ABSTRACT
Objectives: This study explores the experiences and perceptions of nursing students, nursing lecturers, and clinical nurses regarding the factors and contexts leading to medication errors (MEs) in clinical practice at healthcare facilities.
Methods: A qualitative study using in-depth interviews was conducted with 21 participants, including nursing students and lecturers from Pham Ngoc Thach University of Medicine, and clinical nurses at affiliated practice sites. Data were analyzed using thematic analysis.
Results: Seven groups of factors contributing to MEs during clinical practice were identified: (1) Verbal or unclear medication orders; (2) Work overload and simultaneous multitasking; (3) Similar appearance of medications; (4) The gap between theory and practice; (5) Lack of pharmacological knowledge; (6) Fatigue, sleep deprivation, and lack of concentration; and (7) Subjective attitudes.
Conclusion: Factors associated with MEs involve both system-level and individual-level factors. Coordinated solutions from educational institutions, clinical settings, and students are necessary to minimize these errors.
Keywords: Medication errors, clinical practice, nursing students, qualitative research.
1. INTRODUCTION
Patient safety is a top priority in healthcare, in which medication errors (MEs) are among the most common causes of serious medical incidents [17]. MEs can occur at any stage of the medication administration process and not only affect patients but also create psychological pressure on healthcare professionals [5]. According to the National Guidelines on Pharmacovigilance (2021), an ME is any preventable event related to medication that occurs during the planning or administration process [1].
During clinical practice (CP), nursing students frequently participate in supporting medication distribution to patients; however, due to a lack of experience, skills, and environmental pressures, they are at high risk of committing errors [14]. Numerous studies have recorded relatively high ME rates among nursing students: 38.3% in Turkey, 39.68% in Iran [9], 17.3% in the Philippines [6], and 18.8% in Vietnam [4]. This reality poses a significant challenge to medication safety in nursing education. Investigating the causes of MEs to propose appropriate solutions is a crucial foundation for enhancing the quality of nursing training and ensuring patient safety. Nevertheless, most previous studies have primarily utilized quantitative methods, which have not yet deeply explored the lived experiences and specific clinical contexts leading to these errors. Particularly in Ho Chi Minh City, where nursing students often undergo clinical practice at tertiary referral hospitals, the heavy clinical workload creates many potential risks for MEs. Conducting an in-depth qualitative study allows for a comprehensive, rich, and diverse understanding of the situations and causes related to MEs during nursing students' clinical practice. This study aims to explore the experiences and perceptions of nursing students, clinical instructors, and clinical nurses regarding the factors and contexts leading to MEs in clinical practice at healthcare facilities.
2. MATERIALS AND METHODS
2.1. Study Design and Participants
A qualitative study using in-depth interviews was conducted from August 2022 to February 2023 at Pham Ngoc Thach University of Medicine. Participants were selected using a purposive sampling method, consisting of:
Individuals who could not be contacted or were unable to schedule an interview time were excluded from the study.
2.2. Instruments and Data Collection
A semi-structured interview guide was utilized to deeply explore the factors contributing to medication errors (MEs) and the specific situations leading to these errors. The questions were tailored to each target group, consisting of core questions and situational follow-up questions during the interview.
Data collection was conducted through in-depth interviews in a private room, with only the researcher and the participant present. Each interview lasted between 30 and 40 minutes. The entire process was audio-recorded following the informed consent of the participants.
2.3. Data Processing and Analysis
Data from the interviews were transcribed verbatim and saved as Microsoft Word documents. The researcher performed a close reading, coded the information, and categorized the content into themes, which were then summarized into a synthesis table. Thematic analysis was employed to identify recurring and prominent patterns of content. Representative quotes were used to illustrate the themes in the results section. To ensure the reliability of the findings, research team members independently analyzed the data, cross-checked results, and held discussions to reach a consensus on the final contents and themes.
2.4. Ethical Considerations
The study was approved by the Ethics Committee of Pham Ngoc Thach University of Medicine under Decision No. 666/TĐHYKPNT-HĐĐĐ dated April 22, 2022. Participation was entirely voluntary; participants maintained the right to refuse or withdraw at any time without any impact on their studies or employment.
3. RESULTS
Through in-depth interviews, seven primary groups of factors leading to medication errors (MEs) among nursing students were most frequently recorded: (1) Verbal or unclear medication orders; (2) Work overload, with students assigned multiple tasks simultaneously; (3) Medications with similar appearances; (4) The gap between theory and practice; (5) Lack of pharmacological knowledge; (6) Fatigue, sleep deprivation, and lack of concentration; and (7) Subjective attitudes.
3.1. Verbal or Unclear medication orders
Verbal medication orders are a form inherent with many risks, especially in busy clinical environments where information can be misheard or misunderstood. One student shared a night shift situation where a doctor ordered a Glucose infusion, but the nurse communicated it as Saline, leading to incorrect administration until the records were checked: “…I only discovered it after re-checking the records...” (SV3). Another case occurred due to receiving unclear medication orders: “…the student on the night shift did not hear the order clearly from the nurse and prepared a medication for infusion instead of injection…” (SV2).
Furthermore, incomplete medication information also contributes to errors. One lecturer shared a practical situation: “…a nurse handed over a pre-filled syringe and told the student to inject 'that person,' but 'that person' could be anyone in the room, making it impossible to identify according to the '5 Rights' principle” (GV17). Additionally, illegible handwriting in medication orders can lead to incorrect drug information: “…the doctor wrote Paracetamol 500 mg, but because the handwriting was so poor, it was read as 125 mg…” (SV3).
3.2. Work overload and simultaneous multitasking
The excessive workload at tertiary hospitals creates significant pressure for nursing students during clinical practice. Students must undertake a large volume of work while supporting nurses under sub-optimal conditions. One student shared a specific experience: “That night, over forty cases were admitted; the patients were so crowded they had to lie in hallways and on folding cots. The nurse gave me 2-3 sets of medications, but those on cots had no bed or room numbers… I ended up distributing the wrong medication...” (SV4).
Time pressure also causes students to form a habit of working quickly to keep up with the schedule, affecting compliance with care procedures. A lecturer remarked: “…students get used to the way the nurses work quickly to keep up, and it becomes a habit” (GV18). Simultaneously, there is a psychological hesitation to ask for clarification in a fast-paced environment; students are managed by medical staff during shifts and worry that asking again might lead to being evaluated as incompetent or lacking focus, affecting their academic results. A nurse shared: “The cause is overcrowding; the staff’s speed is faster than the students’, but students do not dare to ask again for fear of being scolded...” (ĐD 19).
3.3. Medications with similar appearances
One of the common causes of MEs among nursing students is the similar appearance of certain medications, especially ampules or glass vials. A student shared: “Medication errors occur because the outer packaging is similar, especially glass vials; they look the same and are often stored together in the medicine cabinet; picking them up quickly leads to mistakes” (SV13). Similarities in shape, size, and color—differing only in very small details like the drug name line—increase the risk of error: “…because the two vials were identical, both glass, white, same size, same milliliters, differing only by the text on the vial…” (SV13).
This is particularly true in specialized departments that use many types of small ampule medications. An Anesthesia and Resuscitation nursing student stated: “Two tiny vials, two identical white outer wraps” (SV10). A Midwifery student reflected: “Lidocaine, distilled water in glass ampules, Magnesium Sulfate, and Camic for hemostasis are also easily confused… they are white glass tubes; some have raised red letters, while others have all black letters, making them easy to mistake” (SV14).
3.4. The gap between theory and practice
The gap between theory and clinical reality causes difficulties for nursing students. A lecturer noted: “There is a gap—a hole between theory and practice; for example, there are things I only know because I researched them or had the opportunity to work and interact with facilities that already had those policies” (GV17). Some students believe school content is too idealized compared to reality: “…the school teaches in a way that is too perfect… it hasn't created situations for us to handle, so when we get to the hospital, we don't know how to ensure correct processing...” (SV2). Another student stated: “knowledge at school and in reality is often 30-40% different; some details exist in theory but are greatly shortened in clinical practice” (SV8). Additionally, practice conditions differ significantly: “…lab sessions are only on models, with plenty of equipment and instructor support; the environment is also more relaxed than at the hospital” (SV9). If these differences are not guided in advance, they affect students' confidence and patient safety during clinical practice.
3.5. Lack of pharmacological knowledge
A factor shared by students leading to MEs is a lack of medication knowledge. Students reported lacking confidence in their pharmacological competence when carrying out medication-related orders. One student shared: “I dare not evaluate the pharmacological knowledge of all nursing students, but personally, I am not confident in knowing the information about the medication I give to patients” (SV11).
This deficiency relates not only to remembering drug names but also basic information such as indications, timing of administration, and potential side effects. Another student observed: “students do not clearly understand the usage of that drug, for example, before or after meals, main effects, side effects; if it's the first time encountering that drug, we won't understand it clearly...” (SV1). Some students also frankly acknowledged that not mastering pharmacology can lead to incorrect execution of medication orders: “...lack of pharmacological knowledge; if you don't know the drug, you might make a medication error in the order” (SV12).
3.6. Fatigue, sleep deprivation, and lack of concentration
Physical fatigue and sleep deprivation, especially during night shifts, are factors that directly affect concentration and increase the risk of errors. Many students shared that rest time during shifts is limited, making them groggy and unalert at the start of work. A student shared: “Night shifts usually allow 2-3 hours of sleep; when just switching shifts, I'm still groggy and very tired” (SV3). Another student once took the wrong medication right after waking up: “At that moment I had just woken up… instead of taking Cefo, I took Cefa” (SV13). Students also shared they try to work quickly because they want to go home early to rest before afternoon classes: “Night shift friends are also sleepy and want to finish quickly to rest, while during the day, they want to leave early for lunch to rest before studying in the afternoon…” (SV4). Lecturer observations also showed fatigue and lack of sleep are latent causes of errors: “It’s not just due to sleepiness; lack of concentration or other poor physical conditions also lead to medical errors” (GV17). Echoing this, a nurse shared: “…working too many shifts and lacking sleep is also a cause of medication errors; at my hospital (Children’s Hospital), we need to calculate doses, and if you aren't alert at night, it all gets mixed up immediately” (ĐD20).
3.7. Subjective attitudes
Subjectivity is a factor leading to MEs shared by many lecturers and students. One lecturer noted that students do not realize the severity of MEs: “…sometimes they think it's just pumping medicine in and it won't affect anything; meaning they haven't imagined how dangerous the complications they cause can be, nor realized the importance of injecting medication for the patient” (GV16). Furthermore, a subjective attitude leads to a lack of focus during work, indirectly leading to errors. A lecturer shared: “a common cause is subjectivity and lack of concentration while working. Many times while administering medication, they are thinking about something else and not paying attention to the work they are doing” (GV18).
Failing to carefully check information before and after performing a procedure is a common manifestation of subjectivity. One student shared: “…due to our subjectivity, we don't check before and after the injection” (SV4). Concurring, another student admitted: “when going to the clinic, I just subjectively thought it was correct, so I didn't check again” (SV5). Subjectivity is also shown when students over-rely on memory or become familiar with a patient's face, leading to skipping important identification steps. One case shared: “…subjective because of being familiar with the patient's face, so the friend did not re-check the name and medication. But actually, that patient was named B, not A” (SV8).
The causes of MEs during clinical practice for nursing students are rich and diverse, occurring in many different situations and contexts. Among the above causes, the factor most shared and emphasized as leading to MEs is verbal or unclear medication orders.
4. DISCUSSION
Verbal medication orders are one of the common causes leading to medication errors (MEs), as clearly documented through the sharing of students and lecturers in this study. This method of communication can harbor many risks, especially in busy clinical environments, where information is prone to being misheard, misunderstood, or not re-confirmed. A study in Iran also reported that although verbal orders may be useful in emergencies, they remain a contributing factor to errors and must be controlled. Establishing and adhering to clear order confirmation protocols and limiting verbal communication when not strictly necessary is crucial for ensuring patient safety. Work overload is another factor leading to MEs among nursing students. A study by Musharyanti et al. in Indonesia noted similar findings, where nursing students in clinical environments with limited human resources often had to perform tasks independently without adequate supervision, leading to related errors. Furthermore, the psychological fear of being criticized or reprimanded for asking for clarification multiple times while clinical nurses are busy makes students hesitant to clarify the tasks to be performed, resulting in errors.
Medications with similar appearances are a common cause of errors that have been reported in many studies. A 2020 study by Selig reported that medications with similar packaging (65.5%) and those with similar appearances (58.8%) were among the causes leading to errors. Reports from the World Health Organization show that drugs with similar names or appearances (Look-Alike, Sound-Alike – LASA) are systemic risk factors arising from product characteristics and drug management processes, which can cause confusion even for experienced healthcare professionals. The World Health Organization and other health agencies recommend that improving packaging design is a critical element in ME reduction strategies.
Additionally, the gap between theory and practice was reported as a factor leading to MEs in this study. The discrepancy between theoretical teaching in pre-clinical settings and the application of knowledge in clinical practice causes confusion for students. Similarly, a study in Indonesia reported that nursing students were not well-prepared to apply patient safety content from theory to practical application during nursing procedures. Patient safety education needs to be integrated with real-world situations in the clinical environment. Accessing practical situations helps students better identify and enhance their ability to respond to risks affecting patient safety. Results from both the qualitative study by Musharyanti and the study by Mohaddeseh show that limitations in drug knowledge are a factor causing MEs in nursing students. This cause is quite common and has been recorded in many previous studies. The lack of pharmacological knowledge in students, combined with the presence of LASA medications, creates a resonance that increases the risk of MEs. Strengthening the teaching and review of basic pharmacology, medication safety, and scientific drug management is considered essential to help students improve their ability to identify and prevent errors when using medications.
The state of fatigue and sleep deprivation leading to a lack of concentration among nursing students, which poses a risk of errors during clinical practice, was also reported. Fatigue from long shifts and lack of rest impairs concentration and reduces the ability to recognize and react to high-risk situations during the medication administration process; this directly impacts clinical quality and safety.
Besides systemic factors such as work overload and unclear medication orders, subjective attitudes on the part of the students themselves are also a cause of MEs. A study by Cebeci et al. showed that a lack of awareness regarding the importance of verifying the "5 Rights" is a common subjective cause among final-year students. Similarly, a study in Turkey found that subjective factors, lack of clinical experience, and limited communication with clinical instructors are common subjective causes of medication errors in nursing students. Therefore, it is very important and necessary to raise the awareness of nursing students in ensuring medication safety for patients.
Some limitations of the study include the risk of recall bias as participants recounted ME experiences that had occurred previously. Additionally, with a qualitative research design and a sample selected from students who had already experienced MEs, the research results may be limited in terms of representativeness and generalizability.
5. CONCLUSION AND RECOMMENDATIONS
Medication errors among nursing students stem from both systemic and individual factors. To minimize the occurrence of these errors, clinical practice facilities should standardize medication order communication protocols while strictly limiting verbal orders to a minimum.
Furthermore, educational institutions and clinical sites must collaborate closely to ensure that workloads are appropriately matched to student competencies. It is also essential to arrange reasonable study schedules, prioritize the physical and mental well-being of students, and implement solutions aimed at bridging the gap between theory and practice. Establishing a safety culture that encourages error reporting and experience sharing also plays a vital role in preventing medication errors.
Additionally, clinical instructors should strengthen the provision of clinical drug knowledge, with a particular focus on warning students about Look-Alike, Sound-Alike (LASA) medications. On the students' part, it is imperative to enhance personal awareness and responsibility in preventing medication errors throughout their clinical practice.
REFERENCES
1. Bộ Y tế (2021), Hướng dẫn Quốc gia về cảnh giác dược, ban hành kèm theo Quyết định 122/QĐ-BYT ngày 11/01/2021.
2. Đỗ T. Hà, Phan TM. Trinh, Hồ N. Trâm (2023), Động lực sinh viên điều dưỡng trường Đại học Y khoa Phạm Ngọc Thạch tình nguyện tham gia phòng chống dịch Covid-19, Tạp chí Y học Việt Nam. 528(2): 295-299. https://doi.org/10.51298/vmj.v528i2.6135
3. Phan TM. Trinh, Lê V. Tỉnh, Đặng TN. Thanh et al (2021), Kết quả tự đánh giá của sinh viên về mức độ đáp ứng năng lực theo chuẩn đầu ra chương trình đào tạo Cử nhân Điều dưỡng Trường Đại học Y khoa Phạm Ngọc Thạch năm 2020, Tạp chí Khoa học Điều dưỡng. 04 (3): 37- 46. https://vjol.info.vn/index.php/DHDDND/article/view/64557
4. Phan TM. Trinh, Đỗ T. Hà (2022), Tỷ lệ và nguyên nhân sai sót thuốc trong thực hành lâm sàng theo nhận thức của sinh viên cử nhân điều dưỡng năm 4 Trường Đại học Y khoa Phạm Ngọc Thạch, Tạp chí Khoa học Điều dưỡng. 5(04):110–123. https://doi.org/10.54436/jns.2022.04.527.
5. Ambwani, S., Misra, A. K., & Kumar, R, (2019), Medication Errors: Is it the Hidden Part of the Submerged Iceberg in Our Health-care System?, International Journal of Applied & Basic Medical Research. 9(3):135–142. https://doi.org/10.4103/ijabmr.IJABMR_96_19
6. Apsay, K.L.G., Alvarado, G.G., Paguntalan, M.C et al (2018), Contributing factors to medication errors as perceived by nursing students in Iligan city Philippines, Belitung Nursing Journal. 4(6): 537–544. https://doi.org/10.33546/bnj.566
7. Bell, T., Sprajcer, M., Flenady, T et al (2023), Fatigue in nurses and medication administration errors: A scoping review, Journal of Clinical Nursing, 32(17–18): 5445–5460. https://doi.org/10.1111/jocn.16620
8. Cebeci F, Karazeybek E, Sucu G, Kahveci R, (2015), Nursing students' medication errors and their opinions on the reasons of errors: A cross-sectional survey, Journal of the Pakistan Medical Association, 65: 457–462.
9. Dehvan, F., Dehkordi, A.H., Gheshlagh, R.G et al (2021),The Prevalence of Medication Errors Among Nursing Students: A Systematic and Meta-analysis Study, International Journal of Preventive Medicine. 12 (21). https://doi.org/10.4103/ijpvm.IJPVM_418_19
10. Gunes U, Efteli E, Ceylan B et al (2020), Medication Errors Made by Nursing Students in Turkey, International Journal of Caring Sciences. 13(2): 1183–1191.
11. Ion, R., & Jack, K, (2020), Read it in books: Literary fiction as a tool to develop moral thinking in the educator, Nurse Education Today. 94, 104538. https://doi.org/10.1016/j.nedt.2020.104538
12. Ryan, A.N., Robertson, K.L., & Glass, B.D., (2024), Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions. International Journal of Clinical Pharmacy. 46:26–39. https://doi.org/10.1007/s11096-023-01629-2
13. Selig, K. M., (2020), The Contributing Factors to Student Nurse Medication Administration Errors and Near Misses in the Clinical Setting as Identified By Clinical Instructors. Theses and Dissertations (2597), https://dc.uwm.edu/etd/2597
14. Musharyanti L, Claramita M, Haryanti F et al (2019), Why do nursing student make medication errors? A quality study in Indonesia, Journal of Taibah University of Medical Science. 14(3): 282–288, https://doi.org/10.1016/j.jtumed.2019.04.002
15. Moghaddasi H, (2017), Verbal Orders in Medicine: Challenges; Problems and Solution, JOJ Nurse Health Care. 1(5): 555575.
16. Mohaddeseh M, (2021), Nursing errors and their causes among nursing students, Sage Journal. 16(2): 137–143. https://doi.org/10.1177/1477750920958561
17. Rodziewicz, T. L., Houseman, B., Vaqar, S et al (2024), Medical Error Reduction and Prevention, In StatPearls, StatPearls Publishing.
18. WHO (2023), Medication safety for look-alike, sound-alike medicines. Geneva: World Health Organization; Available from: https://www.who.int/publications/i/item/9789240058897
Phan Thi My Trinh, Do Thi Ha
Pham Ngoc Thach University of Medicine
Corresponding Author: Phan Thi My Trinh; Email: trinhptm@pnt.edu.vn
https://tapchidieuduong.vn/experiences-of-medication-errors-in-clinical-practice-among-nursing-students-a-qualitative-study-in-ho-chi-minh-city-7942.html
Link bài gốc Lấy link
