Medication Safety Event Reporting: Factors That Contribute to Safety Events During Times of Organizational Stress : Journal of Nursing Care Quality

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Medication Safety Event Reporting

Factors That Contribute to Safety Events During Times of Organizational Stress

Cohen, Tara N. PhD; Berdahl, Carl T. MD; Coleman, Bernice L. PhD, NP; Seferian, Edward G. MD; Henreid, Andrew J. BA; Leang, Donna W. PharmD; Nuckols, Teryl K. MD

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Journal of Nursing Care Quality ():10.1097/NCQ.0000000000000720, May 09, 2023. | DOI: 10.1097/NCQ.0000000000000720



Incident reports submitted during times of organizational stress may reveal unique insights.


To understand the insights conveyed in hospital incident reports about how work system factors affected medication safety during a coronavirus disease-2019 (COVID-19) surge.


We randomly selected 100 medication safety incident reports from an academic medical center (December 2020 to January 2021), identified near misses and errors, and classified contributing work system factors using the Human Factors Analysis and Classification System-Healthcare.


Among 35 near misses/errors, incident reports described contributing factors (mean 1.3/report) involving skill-based errors (n = 20), communication (n = 8), and tools/technology (n = 4). Reporters linked 7 events to COVID-19.


Skill-based errors were the most common contributing factors for medication safety events during a COVID-19 surge. Reporters rarely deemed events to be related to COVID-19, despite the tremendous strain of the surge on nurses. Future efforts to improve the utility of incident reports should emphasize the importance of describing work system factors.

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