Student Nurses ‘Assessment of Medical Errors

Abstract

Purpose: The aim of this study was to evaluate the quality of nursing students ‘assessment of cases of medical error. Method: This descriptive cross-sectional study was conducted with 145 nursing students in İzmir, Turkey. The epidemiology of the medical errors that the students witnessed during clinical practice was examined. Then, the success of the students in using the Text-Based Medical Error cases tool developed by the researchers was examined. Results: Of the students, 24.1 % had witnessed medical errors during clinical practice. The percentage of students successfully analyzing cases of medical errors related to patient identification, falling, medication administration, blood transfusions, health-care-associated infections, and pressure ulcers were 51.72%, 7.59%, 17.24%, 8.28%, 45.52%, and 56.55%, respectively. Conclusion: The students ‘ability to evaluate cases of medical error needs improvement.

Keywords

medical errors nursing students education malpractice adverse events

Patient safety is a current and important topic in improving health-care quality. In assuring patient safety in delivering health care, the prevention of medical errors requires professional nursing practices (Mark et al., 2003). Studies conducted with student nurses have reported a high incidence of medical errors during clinical practice, and errors such as medication errors for which students are responsible can cause serious harm to patients; experts have emphasized that students may experience anxiety and fear in practice areas that can increase their risk of errors (Bodur et al., 2012; Cebeci et al., 2014; Wolf et al., 2006). The present study examined how students evaluated cases of medical errors related to patient identification, falling, medication administration, blood transfusions, health-care-associated infections (HCAIs), and pressure ulcers, events which are frequently encountered during their clinical practice, and the epidemiology of those errors.

Methods

This descriptive study was conducted with second-, third- and fourth-year nursing students (N = 841) with clinical practice experience in the academic year 2014–2015. The formula [n = (Nx²xpxq)/(d² x (N - 1) + t²xpxq)] was used to calculate the size of the sample. The likelihood of seeing medical errors (p; 16.6%) was taken as the proportion of errors found in 1995 by the Australian Health Care Quality Association (Wilson et al., 1995). A value of 1.96 with a margin of error of 0.05 was taken as table t value, and 0.05 was taken as the deviation value (Kaushal et al., 2001). This calculation concluded that the sample size should be at least 170 students; a total of 145 students were able to participate in the study.

Data Collection Instruments

Descriptive Information Form. This form contained questions on students ‘age, gender, year of study, number of different clinics where they had practiced, whether they had education on patient safety, whether medical errors had been made in the clinics where they practiced, which errors had been made, and by whom.

Text-Based Medical Error Cases Form. This form developed by the researchers comprised scenarios of medical errors in line with expert opinion and based on actual events. The cases concerned patient identification errors, falling, medication administration errors, blood transfusion errors, HCAIs, and pressure ulcers (see Figure 1). A case analysis form with questions on determining the type of and reasons for the medical error was included for each case (see Figure 2). Comprehensibility and suitability of the text-based medical error (TBME) cases was tested on 14 students who were not in the sample but who had similar characteristics to the sample. After the pilot, the forms were revised in line with the recommendations of three experts. At the data collection stage, the forms were handed out to participating students following a briefing, with 20 minutes to fill them in (Figure 1).

Figure 1

Text-based medical error cases.

Figure 2

Case analysis form.

Data Analysis

The statistics package SPSS 15.0 was used in the evaluation of data, using descriptive statistics. Conformity of data to normal distribution was assessed with the Kolmogorov–Smirnov test; analysis of data which showed a normal distribution was performed using the parametric data chi-square test, and data which did not show a normal distribution was analyzed with the Mann-Whitney μ and Kruskal–Wallis tests.

Ethical Considerations

This research was conducted in accordance with the National and Helsinki Declarations (World Medical Association, 2013). Oral and written approval was obtained from the students, and their identities were kept confidential. Ethical approval was obtained from the Faculty of Nursing Scientific Ethics Committee (May 25, 2015, Number: 27344949/361-1557).

Results

Data from Descriptive Information Form

The mean age of the students was 22.08 years ± 1.49 (min: 19–max: 30); 21.4% were male; 45.52% were in their second year, 30.34% in their third year, and 24.14% in their fourth (intern) year. Average number of clinical sites was 5.67 ± 3.92 (min: 2–max: 15). Education on medical errors or patient safety had been received by 71% of the students; 45.6% of these reported the education as adequate, 7.8% as partially adequate, and 46.6% as inadequate.

A total of 40 medical errors were witnessed by 24.10% of the students during their clinical practice (see Table 1).

Table 1

Types of Medical Errors Witnessed by Participants

Type of Medical Error	Self		Nurse		Physician		Other Student		Total
	n	%	n	%	n	%	n	%	n	%
Not using isolation precautions			4	57.14	3	42.86			7	17.5
Medication error	4	16	13	52	3	12	5	20	25	62.5
Patient identification error	1	33.3	1	33.3	1	33.3			3	7.5
Inadequate patient monitoring			2	100					2	5
Registration error	1	50					1	50	2	5
Surgery on wrong side					1	100			1	2
Total (n)	6	15	20	50	8	20	6	15	40	100

Data from TBME Cases

See Table 2 for students ‘rates of correct analysis of the TBME cases. No statistically significant difference was found in the students ‘mean analysis success scores between second-, third-, and fourth-year students (x² = 1.231; p = .267), students who had or had not had education in medical errors or patient safety (Z = 1.541; p = .123), or students who thought that the education they had received was inadequate, partially adequate, or adequate (x² = 1.235; p = .539).

Table 2

Students ‘Text-Based Medical Error Case Analysis

Text-Based Medical Error Cases			Analyzed Case Correctly
			n	%
CASE I	Type	Patient identification	93	64.14
	Reason	Not checking the identity of the patient	75	51.72
CASE II	Type	Falling	101	69.66
	Reason	Not removing the bed rail	11	7.59
CASE III	Type	Medication administration	103	71.04
	Reason	Administer medication prepared by someone else	25	17.24
CASE IV	Type	Blood transfusion	58	46.90
	Reason	Inadequate patient monitoring	12	8.28
CASE V	Type	Health-care-associated infection	112	77.24
	Reason	Not following the contact isolation precaution	66	45.52
CASE VI	Type	Pressure ulcer	119	82.07
	Reason	Inadequate patient monitoring	82	56.55

Discussion

In studies examining medical error epidemiology, among the most commonly seen types of errors were HCAIs, patient identification errors, pressure ulcers, errors relating to surgical operations, and medication administration errors (von Laue et al., 2003). The rate of nurses making medical errors was higher than other occupational groups (Cebeci et al., 2014; DeBourgh & Prion, 2012; de Vries et al. 2008). In the present study, the epidemiological data obtained based on student reports overlapped with the results in these studies.

Almost half of students did not identify the cause of the error in patient identification, possibly due to students being taught to refer to patients by room and bed numbers, and seeing this behaviour modelled by nursing staff.

Although second- and third-year students were under the supervision and guidance of faculty members, and fourth-grade students (interns) were supervised by clinically responsible nurses, the percentage of students who reported witnessing a medical error either made by themselves or other students was very high (30%). Similarly, in the studies based on student reporting, the rates of errors made by students ranged from 20.4% to 37% (Bodur et al., 2012; Cebeci et al., 2014). Among the types of errors for which students were responsible, most were medication administration errors or patient identification errors; students during their clinical practice made medication administration errors that could have serious consequences for the patient (Cebeci et al., 2014; Wolf et al., 2006). Wolf et al. (2006) emphasized that medication errors by students may be more frequent than predicted, showing the need for revision of patient safety curricula by nursing faculties.

In studies conducted both in simulated environments and in clinical environments, nursing students were found to make patient identification errors (Bodur et al., 2012; Cebeci et al., 2014; Henneman et al., 2010). Similarly, in the present study, patient identification errors formed 7.5% of the error types witnessed by students. Also, 48.28% of the students did not correctly analyze the causes of errors related to patient identification. This may be due to students being taught to refer to patients by room and bed numbers, and seeing this behavior modelled by nursing staff.

Falls are a significant patient safety problem in health institutions throughout the world (Campbell, 2016). The percentage of students who determined the cause of the medical error related to falling was quite low: only 7.59%.

Kim and colleagues reported that nursing student attitudes regarding fall prevention were not sufficient (Kim et al., 2015).

In Case III, medication administration error, 82.76% of the students could not identify the reasons. One possible explanation is that students accept nurses as leaders and tend to follow their instructions; Kazaoka et al. (2007) stated that students tend to administer parenteral drugs prepared by someone else without questioning them. Wolf et al. (2006) concluded that most of students ‘medication errors were due to inexperience.

Less than 10% of students succeeded in analyzing the blood transfusion error of insufficient monitoring during the first 15 minutes (Case IV). This result may be related to inadequate theoretical knowledge about blood transfusions. A number of studies found that nurses ‘level of knowledge about safe blood transfusions was insufficient; transfusion errors generally arose from wrong patient identification or failure to monitor the patient and their vital signs during the transfusion (Hijji et al., 2013; Hogg et al., 2006; Saillour-Glénisson et al., 2002).

Over 80 % of students could not identify the reason for the medication error; one possible explanation is that students accept nurses as leaders and tend to follow their instructions without questioning.

Nurses ‘attitudes played a significant role in the development of pressure ulcers in patients.

Less than half (45.52%) of students successfully analyzed Case V, HCAI. In studies of knowledge levels of medical, nursing, and midwifery students about prevention and control of infection, the authors concluded that students ‘knowledge levels were inadequate, and recommended different training programs such as simulation (Ghalya & Ibrahim, 2014; Legeay et al., 2015; Ojulong et al., 2013).

Case VI was about pressure ulcers, which are among the ten most frequently seen medical errors, and which contribute to rising health-care costs (Cebeci et al., 2014; de Vries et al., 2008). Students were more successful in analyzing this case, but the rate cannot be said to be optimal (56.55%). Students ‘knowledge levels and attitudes may have an effect on their success in analyzing the cases. Two studies (Demarré et al., 2012; Dilie & Mengistu, 2015) found that nurses ‘knowledge levels about pressure ulcers were low, and that nurses ‘attitudes played a significant role in the development of pressure ulcers in patients.

Limitations

The actual medical errors identified in this study (see Table 1) were based on the students ‘reporting; the data depend on their willingness to report. The sample size of 145 was slightly below the calculated minimum of 170.

Conclusions

In this study, nursing students were responsible for 12 of the 40 reported medical errors. Students ‘success in analyzing types of error and especially reasons for depicted medical errors was inadequate. An approach to nursing education that integrates training programs such as simulations and TBME cases is an important pedagogical strategy for developing nursing students ‘knowledge, skills, and competence.

Footnotes

Disclosure. The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

Funding. No budget support was provided from anywhere in the process of conducting the research.

Ayşe Akbiyik, PhD, is an assistant professor and research assistant on the Faculty of Health Sciences, Department of Nursing, at the University of Izmir Katip Celebi in Izmir, Turkey.

Dilek Sari, is an associate professor, College of Nursing, Department of Fundamentals of Nursing, at Ege University in Ismir, Turkey.

Nihal Taşkiran, is an assistant professor in the College of Nursing, Department of Fundamentals of Nursing, at Adnan Menderes University in Aydin, Turkey.

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