EXPLORING REPORTING OF MEDICATION ERRORS AT THE NATIONAL CENTER FOR CANCER CARE AND RESEARCH

Abstract

Objectives: The objectives were to (a) examine the medication error reporting literature and synthesize existing studies to identify key factors affecting reporting practices; (b) quantify the prevalence , nature, and severity of oncology-related medication errors and explore their potential causality using a theoretical framework; and (c) describe the key behavioral determinants (i.e., facilitators and barriers) that influence health professionals' reporting of medication errors, and map these barriers to related behavior change techniques (BCTs). Methods: A search was conducted in CINAHL, Scopus, PubMed, and Embase (up to March 2023) for studies examining factors that influence clinicians' medication error reporting. Two independent reviewers conducted screening, data extraction, and quality assessment. Themes were mapped to the Theoretical domains framework (TDF) using framework synthesis. The study employed a multiphase mixed-methods approach consisting of a retrospective and descriptive qualitative study. A retrospective chart review of medication error reports from 2020 to 2023 at the National Center for Cancer Care and Research (NCCCR) was undertaken. The prevalence of errors relative to all prescribed items was calculated. Errors were classified using the World Health Organization's Anatomical Therapeutic Chemical (ATC) system, and their severity and causality were assessed using Reason's Accident Causation model. The second work package involved semi-structured qualitative interviews with fifteen healthcare professionals working at the NCCCR, including nurses, pharmacists, and physicians. The interviews were guided by the TDF and analyzed using framework analysis to explore behavioral influences on medication error reporting. Results: The review of 14 high-quality studies identified barriers in the TDF domains of beliefs about consequences, emotions, environmental context, and knowledge. It recommends BCTs such as emphasizing the risks of not reporting, supporting emotional well-being, improving reporting system access, and enhancing knowledge through education. For the retrospective study a total of 195 error reports were reviewed. The majority of errors were related to antineoplastic and immunomodulatory agents (41.54%) and were primarily dispensing errors (31.28%). Most errors were classified as near misses (41.03%) and were predominantly reported by nurses (50.26%), reflecting their stronger sense of responsibility for error reporting compared to other healthcare professionals. The primary contributing factor for these errors was active failure, particularly slips (57.95%). In the second work package, the main barriers to medication error reporting were identified within the domains of Environmental Context and Resources, Beliefs about Consequences, and Memory, Attention, and Decision Processes. These barriers were mapped to BCTs to guide the development of targeted interventions. The BCTs focused on improving the usability of the reporting system, highlighting positive outcomes of reporting, providing constructive feedback, creating automated alerts, and assigning designated times for reporting to reduce cognitive load and enhance reporting efficiency. Conclusion: The study identified the frequency and key factors affecting medication error reporting in oncology, emphasizing the need for targeted theory-based interventions to improve reporting practices. The research findings offer actionable recommendations that can inform the development of such interventions leading to enhanced safety practices within oncology care.