurse serves a different medication, let say, IV
promethazine, without detecting it, then an MAE occurs. Or
an antihypertensive was prescribed to be given to patient A,
and it was mistakenly given to B.”
Table 1. Sociodemographic characteristics of respondents
(N¼20)
Characteristic Frequency (n)
Age, y
20–30 12
31–40 8
40 0
Sex
Male 7
Female 13
Marital status
Married 8
Single 12
Level of education
Certificate 6
Diploma 8
Degree (BSN) 3
Certificate in Midwifery 3
Number of years working as a nurse
1–5 13
6–10 6
11–15 1
Area of work
Pediatric ward 4
Surgical ward 8
Emergency ward 4
Maternity or labor ward 3
General ward 1
Employment status
Permanent 20
Contract 0
Research Article 3
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“A medication error occurs when a professional nurse administers
a medication to a patient through a wrong dose or dosage, wrong
time, wrong patient and wrong route of administration and not
observing the 10 Rs of medication (10 rights of medication).”
The 10 Rs mentioned are the right patient, time, med-
ication, dose or dosage, and route. Others are right for
patient refusal, right to client or patient administration,
right assessment, and right evaluation.
Types of MAEs
The respondents were also asked to describe the types of
MAEs that warrant reporting. The MAEs mentioned include
prescribing errors, omission errors, wrong time errors, unau-
thorized drug errors, dose errors, dosage form errors, drug
preparation errors, route of administration errors, adminis-
tration technique errors, deteriorated drug errors, monitor-
ing errors, and compliance errors. Definitions for each type
of MAE are presented in Table 2.
[22]
The study found that
one or more nurses had committed one or more of these
errors. A respondent had the following comment:
“I committed an error where I mistakenly served intravenous
cefuroxime for intravenous ceftriaxone because they come in a
similar vial (resemblance error).”
Causes of MAEs
Identifying the factors that increase the potential of
MAEs is needed to address how best to overcome these
problems to guarantee patient safety. The findings from
the study show that workload, stress and tiredness, staff
strength, inability to calculate drug dosage, poor knowl-
edge of some medications, distractions during medica-
tion administration, and patient-related factors are the
most common factors that contribute to an MAE. Below
are comments provided by the respondents:
“When you are alone on duty, and you have so many patients to
attend to, you will be in a hurry to complete your task and thereby
commit [a medication administration error because of] poor
knowledge on the medication prescribed, inability to calculate the
right dose, and resemblance of two or more medications.”
“Workload, stress from the work, tiredness, fewer staff caring
for a huge number of clients, and distraction during
medication [administration] like phone calls are factors that
contribute to medication errors.”
Reporting MAEs
The study found that some nurses do not report
MAEs when they occur; only a few nurses report such
errors. For example, one respondent shared:
“I have observed a colleague who administered the wrong
medication to a patient before (IV 1/5 normal saline in 4.3%
dextrose), but the nurse in question served IV fluid 10%
DEXTROSE SALINE, and the child ran into hyperglycaemia,
but we corrected it by giving iv fluid normal saline.”
Barriers to MAE Reporting
The study revealed that hospital management and fear
of the consequences of reporting errors are significant
Table 2. Types of medication errors
Medication Error Description
Prescribing error This occurs if there is an inappropriate drug product choice. This is built on warnings, contraindications,
known allergies, existing drug therapy, and other factors (dose, dosage form, quantity, route of
administration, concentration, rate of administration, etc).
Omission error When a nurse fails to administer an ordered dose to a patient before the next scheduled dose or fails to
prescribe a drug product indicated for the patient.
Wrong time error When a nurse administers medication outside a predefined time interval from its scheduled administration
time (each healthcare facility should establish this interval).
Unauthorized drug error Occurs when a nurse administers medication to a patient not authorized by a legitimate prescriber.
Drug dose error Dispensing or administering a dose greater than or less than the amount ordered by the prescriber or
administering multiple doses to the patient is another common error described as a dose error.
Dosage form error Occurs during administration to the patient of a drug product in a dosage form other than that ordered by
the prescriber.
Drug preparation errors Drug products incorrectly formulated or manipulated before dispensing or administration are also an error.
Wrong route error Administration of the correct drug occurs through the wrong route of administration of the correct drug.
Thus, intravenous (IV) medication is given through the oral route (mouth).
Administration technique error It occurs when an inappropriate procedure or improper technique is used in administering a drug other
than the wrong route.
Deteriorated error Administration of a drug that has expired or for which the physical or chemical dosage-form integrity has
been compromised is described as a deteriorated error.
Monitoring error Failure to review a prescribed regimen for appropriateness and detection of problems and to use appropriate
clinical data to adequately assess patient response to prescribed therapy is another administration error.
Compliance error Compliance error also refers to inappropriate patient behavior regarding adherence to a prescribed
medication regimen.
Based on information from Aronson JK.
[22]
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barriers hindering nurses from reporting MAEs. Respon-
dents echoed this as shared below:
“Fear of job loss and license to practice are the major reasons
medication reporting errors are concealed and not reported.”
“Fear for being [subjected to] a management audit and
subsequent lawsuit and withdrawal of practising license.”
Fear of Consequences for Reporting MAEs
Fear of the consequences of reporting MAEs was a major
barrier. The respondents had this to say:
“Fear of litigation, negative reaction from in-charge/nurse
manager or superior, and lack of confidentiality.”
“Fear forms the basis of all the barriers to non-reporting of MAE,
e.g., fear of litigation, embarrassment, lack of confidentiality,
and victimization of the one who commits the error.”
“Lack of confidentiality; when you report, everyone, including
patients and their relatives, will get to know. And guess the
negative tag they will put on you; some might even sue you
because they are knowledgeable about the issue and impact on
their health now.”
Enhancing MAE Reporting by Nurses
The study revealed the need for a system put in place
by management to record medication errors when
patients experience them. Despite the high occurrence
of medication errors, reporting is often done informally.
For instance, errors are mainly discussed verbally with-
out any proper records of such events. However, ave-
nues for patient safety enhancement may be limited
without formal written reports on medication errors.
The respondents had the following suggestions.
“Getting a reporting form, teaching all staff during orientation
for nurses, removing the fear of reporting and its consequences
like litigation and embarrassment, encouraging nurses to
report their MAE freely, and [keeping the information]
confidential by the in-charges ... .”
“Regular in-service training on medication administration and
reporting [would] ensure confidentiality to those who report,
improve staff strength, and empower staff to perfectly and
efficiently report MAEs.”
DISCUSSION
The National Coordinating Council for Medication Error
Reporting and Prevention states that a medication error is
any preventable event that may cause or lead to inappropri-
ate medication use or patient harm.
[23]
Because all respon-
dents were knowledgeable about MAEs, this knowledge
may provide a basis on which quality improvement
decisions may be implemented, a lack of which may result
in poor decision-making. Other studies have identified a
knowledge deficit in determining the correct dose and pre-
venting medication errors.
[6,16,17]
MAEs may be avoided by
giving proper directions; however, some MAEs are related
to professional practice, healthcare products, procedures,
systems, prescribing, order communication, product label-
ling, packaging, nomenclature, compounding, dispensing,
administration, education, and monitoring.
[23]
Our study findings are also consistent with others that
identified system failures or omissions and failure of health
professionals themselves as the major contributing factors
to MAEs.
[18,24–26]
System characteristics such as being
understaffed, poor communication, vague authorization,
an inadequate system of error information exchange, and
an increase in high-risk patients contribute to creating
error-prone hospital surroundings, as do workload and staff-
ing levels, factors that have been shown to affect the rate of
MAEs.
[20,27,28]
Insufficient training and staffing issues have
been identified as critical barriers to error reporting, particu-
larly in resource-constrained environments.
[9]
Poor adherence to medicines policy and lack of compli-
ance with prescriptions ordered by medical professionals
also may contribute to medication errors.
[17,27]
Inadequate
knowledge and lack of pharmacology education among
nurses are other barriers to effective medication administra-
tion.
[18,26]
Thus, it is imperative to create a conducive atmo-
spheretoeducatenursesonwaysandmeanstoreduce
medication errors in their day-to-day care of patients.
Although nurses have an obligation to reduce MAEs,
our study found that most nurses do not report MAEs
when they occur. Another study reported only 20% of
MAEs were reported by nurses.
[24]
Because patient safety is
paramount to the contemporary healthcare delivery
framework and a vital indicator of healthcare effective-
ness, we sought to identify barriers to MAE reporting. We
found that attitudes of hospital management and fear of
consequences are significant barriers hindering nurses
from reporting MAEs. Nurses are afraid of job threats, legal
liability, adverse economic effects, face-saving issues, and
other adverse consequences of reporting. Nurses believe
that reporting medication errors leads to blaming col-
leagues instead of the system, subsequent reporting errors,
and fear of reprimand and punishment. This finding is
consistent with earlier studies, which found that nurses
consider positive or negative consequences before report-
ing MAEs.
[1,6]
If hospital management provides a support-
ive atmosphere for nurses who commit medication errors,
then nurses will be at ease in reporting any error they
commit when administering medications to patients.
ThebarrierstoMAEreportingidentifiedinthisstudy—
fear of punishment, lack of training, and inadequate staff-
ing — interact in complex ways that hinder reporting
behaviors. Fear of punishment, including concerns about
job loss or legal consequences, creates a climate of silence,
particularly when errors are perceived as blameworthy.
This fear is exacerbated by inadequate training, which
Research Article 5
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