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\def\RunningAuthor{Gehan Abd Elfattah Elasrag and Hana Mohammad Abu-Snieneh}
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\articleType{Original Article}
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\title{\textbf{Nurses' Perception of Factors Contributing to Medication Administration Errors}}
\author{Gehan~Abd~Elfattah~Elasrag\textsuperscript{1,2}, 
            Hana~Mohammad~Abu-Snieneh\textsuperscript{*}\textsuperscript{2}~\\[5pt]{\textsuperscript{1}Faculty of Nursing, Menofia University, Egypt}~\\{\textsuperscript{2}Nursing Department, College of Applied Medical Sciences, Jouf University, Sakakah, Al-Jawf, Saudi Arabia}}

\begin{abstract}
Safety and quality care of patients are key aspects and the mean goals of effective health care systems. The reality that medical treatment can harm patients is one that has had to be addressed by the healthcare community in recent years. This study aimed to explore nurses' perception of factors contributing to medication administration errors and reasons for which medication administration errors are not reporting. Descriptive exploratory cross-sectional design carried out to achieve the study aim. The study was conducted in two regional hospitals in Egypt. They had a total bed capacity of 512 beds distributed over three units (emergency, intensive care, and surgical units). A convenient sample of 146 nurses distributed in the morning and afternoon shifts in the units mentioned above was recruited in this study. Medication Administration Errors (MAEs) Reporting Scale used to collect data regarding the nurses' perception of factors contributing to the MAEs. The participants were ranked the most important factor for MAEs occur system reasons (24.73\ensuremath{\pm}1.46), followed by nurses staffing as the second reason of MAEs (24.11\ensuremath{\pm} 2.25). Third, fourth, and fifth-ranked reasons were physician communication (13.37\ensuremath{\pm} 2.7), medication packaging (12.84\ensuremath{\pm}1.87), transcription-related (8\ensuremath{\pm}0.1), respectively. Finally, pharmacy processes (6.9\ensuremath{\pm}2.93) viewed as the least factor for the frequency of MAE. The findings of the present study concluded seven perceived reasons for MAE, namely system reason, nurses' staffing, physician communication, medication packaging, transcription, and pharmacy process. The study recommended the development of active quality assurance systems in all health care environments concerning medications and drug administration. 
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Nurses' perception,\newline factors,\newline Medication Administration Errors
\end{keywords}
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\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Hana~Mohammad~Abu-Snieneh~\\ Phone:\ (+966) 508068899~\\  Email:\ haousnien@ju.edu.sa
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\section{Introduction}
Patient safety and quality care are key aspects and the mean goals of effective health care systems. Safe medication administration is considered a vital indicator of health care quality \unskip~\citep{634956:14880083,634956:14880105}\textit{. }Medication errors are the most common types of adverse events for patients admitted to the hospital. It is leading to disability and death in up to 6.5\% of hospital admissions and harms 1.5 million people annually \unskip~\citep{634956:14880078,634956:14880087}\textit{.} Recent systematic reviews of the prevalence of medication errors in health care settings have found to be widespread \unskip~\citep{634956:14880085,634956:14880093}\textit{.} One reported an estimated average of 19.1\% of total hospital error opportunities. A large proportion of MAEs has actual or potentially harmful effects \unskip~\citep{634956:14880084,634956:14880107}\textit{. }MAEs significant short and long term adverse effect on patient health and life in terms of adverse drug events increased the length of hospital stay, increases costs to clinicians and healthcare systems, morbidity, and mortality. MAEs sometime causes lethal events that led patients to intracranial hemorrhage or aspiration pneumonia \unskip~\citep{634956:14880110}. Besides its adverse effect on the quality of hospital care, reputation, accreditation, and reducing the trust of patients in healthcare professionals and increase healthcare dissatisfaction \unskip~\citep{634956:14880091} \textit{.}

Medication errors occur when medication prescribed, transcribed, dispensed, prepared, distributed, and given. MAE is a common subtype of medication errors and accounted for up to one-third of the errors \unskip~\citep{634956:14880102}\textit{.} MAE defined as a discrepancy between what the patient got or receive and what was planned by the prescriber in the initial order \unskip~\citep{634956:14880077}\textit{.} MAE occurs when there is a difference between the drug received by the patient and the prescriber's intended drug therapy \unskip~\citep{634956:14880100}\textit{. }Prescription and drug administration seem to correlate to the highest number of medication errors (MEs), whether or not harm caused \unskip~\citep{634956:14880090,634956:14880069}\textit{. }MAE is amongst the risky responsibilities in daily nursing practice. The nurses have to be cautious, as the drug administration devours up to forty percent of the nursing time \unskip~\citep{634956:14880103} \textit{.} This nursing task well-thought-out as the highest risky activity, because it involves a high concentration and skill level, due to the complexity of the medication administration process and the interference of various members of the health team, the potential for such errors to occur is increased \unskip~\citep{634956:14880109}.

The key to minimizing medication administration errors in the implementation of effective intervention that focuses on understanding factors contributing to its occurrence. Because nurses are the last link in the chain of the drug management processes, where harm can directly affect the patient, and they become the accountable person for that errors \unskip~\citep{634956:14880066}. However, the working circumstances for the drug administrator, besides the organizational strategic verdicts, are all determinants of the occurrence of that errors \unskip~\citep{634956:14880104,634956:14880088}\textit{.} Frameworks for analyzing medical error \unskip~\citep{634956:14880104}, in addition, to categorizations for recording MAEs are primarily needed if MAEs want to be prevented \unskip~\citep{634956:14880097}.

The recent systematic review discussed the factors contributing to MAEs in hospitals revealed that The most commonly reported unsafe actions are slips and lapses, accompanied by knowledge-based failures and intentional breaches. Conditions contributing to medication administration errors included insufficient written communication (prescriptions, recording, transcription), difficulties with procurement and storing (pharmacy dispensing and management inaccuracies), high perception of workload, problems with medical equipment (access, functionality), patient-related factors (obtainability, perception), staff health (tiredness, exhaustion, and stress) and disruptions/interferences during administration of drug \unskip~\citep{634956:14880085}\textit{.}

\textbf{Significance of the study}

The fact that medical care could injure patients is something that the healthcare system has had to confront in recent years. Egyptian Ministry of Health established the National Office for Handling and Reduction of Medication Errors (NOHRME) to collect, review, analyze, publish and disseminate information, develop a recommendation, and develop educational programs and campaigns for safe medication use.NOHRME Office's statistical data on the occurrence of drug errors are not available. They roughly estimate the actual rate in Egypt that is similar or exceeding that of the USA. It was a minimum one death a day and injury to about 1.3 million people a year in 2009 \unskip~\citep{634956:14880099}\textit{.}

In Egypt, Just a few studies focused on the evaluation of the incident, safety culture assessment, and the development of safety measures manuals. Such research recommended further studies to explore the causes of drug errors and reporting obstacles to these errors in order to help reduce them and strengthen the workplace's culture of patient safety and security. Pointing out and understanding the factors related to medication administration error tendency may empower healthcare specialists to deliver more secure, skilled care, and healthier treatment. The current study addressed one notable concern about the quality of health care services, particularly the factors contributing to MAEs from the nurses' perspective. 

\textbf{Aim}

This study aims to explore nurses' perceptions of,
  
  \begin{enumerate}
  \item \relax factors contributing to medication administration errors
  \item \relax and reasons for which medication administration errors are not reporting.
  \end{enumerate}
  
    
\section{Subjects and Methods}
\textbf{Research design}

The descriptive exploratory cross-sectional design carried out to achieve the aims of this study. A cross-sectional descriptive analysis is a test in which the disease or disorder (here are the MAEs) and possible causes are evaluated at a specific time point(between the dates 15 Feb- 30 April 2019) for a defined population (nurses) without attempting to make inferences or statements of causation \unskip~\citep{634956:14880098}.

\textbf{Research setting}

The study conducted in two regional hospitals in Egypt with a total bed capacity of 512 beds distributed over three units (emergency, intensive care, and surgical units). 

\textbf{Research subjects}

A purposive sample of 146 nurses distributed on morning and afternoon shifts in the units mentioned above were recruited in this study. To be considered for inclusion, the nurses have to have a valid license, worked for more than six months in the same hospital that enables the nurse to be acquainted with policies, regulations, and rules, as a bedside nurse, volunteered to participate in this study. Non-registered nurses, those without a valid license, and newly recruited nurses are disqualified for inclusion in this study. They yield a 100\% response rate. 

\textbf{Tool for data collection}

\textbf{Medication Administration Errors Reporting Scale } \textbf{(\textbf{MAERS) }}

It is a self-reported questionnaire developed by \unskip~\cite{634956:14880113}\textit{\textit{.}} It aimed to measure the perception of nurses to medication administration errors. The scale distributed once for all studied subjects. It entailed three sections. 

The first section concerned with the nurses' socio-demographic characteristics. This section has been changed by the researchers to include nurses' age, gender, marital status, educational level, years of experience, and place of work. Moreover, four additional questions added regarding whether the nursing unit using a dosing system, which model of nursing practice used; nurses perception to their knowledge level about medication administration; and nurses'perception of their training needs. 

The second section aimed to assess the nurses' perception of factors that might cause MAEs. This part contained 29 questions classified under six main headings. Thye were system reasons (7 statements), nursing staffing (7 statements), physician communication (6 statements), medication packaging (3 statements), transcription-related (2 statements), and pharmacy processes (4 statements).

The third section concerned with the assessment of the reason for which medication administration errors are not reported. It includes 16 statements, classified under four main headings. They are fear (5 statements), administration response (4 statements), disagree with the definition (4 statements), and reporting effort (3 statements). The Medication Administration Errors (MAEs) Reporting Scale showed an inter-item correlation coefficient ranging from 0.82 to 0.91. 

\textbf{Scoring system}

Participants asked to specify their agreement level using a six-point Likert scale questionnaire with six classifications ranging from 1=strong disagreement to 6=strong agreement. Each subscale is then calculated separately as mean and standard deviation. Moderately and strongly agreed reasons are considered the top reason behind the occurrence of medication administration errors. Moderately and strongly disagreed reasons are considered the minimum reason is contributing to the occurrence of MAEs. Then a mean score calculated for each subscale in order to rank the factors behind medication administration errors.

\textbf{Procedure}

Medication Administration Errors (MAEs) Reporting Questionnaire used after took permission from authors via email. Also, ethical clearance from the Committee of the Institutional Review Board (IRB) of the study settings. A set of self-reported questionnaires with a sociodemographic survey distributed forall nurses working at the three acute care units at the studied hospitals. They asked to contribute in the current study. The data collected by the co-researchers through distributing closed packages questionnaires (they received training to explain the guidelines for participants). During the distribution and receipt of the research instruments, co-researchers were available. Each set included a cover letter providing information on the study's purpose and significance, the nurses ' expectations, and instructions on instruments' returning.

Also, the cover letter included the researchers ' contact information to enable participants to obtain additional information and ask questions related to the study. Nurses informed that for this study, the information gained from the questionnaires would be used. The nurses requested to sign the cover letter, which stated that there was voluntary participation, that it was based on anonymity and confidentiality; Without any influence, direct or indirect {\textemdash} a code number allocated for each nurse at the starting of the study. The received information is saved confidentially by the researchers. During periods of reduced workload, participants filled out the data collection form in a quiet room to prevent nurses from being affected by the ward work setting. 

The questionnaire has been validated in a sample of ten nurses participating in the pilot study. Ambiguous sentences rectified and created the final version. Pilot study nurses were later omitted from the mainstream sample. The interviews lasted for 15{\textendash}30 min. Five experts validated tool content (two critical care nurses, and three nursing professors specified in critical care and emergency nursing) reviewed all questionnaires regarding its content, clarity, relevance, completeness, and appropriateness. 

\textbf{Data Analysis}

The data were coded, computed, and analyzed using IBM Statistical Package for Social Sciences for Windows (IBM SPSS Statistics) version 21.0. Initially, preliminary data cleaning has done. Data analysis includes frequency, mean, and standard deviation descriptive statistics).
    
\section{Results and Discussion}
Table~\ref{tw-3fc6b7f27b51} demonstrates the demographic characteristics of the nursing staff. It reveals that 48\% of the studied nurses were in age group of 26-30 with mean age of 32 \ensuremath{\pm}0.69, 51.4\% of nursing staff were females, in addition to 58.2\% of them married, 73.3 had bachelor's degree in nursing with mean years of their experience of 7\ensuremath{\pm}0.75, 54.1\% of them was working at critical care units. Moreover, 55.5 \% of nursing staff applied the primary model in nursing practice. All of the participants use the unit-dose system in their hospital. The majority of the sample had self-evaluation as insufficient knowledge (42.46\%) related to medication administration information, and 64.38\% of nurses reported that they need training in medication administration.

Table~\ref{tw-3405842de6d0} shows the nurses' agreement regarding their perception of factors contributing to MARs. The table shows that all nurses agreed that factors related to nursing staffing. It includes unit staffing levels are inadequate, and nurses do not communicate when scheduled medication is delayed), and factors related to transcription (medication orders are transcribed incorrectly to the Kardex). 

Moreover, the majority of nurses perceived system-related reasons as contributing factors. In which 98\% of nurses perceived that the unit staff does not provide enough in-services on new medicines. 96.6\% of them perceived that equipment malfunction might be among the top reasons for medication errors, and 79.5\% believe that it is no easy to find information on medication in their units. Although its seriousness, a few numbers of nurses agreed about factors such as several patients, have the same or alike medication (21.9). The name of many medicines are similar (37\%), nurses in the assigned unit have inadequate medication knowledge (41.1\%), and 63.7\% of nurses reported that they are unaware of a known allergy. 

Table~\ref{tw-49bdf6c8993b} shows nurses' perception of factors with a minimum contribution to MAEs. All nurses disagreed that transcription-related factors (errors are made in the Medication Kardexare) contributing to MAEs and system reasons (nurses shared between different teams and other units, for other care, patients are off the ward). Moreover, the majority of nurses disagreed about the contribution of other factors such as physician communication (physician change frequently orders 98.7\%, physician-nurses poor communication 80.2\%). 

Also, they denied that the pharmacy process might contribute to MAEs as 95.9\% disagreed about the pharmacy did not correctly prepare the medicine, and the pharmacy delivered wrong doses to this unit 93.1\%. Besides, 80.1 of the nurses disagreed that all medications can not be transferred within the agreed time frame for one patient group. This table also shows a few numbers of nurses disagreed about factors such as frequent substitutions of drugs (28.8\%), and factors such as nurses were interrupted to perform other tasks when administering medicines (43.2), and medication orders from physicians are not legible (45.9\%). 

Mean scores of the six domains of MAEs reasons, according to the nurses' perception are showing in Table~\ref{tw-2be298684dc7}. The table shows that participants were ranked the most important factor for MAEs occur was system reasons (24.73\ensuremath{\pm}1.46) then followed by nurse staffing reasons as the second reason of MAEs (24.11\ensuremath{\pm} 2.25). Third, fourth, and fifth-ranked reasons were physician communication (13.37\ensuremath{\pm}2.7), medication packaging (12.84\ensuremath{\pm}1.87), transcription-related (8\ensuremath{\pm}0.1), respectively. Finally, pharmacy processes (6.97\ensuremath{\pm}2.93) are viewed as the least factor for the frequency of MAE. 

Table~\ref{tw-59cc160ea936} shows nurses' perception of the reasons of why MAEs are not reported. There were four reasons why MAEs are not reported. The nurses agree that the four main reasons for not reporting the MAEs are fear, administrative response, disagreement with the definition of MAEs, and reporting effort. All nurses agreed with the fear-related factors. It includes the client or family that may have a negative attitude towards the nurse or may prosecute the nurse if the error was reported. Also, all the nurses agreed with the administration's response, such as there is no positive feedback for medication to be passed correctly. In addition, it is used as an indicator of the quality of nursing care received; too much emphasis is placed on medical errors. Also, all nurses disagree with the definition, such as medication administration error is not defined clearly, and finally, it takes too long to report the incident for a medication error.

Besides, the majority of nurses perceive other reasons behind not reporting such as in cases of medication errors, nursing administration focuses on the patient rather than considering the processes as a potential cause of the error (98.6\%), nurses do not agree with the definition of a drug error by the hospital (97.2\%), nurses think other nurses are incompetent if they make medication errors (96.6\%), if something happens to the patient due to a drug mistake, nurses could be blamed (96.6\%).

Accordingly, Table~\ref{tw-cd026bcd12e8} shows the nurses' perception of reasons for why medication administration errors are not reporting. They stated that the fear (25.23\ensuremath{\pm}1.77), was observed as the key reason for MAEs was not reporting, trailed by administrative reason (23.14\ensuremath{\pm}0.78), and then disagreement with the definition (13.21\ensuremath{\pm}0.75). Finally, the reporting effort (11.15\ensuremath{\pm}0.43) was observed as the least important reason for MAEs reporting.  Concerning age, gender, place of work, years of experience, and education level, Table~\ref{tw-4f0902f13475} shows a highly statistically significant positive correlation with all factors contributing to MAE at P{\textless}0.001. 


\begin{table*}[!htbp]
\caption{\boldmath {Frequency and percentage distribution of sociodemographic characteristics of nurses under study (no. 146)} }
\label{tw-3fc6b7f27b51}
\centering 
\begin{threeparttable}

\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.5393\linewidth-2\tabcolsep}p{\dimexpr.22970000000000002\linewidth-2\tabcolsep}p{\dimexpr.231\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Sample Characteristics  & Frequency  & Percent (\%) \\
\tblmidrule 
\textbf{Age} &
   &
  \\
26-30 &
  71 &
  48\\
31-35 &
  57 &
  39\\
{\textgreater}35 years &
  18 &
  12.3\\
\textbf{M \ensuremath{\pm}SD } &
  \multicolumn{2}{p{\dimexpr(.4607000000000001\linewidth-2\tabcolsep)}}{\cAlignHack                    32 \ensuremath{\pm}0.69}\\
\textbf{Gender} &
   &
  \\
 Male &
  71 &
  48.6\\
Female &
  75 &
  51.4\\
\textbf{Marital Status } &
   &
  \\
Single &
  57 &
  39\\
Married &
  85 &
  58.2\\
Divorced &
  1 &
  0.7\\
Widow &
  3 &
  2.1\\
\textbf{Educational Level} &
   &
  \\
BNS &
  107 &
  73.3\\
Technical Institute Diploma &
  39 &
  26.7\\
\textbf{Years of experience } &
   &
  \\
less than 5 years  &
  78 &
  53.4\\
5  {\textendash} 10 years &
  44 &
  30.1\\
{\textgreater}10 years  &
  24 &
  16.4\\
\textbf{M \ensuremath{\pm}SD } &
  \multicolumn{2}{p{\dimexpr(.4607000000000001\linewidth-2\tabcolsep)}}{\cAlignHack 7 \ensuremath{\pm}0.75}\\
\textbf{Unit} &
   &
  \\
Critical care unit &
  79 &
  54.1\\
Emergency unit &
  35 &
  24\\
Surgical unit &
  32 &
  21.9\\
\textbf{Model of nursing practice} &
   &
  \\
Team &
  65  &
  44.5 \\
Primary &
    81 &
    55.5\\
\textbf{Using the unit-dose system} &
   &
  \\
Yes &
  146 &
  100\\
No &
  0 &
  0\\
\textbf{Self {\textendash}evaluation Knowledge level} &
   &
  \\
Sufficient &
  15 &
  10.27\\
Fair &
  41 &
  28.08\\
Insufficient &
  62 &
  42.46\\
Extremely insufficient &
  28 &
  19.17\\
\textbf{Training need} &
   &
  \\
Need &
  94 &
  64.38\\
No comment &
  30 &
  20.54\\
No need &
  22 &
  15.06\\
\tblbottomrule 
\end{tabulary}\par 
\begin{tablenotes}\footnotesize 
    
\item{M: Mean score SD: Standard Deviation score }
\end{tablenotes}
\end{threeparttable}

\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Nurses' perception of factors contributing to medication administration errors} }
\label{tw-3405842de6d0}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.7078\linewidth-2\tabcolsep}p{\dimexpr.14139999999999995\linewidth-2\tabcolsep}p{\dimexpr.15080000000000002\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Factors & \multicolumn{2}{p{\dimexpr(.2922\linewidth-2\tabcolsep)}}{Moderately and Strongly Agree}\\
\rowcolor{kwdboxcolor} & Frequency  & Percent (\%) \\
\tblmidrule 
\textbf{System reasons } &
   &
  \\
The unit staff does not receive enough in-services on new medications &
  143 &
  98\\
Equipment malfunctions or is not set correctly (e.g., IV pump) &
  141 &
  96.6\\
In this unit, there is no easy way to lookup information on medications &
  116 &
  79.5\\
Many patients are on the same or similar medications &
  32 &
  21.9\\
\textbf{Nurse staffing} &
   &
  \\
Unit staffing levels are inadequate &
  146 &
  100\\
When scheduled medications are delayed, nurses do not communicate the time when the next dose is due &
  146 &
  100\\
The nurse is unaware of a known allergy &
  93 &
  63.7\\
Nurses on this unit have limited knowledge about medications &
  60 &
  41.1\\
\textbf{Medication packaging} &
   &
  \\
The packaging of many medications is similar &
  93 &
  63.7\\
Different medications look alike &
  82 &
  56.2\\
The names of many medications are similar &
  55 &
  37\\
\textbf{Transcription-related } &
   &
  \\
Medication orders are not transcribed to the Kardex correctly &
  146 &
  100\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Nurses' perception of factors with minimum contributions to medication administration errors} }
\label{tw-49bdf6c8993b}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.6816000000000001\linewidth-2\tabcolsep}p{\dimexpr.14999999999999996\linewidth-2\tabcolsep}p{\dimexpr.16840000000000003\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Factors & \multicolumn{2}{p{\dimexpr(.3184\linewidth-2\tabcolsep)}}{\cAlignHack Moderately and Strongly Disagree }\\
\rowcolor{kwdboxcolor} & Frequency   & Percent (\%) \\
\tblmidrule 
\textbf{Physician communication} &
   &
  \\
Physicians change orders frequently &
  144 &
  98.7\\
Poor communication between nurses and physicians &
  117 &
  80.2\\
Physicians' medication orders are not clear &
  116 &
  79.4\\
Verbal orders are used instead of written orders &
  111 &
  76\\
Abbreviations are used instead of writing the orders out completely &
  98 &
  67.1\\
Physicians' medication orders are not legible &
  67 &
  45.9\\
\textbf{Transcription-related } &
   &
  \\
Errors are made in the Medication Kardex &
  146 &
  100\\
Pharmacy processes  &
   &
  \\
The pharmacy does not prepare the medication correctly &
  140 &
  95.9\\
The pharmacy delivers incorrect doses to this unit &
  136 &
  93.1\\
The pharmacy does not label the medication correctly &
  90 &
  61.6\\
Pharmacists are not available 24 hours a day &
  74 &
  50.7\\
\textbf{Nurse staffing} &
   &
  \\
All medications for one team of patients cannot be passed within an accepted time frame &
  117 &
  80.1\\
Nurses are interrupted while administering medications to perform other duties &
  63 &
  43.2\\
\textbf{System reasons } &
   &
  \\
Nurses get pulled between teams and from other units &
  146 &
  100\\
Patients are off the ward for other care &
  146 &
  100\\
Frequent substitution of drugs (i.e., cheaper generic for brand names) &
  42 &
  28.8\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Nurses' perception mean score for factors contributed to medication administration errors} }
\label{tw-2be298684dc7}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.3694\linewidth-2\tabcolsep}p{\dimexpr.24300000000000004\linewidth-2\tabcolsep}p{\dimexpr.20509999999999998\linewidth-2\tabcolsep}p{\dimexpr.1825\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Factors  & Item score & M & SD\\
\tblmidrule 
System reasons  &
  42 &
  24.73 &
  1.46\\
Nurse staffing  &
  36 &
  24.11 &
  2.25\\
Physician communication  &
  36 &
  13.37 &
  2.7\\
Medication packaging  &
  18 &
  12.84 &
  1.87\\
Transcription-related  &
  12 &
  8 &
  0.1\\
Pharmacy processes  &
  24 &
  6.97 &
  2.93\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Nurses' perception of reasons behind medication administration errors are not reported} }
\label{tw-59cc160ea936}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.6095000000000001\linewidth-2\tabcolsep}p{\dimexpr.18459999999999997\linewidth-2\tabcolsep}p{\dimexpr.20590000000000003\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Reason  & \multicolumn{2}{p{\dimexpr(.3905\linewidth-2\tabcolsep)}}{Moderately and Strongly \mbox{}\protect\newline Agree}\\
\rowcolor{kwdboxcolor} & Frequency  & Percent (\%)\\
\tblmidrule 
\textbf{Fear} &
   &
  \\
Nurses believe that other nurses will think they are incompetent if they make medication errors &
  141 &
  96.6\\
The patient or family might develop a negative attitude toward the nurse or may sue the nurse if a medication error is reported &
  146 &
  100\\
Nurses are afraid the physician will reprimand them for the medication error &
  63 &
  43.2\\
Nurses fear adverse consequences of reporting medication errors &
  35 &
  24\\
Nurses could be blamed if something happens to the patient as a result of the medication error &
  141 &
  96.6\\
\textbf{Administrative response} &
   &
  \\
No positive feedback is given for passing medications correctly &
  146 &
  100\\
Too much emphasis is placed on med errors as a measure of the quality of nursing care provided &
  146 &
  100\\
When med errors occur, nursing administration focuses on the individual rather than looking at the systems as a potential cause of the error &
  144 &
  98.6\\
The response by nursing administration does not match the severity of the error &
  136 &
  93.2\\
\textbf{Disagree with the definition of MAEs} &
   &
  \\
A medication error is not clearly defined &
  146 &
  100\\
Nurses do not agree with the hospital's definition of a medication error &
  142 &
  97.2\\
\textbf{Reporting effort} &
   &
  \\
Filling out an incident report for a medication error takes too much time &
  146 &
  100\\
Contacting the physician about a medication error takes too much time &
  18 &
  12.3\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Nurses' perception of reasons for why medication administration errors are not reporting} }
\label{tw-cd026bcd12e8}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.38839999999999996\linewidth-2\tabcolsep}p{\dimexpr.20669999999999998\linewidth-2\tabcolsep}p{\dimexpr.2345\linewidth-2\tabcolsep}p{\dimexpr.1704\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Reasons   & Item score & M & SD\\
\tblmidrule 
Fear  &
  30 &
  25.23 &
  1.77\\
Administrative response  &
  24 &
  23.14 &
  0.78\\
Disagree with definition  &
  24 &
  13.21 &
  0.75\\
reporting effort  &
  18 &
  11.15 &
  0.43\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {The relationship between socio-demographic characteristics and factors contribute to medication administration errors occurrence} }
\label{tw-4f0902f13475}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.17380000000000003\linewidth-2\tabcolsep}p{\dimexpr.1462\linewidth-2\tabcolsep}p{\dimexpr.16\linewidth-2\tabcolsep}p{\dimexpr.16\linewidth-2\tabcolsep}p{\dimexpr.16\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Items  & Age & Gender  & Place of working & Years of experience & Education level\\
\tblmidrule 
System reasons  &
  (r = 0.527, P  = 0.000)  &
  (r = 0.319, P  = 0.000)  &
  (r = 0.372, P  = 0.000)  &
  (r = 0.534, P  = 0.000)  &
  (r = -0.449, P  = 0.000) \\
Nurse staffing &
  (r = 0.495, P  = 0.000)  &
  (r = 0.624, P  = 0.000)  &
  (r = 0.408, P  = 0.000)  &
  (r = 0.444, P  = 0.000)  &
  (r = -0.279, P  = 0.000) \\
Physician communication &
  (r = 0.591, P  = 0.000)  &
  (r = 0.821, P  = 0.000)  &
  (r = 0.844, P  = 0.000)  &
  (r = 0.675, P  = 0.000)  &
  (r = -0.644, P  = 0.000) \\
Medication packaging &
  (r = -0.674, P  = 0.000)  &
  (r = 0.820, P  = 0.000)  &
  (r = -0.77, P  = 0.000)  &
  (r = -0.613, P  = 0.000)  &
  (r = 0.540,  \mbox{}\protect\newline  = 0.000) \\
Pharmacy processes  &
  (r = 0.663, P  = 0.000) &
  (r = 0.887, P  = 0.000) &
  (r = 0.829, P  = 0.000) &
  (r = 0.649, P  = 0.000) &
  (r = -0.607, P  = 0.000)\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
Medication administration error is one of the reasons that causes death and injury to patients and the most serious threats to the healthcare system in all countries around the world \unskip~\citep{634956:14880076,634956:14880088}\textit{. }It drains the financial resources of hospitals worldwide extensively. \unskip~\citep{634956:14880094} \textit{.} This study conducted to explore nurses' perception of factors contributing to medication administration errors and reasons for which medication administration errors are not reporting.

The current study conducted on the sample of 146 nurses working in acute care settings (emergency, ICU, and surgical words), around half of the studied nurses' age was between 26-30 with a mean age of 32 \ensuremath{\pm}0.69. This finding is emphasized by the current findings as about three-quarters of them has a bachelor degree of nursing with the mean of 7\ensuremath{\pm}0.75 year experience. Moreover, more than half of them were females, married, working in critical care units, their units apply a primary model of care, and all units use the unit-dose system. Two-fifths of the studied nurses reported insufficient knowledge related to medication administration, and about two-thirds reported a need for training on medication administration.

These findings may be referred to insufficient on job training regarding safety, particularly medication administration. It is evidenced by the present study findings when most of the studied nurses reported The unit nurses are not obtaining enough new medicines in-services, about four-fifths of them reported that they have difficulties to check medicine information. This finding is consistent with \unskip~\cite{634956:14880063}\textit{,} who reported unit nurses did not obtain sufficient in services on new medication as the most significant factors associated with the occurrence of errors among (69.6\%) of their studied nurses. \unskip~\cite{634956:14880101,634956:14880112} reported that the staff not received enough training are among the contributing factors for MAEs, and it reflects a system failure.

Also, about two-thirds reported that they are unaware of a known allergy, and about two-fifths reported a limited knowledge about medications. A similar sociodemographic characteristic has shown by \unskip~\cite{634956:14880063,634956:14880106}\textit{. }The later classified their sample according to their knowledge of medication errors prevention and reported that 34\%of the nurses had an average level of knowledge, 30\% had poor knowledge, 28\% of them categorized as having very poor knowledge, and only 8\% had a good knowledge level \unskip~\citep{634956:14880106} \textit{.}

Concerning nurses' perception of top factors that might contribute to MAEs, all nurses agreed about the contribution of nursing staffing related factors when unit staffing is inadequate, or there is poor communication among nurses when scheduled medication is delayed. All of the studied nurses also agreed about transcription-related factors such as drug orders are not correctly transcribed to the Kardex. 

Several studies confirmed a link between systemic organizational features and medication errors and. These comprise staff nurses' adequacy, overtime hours, hours worked each week, staff mix, and other factors that reflect the design of the work \unskip~\citep{634956:14880076}\textit{.} Also, \unskip~\cite{634956:14880080} reported that 97.8\% of the studied nurses perceived tiredness due to workload as a contributing factor to MAEs. The findings of this study also agreed with earlier international researches, who found that nurses' staffing was a significant factor that contributes to medication errors \unskip~\citep{634956:14880063,634956:14880070,634956:14880079,634956:14880115}.\textit{\space }The current study findings were inconsistent with \unskip~\cite{634956:14880092}, who study "nurse staffing and medication errors: cross-sectional or longitudinal relationships." They reported no support for the relationship between nurse staffing and medication error cross-sectionally or longitudinally.\textit{}

Although its importance, a few numbers of the current study nurses agreed about factors such as many patients on the same or similar medication (one fifth), the name of many medications similar (one third). These may reflect that although the similarity of the drug names, and commonality of use among patients, the nurses did not consider them as a hindering issue in the current study. These findings might elaborate on an exceptional nurses' experience in their workplace (that exceed five years in about half of the current study sample), so they can overcome this problem.

This explanation was reported by \unskip~\cite{634956:14880076}. They found a statistically significant association between the experience of nurses and the packaging of medicines. \unskip~\cite{634956:14880076} also reported an inverse relationship between the nurses' experience and MAEs occurrence. \unskip~\cite{634956:14880117} reported the same relation between MAE and nurses' experience. A contradiction to this study, \unskip~\cite{634956:14880108}\textit{,} reported that on the units that had more nurses with a higher experience, more pediatric medication administration errors reported at p=0.001. This contradiction with current study findings may be referred to as the later study conducted in pediatric neonatal units.

\unskip~\cite{634956:14880063} also report\textit{ similar findings,} the names of many drugs are similar (42.1\%), different drugs look similar (33.7\%), and the packaging of many drugs is nearly identical (45.3\%).All these factors perceived by the nurses to be associated with medication administration errors. \unskip~\citep{634956:14880114,634956:14880086,634956:14880096} reported similar findings.

The current study also revealed the nurses' perception of factors they perceived to have a minimum contribution to MAEs.All nurses disagreed that system reason factors such as (Nurses are split between teams and other units, and patients are off the ward for other care), and transcription-related factors such as errors are made in the Medication Kardexare contributing to MAEs. This may be because current study nurses are working in acute care settings. They are always kept in their place due to their highly skilfull level and experience. Also, patients in such units are minimally transferred to other units for care. In contrast to the above findings, \unskip~\cite{634956:14880063} reported nurses' agreement on such factors as nurses split between teams and other units as a contributing factor among 73.8\% of the studied nurses. The patient is off the ward for other care, is also revealed as a contributing factor by 64.4\% of the nurses in \unskip~\cite{634956:14880063} study, which is contradicting to the current study findings. This difference could be due to methodological and setting differences as the current study conducted in two leading hospitals, in which acute patients cared for in acute care settings. Errors are made in the medication Kardex was also reported by 63.1\% of \unskip~\cite{634956:14880063} studied nurses. The difference in findings may be referred to as the quality of nurses and their experience in the present study as they were keen when modifying or transcribing the medication in the Kardex.

Moreover, the majority of the current study nurses disagreed about the contribution of other factors such as physician communication (physician change orders frequently, poor communication between nurses and physicians). Also, they denied that the pharmacy process might contribute to MAEs as most of them disagreed about pharmacy incorrectly prepare the medication and delivers wrong doses to their units. This finding may reflect excellent physician-nurse communication and precise pharmacy process in the current study settings 

In contrast to the current study \unskip~\cite{634956:14880075} reported that poor physician-nurse relationships might be the reason for medication administration errors due to physicians do not devote sufficient time for nurses to discuss the care options or listen to the nurses' perspectives. Poor communication accounts for over 60\% of the root causes of sentinel events reported to the Joint Commission (JC) \unskip~\citep{634956:14880065}\textit{.} Regarding the pharmacy process, \unskip~\cite{634956:14880095} agreed with the current study finding that pharmacy process factors were not revealed as factors that can increase the error of medication administration in the healthcare organization.

The participants in the current study ranked the system errors as first in the categorization of the most important perceived contributing factors, followed by nurses staffing, then physician communication, transcription-related, and finally, pharmacy process at the last one. Similar studies mentioned the same contributing factors' grouping with a different ranking. \unskip~\cite{634956:14880076} contrasted the current study findings. They conducted a study entitled "emergency department nurses' perception toward factors influencing the occurrence of medication administration errors." They reported that the nurses perceived doctor contact as the highest-ranked factor influencing the incidence of MAEs. A package of medicines followed it, then a pharmacy system, and at least rank is the nursing staff. \unskip~\cite{634956:14880064} revealed that nurses perceived the relationship between physician and nurse as the fourth category of medication administration errors. \unskip~\cite{634956:14880064} added that the emergence of novel drugs in the market made it almost impossible for the health care professional to keep up-to-date with all the latest medication information. 

The present study showed nurses' perception of the reasons of why MAEs are not reported. The study documented four reasons why medication administration errors are not reported. They are fear, administrative response, disagreement with the definition of MAEs, and reporting effort. All nurses agreed with the fear-related factors such as the patient or family may have a negative attitude towards the nurse or the nurse prosecute if a drug failure has been identified. Also, an administrative response such as no positive feedback is received for the correct transmission of medicines, and too much emphasis is put on MAEs as an indicator of the nursing care quality. They disagreed with the definition, such as drug error is not defined clearly, and finally, It takes too long to file the incident report for a drug mistake.

Besides, the majority of nurses perceive other reasons behind not reporting that nursing administration focuses on the patient rather than considering the processes as a potential cause of the error (98.6\%). Also, nurses disagreed with the interpretation of a drug error by the hospital (97.2\%), and nurses think other nurses feel they are inept when they make drug errors (96.6\%). If something happens to the patient due to the drug mistake, the nurses could be blamed (96.6\%).

An initial study lead by \unskip~\citet{634956:14880113}\textit{,} who developed the standardized study tool, surveyed 1,384 nurses. The nurses reported a firm agreement with the barrier of no positive feedback to correctly pass the medicines. They reported that if something happens to the patient, nurses could be blamed. They also reported that when medication errors occur, instead of the system, the focus is on the individual, nurses. They added that they might not feel the errors are sufficiently important to report; nurses think that other nurses feel they are inept. Finally, nurses are concerned about the adverse effects of reporting medication administration errors. \unskip~\citep{634956:14880072} reported similar findings.

The present study nurses ranked the reason for which they are not reporting the MAEs. They reported four factors which are fear, followed by administrative reasons, then disagreement with the definition, and finally reporting effort. \unskip~\cite{634956:14880094}\textit{,} reported similar factors with different rank. The administrative response was identified as the top perceived obstacle, followed by fear. \unskip~\citep{634956:14880068} reported administrative reason and fear among the barrier for not reporting the MAEs.

This finding is compatible with other studies that have found a lack of appreciation and awareness of medication administration errors in addition to the fear of administrative judgment on the person who responsible for medication error were among the most obstacles identified by nurses to reporting medication errors. \unskip~\citep{634956:14880115,634956:14880067,634956:14880071,634956:14880081,634956:14880082,634956:14880089,634956:14880116,634956:14880111,634956:14880074}\textit{. }

Regarding the association of MAEs to the sociodemographic characteristics of the studied nurses, the present study revealed a significant association between sociodemographic characteristics and contributing factors of MAEs. In contrast to this finding, \unskip~\cite{634956:14880076} reported a no statistically significant difference between sociodemographic characteristics and factors contributing to MAEs. Also, \unskip~\cite{634956:14880094} reported no association between the sociodemographic characteristics and factors contributing to MAEs.
    
\section{Conclusions}
The present study concluded that all nurses perceived factors related to nursing staffing, such as unit staffing levels are inadequate, and nurses do not communicate when scheduled medication is delayed. Also, factors related to transcription (drug orders are not correctly transcribed to the Kardex) as top factors that could be contributed to MAEs.

All nurses perceived that the fear {\textendash}related factors (the patient or family may have a negative attitude towards the nurse or the nurse might be sue if a drug failure has been identified); administrative response such as there is no positive feedback on the proper passing of medicines and too much stress is put on medical errors as a measure of the quality of nursing care provided.; disagree with a definition such as hospitals are not define medication clearly. Finally, it takes too long to file the incident report for a drug error are the top factors for being not reporting the MAEs.

\textbf{Implication }

It is vital to develop effective quality assurance programs in all health care settings in relation to medication and medication administration, to assure patient safety. Clinical and academic nursing educators need to reinforce the importance of medication rights and the calculation of medicines. The nurses should be prepared with adequate knowledge through a robust education program, and clear communication between staff is essential. Development of procedures book, protocols, and guidelines specific to the emergency, intensive care, and surgical units. Reproduction of this study on a larger probability sample and nurses employed in nonacute care settings still needed.
\section*{Acknowledgement}The researcher would like to acknowledge all those persons and nurses who give help and guidance.
    

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