International Journal of Africa Nursing Sciences 17 (2022) 100504

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International Journal of Africa Nursing Sciences

journal homepage: www.elsevier.com/locate/ijans

Nurses’ perceptions of medication administration safety in public hospitals

in the Gauteng Province: A mixed method study
Alwiena J. Blignaut a, *, Siedine K. Coetzee b, Hester C. Klopper c, Suria M. Ellis d
a
School of Nursing Science, North-West University, South Africa
b
Albertina Sisulu Research Chair in Nursing Science, NuMIQ Research Unit, North-West University, South Africa
c
Department of Global Health, Stellenbosch University, South Africa
d
Statistical Consultation Service, North-West University (Potchefstroom Campus), South Africa

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Limited data on factors perceived to impact on medication administration errors and possible so­
Medication administration errors lutions to such errors in low- and middle-income settings like South Africa is available.
Low- and middle-income countries Methods: A mixed-methods research design was used. Data were gathered from 280 medication administrators
Medication safety
using self-report surveys, and 15 nursing unit managers using semi-structured individual interviews.
Causes
Solutions
Results: Causes of medication error related to communication, human, environmental and medication factors
were considered to have a moderate risk. Workload (M = 3.39; SD 0.91), stock problems (M = 3.18; SD 0.96) and
illegible prescriptions (M = 3.05; SD 1.09) pose the greatest threats to medication administration safety. Most
participants (n = 184; 71.1 %) agreed that medication errors never or rarely occurred in their units. The majority
of respondents graded overall patient safety as excellent or very good (n = 161; 61.5 %). On safety culture,
nurses felt that they are actively attempting to improve medication safety (n = 239; 90.5 %), that people support
one another in the unit (n = 216; 80 %), and that their procedures and systems are good at preventing errors (n
= 210; 80.2 %). Participants felt that medication administration errors were rarely reported, mostly due to fear
and administrative response. Qualitative findings supported the quantitative data, adding knowledge, skill and
attitude of staff as further threats to medication administration safety. Adherence to protocols, auditing, edu­
cation and training, collaboration and support, communication, awareness of changes, resource management and
time management were identified as possible mitigating factors.
Conclusions: Solutions aimed at preventing medication errors should be based on causes identified within a
specific context. In the Gauteng Province, multidisciplinary collaboration and communication; support of nurses
by the hospital administration; hospital systems, procedures and initiatives; better resource management and
improved pharmacological training could be seen as the foundation for improved medication administration
safety.

1. Introduction problem is deemed so detrimental that the World Health Organization

(WHO, 2020a) launched a “Medication Without Harm” campaign as the
Globally, the cost associated with medication errors has been esti­ third Global Patient Safety Challenge.
mated at well over 40 billion dollars annually (World Health Organi­ Identifying causes of medication error may contribute towards
zation [WHO], 2020a). This monetary loss is anything but negligible, addressing this challenge. Numerous factors can contribute to medica­
but an even worse consequence of these errors at hospitals is that they tion errors, including communication, human, environmental and
could harm patients rather than being of benefit to them, sometimes to medication-related factors (Blignaut et al., 2017; Blignaut, 2016).
the degree of loss of life (Blignaut et al., 2017; Blignaut, 2016). This Attempting to provide an estimate of the problem, a systematic

Abbreviations: AHRQ, Agency of Healthcare Research and Quality; ANOVA, analysis of variances; COREQ, Consolidated Criteria for Reporting Qualitative Studies;
NWU, North-West University; RN4CAST, Registered Nurse Forecast; SA, South Africa; SPSS, Statistical Package for the Social Sciences; STROBE, Strengthening the
Reporting of Observational Studies in Epidemiology; WHO, World Health Organisation.
* Corresponding author at: Private Bag X6001, North-West University (Potchefstroom Campus), School of Nursing Science, Potchefstroom 2531, South Africa.
E-mail address: [email protected] (A.J. Blignaut).

https://doi.org/10.1016/j.ijans.2022.100504
Received 13 May 2022; Received in revised form 20 October 2022; Accepted 24 October 2022
Available online 7 November 2022
2214-1391/© 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
A.J. Blignaut et al. International Journal of Africa Nursing Sciences 17 (2022) 100504

review of 91 studies was conducted and a median medication error 2.4. Population and sampling
incidence of 19.6 % of total opportunities for error was calculated (Keers
et al., 2013). However, most studies included were from high-income Multi-level sampling was applied. Proportionate sampling of hospital
countries, raising concern that fewer data are available from low- and levels was conducted: From 27 public hospitals in Gauteng Province two
middle-income countries, where the incidence of errors tends to be tertiary hospitals, three provincial hospitals and three district hospitals
higher (Blignaut et al., 2017; Keers et al., 2013). were included (n = 8). An all-inclusive sample of medication adminis­
Overall safety culture and reporting systems of a unit impact on the trators (professional, enrolled [two-year diploma] and student nurses) in
incidence of medication error (Baraki et al., 2018). Reporting systems medical and/or surgical units, working on all shifts within a two-week
mitigate the risk of repeated errors, underlining the need for safe routes period at these hospitals, was selected to complete surveys (N = 683).
for nurses to report errors and near-misses (Hammoudi et al., 2018). A sample size of 247 was determined to be adequate with a 5 % error
Globally, interventions to mitigate medication administration errors margin and 5 % level of significance (Lenth, 2018). Two nursing unit
are either focused on improving the nurse’s ability to administer managers from each hospital, from a randomly selected medical and a
medication safely or enhancing the environment to limit the risk of er­ randomly selected surgical unit were also interviewed (N = 16).
rors. Examples of such interventions include training (Dagne &
Mekonnen, 2021), strict adherence to protocols such as double-checking 2.5. Data collection
(Kadang, Sitanggang, Sanjun, Sitanggang, & Sakti, 2021), supportive
pharmacy services (Kwong & Fong, 2020), and workplace culture in­ Quantitative data collection was done by means of a self-
terventions ranging from communication-interventions to workload administered survey. Sufficient surveys together with informed con­
guidelines (Gorgich, Barfroshan, Ghoreishi, & Yaghoobi, 2016). sent forms were left with the unit manager for all four the rotating shifts
Although evidence of an abundance of these mitigating interventions of his/her unit. An opaque fabric bag with a post-split was put up in a
exists (Lee, 2017), the practice setting dictates the effectiveness of such central area of each participating unit where participants could post
interventions (Berdot et al., 2016). Further limiting the effectiveness of their surveys and completed informed consent forms in two different
interventions, research within the African continent on addressing the envelopes that were provided. This bag remained in the unit for two
medication administration error problem is limited (Wondmieneh et al., weeks to allow enough time for all medication administrators from all
2020). As the theoretical framework set by the WHO research cycle for shifts to complete the survey. The data collector then collected the bags
patient safety, where determining causes of a patient safety concern from the different units after the two weeks had lapsed. This day of
should precede attempts to develop solutions for that concern within a collection was indicated on each bag.
given context (WHO, 2020b) dictates, this research not only adds to the The following elements were included in the survey:
limited research available on developing country medication safety The Causes of Medication Administration Errors Survey (Blignaut,
challenges, but also provides the international readership with percep­ 2016) has four subscales, namely: communication (10 items); human
tions on possible solutions from the nursing managers engaged directly factor (11 items); environment (14 items); and medication-related (10
with these challenges. items) causes of medication error. These were measured on a four-point
Likert scale from ‘No risk’ (1) to ‘Significant risk’ (4).
2. Methods Two questions were derived from the Registered Nurse Forecast
(RN4CAST) survey. One seven-point Likert scale item, ranging from
2.1. Aim ‘Never’ (1) to ‘Every day’ (7), determined perceptions of medication
error incidence in the unit. Another five-point Likert scale item, ranging
The aim of this study was to determine perceived factors impacting from ‘Excellent’ (1) to ‘Failing’ (5), determined respondents’ grade for
on medication administration errors, and possible solutions to these, overall patient safety in the unit (Sermeus et al., 2011).
according to nurses in the medical and surgical units of public hospitals The following section of the survey originated from the Agency of
in Gauteng Province of South Africa (SA). Healthcare Research and Quality (AHRQ) Hospital Survey on Patient
Safety Culture. Seventeen five-point Likert scale items, ranging from
‘Strongly disagree’ (1) to ‘Strongly agree’ (5), represented five patient
2.2. Design
safety culture composites in the unit, comprising non-punitive response
to errors (three items); organisational learning (two items); overall
A mixed-methods sequential explanatory design was employed. The
perceptions of patient safety (four items); staffing (four items); and
quantitative phase applied a cross-sectional survey design conducted
teamwork (four items). Also drawn from the AHRQ survey, incidence of
according to Strengthening the Reporting of Observational Studies in
reporting in the unit consisted of three five-point Likert scale items,
Epidemiology (STROBE) guidelines (Cushieri, 2019), while the quali­
ranging from ‘Never’ (1) to ‘Always’ (5) (Sorra et al., 2016). A fourth
tative phase used a qualitative descriptive inquiry with individual semi-
item was added to this subscale by the researchers to determine the
structured interviews according to Consolidated Criteria for Reporting
perception of incidence of reporting errors which caused harm to a
Qualitative Studies (COREQ) guidelines (Booth et al., 2014).
patient.
Lastly, from the Medication Administration Error Reporting Survey
2.3. Study setting (Wakefield et al., 2005), 16 six-point Likert scale items, ranging from
‘Strongly disagree’ (1) to ‘Strongly agree’ (6), representing four different
This study was conducted in the Gauteng Province of South Africa, subscales of reasons for non-reporting of medication errors were
the province containing the largest proportion of SA’s population with included. Subscales comprised disagree with definition of medication
the highest concentration of hospitals. SA has a two-tiered, and unequal, error (four items); reporting effort (two items); fear (five items); and
healthcare system (Rensburg, 2021). The private sector is largely funded administrative response (four items).
through individual contributions to medical aid schemes or health in­ Qualitative data was collected by means of semi-structured individ­
surance while the public sector is state-funded and caters to the majority ual interviews conducted by the researcher. Interviews took an average
(71 %) of the population (Rensburg, 2021; StatsSA, 2018). The public of 20 min to complete and was conducted within the units of the unit
sector is underfunded while most South Africans cannot afford private managers interviewed, in a room chosen by respective unit managers.
care (Rensburg, 2021). This sector consists of three levels of care, This ensured a private and interruption-free environment.
namely tertiary, provincial and district hospitals (Malakoane et al., The four fundamental epistemological standards listed by Lincoln
2020). and Guba (1985) were applied to ensure the trustworthiness of this

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A.J. Blignaut et al. International Journal of Africa Nursing Sciences 17 (2022) 100504

study. Strategies applied included triangulation of method and source, determined by exploratory and confirmatory factor analysis. The Kaiser-
prolonged engagement, peer debriefing, member checking, saturation of Meyer-Olkin measure of sampling adequacy and goodness-of-fit mea­
data and use of a co-coder. sures for all subscales were deemed acceptable. Cronbach’s alpha was
The top three causes of errors in medication administration were calculated to determine the reliability of subscales and compared to
identified from the results of the survey, and these were followed-up those obtained in previous studies (Table 1).
with probing questions. The semi-structured individual interview In the context of SA only two subscales (‘Teamwork’, and ‘Non-pu­
schedule comprised the following questions: nitive response to error’) of the AHRQ composite concerning safety
culture reflected acceptable reliability. All other subscales of this com­
1. In your opinion, what are the main causes of medication errors in posite were therefore reported as individual items.
your unit? For the qualitative findings, inductive thematic content analysis was
2. How can this risk be limited? used as proposed by Cresswell (2009) using the following steps: Orga­
3. High workload, stock distribution problems and illegible pre­ nise and prepare, develop a general sense, code the data, describe and
scriptions were identified as the main causes of medication errors. identify themes, represent findings and interpret the data.
What can be done to lessen the staff’s workload?
4. What can be done to limit stock distribution problems?
2.7. Ethical considerations
5. What can be done about illegible prescriptions?
6. Is there anything else you would like to add with regard to improving
Ethical clearance was granted by the North West University and the
medication administration safety?

Table 2
A pilot interview was conducted (not included for analysis) with a
Means and standard deviations of individual items and subscales.
professional nurse to assess the clarity of the questions and the time­
frame needed for interviews. No changes to the interview schedule were Individual items and Description of scale Mean Standard
factorable subscales Deviation
deemed necessary. Two participants agreed to be interviewed, but did
not give consent for audio recording thereof, so detailed notes were Communication related Causes subscale: Four- 2.51 0.786
causes of medication errors point scale: No risk (1) to
made on these interviews. Recordings of the other interviews were
Human factors causing Significant risk (4) 2.46 0.988
transcribed verbatim. Data were collected from April to August 2014. medication administration
errors
Environmental causes of 2.89 0.723
2.6. Data analysis
medication administration
errors
Data were analysed using the computer software program Statistical Medication related causes of 2.52 0.811
Package for the Social Sciences Version 23 (SPSS Inc., 2016). De­ medication errors
mographics and the results of scales were presented using descriptive Incidence of medication RN4CAST Individual Item: 2.37 1.336
administration errors Seven-point scale: Never
statistics (means, frequencies, percentages and standard deviations). In
(1) to Every day (7)
addition, the relationships between the main study variables were tested Overall grade on medication RN4CAST Individual Item: 2.18 0.890
using Spearman’s rank-order correlations, while associations between administration safety Five-point scale: Excellent
the personal and situational demographics and the main study variables (1) to Failing (5)
We have enough staff to AHRQ safety culture 1.76 1.026
were tested using Spearman’s rank-order correlations, t-tests, analysis of
handle the workload individual items: Five-
variances (ANOVAs) and effect sizes. The validity of the instrument was Staff work longer hours than point scale: Strongly 3.74 1.145
is best for patient care disagree (1) to Strongly
Table 1 We are actively attempting to agree (5) 4.20 0.805
improve medication safety
Cronbach alphas for the subscales of the instrument.
We use more temporary staff 1.83 1.127
Origin / portion Subscale Cronbach alpha than best for patient care
Mistakes have led to positive 3.62 1.071
Previous Current
changes here
study study
It is just by chance that more 3.45 1.234
Demographics Not applicable Not applicable serious medication
Derived from Communication-related – 0.89 administration mistakes
systematic review causes of medication error don’t happen around here
Human factor-related causes – 0.95 We work in “crisis mode” 3.78 1.167
of medication error doing too much, too
Environment-related causes – 0.80 quickly
of medication error Safety is never sacrificed to 3.37 1.259
Medication-related causes of – 0.92 get more work done
medication error We have medication 2.44 1.278
RN4CAST Incidence of medication Not applicable – single administration safety
errors item problems
RN4CAST Grade on overall patient Not applicable – single Our procedures and systems 3.96 1.026
safety item are good at preventing
AHRQ survey Teamwork within units 0.79 0.69 errors
Non-punitive response to 0.78 0.56 Teamwork within units AHRQ Safety Culture 3.79 0.858
error Non-punitive response to Subscales: Five-point 3.16 0.967
Organizational learning 0.71 0.43 error scale: Never/strongly
Staffing 0.62 0.30 Incidence of reporting disagree (1) to Always/ 3.27 1.271
Overall perceptions of patient 0.74 0.15 strongly agree (5)
safety Disagreement with the Reasons on non-report: 2.28 1.153
AHRQ survey Incidence of reporting 0.85 0.89 definition of medication Six-point scale: Strongly
Wakefield survey Disagree with definition 0.77 0.74 error disagree (1) to Strongly
Reporting effort 0.87 0.75 Reporting effort agree (6) 2.46 1.510
Fear 0.86 0.83 Fear 3.47 1.487
Administrative response 0.77 0.76 Administrative response 3.42 1.370

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A.J. Blignaut et al. International Journal of Africa Nursing Sciences 17 (2022) 100504

Gauteng Department of Health. Goodwill consent was provided by each = 60; 23.2 %) or occurring a few times a year or less in their units (n =
of the participating hospitals. The researchers sought to comply with 124; 47.9 %). Only four respondents (1.5 %) perceived that medication
sound ethical principles, including respect, scientific merit and integrity, errors could occur in their units every day.
distributive justice, and beneficence in all aspects of the study The majority of respondents perceived the overall grade of patient
(Department of Health, 2015). safety as excellent or very good (n = 161; 61.5 %).
Three safety culture items related to staffing shortages triggered
2.8. Findings concern: 83 % (n = 230) of respondents disagreed that there are enough
staff to handle the workload, 72.3 % (n = 190) agreed that they work in
From 683 survey distributed, two hundred and eighty (280) “crisis mode”, doing too much, too quickly, and 70.5 % (n = 186) agreed
completed surveys were returned, a 41 % response rate. Surveys with that staff work longer hours than is best for patient care. However, on
few missing responses were still included, reporting only valid per­ the positive side, nurses felt that they are actively attempting to improve
centages. In terms of the interviews, although data saturation was medication safety (n = 239; 90.5 %), that people support one another in
reached after ten interviews, five more were conducted (n = 15) to the unit (n = 216; 80 %), and that their procedures and systems are good
ensure that no new data emerged. at preventing errors (n = 210; 80.2 %).
Most degrees of error severity were only reported sometimes,
2.9. Demographics although the errors that could cause harm to the patient were reported
more often, albeit not always. A quarter of participants (n = 60; 26 %)
Most participants were female (n = 220; 89.8 %), professional nurses perceived that medication errors that cause harm to patients were never
(n = 120; 51.3 %) with a 4-year diploma in nursing (n = 113; 48.3 %) or rarely reported, while 32.9 % (n = 77) perceived that errors that
and permanently employed (n = 236; 94.4 %). The largest proportion of could potentially harm the patient were never or rarely reported.
respondents were aged 35–45 years (n = 98; 43.2 %) and had 5–9 years The main reasons for not reporting medication errors were fear and
of working experience in the current hospital (n = 124; 59.6 %). administrative response, where the following items were rated highest:
nurses are blamed if something happens to patients (M = 4.47; SD 1.84),
2.10. Descriptive statistics individuals rather than systems are implicated for errors (M = 4.10; SD
= 1.93), and the patient or family may develop a negative attitude to­
Table 2 presents responses for individual items and subscales. ward the nurse (M = 4.05; SD 2.02).
Causes of medication error related to communication, human,
environmental and medication-related factors were considered to have a 2.11. Correlations between individual items and subscales
moderate risk, with the following causes being the most common: high
patient-to-nurse-ratio (M = 3.44; SD 0.87), work overload (M = 3.39; SD Table 3 presents the correlations between the different individual
0.89), inadequate staffing (M = 3.36; SD 0.89), stock distribution items and subscales. In these analyses, only findings that are statistically
problems (M = 3.18; SD 0.96), high acuity level of patients (M = 3.09; significant (at the 0.05 and 0.01 levels) and have a medium or large
SD 1.0) and illegible prescriptions (M = 3.05; SD 1.09). The three main correlation are reported on. According to Cohen (1988) the following
causes of medication error were thus summarised as workload guidelines can be used for the interpretation of correlations: (a) small r
(including high patient-to-nurse ratio, work overload, inadequate = 0.1, (b) medium r = 0.3, and (c) large r = 0.5.
staffing and patient acuity), stock distribution problems, and illegible These results show that ‘Communication-related causes of medica­
prescriptions. tion error’ is related to ‘Administrative response’.
Most participants perceived medication errors as never occurring (n Furthermore, the AHRQ safety culture subscales and individual items

Table 3
Correlations between individual items and subscales regarding medication administration safety.

**Correlation is significant at the 0.01 level (2-tailed).

*Correlation is significant at the 0.05 level (2-tailed).

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A.J. Blignaut et al. International Journal of Africa Nursing Sciences 17 (2022) 100504

point to the fact that the items ‘We are actively doing things to improve problems and illegible prescriptions.
medication safety’, ‘Our procedures and systems are good at preventing High workload of nurses was not only due to the staff shortages
errors’, and ‘Teamwork’ had the most impact on ‘Medication error evident in some hospitals, but also caused by a lack of time-management
incidence’ and ‘Grade of overall patient safety’. skills.
Finally, ‘Our procedures and systems are good at preventing errors’
“I don’t think there is anything we can do other than getting more
and ‘Non-punitive response’ had the most impact on reasons for non-
hands…” (2/2/4);
reporting, and ‘Disagree with definition of medication error’ had the
“And then the ratio between the nurses and the patients is poor (2/12/
most impact on ‘Medication error incidence’ and ‘Grade of overall pa­
23).
tient safety’.
There were no correlations with the demographic data (age, years of Time-management as a causative factor related to medication
experience). administration errors was discussed as both a result of circumstances
external to the nurse
2.12. Associations between demographic and hospital data “Sometimes there are many patients and IV (intravenous) medication
takes a lot of time, if you have to put up a drip first” (2/6/12)
Regarding demographic data, there was a significant association
between female participants and increased reporting of ‘Medication or as result of poor time-management skills of the nurse
error incidence’ (d = 0.60; p = 0.05). Also, provincial hospitals had “Time – the nurse just wants to finish the medication round as fast as
higher scores of the item ‘We use more agency/temporary staff than is possible” (2/6/12).”
best for patient care’ (d = 0.66; p < 0.001).
Medication administrators participating in the survey concurred that
2.13. Qualitative results workload was the biggest threat to medication administration safety.
Two aspects of work overload correlated with the results of this phase,
Three themes emerged during thematic content analysis, each with namely inadequate staffing and high patient-to-nurse ratio.
its own sub-themes. A summary of these is presented in Table 4. Stock problems was the most reported medication-related cause of
During the interviews, participants agreed and elaborated on the medication administration error identified by survey respondents, the
three main causes of medication administration errors as was deter­ second most prevalent overall cause of medication administration error.
mined from the surveys, namely high workload, stock distribution In the qualitative phase of the study, stock distribution problems were
divided into two categories, viz. availability, and communication.
Availability problems were identified from the following statements:
Table 4
Themes and sub-themes identified from semi-structured interviews. “Like now we’ve got a problem where Perfalgan has been taken
Main themes Sub-themes completely off the tender, and it’s one of those drugs that you really need
Expansion on causes of medication administration errors High workload
for your patients who are unable to swallow” (2/2/5);
determined in the survey Staff shortages “There is no stock in the pharmacy” (2/3/7).
Timeous processes
Stock problems
Stock distribution problems often occur after hours or in emergency
Availability situations, where the pharmacy or doctor cannot be contacted
Communication immediately:
Illegible
prescriptions “But if you get a patient during the night and he has that prescribed and
Attitudes it’s a motivation drug, so the pharmacist is at home, so it becomes a
Other causes of errors Knowledge and challenge” (2/2/5).
skills
Patient condition Ineffective communication was found to aggravate the stock distri­
Recommendations to reduce medication administration Protocol adherence
bution problems:
errors Identifying patients
Check expiry dates “So it limited our time queuing at pharmacy, calling again, because to
Order on time
pick up a phone and to go, it’s a waste of time (2/9/18).
The five rights
Audit Although stock distribution problems were reported to be the second
Education &
biggest cause of medication administration errors, medication admin­
training
Student nurses istrators reported communication to only contribute a small risk to these
All administrators errors in the survey.
Doctors Attitudes were seen as an important factor impacting on medication
Collaboration administration safety related to illegible prescriptions:
Nurses helping
Patients helping “But you know different personalities with the people, you get doctors
Doctors helping
who are more friendlier to correction, then you get those that are like ‘you
Emotional support
Communication don’t dare’” (2/2/6).
Nurses – doctors
Illegible prescriptions was reported by survey respondents to be the
Pharmacy – unit
Doctor – patients third biggest risk factor in leading to medication administration errors.
Other personnel In the following paragraphs the researcher discusses the sub-themes
Change awareness that emerged from the data analysis under the theme “other causes of
Unknown products medication administration errors”.
New distributors
Unknown dosages
Knowledge and skills were mentioned to contribute to the inci­
Manage resources dence of medication administration errors. Specific gaps in pharmaco­
Medications logical knowledge of the medication administrator were identified.
Assisting devices
Time management

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A.J. Blignaut et al. International Journal of Africa Nursing Sciences 17 (2022) 100504

“…not having enough knowledge of the treatment that you are giving…” “Whoever is responsible for the ordering, if they order then there wouldn’t
(1/2/4); be any problems…” (3/6/13);
“Or not understanding the prescription itself, it could also cause an error” “There are the same five rights, they still work for us” (3/7/14).
(1/10/19);
In order to up-keep the careful attendance to protocol, some form of
Specific pharmacological knowledge deficits were mentioned as supervision is required. Auditing was mentioned as a method of
pertaining to the name of the medication monitoring medication administration processes and thus also the
adherence to existing procedures or protocols.
“…and then inexperience also, if you don’t know the medication; the
generic and the what-what…” (1/7/14) “The HOD (head of department) is coming to the ward checking…” (3/
4/9);
or to the correct dosage of a medication
“We are addressing it on our mortality and morbidity meeting” (3/3/7).
“Or maybe the one who is giving the medication does not know the correct
Unit managers play a central role in the management of medication
doses” (1/3/7).
administration errors as they have a strong influence on nurses’ conduct.
The relationship between knowledge and both wrong medication For this reason, audits on medication administration might improve
and wrong dose error was established in an observational study in the medication administration safety.
same context as this study when wrong medication and wrong dose Education and training were other categories mentioned as solu­
errors were related to the rank of the administrator (Blignaut et al., tions to medication administration errors. Education and training were
2017). In both relationships the student nurses made more medication mentioned with relation to student nurses,
administration errors than the other rank-groups, revealing that the
“We don’t get time for these little ones to teach them properly. Maybe this
medication administrators with less knowledge were more prone to
will minimize this medication error. Even every error will be minimized if
make these errors. However, from survey data knowledge was reported
there is someone following them” (3/9/23).
to only be a small contributing factor in causing medication adminis­
tration errors. all medication administrators,
Competency or skills was mentioned and closely related to the
“I think there must be on-going, continuous learning. You see, we have to
knowledge of the medication administrator in causing medication
always see that nursing staff goes for education, because some people get
administration errors:
too comfortable, they think, ‘no, I’m used to this, I’ve been doing this’ and
“Eh, the reason might be the staff competency, if the staff is not
that is where now the mistakes are going to be done” (3/8/16);
competent, they are not skilled enough to administer the medication”
(1/5/10). and also doctors, especially for the legibility of their handwriting:
Though seen as a major concern by unit managers, in general
“Because with us nurses, they teach us to write like this and like that, but
medication administrators reported slips to only pose a small risk in
to them (doctors), it is as if they don’t teach that” (3/9/18).
medication administration error in surveys.
The condition of the patient, or the patient acuity was mentioned Though supervision of students might help them to grow profes­
by participants to impact on medication administration safety. In this sionally, collaboration and support among the unit-staff was stated to
study the condition of the patient was most often referred to when the lighten the burden of the workload. The assistance was not only limited
problem of a patient not being able to swallow oral medications was to unit staff helping one another;
discussed:
“We have to help each other…” (3/1/2);
“We’ve got patients that have difficulty swallowing, and we have to grind
but also including the patient assisting in his/her own care:
medication” (1/7/14);
“We don’t have devices to crush those tablets for patients who are not able “If you have patients who are okay, then they can just be reminded about
to swallow a pill like it is” (1/9/17). the time, and they can take their own medication” (3/4/10).
Mean scores reported by medication administrators in surveys indi­ The assistance within the unit could be supplemented by assistance
cated that patient acuity posed a moderate risk of contributing to from outside the unit, especially from doctors:
medication administration error incidence.
“If we can work collaboratively with the doctors, then the doctors insert
Another aspect of the patient’s condition, viz. restlessness was
the drip for the medication prescribed, then the nurses are going to
mentioned as contributing to medication error incidence:
administer” (3/5/11).
“Inclusive, which is also another challenge, it is the patient’s condition.
Furthermore, the help required was said to be more than physical,
You sometimes find patients who are restless, so that is causing challenges
but also emotional:
with regards to the administration of medication” (1/4/15).
“Maybe if there can be someone who can council them about the work
Again the survey study sample agreed that uncooperative patients
stress, that might maybe help” (3/8/15).
posed a moderate risk in causing medication administration errors.
Eight sub-themes focused on strategies of medication administration Collaboration is based on good communication. Communication,
error prevention were uncovered. especially between nurses and doctors, was seen by several participants
Adherence to existing protocols was mentioned by several par­ as key in upgrading medication administration safety, though some
ticipants as a key contributing factor in enhancing medication safety. included communication between the pharmacy and the unit, or be­
These protocols might include properly identifying the patient, checking tween the doctor and the pharmacy or the patient, and even with other
expiry dates of medications, ordering medications according to estab­ related staff-members. Communication is also not only verbal, but
lished schedules, correct documentation and mostly adhering to the five clarity and timeous written communication was also required. Firstly,
rights of medication administration. communication between doctors and nurses was addressed:
“If they did not identify the patient correctly, then they will continue with “It is up to the sister who is doing the rounds to remind the doctor to say,
many errors.” (3/10/19); ‘remember, they don’t keep this dose, they have this dose’” (3/4/9).
“…like you first check the expiries (expiry dates)…” (3/9/16);
Communication between the unit and the pharmacist is also

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A.J. Blignaut et al. International Journal of Africa Nursing Sciences 17 (2022) 100504

important, “You have different tenders almost every-six months, so the labelling, the
packaging, is different from the previous one and you tend to think that
“Inform the pharmacy first. If they say they don’t have the medication,
you don’t have that product, but you have it in a different packaging” (3/
then they make alternative, but they write us a letter” (3/1/2);
2/4).
as well as between the doctor and the pharmacist,
Confusion about dosages could be limited if standardised dosing was
“And the pharmacists comes down on you, they don’t even call the incorporated:
doctor…” (3/2/6);
“Maybe if there is new policy to limit types of medications, it should be a
or between the doctor and the patient, protocol to give a common script, so that people with the same type of
disease can be given the same type of treatment and the nurses can become
“So the thing is communication and giving the patient information” (3/5/
accustomed to these protocols” (3/6/13).
12);
Managing resources more effectively could limit medication
as was communication between the unit and other staff members
administration errors. Pharmacists providing alternatives to prescribed
involved:
medications that were not available or having access to equipment that
“My suggestion was communication with the kitchen people to at least could enhance effectivity in medication administration were provided as
deliver breakfast early” (3/4/9). examples:
Clarity of written communication was also emphasised, again “They (the pharmacists) can dispense, I mean if I want Panado and you
focusing on the problem of illegible prescriptions: want Paracetamol, it’s the same thing!” (3/2/5);
“If they (the pharmacists) can give us what they have, or an alternative.”
“But if it is not legible then we do ask, ‘Doctor, what is it that you have
(3/3/6).
written here?’ then they will come and tell you or print it on the side” (3/
1/3). The following resources that could ease the medication administra­
tor’s work, were proposed:
The lack of communication regarding change in medication suppliers
led to confusion. This frequent change in medication or medication “If at least we can have two trolleys in the ward, then the other one can
providers was mentioned by a few participants to be a frustration. As start this side” (3/7/14);
strategies related to change awareness, they suggested the use of “A recon device (a reconstitution device used for constituting a drug in a
known products, keeping to the same distributor and known dosages as vial with a liquid in a second container such as a parenteral solution
solution to this problem. As part of keeping to what was known, it was container) is quicker, but the management would not go for it” (3/9/17);
suggested that doctors prescribed generic names so that the nurses could “We used to have this things to help us crush (indicating the use of a
get used to a specific name and not get confused about the different mortar and pestle)” (3/9/17);
names.
Lastly, another factor that needed management, time, was
“Doctors could prescribe medication using generic names it will make it mentioned. Time-management could assist medication administrators
much simpler for the staff” (3/7/15). to finish their tasks more effectively.
The following was said about keeping to the same distributor:

Fig. 1. Amalgamation of research findings, and proposed solutions to medicine administration errors.

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A.J. Blignaut et al. International Journal of Africa Nursing Sciences 17 (2022) 100504

“You know, whatever what you start in time, it will help… We don’t walk nursing unit managers also reiterated nurses’ responsibility for time
like nurses. That is why we say there is no time, but if you keep time, walk management.
like a nurse, you will finish in time” (3/10/20). Patient acuity was indicated as impacting on medication adminis­
tration errors, and this is also confirmed by the literature (Ragau et al.,
Several overlaps were recognised between the results from the
2018). In this study, patients not being able to swallow and being un­
quantitative phase and the qualitative phase. Fig. 1 presents these
cooperative were the specific acuity issues indicated.
overlaps, together with recommendations flowing from the integrated
There is global agreement with the finding that problems in stock
findings.
availability or distribution from the pharmacy are leading medication-
related causes of medication administration errors (Brits et al., 2017;
3. Discussion
Foo et al., 2017; Hammoudi et al., 2018). According to nursing unit
managers, 24/7 availability of medications could contribute greatly to
Provincial hospitals, receiving both down-referred patients from
timeous medication administration.
tertiary hospitals and up-referred patients from district hospitals (Cull­
Although participants aptly identified specific medication adminis­
inen, 2006) might experience exacerbated levels of staff-tension and
tration risks, perceptions related to incidence of medication adminis­
related negative nurse outcomes. This could be the cause of the associ­
tration error could be skewed, as this was perceived as occurring only a
ation between provincial hospitals and the increased record of use of
few times a year, in contradiction to the literature derived from data
temporary staff.
obtained within the African context on the topic (Baraki et al., 2018;
Another African context study done in Ethiopia found similar find­
Blignaut, 2016). This could also be as a result of participants disagreeing
ings in that female nurses are more prone to report medication admin­
with the definition of medication error, as was found in this research.
istration errors than male nurses (Asefa et al., 2021). The authors from
Participants reported units’ overall medication administration safety as
that study postulated that female nurses fell victim to interruptions more
very good, and correlations showed that this was based on the fact that
often than male nurses, leaving them vulnerable to committing more
there were active measures in place towards improvement thereof.
medication administration errors and therefore having more to report
It is concerning that participants held negative perceptions towards
than their male colleagues.
teamwork, as it is highly correlated with medication administration
Communication was implicated as a moderate risk in causing
safety and its overall improvement. This was confirmed in the literature
medication administration errors, which is confirmed by the literature
and reiterated in this study, in that collaboration between various team
(Hammoudi et al., 2018). Better nurse-doctor communication was pro­
members is mentioned as a central theme for facilitating a safety climate
posed as vital in improving medication administration safety, although
(Saville et al., 2020) and mitigating nurse errors (Hammoudi et al.,
communication with other role-players should not be neglected. For
2018; Ragau et al., 2018).
example, pharmacists’ accurate communication regarding medication
In general, safety climate issues not only impact on the incidence of
stock changes would also mitigate errors (Foged et al., 2018).
medication administration errors, but also on nurses’ perception of
Regarding written communication, several studies agreed that
medication errors and their reporting thereof (Abbasi et al., 2019). This
illegible prescriptions contributed to medication errors (Heydari et al.,
explains the correlations between safety climate items and medication
2019; Raja et al., 2019) one of which was also conducted within the
error incidence and the overall grade of patient safety reported by sur­
South African context (Brits et al., 2017). Survey participants identified
vey respondents.
this as the third most common cause of errors, and nursing unit man­
Lastly, the greatest reasons for non-reporting of medication admin­
agers discussed the attitudes of all role-players as key in addressing this
istration errors, namely fear and administrative response, should be
problem successfully.
addressed as a matter of urgency. Reporting of medication errors or
Communication is as important pre-error as it is after a medication
near-misses is of the utmost importance in order to plan and initiate
administration error has occurred. Adequate reporting of errors could
proactive measures to contain and prevent errors, and the only way that
prevent repeating of mistakes. Yet, as communication-related causes of
the incident-reporting culture can be addressed is through a non-
medication error was proven to administrative response, it is clear that
punitive safety reporting system (Farag et al., 2020; Prihartono &
communication from management might also impede medication
Wibowo, 2020). Such a system provides the foundation for effective
administration safety post medication administration error. Farag et al.,
auditing, as was proposed by nursing managers, and furthermore pro­
2020 advocate for open and safe communication channels when
vides a means of supporting nurses who committed medication admin­
reporting medication administration errors.
istration errors and often have negative psychological outcomes (Mok
Human factor-related causes of medication error were considered to
et al., 2020), reiterating the need for emotional support (Hammoudi
be of moderate risk to medication safety, and this was raised by most
et al., 2018), as proposed by interviewees.
nurse managers in this study. Shams (2017) mentions that human fac­
tors, such as deficits of knowledge, skills, attitudes, protocol adherence
4. Strengths and limitations
and audits, are some of the most common reasons for medication
administration errors (Cabilan et al., 2017; Foo et al., 2017; Keers et al.,
The main strength of this study is that it adds data on medication
2013). Managers thus highlighted education and training as a crucial
safety from low- and middle-income countries. Furthermore, using the
intervention to address medication safety issues (Lapkin et al., 2016).
WHO research cycle for patient safety, it not only determines causes of
This training should include high-quality pharmacological training, and
patient safety concern, but also attempts to develop specific solutions
in the clinical setting should preferably be conducted by clinical ac­
within the given context.
companists, so that there is no further increase in nurses’ workload.
Limitations of this study include the fact that the survey results were
In fact, workload should not be exacerbated in any way, as high-,
reliant on the perceptions of respondents, which could have led to
middle- and low-income countries alike identify heavy workload as the
medication administration errors being underreported due to fear for
most important determinant of medication error (Salami et al., 2019).
the reputation of hospitals and/or lack of insight. However, the simi­
However, as reported by participants, attempting to lighten the work­
larities in responses between units and hospitals contributed to the
load by means of temporary staff employment could intensify patient
reassurance that the results were in fact a reflection of reality. Solutions
safety issues in general (Saville et al., 2020). Literature-supported so­
for medication safety problems were limited only to nurses’ inputs,
lutions to high workload may include the use of pharmacist assistants to
excluding the views of other relevant health team members. However,
replenish ward stock (Foo et al., 2017), and self-administration of
nurses are the primary agents in medication administration, and their
medication by competent patients (Lapkin et al., 2016), although
views were therefore deemed most important.

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A.J. Blignaut et al. International Journal of Africa Nursing Sciences 17 (2022) 100504

5. Conclusions Cabilan, C. J., Hughes, J. A., & Shannon, C. (2017). The use of a contextual, modal and
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Funding sources 1384168
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nursing home nurses’ willingness to report medication near-misses. Journal of
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Research Foundation of South Africa (Grant No 123541). The Chair­ Foged, S., Nørholm, V., Andersen, O., & Petersen, H. V. (2018). Nurses’ perspectives on
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holder acknowledges that opinions, findings and conclusions or rec­ medication administration: A qualitative study. Journal of Clinical Nursing, 27,
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supported research is that of the author(s) alone, and that the NRF ac­ Foo, G. T. T., Tan, C. H., Hing, W. C., & Wu, T. S. (2017). Identifying and quantifying
weaknesses in the Closed Loop Medication Management System in reducing
cepts no liability whatsoever in this regard.
medication errors using a direct observational approach at an academic medical
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Declaration of Competing Interest Gorgich, E. A. C., Barfroshan, S., Ghoreishi, G., & Yaghoobi, M. (2016). Investigating the
causes of medication errors and strategies to prevention of them from nurses and
nursing student viewpoint. Global Journal of Health Science, 8(8), 220–227.
None. Hammoudi, B. M., Ismaile, S., & Yahya, O. A. (2018). Factors associated with medication
administration errors and why nurses fail to report them. Scandinavian Journal of
Acknowledgement Caring Sciences, 32, 1038–1046.
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Arbabisarjou, A., & Joulaei, H. (2019). Study causes of illegible handwriting
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Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013). Prevalence and nature
of medication administration errors in health care settings. Annals of
All authors meet the criteria for authorship, have approved the final Pharmacotherapy, 47, 237–256.
article and all those entitled to authorship are listed as authors. AJB was Kwong, C. K., & Fong, B. Y. (2020). Quality management of inpatient medication
responsible for the conception and design of the study, acquisition, administration in Hong Kong Public Hospitals. Asia Pacific Journal of Health
Management, 15(2), 91–98.
analysis and interpretation of data, as well as drafting the article. SKC
Lapkin, S., Levett-Jones, T., Chenoweth, L., & Johnson, M. (2016). The effectiveness of
assisted in the conception and design of the study, analysis and inter­ interventions designed to reduce medication administration errors: A synthesis of
pretation of data and revising the article, while HCK added to the findings from systematic reviews. Journal of Nursing Management, 24, 845–858.
conception and design of the study, and critical revision of the article. Lee, E. (2017). Reporting of medication administration errors by nurses in South Korean
hospitals. International Journal for Quality in Health Care, 29, 728–734.
SME analysed the data, assisted with the interpretation of data, and Lenth, R. (2018). Java applets for power and sample size. http://www.stat.uiowa.edu/
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019-4862-y
to the corresponding author. Mok, W. Q., Chin, G. F., Yap, S. F., & Wang, W. (2020). A cross-sectional survey on
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