Before we initialized the qualitative synthesis, the researchers sorted out the most occurring or common barriers to reporting medication errors among the included studies. The researchers then quantified the barriers by presenting them in frequencies and rank-ordered them from the most to the least occurring. We believe this will give a clearer picture of the main issues serving us impediments in reporting medication errors among nurses. If these bottlenecks identified are given much attention by policymakers and other relevant stakeholders it will go a long way to improve patient safety. Fear of negative consequences/lawsuit/punitive actions were the most frequent (64%) barrier to reporting medication errors among nurses [12, 21-23, 25, 26, 29, 31, 32]. Facilities not having a clear definition of medication error [26, 28, 30-32] and nurses not being aware or not able to identify errors [20, 24, 27, 30, 31] were the second most reported barriers among the included studies.
Study characteristics
The study approaches used were mainly quantitative descriptive cross-sectional (12), mixed-method (1), and qualitative study explorative design (1). The cumulative sample size comprised 3,299 nurses. The sample size for the quantitative studies ranged from 135 to 548 and the qualitative study involved 23 nurses. Three studies were conducted in Iran [25, 28, 32] and Saudi Arabia [12, 22, 31], and a study each in Malaysia [23], Jordan [20], South Korea [21], Taiwan [24], United States [29], Ethiopia [26], Pakistan [27] and Turkey [30]. Two studies utilized a theoretical or conceptual framework. The Theoretical Domains Framework model was utilized by Alrabadi et al. [20] and the Theory of Planned Behavior was utilized by Shahzadi et al. [27] (See Table 1).
Table 2: Themes generated from data analysis
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Main themes
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Subthemes
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Organizational barriers
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Reporting system
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Definition of medication error
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Management behavior
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Professional and behavioral barriers
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Personal reasons/ lawsuit
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Knowledge/recognition of error
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During the data analysis two major themes and five subthemes regarding barriers to medication errors reporting emerged. The two major themes included organizational barriers and professional/behavior-related barriers to reporting medication error as shown in table 2.
Organizational barriers
Organizational barriers were categorized into three subthemes of barriers to medication error reporting; reporting system, definitions of medication error, and management behavior.
Reporting system
The researchers identified in the studies that there was no clear or proper medication error reporting system [27] therefore making the process of reporting cumbersome, especially the use of the medication incidence reporting which served as a major barrier to underreporting [20]. Some studies documented that medication error reporting consumed much time [21, 27, 29-31] whiles Dyab et al. [23] reported lack of time, tiredness, and heavy workload as barriers to reporting medication errors. Rutledge et al. [29] revealed that the forms used to report medication errors are long which posed as a barrier to reporting medication errors.
Definitions of medication error
It was indicated in some studies that because there was no precise definition of medication error within the hospital [26, 28, 30-32], there were disagreements regarding the definition of medication error and what should constitute a reporting event [22, 26, 30, 31].
Management behavior
Several studies revealed that reporting medication administration errors may result in punitive actions by management or negative consequence [12, 21-23, 25, 26, 29, 31, 32] thereby creating fear among nurses [21, 23, 25, 26, 29]. Also, a negative response from the hospital administration was identified by Shahzadi et al. [27] as a key deterrent to reporting medication errors by nurses. Nurses indicated in several studies that they were not given feedback after reporting medication administration error [12, 21-23, 25, 30] which contributed to underreporting or not barrier medication errors. The researchers also observed that the nursing administration focuses on the individual rather than using the systems approach to solve the problems [12, 22, 25, 28, 31] which served as a major barrier to reporting medication error. Nurses indicated that too much emphasis is placed on medication errors as a measure of the quality of nursing care [22, 28, 31] therefore impeding error reporting. Nurses fear being blamed by management [23, 24, 29, 31] for reporting medication errors. Lack of confidentiality in management in reporting medication errors [23].
Professional and behavioral barriers
Under the professional behavioral barriers two subthemes were identified; personal reasons, and knowledge of error.
Individual reasons/lawsuit
Personal reasons such as criticism from colleagues or other professionals was a barrier to medication error reporting [21, 30] because they felt they will be embarrassed or discriminated against if they report medication administration errors [23]. Nurses personally felt they could be blamed [29] if something negative happens to the patient [22] so they were not encouraged to report medication errors. Nurses feared that reporting medication errors will negatively impact their job records [23] or they might lose their job [20, 30] which served as an impediment to reporting medication errors. Nurses without reporting experience on medication error reporting were a barrier [24]. A tag on their professional identity or fear of being labeled as incompetent and an inadequate nurse [24] was also identified as a barrier to medication error reporting. One major key factor impeding medication error reporting in some studies was the fear of legal actions against nurses by patients or their families [12, 21, 25, 29]. Forgetting to report medication errors was another individual barrier [32].
Knowledge of error/unawareness of error
Inadequate knowledge of nurses about what constitutes medication error [20] leads to underreporting. Nurses did not see the gravity of the medication error to warrant reporting [20, 27, 31]. The inability of nurses to identify that an error has occurred hindered reporting of medication errors [20, 24, 27]. Medication administration errors that occurred without patient harm did not warrant reporting [24]. Unawareness of the occurrence of medication errors [30] also leads to nurses not reporting medication errors.