Introduction

A crucial component of nursing practice is administering medications, which calls for precision and attention to detail to guarantee patient safety. Nonetheless, medication administration errors (MAEs) remain a major healthcare concern, affecting both healthcare systems and patient outcomes. [1,2] MAEs are characterized as variations from the recommended pharmaceutical regimen, such as mistakes in dosage, timing, mode of administration, or forgetting to take a necessary prescription.[3,4] According to Nkurunziza et al., MAEs affect 18.7% to 56% of hospitalized patients worldwide, and in Australia, patients who experienced this issue made up 60% to 80% of the total.[5] Indeed, it is the eighth leading cause of mortality in the United States, accounting for more fatalities than vehicle crashes, breast cancer, and AIDS combined.[1] Additionally, between 2007 and 2016, 517,384 MAEs caused 229 fatalities in England and Wales, according to Härkänen et al.[6] The impact of MAES on the number of years of healthy life lost is roughly doubled in low- and middle-income nations.[7]

MAEs is widespread in East Africa, where it occurs in 9.4% to 80% of all drug administrations.[8] A study in a tertiary healthcare facility in West Africa, specifically in Ghana, found that 27.2% of nurses had made a medication administration error, with omission errors accounting for the most common type (n = 281, 77.6%) and incorrect time errors for the second most common type (n = 58, 16%).[9]

Research on the perspective and contributing variables to medication administration errors at the University College Hospital in Ibadan, southwest Nigeria, is also noteworthy. The study's results showed that 47.3% of respondents thought that a higher patient-to-nurse staffing ratio could result in errors. In comparison, 52.7% of respondents cited confusion regarding medications with similar names as the main contributing factor. Administration errors were attributed by 42.3% and 39.3% of respondents, respectively, to the usage of abbreviations and trouble interpreting handwritten directives.[10]

The factors associated with MAEs among nurses include lack of training, unavailability of guidelines for medication administration, interruption during medication administration, poor communication, inadequate work experience, and short work experience. [1,11,12]

Studies on MAEs are limited to tertiary public health institutions in the southeastern part of Nigeria. Given that MAEs are still common in hospitals today, it's critical to find focused strategies to reduce their frequency. Hence, this study focused on identifying the frequency, types, and factors linked to drug administration errors among nurses in tertiary institutions in south-eastern Nigeria.

Methods

Design and Study Setting

A descriptive cross-sectional survey design was used to determine the frequency and type of medication administration errors occurring as well as the factors associated with medication administration errors among nurses in University Teaching Hospital (UNTH) Ituku-Ozalla, Enugu Nigeria.

The University of Nigeria Teaching Hospital Ituku-Ozalla, Enugu State is a prominent tertiary hospital along the Enugu- Port-Harcourt expressway in Nkanu West Local Government Area of Enugu State. The hospital comprises 41 main departments with three output patient post in Nsukka, Abagana, and Isuochi. It occupies an area of 500 hectares and has 22 wards, an administrative department, and different clinics. As a tertiary institution, it provides a variety of health services for all Southeast and beyond, thereby serving as a referral centre and training institution. The hospital provides adequate clinical materials for training of their staff and students, provides quality inpatient and outpatient services to clients, conducts and promotes research on matters about health as well as the provision of clinical materials and equipment for research. It provides in-patient and outpatient services, the hospital provides teaching facilities for the training of medical students, resident doctors, student nurses, pharmacists, and laboratory scientist students. The hospital has 24-hour accident and emergency services, which provide preventive, promotive, curative, and rehabilitative services.

Sample and Sampling Technique

The study population comprises registered nurses working in the University of Nigeria Teaching Hospital, Ituku Ozalla. According to data obtained from the nursing services division University of Nigeria Teaching Hospital in 2023, the total population was six hundred and fifty-one (651) nurses comprising nurses from various units/departments and this was used to calculate the sample. The study population of 651 was used for the calculation of the sample. The minimum sample size was calculated using the Power Analysis formula which gave a sample size of 251 after considering the 10% attrition rate possible from nonresponse and incomplete answers.

Purposive sampling was employed to choose nurses who participated in the study. A sample of 251 Nurses who met the inclusion criteria were conveniently selected to respond to the questionnaire. Their responses were collected on the same day and screened for completeness.

Inclusion and exclusion criteria

Registered nurses working in UNTH, Willing and available, emotionally, physically, and mentally well at the time of data collection were recruited for the study. Those who were not involved in medication administration practice, the ones serving in administrative positions, and intern nurses were excluded from the study.

Instrument

Data collection was done using a researcher-designed questionnaire with a four-point rating scale. The instrument comprised 32 items and was divided into five sections which assessed the demographic data of the respondent, frequency of MAEs, types of MAEs, nurse-related factors associated with MAEs, and institutional-related factors associated with MAEs respectively

The instrument was validated by two research experts whose input was applied in modifying the tool before using the instrument for field testing. To ensure the reliability of the instrument, it was pretested through a pilot study among 25 nurses who met the inclusion in Enugu State University Teaching Hospital Parklane Enugu. The internal reliability test using Cronbach's alpha measure of agreement was used to test the consistency of the instrument and it yielded data between 0.74 and 1.000, thereby confirming that the instrument is reliable.

Data Collection Procedure

The researcher and a research assistant administered the questionnaire by hand to the nurses at their convenience. The Nurses were given sufficient time to respond to the questions to avoid incomplete responses and non-retrieval of instruments which are common in cross-sectional surveys. The questionnaires were collected immediately and cross-checked to ensure they were properly filled.

Data analysis

The raw data were checked for completeness and consistency of response, sorted, categorized, and coded. Descriptive statistics—frequencies, percentages, mean, and standard deviation were used to summarize the items of the questionnaire. The mean and standard deviation were used for the 4-point scale items that assessed the influencing factors on MAEs. A decision was made using a cuff-off of 2.5; hence item with a mean (M) >2.5 was judged to be an influencing factor. The inferential statistics – Chi-Square test with the Fisher exact test was used to test the hypothesis at a 5% level of significance; the Fisher exact test was used if data failed to meet the Chi-Square test assumption. A significant relationship hence existed if the p-value was less than .05; otherwise, no significance. These analyses were done with the aid of IBM Statistical Package for Social Sciences (SPSS) version 25 and Microsoft Excel.

Ethics

The study protocol was approved by the research and ethics committee of the University of Nigeria Teaching Hospital (UNTH) with Ref. number UNTH/HREC/2023/06/645 Furthermore, an administrative permit was obtained from the Nursing Officers in charge of the wards. Informed consent was obtained from the respondents, and confidentiality and anonymity were ensured throughout the research process.

Results

Out of the 251 copies of the questionnaire administered, 245 copies of the total questionnaire were properly filled in and returned, making a return rate of 97.6%.

The age distribution of the respondent ranged from 20-53 years with a mean and standard deviation, of 35.92±7.84, and the modal age group, 30-39 years (38.4%). Most of the respondents were females 234(95.5%) and many were married 182(74.3%). Majority of them had bachelor’s degree 123(50.2%), Nursing officer (NO) 68(27.8%) and SNO 58(23.7%), and had 5-10 years working experience 97(39.6%) [Table 1].

Research Question 1: How frequent are medication administration errors among nurses in UNTH?

As shown in Table 2, the frequency of medication administration errors was 212(86.5%). Among these, 49(23.1%) committed the error once, 74(34.9%) twice, 44(20.8%) thrice and 16(7.5%) more than 3 times.

Research Question 2: What types of medication administration errors occur among nurses in UNTH?

Findings from Table 3 reveal that the major medication administration error committed by the nurses was giving patients a drug at the wrong time 158(74.5%). Others included administering the wrong dose to a patient 137(64.6%) and administering medication to patients and documenting it wrongly 129(60.8%).

Research Question 3: What are the nurse related factors of medication administration error among nurses of university of Nigeria Teaching Hospital, Ituku-Ozalla Enugu?

Table 4 revealed that the major nurses’ related factors of medication administration error were misidentification of drugs (2.71±1.00), interruption and distraction (2.65±0.93), and similar drug names (2.54±0.95). The nurse-related factors were perceived as high among 99 (40.4%) of the nurses.

Research Question 4: What are the institutional-related factors of medication administration error among nurses of university of Nigeria Teaching Hospital, Ituku-Ozalla Enugu?

The result in Table 5, shows that the institutional-related factors of medication administration error among nurses were inadequate staffing (2.71±0.97), poor drug storage (2.70±0.90), illegible handwriting of doctors (2.64±0.96), unavailability of drugs in pharmacy (2.59±0.91) and wrong prescription by doctors (2.59±0.96).

Hypothesis: There is no significant association between the demographic characteristics of the nurses and medication administration error.

Table 6 presents the result of the relationship between socio-demographic characteristics and personnel-related factors. There was a significant association between the nurse’s gender and their personal related factors of medication administration error (p = .048). The factors were perceived more among female nurses (43.1%) than male nurses (10.0%). No significant association existed between other socio-demographic characteristics of the nurses and their personal related factors of medication administration error.

Discussion

The present study revealed that most of the nurses had committed medication administration errors. The magnitude of the medication administration errors reported in this study is higher when compared with that documented by Mohammed, et al,[12] whose findings showed a prevalence of 59.9% among Nurses in Addis Ababa Federal Hospitals, Ethiopia, as well as that reported by Haile et al [13] in Goba Referral hospital Southeast Ethiopia with prevalence (62.3%) and in tertiary care hospital in Addis Ababa with a prevalence (68.1%).[1] On the other hand, the prevalence in our study is favorably compared with that documented by a previous author, whose findings showed a prevalence of 81.9% among Nurses working at tertiary care hospitals in Karachi Pakistan.[14] A possible explanation for the high prevalence of medication administration errors in this study may be primarily due to institutional factors such as inadequate staffing, wrong prescriptions by doctors, and illegible handwriting of doctors. It could also imply that either the quality of nursing care as regards administration of medications was poor or perhaps, most of the nurses’ misidentified drugs. The fact that all three countries are low-income nations may be the reason for the similarities between this study and earlier research conducted in Ethiopia and Pakistan. They are therefore probably going to have high patient-to-staff ratios and little technology integration which is critical in reducing medication errors. Given the negative treatment outcomes of MAEs on hospitalized patients, nurses should develop and use evidence-based guidelines for medication administration.

As regards the number of times nurses had committed medication administration errors, the majority of the nurses had committed MAEs twice, and few had committed MAEs more than thrice within the period of twelve (12) months. This result is consistent with a previous study which found that most of their respondents (68.1% and 59.9% respectively) had encountered MAEs twice within the previous 12 months. [1,12]

However, this finding contrasts with the study of Tsegaye, et al., whose findings showed that a greater percentage of nurses (52.7%) had committed MAEs more than 3 times.[11] This disparity may arise from differences in the nurses' locations and institutional conditions, such as a strong commitment to patient safety by the leadership, an improved staff-to-patient ratio, and funding for staff training initiatives that emphasize drug safety and error avoidance. The nurse manager should conduct weekly medication administration audits/reviews where MAEs will be discussed, identify erring staff, and suggest ways of averting such problems in the future.

From the findings of the study, failure to administer medication at the right time was the most frequent breach in the rights of medication administration and is consistent with previous studies that identified incorrect timing as the most common MAEs.[5,12] The agreement between these studies may be linked to common systemic-level inefficiencies and nurse-related challenges like complex workflow and high patient-to-nurse ratio, hence there is an urgent need for interventions aimed at reducing nurse workloads, optimizing staff levels, and streamlining workflows to ensure timely medication delivery. The issue of incorrect dosage timing may be resolved by implementing double-check procedures, standard medication administration schedules, automated medication alerts, and better record-keeping.

The findings of this study showed that the major perceived nurse-related factors contributing to MAEs were misidentification of drugs, interruptions, distractions, and similar drug names. These results underscore the important areas requiring intervention to enhance medication use. The importance of interruptions and distractions concurs with findings reported by another author who observed that more clinical errors and procedural failures occurred as a result of interruption during medication preparation and administration.[15] Also, some authors reported interruptions during medication administration as the most frequently implicated in MAEs.[16,17] This proposes a lingering matter in healthcare settings where safe medication administration by nurses is hindered by conditions demanding their attention.[18] Likewise, Ayorinde and Alabi [10] and Brabcová et al [16] noted that similarity in drug names was responsible for a substantial proportion ( 52.7% and 4.1 ± 1.4 respectively) of MAEs in their study. Electronic built-in alerts and enhanced labeling could be useful in mitigating such errors. Again, reduction in distraction during medication administration, optimization of workflow, and staff education could decrease the rate of recurrence of these errors.

Furthermore, the present study highlighted institutional-related factors of MAEs. The majority of the respondents agreed beyond average that medication administration errors also occur due to inadequate staffing, aligning with findings by various authors, where the majority of the respondents (69.7%, p-value of 0.004 and 4.41 ± 0.81 respectively) reported inadequate staffing as a contributing factor to medication errors.[18,19-21] This emphasizes the need for institutions to address workforce shortages because it can compromise patient care. The finding that illegible handwriting of doctors is an important contributor to MAEs agrees with earlier studies which found illegible recording as a major factor contributing to MAEs. A transition to an electronic prescribing system will be handy in ameliorating errors associated with handwritten prescriptions. [16,22]

No significant association was found between medication administration error and the demographic characteristics: age (p = .376), gender (p = .647), rank (p = .067), working experience (p = .141), and highest academic qualification (p = .373). These findings suggest that demographic characteristics may not play a significant role in influencing medication administration among nurses. A possible explanation could be that the sample size was not large enough to detect a significant association, or perhaps the research design was not robust enough. Differences in sample sizes could influence the statistical power to notice association, while disparities in geographical locations might show differences in training, policies, or cultural behaviors towards the administration of medication. Moreover, it is possible that respondents were not entirely sincere in responding to the questions. Several studies have tested the relationship between medication administration errors and demographic characteristics. A previous study on the Influence of Nurses’ Characteristics on Medication Administration showed strong evidence that nurses' level of education, and length of experience are directly associated with the occurrence of MAES.[23] Similarly, Sharbaafchi Zadeh et al. and Di Muzio et al. reported that the greater the number of years of experience, the lower the rate of MAEs (p<.05).[24,25] As regarding age and gender; Tabatabaee et al. [26] and Kerari andInnab[23] reported that there was no statistically significant relationship between MAEs and the age and gender of nurses (p> 0.05). In contrast, other authors found a significant association between MAEs and gender (p= 0.014).[24] These varied results could be because of different sample sizes, different research designs, and different geographical locations where this research was conducted. These findings emphasize the necessity of more investigation into factors other than demographic characteristics that may affect MAEs such as workload and organizational culture.

Strengths and Limitations of the Study

The study has several strengths such as a high response rate (97.6%), a heterogeneous sample of nurses of different academic qualifications, Ranks/Cadre, and years of experience. Its ability to provide information on the frequency and perceived associated factors of Medication administration errors is also its strength. Nonetheless, the study is limited by several factors, first, is related to the self-report nature of information provided through a self-administered questionnaire which could be subject to recall bias or underreporting due to fear of reprisal or social desirability. Secondly, the study did not directly observe MAES but rather relied on nurses’ perceptions which may not be a correct reflection of actual occurrences.

Conclusion

Medication administration errors (MAEs) are major problem in nursing practice that can have serious consequences for patients. The factors that contribute to MAEs include nurse factors, institutional factors, and others. These factors can be addressed through improved training and education, better communication and teamwork, adequate staffing levels, and the use of technology to prevent errors. To prevent MAEs and improve medication safety, nursing leaders must prioritize patient safety and provide nurses with the resources, training, and support they need to administer medications safely. By promoting a culture of safety, emphasizing the importance of medication safety in nursing education programs, and encouraging nurse empowerment in reporting errors and near misses, we can work towards reducing medication errors in healthcare settings. Addressing MAEs and their associated factors is a joint responsibility of the entire healthcare team, and requires collaboration and cooperation among all healthcare professionals. By working together to prevent errors and prioritize patient safety, we can strive towards improving the quality of care and medication administration in nursing practice.

References

1. Wondmieneh A, Alemu W, Tadele N, Asmamaw D. Medication administration errors and contributing factors among nurses: a cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nurs 2020 Jan; 19: 4. https://doi.org/10.1186/s12912-020-0397-0
2. MacDowell P, Cabri A, Davis M. Medication Administration Errors. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Patient safety network. Available at: https://psnet.ahrq.gov/primer/medication-administration-errors. Accessed 3^rd March 2025
3. Jessurun JG, Hunfeld NG, de Roo M., van Onzenoort, HA, van Rosmalen J, van Dijk et al. Prevalence and determinants of medication administration errors in clinical wards: A two-centre prospective observational study. Journal of Clinical Nursing. 2022 Jan; 32: 208–220. https://doi.org/10.1111/jocn.16215
4. Koyama AK, Maddox CS, Li L, Bucknall T, Westbrook J I. Effectiveness of double checking to reduce medication administration errors: a systematic review. BMJ Quality and Safety. 2020 Aug; 29(7): 595–603. https://doi.org/10.1136/bmjqs-2019-009552
5. Nkurunziza A, Chironda G, Mukeshimana M, Uwamahoro MC, Umwangange ML, Ngendahayo F. Factors contributing to medication administration errors and barriers to self-reporting among nurses: a review of the literature. Rwanda J Med Health Sci. 2020 Feb ;2(3):294–303. doi:10.4314/rjmhs. v2i3.14
6. Härkänen M, Vehviläinen-Julkunen K., Murrells T, Rafferty AM, Franklin BD. Medication administration errors and mortality: Incidents reported in England and Wales between 2007 ̶ 2016. Research in Social and Administrative Pharmacy 2019 July; 15(7): 858–863. https://doi.org/10.1016/j.sapharm.2018.11.010
7. Parthasarathi A, Puvvada R., Patel H, Bhandari P, Nagpal, S. Evaluation of Medication Errors in a Tertiary Care Hospital of a Low- to Middle-Income Country. Cureus. 2021 July; 13(7): e16769. https://doi.org/10.7759/cureus.16769
8. Baraki Z, Abay M, Tsegay L, Gerensea H, Kebede A, Teklay H. Medication administration error and contributing factors among pediatric inpatient in public hospitals of Tigray, northern Ethiopia. BMC Pediatrics. 2018 Oct;18(1): 321. https://doi.org/10.1186/s12887-018-1294-5
9. Acheampong F, Tetteh AR, Anto BP. Medication Administration Errors in an Adult Emergency Department of a Tertiary Health Care Facility in Ghana. Journal of Patient Safety. 2016 Dec ;12(4): 223–228. https://doi.org/10.1097/PTS.0000000000000105
10. Ayorinde MO, Alabi PI. Perception and contributing factors to medication administration errors among nurses in Nigeria. International Journal of Africa Nursing Sciences. 2019;8(3):399-405. https://doi.org/ 10.12691/ajnr-8-3-10
11. Tsegaye D, Alem G , Tessema Z , Alebachew W. Medication Administration Errors and Associated Factors Among Nurses. International Journal of General Medicine. 2020 Dec; 13: 1621–1632. https://doi.org/10.2147/IJGM.S289452
12. Mohammed T, Mahmud S, Gintamo B, Zelalem NM, Zemichael G. Medication administration errors and associated factors among nurses in Addis Ababa federal hospitals, Ethiopia: a hospital-based cross-sectional study. BMJ Open 2022 Dec;12: e066531. doi:10.1136/bmjopen-2022-066531
13. Haile HF, Melku AT, Abdi AG. Magnitude of medication administration error and associated factors among nurses working in Madda Walabu University Goba referral Hospital, Bale Zone Oromia region, Southeast Ethiopia. International J of Epidemiology and Public Health Research. 2022 Mar; 2(1) :1-11 DOI: http;//doi.org/03.2022/1. 1027.
14. Raja, Badil, Kumar P, Ali S, Shah H, Awan MF. Medication administration errors: a study of frequency and contributing factors among nurses working at tertiary care hospitals. Isra Med J. 2020 Sept; 12(3): 154-158.
15. Santomauro C, Powell M., Davis C , Liu D, Aitken LM , Sanderson P. Interruptions to Intensive Care Nurses and Clinical Errors and Procedural Failures: A Controlled Study of Causal Connection. Journal of Patient Safety. 2018 Aug; 17(8): e1433–e1440. https://doi.org/10.1097/PTS.0000000000000528
16. Brabcová I, Hajduchová H, Tóthová V et al. Reasons for medication administration errors, barriers to reporting them and the number of reported medication administration errors from the perspective of nurses: A cross-sectional survey. Nurse Educ Pract. 2023 Jul;70:103642. doi: 10.1016/j.nepr.2023.103642. https://doi.org/10.1016/j.nepr.2023.103642
17. Suclupe S , Martinez-Zapata M, Mancebo J, Font-Vaquer A, Castillo-Masa A, Viñolas I, Morán I, Robleda G. Medication errors in prescription and administration in critically ill patients. J. Adv. Nurs. 2020 Feb; 76 :1192–1200. https://doi.org/10.1111/jan.14322
18. Banu M, Mondal R , Begum T. Factors influencing medication errors among nurses at a tertiary level hospital in Bangladesh. Asian J. Med. Biol. Res. 2024 Oct;10(4):131-140; https://doi.org/10.3329/ajmbr.v10i4.75337
19. Shohani M, Tavan H . Factors Affecting Medication Errors from the Perspective of Nursing Staff. Journal of Clinical and Diagnostic Research. 2018 March;12(3):1-4 DOI:10.7860/JCDR/2018/28447.11336
20. Ratanto R, Hariyati RTS, Mediawati AS, Eryando T. Workload as the most Important Influencing Factor of Medication Errors by Nurses. Open Nurs J 2021 Nov ; 15: 204-210 http://dx.doi.org/10.2174/1874434602115010204
21. Alotiabi JS. Causes of medication administration errors and barriers to reporting as perceived by nurses in Saudi Arabia: A qualitative study. Belitung Nursing Journal. 2024 Apr ;10(2): 215–221. https://doi.org/10.33546/bnj.3249
22. Booth Z, Leigh S, Rubina S, Mahumane G. Impact of Illegible Prescriptions on Dispensing Practice: A Pilot Study of South African Pharmacy Personnel. Pharmacy. 2022 Oct; 10: 132. 10.3390/pharmacy10050132.
23. Kerari A, Innab A. The Influence of Nurses’ Characteristics on Medication Administration Errors: An Integrative Review. SAGE Open Nursing. 2021June ;7. doi:10.1177/23779608211025802
24. Zadeh NS, Souri S, Rostami Z, Aghilidehkordi G. Occurrence and reporting of nurses’ medication errors in a teaching hospital in Isfahan. Journal of Health Administration. 2019 Jan; 21 (74) :75-86 . http://jha.iums.ac.ir/article-1-2826-en.html
25. Di Muzio M, De Vito C, Tartaglini D, Villari P. Knowledge, behaviours, training and attitudes of nurses during preparation and administration of intravenous medications in intensive care units (ICU). A multicenter Italian study. Applied Nursing Research. 2017 Oct;38(2):129–133. https://doi.org/10.1016/j.apnr.2017.10.002
26. Tabatabaee SS, Ghavami V, Javan-Noughabi J, Kakemam E. Occurrence and types of medication error and its associated factors in a reference teaching hospital in northeastern Iran: a retrospective study of medical records. BMC Health Serv Res. 2022 Nov; 22(1):1420 https://doi.org/10.1186/s12913-022-08864-9