Earticle

본 연구는 정신과 간호사의 투약 오류 경험을 심층적으로 이해하기 위한 현상학적 질적 연구이다. 자료 수집은 2025년 4월 15일부터 6월 15일까지 이루어졌으며, 전문 정신과 병원에 근무하는 간호사 9명을 대상으로 심층 면담을 실시하였다. 수집된 자료는 Colaizzi의 7단계 분석 절차를 적용하여 분석하였다. 분석 결과, 총 3개의 주요 주제와 6개의 하위 주제가 도출되었다. 간호사들은 투약 오류 이후 환자의 생명에 대한 위협감, 자책감, 불안 등 극심한 정서적 고통을 경험하였으며, 이는 업무 집중력 저하와 직무 스트레스로 이어져 간호 실무와 환자 안전에 부정적인 영향을 미치는 것으로 나타났다. 그러나 환자의 회복과 동료의 지지는 간호사의 정서적 회복과 직무 지속의 동기가 되었으며, 오류 경험은 궁극적 으로 전문성 강화와 임상적 성숙으로 이어졌다. 이러한 결과는 정신과 간호사를 위한 예방적 교육, 심리적 지원 프로그램, 상담 서비스의 필요성을 시사하며, 동료 간 지지와 긍정적인 조직 문화 조성이 간호사의 심리적 안정과 직무 만족도 향상에 기여함을 보여준다. 또한, 조직 차원의 안전한 근무 환경 구축과 제도적 지원은 환자 안전과 정신과 치료의 질 향상에 필수적인 요소임을 확인하였다.

This phenomenological study investigates the lived experiences of psychiatric nurses who have encountered medication errors, utilizing Colaizzi' s seven-step method of phenomenological analysis. Between April 15 and June 15, 2025, in-depth interviews were conducted with nine nurses employed in specialized psychiatric hospitals. The analysis revealed three core themes and six subthemes that highlighting participants' emotional distress, professional self-doubt, and psychological burden following medication errors. Participants reported experiencing guilt, fear of patient harm, and disrupted therapeutic relationships. Nevertheless, they also described personal growth, improved therapeutic relationships, and enhanced clinical vigilance as positive outcomes. The findings underscore the importance of structured educational interventions, comprehensive institutional support systems, and the establishment of a non-punitive safety culture to prevent errors and facilitate psychological recovery. The implementation of peer support networks and the promotion of open communication between clinical staff and administrators are critical for improving medication safety and maintaining professional well-being in psychiatric care settings

Background & Objectives: Fixed-dose combinations (FDCs) offer advantages in adherence and cost-effectiveness compared to free combinations (FCs), but they can also complicate the prescribing process, potentially leading to therapeutic duplication (TD). This study aimed to identify the prescribing patterns of FDCs for dyslipidemia and investigate their associated risk of TD. Methods: This was a retrospective cohort study involving drugs that included statins, using Health Insurance Review & Assessment Service- National Patient Sample (HIRA-NPS) data from 2018. The unit of analysis was a prescription claim. The primary outcome was TD. The risk ratio of TD was calculated and adjusted for patient, prescriber, and the number of cardiovascular drugs prescribed using a multivariable Poisson model. Results: Our study included 252,797 FDC prescriptions and 515,666 FC prescriptions. Of the FDC group, 46.52% were male patients and 56.21% were aged 41 to 65. Ezetimibe was included in 71.61% of the FDC group, but only 0.25% of the FC group. TD occurred in 0.18% of the FDC group, and the adjusted risk ratio of TD in FDC prescriptions compared to FC was 6 . 44 (95% CI 5 . 30-7. 82). Conclusions: Prescribing FDCs for dyslipidemia was associated with a higher risk of TD compared to free combinations. Despite the relatively low absolute prevalence of TD, the findings underline the necessity for strategies to mitigate this risk when prescribing FDCs for dyslipidemia. Our study suggests the potential utility of Clinical Decision Support Systems and standardizing nomenclature in reducing medication errors, providing valuable insights for clinical practice and future research.

Purpose: This study investigated the effects of aroma inhalation on sleep quality, professional quality of life (QoL), and near-misses in medication errors during night shifts among emergency room nurses. Methods: A randomized crossover experimental design was used to determine the effects of this intervention. The research participants included 55 nurses (29 in Group 1 and 26 in Group 2) who worked as nurses in the emergency room at a tertiary general hospital in Chungcheongbuk-do, South Korea. Aroma inhalation was conducted on the night shift. Sleep quality, professional QoL, and near-misses in medication were measured before and after inhalation of the aroma. Data was analyzed using the independent t-test, the chi-square test, and a linear mixed-effects model. Results: The aroma treatment group had significantly better sleep quality than the non-treatment group (p < .010), and the sleep time on the third day of aroma treatment was longer than that of the non-treatment group (p = .008). However, there were no signs of improvement in professional QoL or near-misses in medication errors in response to aroma treatment. Conclusion: Aroma inhalation effectively improved sleep quality and increased sleep duration in emergency room nurses. Therefore, aroma inhalation is suggested as an intervention to improve the sleep quality of emergency room nurses who work night shifts. Follow-up studies are needed to build a more robust evidence base to inform strategies for improving nurses' professional QoL and patient safety during medication management.

Purpose: Falls and medication errors are the most common patient safety incidents globally. Kolb’s experiential learning theory supports the application of cognitive learning in clinical settings. This study examined the effectiveness of Experiential Learning?Based Fall and Medication Error Prevention Education (EFMPE), utilizing virtual reality and room of errors. Methods: A randomized controlled trial was conducted with 28 fourth-year nursing students (15 experimental, 13 control). The experimental group participated in EFMPE from February 1 to 6, 2024, comprising six sessions of 2 hours each. The control group received traditional lectures. Safety control confidence and course interest were measured before and immediately after the intervention; safety control confidence was reassessed 6 weeks later. Results: Both groups showed immediate improvement; however, only the experimental group sustained increased safety control confidence after 6 weeks (Wald χ2=13.21, p<.001). Course interest was significantly higher in the experimental group post-intervention (Wald χ2=10.64, p=.001). Conclusion: These preliminary findings suggest that EFMPE potentially supports the prevention of falls and medication errors in clinical practice.

Purpose: This study aimed to identify the influence of medication errors and medication safety competency on the medication safety activities of general hospital nurses. Methods: A descriptive survey was conducted among 212 nurses with more than three months of work experience in seven general hospitals in K metropolitan city and M city. Data were collected from June 27?July 6, 2023 and analyzed using the independent t-test, one-way ANOVA, Pearson’s correlation coefficients, and stepwise multiple regression. Results: The medication safety activities score was 4.02(±.50) and had significant correlations with medication safety competency (r=.55, p＜.001) and medication errors (r=?.34, p＜.001). In the multiple regression analysis, medication safety competency (?=.49) and medication errors (?=?.21) were significant predictors and explained approximately 33% of the medication safety nursing activities (F=53.41, p＜.001). Conclusion: To improve medication safety nursing activities, effective strategies to reduce medication errors must be sought, and strategies that reflect approaches to each sub-area of medication safety competency are required.

목적: 본 연구의 목적은 최근 3년간의 간호사 투약오류의 특성을 파악하고 분석하기 위함이다. 방법: 환자안전 사고 중 간호사에 의한 투약오류를 분석하는 후향적 조사연구이다. 연구자료는 2017년 1월부터 2019년 12월까지 3년간 수집되었다. 자료는 SPSS 26.0 프로그램을 이용하여 빈도, 백분율, x2-test와 로지스틱 회귀분석을 이용하여 분석하였다. 연구결과: 전체 677건의 투약오류 중 간호사에 의한 오류는 275건(40.6%)이었다. 간호사 투약오류 중 근접오류 154건(56.0%), 정맥주사제 170건(61.8%), 잘못된 용량 102건(37.1%), 반복적인 업무에 대한 부주의가 98건(35.6%)으로 가장 많았다. 투약오류는 부서별, 간호사 경력별, 환자안전사고 유형별로 차이를 보였다. 로지스틱 회귀분석 결과 위해사건의 위험요인은 수액 주입(OR=3.93, 95% CI: 1.26∼12.27), 인슐린 피하주사(OR=39.06, 95% CI: 4.58∼333.18), 일혈/침윤(OR=7.26, 95% CI: 1.85∼28.53)의 발생으로 나타났다. 결론: 투약오류를 예방하는 가장 간단하고 효과적인 방법은 5 right를 지키는 것이며, 일반적인 교육보다는 부서별, 간호사 경력별로 차별화된 교육프로그램 개발이 필요하다. 투약바코드 시스템이나 팀간호 방법과 같은 병원 차원의 통합적 중재 또한 필요하다.

Purpose: The purpose of this study was to identify and analyze the characteristics of nurses’ medication errors during three years. Methods: Retrospective survey study design was used to analyze medication errors by nurses among patient safety accidents. Data were collected for three years from January, 2017 to December, 2019. Data were analyzed using frequency, percentage, x2-test, and logistic regression with SPSS 26.0 program. Results: Of a total 677 medication errors, 40.6% were caused by nurses. Among the medication errors, near miss (n=154, 56.0%), intravenous bolus injection (n=170, 61.8%), wrong dose (n=102, 37.1%) and carelessness for repetitive work (n=98, 35.6%) were the most common. Medication errors differed by department, and nurses’ career, and patient safety accident type. The results of the logistic regression analysis showed that the risk factors of adverse events were medication of fluids (OR=3.93, 95% CI: 1.26~12.27), insulin subcutaneous injection (OR=39.06, 95% CI: 4.58~333.18), and occurrence of extravasation/infiltration (OR=7.26, 95% CI: 1.85~28.53). Conclusion: The simplest and most effective way to prevent medication errors is to keep 5 right, and a differentiated education program according to department and nurse career is needed rather than general education programs. Hospital-level integrated interventions such as a medication barcode system or a team nursing method are also necessary.

The purpose of this study was to analyze chemotherapy-related medication errors detected by pharmacist in outpatient department and to evaluate efficacy of new alert system in chemotherapy monitoring program to prevent them. Finally, we evaluated the efficacy of pharmacists’prescription review. The study was performed at Asan Medical Cancer Center pharmacy from October 2008 to September 2010. We reviewed medication orders by using chemotherapy monitoring program and Electronic medical record (EMR), and compared the quantity and quality of reviewing medication orders and intervention after applying new alert system. During the study period, the number of medication monitoring increased from 47,928 to. 59,618. And, the frequency of pharmacists’interventions increased, especially anticancer-drug dosage related interventions increased from 31% to 46%. When we analyzed the reason of dosage errors,laboratory data related errors increased from 9% to 16%. We confirmed that pharmacists’chemotherapy monitoring and intervention improved qualitively and quatitatively after applying new alert system. And, it prevented potential harm due to medication errors.

PurposeThis study aimed to evaluate the effectiveness of a simulation based clinical decision-making program for preventing high-alert medication errors among intensive care unit nurses. MethodsA nonequivalent control group pre/post-test design was employed. The study involved 40 nurses working in the intensive care unit of a tertiary general hospital. The results for an experimental group (n = 20) that participated in the simulation-based clinical decision-making program for preventing high-alert medication errors (duration 180 minutes) were compared with those of a control group (n = 20) that received lecture education (duration 90 minutes). The intervention was conducted and data were collected from June 24 to October 31, 2024. Registered with the Clinical Research Information Service (KCT0010214). ResultsThe experimental group exhibited improved clinical decision-making ability (χ2 = 10.57, p = .005), reduced risk of high-alert medication errors (χ2 = 6.17, p = .046), and fewer experiences of near-miss medication errors (χ2 = 7.05, p = .008) compared to the control group immediately and 3 months after the intervention. ConclusionThe findings suggest that the program can be effectively used to improve the clinical decision-making ability and to reduce the risk of high-alert medication errors among intensive care unit nurses, thereby contributing to ensuring medication safety in intensive care units by reducing the occurrence of medication errors.

Purpose: This study was aimed to identify the mediating and moderating effects of safety-specific transformational leadership on the relationship between barrier to and intention of reporting medication errors. Methods: Two hundred thirty seven nurses from seven different hospitals participated in the study. Safety-specific transformational leadership was measured by an instrument with 10 items, barrier to reporting medication errors with 16 items, and intention of reporting medication errors with 3 items. The data was collected from September to October 2012. Descriptive statistics, factor analysis, t-test, ANOVA, Pearson correlation coefficient and a hierarchial regression analysis were used. Results: There were significant negative correlations between the subcategories of barrier to reporting medication errors and intention of reporting medication errors (r=-.16~-.27, p<.001), and a positive correlation between the intention and safety-specific transformational leadership (r=.25, p<001). Transformational leadership was a mediator between barrier to and intention of reporting medication errors. Conclusion: Safety-specific transformational leadership mediated the relationships between barrier to and intention of reporting medication errors. Enhancing safety-specific transformational leadership of nursing unit managers is necessary to increase the intention to reporting medication errors.

병원간호사의 고위험 정맥주사 약물의 투약오류에 대한 인식과 경험을 파악하고 투약오류의 원인과 개선방안을 파악하기 위해 시도되었다. 연구 대상은 D시에 위치한 일개 대학병원에 근무하는 고위험 정맥투약 관련 업무경험이 있는 간호사를 대상으로 2021년 5월 16일~30일 간 자료 수집하였다. 연구 결과 고위험 정맥주사 투약안전 문제점의 핵심요인으로 병동 별 주요 약물의 투약 protocol 부재, 투약 주입기기의 작동 교육 부족, 표준화 된 고위험 정맥주사 투약수행 절차 미확립, 간호사 대상의 개별화 투약교육 부족, 병원 자체 약물집 부족 혹은 미비치, 비슷한 용기의 포장 약물 확인 부족의 6가지가 도출되었다. 간호실무적 차원에서 고위험 정맥주사 투약안전 프로그램을 적용하고 안전결과 지표를 확인할 수 있는 추후 연구 수행을 제언한다.

This study was attempted to identify the perception and experience of hospital nurses on medication errors of high-risk intravenous drugs, and to identify the causes of medication errors and ways to improve them. The subjects of the study were nurses with work experience related to high-risk intravenous administration working at a university hospital located in D City, and data were collected between May 16 ~ 30, 2021. As a result of the study, six key factors were identified as the key factors in the safety of high-risk intravenous injections: the lack of a protocol for the administration of major drugs in each ward, the lack of training in the operation of the injection machine, the lack of standardized procedures for administering high-risk intravenous injections, the lack of individualized medication training for nurses, the lack or lack of the hospital's own drug list, and the lack of identification of drugs packaged in similar containers. At the nursing practice level, it is proposed to apply a high-risk intravenous medication safety program and conduct a future study to identify safety outcome indicators.

Background: Medication errors in oncology may cause severe clinical problems due to low therapeutic indices and high toxicity of chemotherapeutic agents. We aimed to investigate unintentional medication errors and underlying factors during chemotherapy preparation and administration based on a systematic survey conducted to reflect oncology nurses experience. Materials and Methods: This study was conducted in 18 adult chemotherapy units with volunteer participation of 206 nurses. A survey developed by primary investigators and medication errors (MAEs) defined preventable errors during prescription of medication, ordering, preparation or administration. The survey consisted of 4 parts: demographic features of nurses; workload of chemotherapy units; errors and their estimated monthly number during chemotherapy preparation and administration; and evaluation of the possible factors responsible from ME. The survey was conducted by face to face interview and data analyses were performed with descriptive statistics. Chi-square or Fisher exact tests were used for a comparative analysis of categorical data. Results: Some 83.4% of the 210 nurses reported one or more than one error during chemotherapy preparation and administration. Prescribing or ordering wrong doses by physicians (65.7%) and noncompliance with administration sequences during chemotherapy administration (50.5%) were the most common errors. The most common estimated average monthly error was not following the administration sequence of the chemotherapeutic agents (4.1 times/month, range 1-20). The most important underlying reasons for medication errors were heavy workload (49.7%) and insufficient number of staff (36.5%). Conclusions: Our findings suggest that the probability of medication error is very high during chemotherapy preparation and administration, the most common involving prescribing and ordering errors. Further studies must address the strategies to minimize medication error in chemotherapy receiving patients, determine sufficient protective measures and establishing multistep control mechanisms.

OBJECTIVES: Medication errors (MEs) made by nurses are the most common errors in emergency departments (EDs). Identifying the factors responsible for MEs is crucial in designing optimal strategies for reducing such occurrences. The present study aimed to review the literature describing the prevalence and factors affecting MEs among emergency ward nurses in Iran. METHODS: We searched electronic databases, including the Scientific Information Database, PubMed, Cochrane Library, Web of Science, Scopus, and Google Scholar, for scientific studies conducted among emergency ward nurses in Iran. The studies were restricted to full-text, peer-reviewed studies published from inception to December 2019, in the Persian and English languages, that evaluated MEs among emergency ward nurses in Iran. RESULTS: Eight studies met the inclusion criteria. Most of the nurses (58.9%) had committed MEs only once. The overall mean rate of MEs was 46.2%, and errors made during drug administration accounted for 41.7% of MEs. The most common type of administration error was drug omission (17.8%), followed by administering drugs at the wrong time (17.5%) and at an incorrect dosage (10.6%). The lack of an adequate nursing workforce during shifts and improper nurse-patient ratios were the most critical factors affecting the occurrence of MEs by nurses. CONCLUSIONS: Despite the increased attention on patient safety in Iran, MEs by nurses remain a significant concern in EDs. Therefore, nurse managers and policy-makers must take adequate measures to reduce the incidence of MEs and their potential negative consequences.

preOBJECTIVES: This study aimed to examine the prevalence and types of medication errors (MEs), as well as barriers to reporting MEs, among nurses working in 7 teaching hospitals affiliated with Kermanshah University of Medical Sciences in 2016. METHODS: A convenience sampling method was used to select the study participants (n=500 nurses). A self-constructed questionnaire was employed to collect information on participants’ socio-demographic characteristics (10 items), their perceptions about the main causes of MEs (31 items), and barriers to reporting MEs to nurse managers (11 items). Data were collected from September 1 to November 30, 2016. Negative binomial regression was used to identify the main predictors of the frequency of MEs among nurses. RESULTS: The prevalence of MEs was 17.0% (95% confidence interval, 13.7 to 20.3%). The most common types of MEs were administering medications at the wrong time (24.0%), dosage errors (16.8%), and administering medications to the wrong patient (13.8%). A heavy workload and the type of shift work were considered to be the main causes of MEs by nursing staff. Our findings showed that 45.0% of nurses did not report MEs. A heavy workload due to a high number of patients was the most important reason for not reporting MEs (mean score, 3.57±1.03) among nurses. Being male, having a second unrelated job, and fixed shift work significantly increased MEs among nurses (p=0.001). CONCLUSIONS: Our study documented a high prevalence of MEs among nurses in the west of Iran. A heavy workload was considered to be the most important barrier to reporting MEs among nurses. Thus, appropriate strategies (e.g., reducing the nursing staff workload) should be developed to address MEs and improve patient safety in hospital settings in Iran.

Background: Patient safety and accurate implementation of medication orders are among the essential requirements of par nursing profession. In this regard, it is necessary to determine and prevent factors influencing medications errors. Although many studies have investigated this issue, the effects of psychosocial factors have not been examined thoroughly. Methods: The present study aimed at investigating the impact of psychosocial factors on nurses' medication errors by evaluating the balance between effort and reward. This cross-sectional descriptive study was conducted in public hospitals of Tehran in 2015. The population of this work consisted of 379 nurses. A multisection questionnaire was used for data collection. Results: In this research, 29% of participating nurses reported medication errors in 2015. Most frequent errors were related to wrong dosage, drug, and patient. There were significant relationships between medications errors and the stress of imbalance between effort and reward (p < 0.02) and job commitment and stress (p < 0.027). Conclusion: It seems that several factors play a role in the occurrence of medication errors, and psychosocial factors play a crucial and major role in this regard. Therefore, it is necessary to investigate these factors in more detail and take them into account in the hospital management.

Purpose: The purpose of this study was to investigate the factors affecting medication errors and the medication management educational needs of community-dwelling older adults. Methods: From February 20 to February 23, 2017, 150 elderly people aged 65 or older were surveyed using a structured questionnaire. Results: A total of 85.7% of the older adults were taking medication, but their drug knowledge was found to be low. The medication error rate was 24.9%, and the score for medication management education requirement was 3.61 out of a possible 5points. Factors affecting medication errors were perceived health status and knowledge of medication, and their explanatory power was 43% in total. Conclusion: It was concluded that nursing intervention is needed to reduce older adults' medication errors and to increase their knowledge of medication. Additionally, groups of older adults with high medication errors should be intensively educated, and when developing a medication management education program, the contents of the sub-areas and items in which the participants' needs were high should be reinforced.

Purpose: This study aimed to identify the factors affecting the chemotherapy medication errors made by new nurses and to use the results as basic data for the development of a chemotherapy medication nursing education program for new nurses. Methods: This cross-sectional study was conducted with 189 new nurses working at a general hospital and a tertiary general hospital in Korea. The data collection period was from January 11 to February 7, 2021. The data collected during this study were analyzed using the IBM SPSS statistics version 25.0 program. Data analysis included descriptive statistics, independent t-test, ANOVA, and logistic regression analysis. Results: One factor influencing chemotherapy medication errors was new nurses' educational needs (odds ratio=.18, p=.005). As educational needs increased, the probability of making errors in medication was reduced by .18. Conclusion: It is necessary to develop a chemotherapy medication education program tailored to the educational needs of new nurses by considering the education period, method, and content, with a focus on the content with high demand from new nurses.

목적 본 연구는 병원급 의료기관에서의 투약오류 관련 요인을 파악하여 투약안전을 위한 기초자료를 제공하고 투약 오류 예방을위한 중재 프로그램 개발을 수행하기 위해 근거자료를 제시하기 위해 이차분석 자료를 활용한 후향적 조사연구이다. 방법 연구 목적에 따라 의료기관 인증평가원에서 공개한 2021년 환자안전보고데이터를 활용하여 환자안전사고 총 13,146건에서투약오류 4,198건 중 정신병원, 한방병원을 제외하였고 병원급 의료기관에서 결측치를 제외한 1,705건을 대상으로 SPSS/WIN 26.0 프로그램을 활용하여 기술통계, Chi-square test, 다항로지스틱 분석을 수행하였다. 결과 투약오류의 위해 정도는 근접오류는 70.4%(1,201명), 위해사건 26.1%(445명), 적신호사건 3.5%(59명)로 나타났다. 투약오류의 근접오류, 위해사건, 적신호 사건의 위해정도는 연령, 근무시간, 발생장소, 병원 유형, 병상 규모에 따라 차이가 있었고, 투약오류의 위해사건에 영향을 미치는 요인은 연령, 발생 장소, 병상 규모였으며, 투약 오류의 적신호 사건에 영향 미치는 요인은 초번근무, 발생 장소로 확인되었다. 결론 의료기관에서 투약 오류를 예방하기 위해서는 근무 부서별 투약오류에 영향을 미칠 수 있는 요인을 조직적, 관리적, 시스템, 인적 요인 등 다양한 측면으로 파악하고 충분한 의료인력 확보, 긍정적 근무환경 조성, 투약 안전시스템 개선과 더불어 투약오류 보고에 대한 환류와 개선 활동이 적극적으로 이루어져야 한다.

Objectives This study aimed to identify factors related to medication errors in hospitals, provide basic data for medication safety, and to provide evidence to develop an intervention program to prevent medication errors. Methods This cross-sectional descriptive study was using the 2021 patient safety report data released by Korea Institute for Healthcare Accreditation. Of the total of 13,146 patient safety incidents, 4,198 medication errors were used, excluding psychiatric hospitals, oriental medicine hospital, and missing data were excluded. Descriptive statistics, Chi-square test, and multinominal logistic analysis were performed using SPSS 26.0 program. Results Factors affecting adverse events of medication errors were age, the place of occurrence and bed size. In addition, the factors influencing the sentinel event of medication error were the evening shift, the place of occurrence. Among the medication errors 70.4% (1,201) were near misses, 26.1%(445) were adverse events, and 3.5% (59) were sentinel events. Conclusions In order to prevent medication errors in medical institutions, factors that can affect medication errors by work department should be identified in various aspects, such as organizational, management, system, and human factors, and sufficient medical personnel, positive working environment, and medication safety system should be improved.

Objectives: The aim of this study was to identify predictive factors (fatigue, labor intensity, quality of sleep, and job stress) of medication errors in clinical nurses to improve patients’ safety. Methods: The participants of this study were 148 female nurses who have clinical experience for more than 1 year at K hospital and pregnant nurses among them were excluded. The data were collected from February 27th to March 20th, 2019. The measurements of medication errors, fatigue, labor intensity, quality of sleep, and job stress were used. Data were analyzed with descriptive statistics, t-test, ANOVA, Scheffe? test, Pearson correlation coefficients and multiple regression analysis using IBM SPSS/WIN 23.0. Results: The predictive factors associated with nurses’ medication errors were clinical experience (β= -0.41), fatigue (β= 0.31), work department emergency room (β= 0.28), work department surgery ward (β= 0.25), and job stress (β= 0.23). The results showed that the nurses who had less clinical experience and felt more fatigue or job stress, were likely to have more medication errors. Also, the nurses who work in emergency room or surgery units, experience more medication errors. Conclusions: Clinical experience, fatigue, work area-emergency room, work area-surgery word and job stress were the main influential factors on medication errors of clinic nurse. Theses influential factors should be integrally considered in nursing management to decrease medication errors. Especially, it is needed to develop a programs that can indirectly improve clinical experience to prevent medication errors.

Purpose: Shift work disrupts the synchronization between the human biological clock and the environment. Sleep disturbances are common for shift work nurses, and may threaten patient safety. This study was done to investigate the sleep characteristics and medication errors (ME) of intensive care unit (ICU) nurses who work shifts, and ascertain if there is an association between these factors. Methods: Data were collected using a self-report questionnaire from 126 ICU nurses on three shifts. Collected data included their sleep characteristics including sleep patterns and sleep disturbances, and ME for the past 2 weeks. Results: There were significant differences in sleep duration and sleep latency according to shift. Day shift nurses had the shortest sleep duration, and their sleep latency was the longest (about 49 minutes) compared to nurses on evening and night shifts; 54% reported sleep disturbances, 16% experienced ME, and among these nurses 50% were on the night shift. Logistic regression analysis revealed significant associations between nurses' sleep duration and ME (adjusted OR 0.52 [95% CI 0.32-0.85]). Conclusions: The results confirmed that shift work nurses in the ICUs experience sleep disturbance, and that less sleep is associated with ME.

본 연구는 간호사의 투약오류에 대한 인식과 경험, 투약오류의 원인을 파악하고, 인식과 경험 간의 관련성을 규명함으로써 간호서비스의 질 향상을 위한 기초자료를 제공하고자 간호사 398명을 대상으로 시도된 서술적 조사연구이다. 간호사들이 가장 많이 인식하고 있는 투약오류는 ‘잘못된 투약경로(99.2%)’였으며, 다음으로 ‘과다 용량투여(99.0%)’, ‘잘못된 환자(98.7%)’의 순이었다. 3개월 동안 간호사들이 가장 많이 경험하고 있는 투약오류로는 ‘환자의 복약여부를 확인하지 않는 경우(59.5%)’였으며, 다음으로 ‘환자나 보호자에게 투약을 위임하는 경우(57.0%)’로 나타났다. 투약오류의 인식도와 경험도는 유의한 역상관 관계를 나타내, 간호사의 투약오류 인식도가 낮을수록 경험도는 유의하게 높아지는 것으로 나타났다(r=-.199, p<.001). 이러한 연구결과는 간호사들의 투약오류 실태를 파악하고, 투약오류에 대한 간호사들의 인식이 경험과 직접적인 관련이 있었음을 밝힘으로써 투약오류 예방 교육프로그램 개발에 유용한 자료를 제공한다.

The purposes of this study was to identify nurses' perception and experience of medication errors, examine the correlation between perception and experience of medication errors and provide basic data for care quality improvement. As for the subjects of this survey, 398 clinical nurses who took charge in administration of medicine from four hospitals. The questionnaire used in this research was composed of 20 cases of medication error. The most frequently perceived medication error was ‘wrong route error' (99.2%), followed by ‘over dose error' (99.0%) and ‘wrong patient error' (98.7%). The most frequent type of error experienced by nurses during 3 months was 'not checking whether the patient took the medication' (59.5%). This study found a correlation between perception and experience of medication errors, that is, the lower the perception of medication errors, the higher the experience of making them. As for cause of occurrence of medication error, 83.2% of nurses responded as with ‘Failure to follow the five rights of medication administration'. Nurse perceptions of medication errors affect experience of medication errors significantly. The study findings can be used in programs designed to promote medication error recognition.