2025 Volume 29 Issue 1 Pages 9-18
Objective: To clarify the specific causes of medication errors that occurred in nursing homes in Japan, focusing on the detail of the errors, the number of times they occurred, and the most frequently occurring word in accident reports ("confirmation)" in the process of taking medication. Based on the results, we made recommendations for medication error prevention.
Methods: We created a co-occurrence network and conducted content analyses of sentences containing the word "confirmation" in 156 accident reports related to medication errors in the two nursing homes.
Results: Details of the medication errors were divided into 14 categories, with "omission" being the most common detail (109 cases). In the co-occurrence network, "confirmation" was at the center, with "omission," "wrong resident," and "wrong time" as connections. Sentences containing "confirmation" were extracted for content analysis; 70 sentences described insufficient confirmation and 74 described factors that may have influenced confirmation. Those with insufficient confirmation were classified into four categories: [Drugs] (22 cases), [Medication information on the package] (21 cases), [Finish taking the medicine] (14 cases) and [Medication instructions] (13 cases). Factors that may have influenced "confirmation" included "lack of compliance with confirmation rules" (21 cases) and "assumptions"(13 cases).
Conclusion: There is a link between "confirmation" and medication errors, and our results suggest insufficient confirmation leads to medication errors. To prevent insufficient confirmation, it is necessary to review the methods and timing of confirmation, change the color of the medicine packets, and consider introducing computer systems.
