Medication administration errors and predictive role of resilience and emotional exhaustion in a sample of Iranian nurses

Medication errors are one type of medical error, and maintaining patient safety and preventing the harm caused by this type of error is one of the important aspects of nursing care [1]. This is because the implementation of medication orders is an important part of the treatment and care process of the patient, which is the main part of nurses’ practice [2]. As one of the most common and significant problems in health systems, medication errors can be considered a threat to patients’ health [3]. Medication errors have a detrimental effect on healthcare systems around the globe. For example, worldwide, errors related to medication are responsible for 5–41.3% of all hospital admissions and contribute to 22% of readmissions following discharge [4]. In England, 237 million medication errors happen each year at various stages of the medication process [5]. One in every five Americans has encountered a medication error during their healthcare treatment [6]. Moreover, studies have shown that 10% of the causes of patients’ death are related to medication errors [7, 8]. In the U.S., approximately 7,000 to 9,000 individuals lose their lives annually as a result of medication errors [9]. In Iranian hospitals, medication error rate was estimated at 10.9% and the average occurrence of medication administration errors within three months for each nurse is 19.5 cases [10]. Among Iranian nurses, the 6 most commonly reported errors include: wrong time of drug administration, wrong injection method, giving the wrong drug, error in drug calculations, and neglecting drug interactions [8, 11]. A recent systematic review reveals that 54% of nurses in Iran have encountered medication administration errors. The most frequently reported types of errors among nurses were incorrect timing (27.3%) and incorrect dosage (26.4%) [12]. Medication errors lead to adverse consequences such as increased length of hospital stay and treatment costs, loss of patient trust, patient dissatisfaction with health service provider systems, and nurses’ stress and moral conflicts [13, 14]. Studies have shown that several factors can increase the incidence of medication errors in nurses. Some of these factors such interruptions/distractions [12], shortage of time, lack of equipment, lack of personnel on the one hand [3, 7, 8, 11] and increased workload and the consequent physical fatigue, as well as frequent job stress and tension on the other hand, are regarded as hidden factors affecting medication errors in previous studies [15‐17]. These factors have led to emotional exhaustion and job burnout in nurses, which is associated with a decline in the quality of nursing services and increased likelihood of patient harm [16].

Job burnout is one of the predicaments that have plagued healthcare organizations today [16]. In clinical settings, job burnout means loss of feeling towards and interest in the client, leading to provision of inappropriate and inhumane care for them [18]. Maslach described burnout syndrome as a state of emotional exhaustion stemming from stress related to interactions with others [19]. Emotional exhaustion is a long-lasting physical and emotional fatigue caused by overwhelming work and/or personal pressures and ongoing stress. Responses to burnout can involve emotional reactions, including feelings of emotional exhaustion [20]. Nurses can easily experience burnout and, as a result, emotional exhaustion due to the highly stressful nature of their job [21]. The global prevalence of job burnout among nurses is 11.23% [16]. In Iran, the prevalence of burnout among Iranian nurses has been reported between 25 and 89%, which indicates moderate to high burnout rate in nurses [22]. Job burnout and emotional exhaustion in nurses are associated with symptoms such as failure to show up on time for work shifts, lack of commitment to work, anxiety or depression, and changing or replacing jobs [18, 21, 22]. These factors have diminished the quality of providing care to patients [15, 16, 22, 23], which is a threat to patient safety and increases the incidence of medication errors [17, 23].

Recent research has indicated a connection between resilience and emotional exhaustion, suggesting that resilience may help protect individuals from experiencing emotional exhaustion [21]. Resilience is one of the most important abilities of human beings that can help them effectively adapt to stressors in difficult conditions and mental pressures. Resilience is a factor that helps people to face and adapt to difficult and stressful life conditions and protects them from mental disorders and life problems [24]. In fact, resilience allows a person to overcome environmental stress in difficult situations by adapting to the situation and having a positive outlook. This feature helps the individual to avoid early burnout and emotional exhaustion caused by the difficulty of work [25, 26]. Studies have shown that increased resilience reduces work stress, improves nurses’ quality of work life, and enhances their job satisfaction [27, 28]. Also, improving the level of resilience in nurses has been associated with fostering professional growth, better patient management at the bedside [29], and reduced burnout and emotional exhaustion [21, 25]. This will not only improve the quality of nursing care, and thus the services provided, but also enhance the level of patient safety and care [26, 29]. Therefore, resilience can be regarded as one of the effective factors in reducing the amount of medication errors.

Identification of the factors contributing to medication errors can potentially provide useful and valuable information for healthcare policymakers in designing and implementing effective interventions aimed at reducing medication errors and improving patient safety. However, limited studies have been conducted on the association of factors such as emotional exhaustion and resilience with medication errors. Therefore, this study aimed to determine the rate of medication errors, emotional exhaustion, and resilience in a sample of Iranian nurses. This study also assessed whether resilience and emotional exhaustion could predict medication administration errors among nurses.

A total of 272 nurses were included in the study. The mean age of the nurses was 33.72 ± 7.62 years. Most of them (78.3%) were female, 56.3% were married, 90.1% had a bachelor’s degree, 81.6% worked rotating shifts, and 62.8% worked more than 40 h a week. Other characteristics are presented in Table 1.

Demographic characteristics of the nurses according to the mean levels of their medication administration errors, resilience, and emotional exhaustion are presented in Table 1. The table indicates that there were no significant differences between the mean scores of medication administration errors, resilience, and emotional exhaustion based on gender, marital status, parental status, education level, shift schedule, and weekly work hours of the nurses. However, a significant difference was observed in medication administration errors, resilience, and emotional exhaustion based on the level of interest in the nursing field. Nurses with a greater interest in the nursing field reported higher levels of resilience, lower emotional exhaustion, and fewer medication administration errors. Additionally, there was a significant difference in the mean medication administration error scores based on the nurses’ age and work experience. Nurses with greater age and work experience reported fewer medication administration errors. Furthermore, a significant difference was found in the mean emotional exhaustion scores based on employment status and the departments where nurses worked. Nurses in mandatory service and those who worked in oncology departments reported significantly higher levels of emotional exhaustion (Table 1).

The mean of the nurses’ medication administration errors was 10.29 ± 10.02. In total, 85.3%, 13.2%, and 1.5% of nurses had low, moderate, and high medication administration errors, respectively. The mean score of nurses’ resilience was 56.65 ± 8.28. Additionally, 7%, 23.8%, and 76.1% of nurses had weak, moderate, and high resilience, respectively. The mean score of nurses’ emotional exhaustion was 29.97 ± 7.92. Furthermore, 2.2%, 23.2%, and 74.6% of nurses had low, moderate, and high emotional exhaustion, respectively. The results showed that nurses who reported higher resilience and less emotional exhaustion reported significantly fewer medication administration errors (Table 2).

Table 3 shows the frequency distribution of different types of medication administration errors based on questionnaire questions. The administration of several oral medicines together, the administration of painkillers after surgery without a doctor’s prescription, and the administration of medicine later or earlier than the prescribed time were the most common medication administration errors among nurses (Table 3).

The aim of this study was to determine the rate of medication administration errors in nurses and to examine the predictors of these errors. According to the results of the present study, 85.7% of the nurses participating in the study had experienced a medication error at least once during the last 6 months. In line with the results of the present study, the results of a similar study in Iran also reported that the rate of medication administration errors among nurses during the last 6 months was over 85%, which was an average of 3.6 cases per nurse [2]. According to the results of a systematic review, the prevalence of medication administration errors in Iranian nurses over a 3–6-month period has been reported in various studies to be between 10 and 80% [8]. The results of studies in other countries also show that a large number of nurses experience medication errors during their working period, which is in line with the results of the present study [5, 9, 38, 39]. However, one of the important results in the present study was that only 14.7% of the nurses reported the incidence of errors during drug administration as moderate to high, with more than 85% reporting that their error rate was small. This result did not run counter to our expectation since the results of previous studies have also shown that many medication errors occur for various reasons, including fear and concern about the consequences of reporting them. These consequences include reduced trust of colleagues, legal issues, negative reactions from patients or their families, and the reactions of the management [7, 40‐42]. The results of a recent study in Saudi Arabia on 408 nurses showed that more than half of the nurses had committed medication errors while less than half had reported the errors [43]. Although in the present study we tried to reassure the nurses that their information is only used for research purposes, the bias of the nurses in reporting their error rate was evident to some extent.

In the present study, the majority of nurses reported their level of emotional exhaustion as one of the important dimensions of burnout as moderate to high and their resilience as high, which is consistent with many previous studies [23‐25]. In addition, the present study showed a positive and significant correlation between emotional exhaustion and medication error rate. The results of previous studies on the relationship between burnout and the incidence of medication errors have also shown that with the increase in burnout, the rate of medication errors rises significantly [17, 44, 45]. Nurses’ fatigue and emotional exhaustion, which are caused by their multiple tasks, high workload, night work, etc., are among the factors that greatly reduce the quality of care and the degree of patient safety, which naturally affects the occurrence of medication errors [23, 46, 47]. However, the linear regression results of our study showed that emotional exhaustion cannot act as a predictor of medication errors. Contrary to this result, Montgomery et al. (2021), who examined the predictive role of burnout in the occurrence of medication errors, found that all dimensions of burnout were significant predictors of medication errors [17]. Perhaps this discrepancy in results can be attributed to the difference in the variables examined in the two studies. In the present study, in addition to emotional exhaustion, resilience was also included in the regression model, and this variable was found to be the main predictor of medication administration errors in nurses. More particularly, our results showed that the amount of medication administration errors decreased 0.42 times with one unit increase in resilience. In line with the results of the present study, Pappa et al. (2023) showed that the level of resilience in nurses plays a pivotal role not only in the occurrence of clinical errors but also in dealing with errors during the daily work schedule [48]. However, it cannot be definitively stated that emotional exhaustion does not predict medication administration errors. It is possible that emotional exhaustion indirectly influences the occurrence of medication administration errors. On the other hand, in the present study, we examined only one dimension of burnout. Consequently, further research is necessary in this area.

In addition, our study demonstrated that resilience not only plays a crucial role in preventing medication administration errors but also significantly reduces emotional exhaustion. This result has been confirmed by many previous studies that have shown that nurses who use resilient behaviors and capacities in facing professional problems to maintain their health, suffer less emotional exhaustion [25‐27]. Resilience is one of the most important psychological aspects contributing to the professional performance of nurses, which is associated with their increased job satisfaction and improved quality of life [27]. In addition, studies have shown that the development of resilience in nurses is related to their efficient use of coping mechanisms [49]. This highlights the need to promote individual adaptation factors and to cultivate coping methods including resilience in nurses so that they can deal with the daily stress caused by the difficulties of work and show better adaptation. This naturally plays a role in reducing the emotional exhaustion of nurses, which in turn will not only lead to providing safe services to patients but also be effective in reducing medication errors [23].

In the present study, no significant difference was observed in the amount of medication administration error in terms of gender, educational attainment, marital status, work shift, having children, or working overtime. However, our results showed that nurses who were younger and had a lower work experience reported a higher error rate. The results of linear regression also showed that with increasing age and work experience, the medication administration error rate decreases 0.51 and 0.80 times respectively. In line with the results of the present study, previous studies have also shown that with increasing years of service, there will be a significant decrease in the occurrence of medication errors in nurses [2, 39, 41, 43, 50]. Obviously, as nurses become more experienced at work, their abilities are improved and they have the opportunity to become familiar with drugs and their side effects and learn more about safe drug administration techniques [35, 51].

The results of the present study showed that nurses who were more interested in their job reported lower error rate, less emotional exhaustion, and higher resilience. Having a positive attitude towards their profession and job satisfaction enhances the self-confidence and efficiency of nurses. As a result, they work with more mental comfort and less stress, which will lead to reduced emotional exhaustion and elevated resilience, resulting naturally in fewer clinical errors [52, 53].

The results of the present study showed that the majority of nurses participating in this study had experienced some degree of medication administration errors. High medication error rates were associated with low resilience, low work experience, and low interest in the nursing profession. Therefore, it is essential to conduct courses focused on resilience to enhance cognitive-emotional regulation, behavioral skills, and mindfulness practices, while also teaching positive coping strategies to help nurses manage stressful situations. Also, healthcare systems should consider reducing the nurses’ workload and improving their job security in order to foster motivation and increase interest in their profession. In addition, it is imperative that nurses receive continuous training dedicated to knowledge of drugs and their side effects, as well as the correct techniques of drug administration.