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Errors and Near-miss Errors Encountered By Nursing Students in Clinical Settings in Governmental Universities, Khartoum State (2018)

Background: Identifying and analyzing the occurrence and sort of student clinical errors which will allow for early detection of problems and offer chance for system evaluation and improvement. This study intended to explain the types of errors along with near-miss errors encountered by nursing students in clinical settings. Methods: This descriptive cross-sectional study was conducted at five recognized governmental universities in Khartoum State and included 470 nursing students in their fourth year (2017–2018)who met the selection criteria of the study. A full-converge sampling method was used and data were first collected by the researcher using published self-administered survey and then analyzed. Results: Initially, the study included 519 nursing students but only 470 of them responded(at a rate of 90.5%).The responses showed that while one-third of them, that is, 162(34.5%) students, had never encountered an error, 99(21.1%), 79 (16.8%), 71 (15.1%), 46(9.8%), and 13(2.8%) of them encountered errors with respect to needle stick, medical administration, omission of treatment, and wrong treatment, respectively. Regarding the near-miss errors encountered by the respondents, almost half, that is, 202(43%)of them had never encountered a near-miss errors, while 112(23.8%), 106(22.6%), 18(3.8%),17(3.6%), and 15(3.2%) of them encountered near-miss errors with respect to medication administration, omission of treatment, wrong patient, providing wrong treatment and others such as improper bedrail used, did not follow sterile precautions respectively. Conclusion: This study concluded that errors and near-miss errors exist and that awareness on clinical errors and near-misses need to be raised and strategies be developed for error management.


Introduction
A near-miss error is defined as "an error that has the potential to cause an adverse event (patient harm) but fails to do so because of chance or because it is intercepted."The Institute of Medicine(IOM) also defines a near-miss as "an act of commission or omission that could have harmed the patient but did not cause harm as a result of chance, prevention or mitigation" [1].
Many factors that contribute to the development of a near-miss have been identified; these include individual factors, system factors, and chaotic environments [2].
Adverse events are defined as the harm, whether transient or permanent, caused by medical interventions relatively to the core situation of the patient [3].
Moreover, the cost of preventable medication errors in the United States(US) is on average $20 million. It has been reported that 672,000 patients are injured and98,000 die due to preventable medication errors each year. In addition, the European Medicines Agency has reported that the estimated annual cost of preventable medication errors in European countries varies between 4.5 and21.8 billion euro. In developed countries, the World Health Organization (WHO) has emphasized that one in every ten patients is injured because of errors or adverse events during their hospital process [4].
Concerning nursing, the common reply to student error has been some type of punishment, vary from a verbal warning to abrupt release or dismiss. This environment of shame and blame remains widespread. Also, several faculty members accept that individual self-vigilance is what matters most and that if an error or a near-miss occurs, the student is at a mistake; if the fact of student errors becomes open knowledge, clinical organization may be unwilling to have students in their facilities [5].
Education in nursing schools is expected to be up-to-date and of high quality, which should be done by ensuring that the new novice nurses are able to offer safe patient care in a variety of clinical settings [6].
Nursing students are one of the primarily responsible bodies for their effective implementation of skills and perception of students is an significant factor in determining types of errors in clinical settings.
In Sudan, due to the lack of awareness about errors and near-miss errors and the absence of patient safety reporting systems, no published statistics on the topic were available. Upon checking with hospital faculties, the researchers found that no tool was available for the nurse students to repot errors or near-miss errors. Therefore, this study was carried out to clarify the types of errors and near-miss errors encountered by nursing students in clinical settings.

Materials and Methods
To find out the types of errors and near-miss errors encountered by nursing students in clinical settings, an exploratory cross-sectional study was conducted using a published self-administered survey [6]and including470 nursing students in their fourth year (2017-2018)who met the selection criteria of the study. It is a full-coverage sample.

Results
In this descriptive survey, a total of 519 of nursing students were included from five governmental universities located in Khartoum state. Of these, 49 did not take part in the survey by either refusing to participation or submitting largely incomplete questionnaires. This resulted in a final sample size of 470 students with a response rate of 90.5%. As shown in Figure 1, among the 470 respondents, inpatients' setting was the most frequently ticked response for the clinical teaching site at 93.2%.

Discussion
The code of ethics in nursing obligate nurses to provide safe, competent, and ethical care. This study describes the types of errors and near-miss errors encountered by fourth-year nursing students in clinical settings.
The results of this study demonstrated that of the 470 students included, 162(34.5%) had never encountered errors, while 99(21.1%) of them encountered errors such as did dressing inappropriately, tried to remove the urinary catheter without aspirating the amount of water used for fixation, used tap water for oxygen humidification, shared oxygen mask and suction catheters were, followed by medication administration by79 (16.8%). This is comparable with the study conducted in San Franciscoincluding121 prelicensure nursing students, in which the greater part of the subjects replied not at all encountering an error. However, for the students who had been exposed to an error, medication administration was the most frequent type followed by wrong treatment provided to the patient, omission of treatment, and needle stick [6].The annual cost of preventable medication errors is staggering, with a reported $10.3 billion price tag for avoidable healthcare spending [10].
Interestingly, 38 systematic reviews focused on the barriers to reporting medication errors and near-misses in nursing revealed that organizational barriers such as culture, the reporting system, and management behavior in addition to personal and professional barriers such as fear, accountability, and characteristics of nurses are the most common barriers to reporting medication errors [11].
Nursing students often meet strangers while in their clinical site, having to organize and handle patient care in a complex environment. Indeed, developing an innovative pharmacology and medication administration will better prepare the nursing students for practice and to enter the workforce, capable of offering quality care, as well as acquiring critical thinking skills related to pharmacology and safe medication administration [8].
The present study also confirmed needle stick injuries (NSIs) in71 (15.1%) participants. This is in line with a study conducted in Jordan including162 students from different levels which reported that the two-thirds of the student nurses practiced NSIs.
Nursing students must be well-informed to distinguish the severity of such incidences and thus be qualified to avoid unintentional exposure while performing their nursing duties. Also, continuous in-service training must be integrated into the curriculum and workplace on a regular basis, particularly when there are innovations and changes made on the prickly instruments [9].
Besides, regarding the near-miss errors encountered by the respondents,202(43%) of them had never encountered a near-miss error, while 112(23.8%) reported near-miss errors such as improper bedrail used, did not follow sterile precautions, inappropriate use of some equipment, chemotherapy spilled, gave the patient wrong information about nutrition, followed by medication administration most of the time. This is in-line with a study conducted in San Francisco that reported that a greater part of nursing students did not encounter a near-miss event, and those who did, a near-miss or medication error event led the list [6].
It is important that the clinical nurse and instructors focus on safe medication administration practice in order to build a culture of safe and quality patient care. Also, we need to incorporate tools to report near-miss errors in order to put forward a process to identify potential adverse events before they occur.
In addition to voluntary disclosure of near-misses, it may also help improve students' outcome and increase transparency.
However, it is necessary to develop a non-blaming, non-punitive, and non-fearful learning culture at unit and organizational level [11].

Limitations
The main limitation of this study is that it included only upper-level students (fourth year). It would be more interesting to compare the different levels of nursing students. Moreover the lack of literature in national settings for comparing the results of the study should be considered and this study is hoped to be an input to this regard.

Conclusion
This study concluded that errors and near-miss errors exist in clinical settings and explains the importance of a classroom and clinical instructions regarding safe, appropriate care, and strategies for error management, The main challenge associated with nursing education is developing an educational framework with an emphasis on innovation and the encouragement of an open safe culture in which students can learn from their mistakes. Also, awareness on clinical errors and near-misses need to be raised and strategies for error management be developed.