Hemşireler tarafından yapılan ilaç hatalarının kök neden analizi ve bu hataların bildirilmesinin önündeki engeller: bir hastane örneği

Abstract

Amaç: Bu çalışma, hemşirelerin mesleki uygulamaları sırasında ve son altı ay içinde yaşadıkları veya tanık oldukları ilaç hatası türlerini belirlemeyi amaçlamaktadır. Ayrıca bu hataların bildirilmesinin önündeki bireysel ve kurumsal engelleri tespit etmeyi ve kök neden analizi yoluyla temel nedenlerini ortaya çıkarmayı hedeflemiştir. Yöntem: Tanımlayıcı ve kesitsel tipteki bu çalışma, Mayıs–Temmuz 2025 tarihleri arasında Türkiye’de bir üniversite hastanesinde yürütülmüştür. Yatan hasta kliniklerinde ve acil servislerde görev yapan toplam 144 hemşire, tabakalı rastgele örnekleme yöntemiyle seçilmiştir. Veriler, literatürden yararlanılarak geliştirilen yarı yapılandırılmış bir anket formu ile toplanmıştır. Verilerin analizinde tanımlayıcı istatistikler, ki-kare testi, Mann-Whitney U testi ve lojistik regresyon analizi kullanılmıştır. Bulgular: Hemşirelerin neredeyse tamamı ilaç uygulama hatası yaptığını veya buna tanık olduğunu bildirmiştir. En sık görülen hata türleri doz atlama ve yan etkilerin izlenmemesidir. Yüksek iş yükü (%81,9), yorgunluk (%61,8) ve deneyim eksikliği (%45,8) başlıca nedenler olarak belirtilmiştir. Hemşirelerin yalnızca küçük bir kısmı bu hataları resmi olarak bildirmiştir. Hatanın ciddi olmadığı veya hasta üzerinde etkisi bulunmadığı inancı ile cezalandırılma korkusu, bildirim önündeki önemli engeller olarak belirlenmiş ve bu faktörlerin resmi bildirim yapma olasılığını anlamlı derecede azalttığı görülmüştür (p < 0,05). Sonuç: Hemşireler arasında görülen ilaç hataları, bireysel ve sistemsel faktörlerin birleşiminden kaynaklanmaktadır. İlaç güvenliğini artırmak için istihdam, eğitim, destekleyici kurum kültürü ve hata bildirim sistemleri konularında iyileştirmeler yapılmalıdır. Bildirim oranlarını artırmak ve hasta güvenliğini geliştirmek için cezalandırıcı olmayan bir ortamın oluşturulması önem arz etmektedir.

Keywords

• İlaç Hataları
• Hemşireler
• Hata Bildirimi
• Kök Neden Analizi
• Hasta Güvenliği
• Sağlık Hizmetleri

Obstacles to root cause analysis and reporting of medication errors made by nurses: a hospital example

Abstract

Aims: This study aimed to identify the types of medication errors experienced or witnessed by nurses during their professional practice and in the past six months. It also sought to determine the individual and institutional barriers to reporting these errors and to identify the root causes through root cause analysis. Methods: A descriptive cross-sectional study was conducted between May and July 2025 at a university hospital in Turkiye. A total of 144 nurses working in inpatient clinics and emergency departments were selected using stratified random sampling. Data were collected using a questionnaire developed based on the literature. Descriptive statistics, Chi-square tests, Mann-Whitney U tests, and logistic regression analysis were used to analyze the data. Results: Nearly all nurses reported having experienced or witnessed medication administration errors. The most common error types were missed doses and failure to monitor side effects. High workload (81.9%), fatigue (61.8%), and lack of experience (45.8%) were cited as major causes. Only a small portion formally reported these errors. Beliefs that the error was not serious or had no patient impact, and fear of punishment, were significant barriers to reporting (p<0.05). Logistic regression analysis revealed that such beliefs significantly reduced the likelihood of formal error reporting. Conclusion: Medication errors among nurses are caused by a combination of individual and systemic factors. To improve medication safety, interventions must address staffing, training, supportive culture, and error-reporting systems. Establishing a non-punitive environment is essential for increasing reporting rates and enhancing patient safety.

Keywords

• Medication errors
• nurses
• error reporting
• root cause analysis
• patient safety
• health services

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