Introduction

Drug safety is recognized as an important component of patient safety. Medication errors frequently occur, thereby increasing the risk of damage to the patients and raising healthcare system costs (4). Following motor vehicle accidents, diabetes, renal diseases, breast cancer, and flu, adverse drug events are the fifth leading cause of death in the United States (5). Based on recent reports, approximately 200,000 Americans die from preventable medical errors, including facility-acquired conditions, and millions may be affected by these errors. According to statistics, medical errors cost the United States 19.5 billion dollars in 2008 (6).

Common medication errors include wrong drug prescription, wrong route and time of drug administration, medication administration more than the prescribed dosage, dosage calculation errors, and drug administration to the wrong patient (7). Overall, forming an overall image of medication errors is challenging in developing countries, which may be attributed to lack of error reporting systems, inaccurate reporting, and scarcity of studies in this area in these countries. Although the exact incidence of medical and nursing malpractice has not been determined in Iran, it seems unlikely that Iran would have a better status than Western countries. The rise in complaints against physicians and midwives to medical councils and courts could prove this issue (8).

The perinatal safety movement was started in 1999 by publishing an article about the prevention of patient injury and medical malpractice claims. In this research, the authors described the characteristics of highly reliable perinatal units (9). Overall, management of medication errors is of particular importance, considering the adverse outcomes on patient health and safety as the most important healthcare priorities and indicators in Iran (10, 11). Medication errors may lead to maternal mortality, prolonged hospitalization, and increased treatment costs. As a result, such errors may eventually cause conflict and stress for health providers and increase client dissatisfaction with the health system (11-15).

In a qualitative study by Lynden, nurses defined patient safety as the protection of physical, psychological, and emotional wellbeing of the patient and his/her family. Nurses could maintain patient safety through preparing the environment, anticipating the potential pro-blems, and preventing errors before they affected the patient (16). With regard to the reporting of medication errors, previous studies have shown that only serious adverse events caused by medication errors are reported (10), while less important errors may be neglected (17). In a study conducted in Iran, the results showed that 72% of nurses did not report medication errors (18).

Previous studies have shown that working conditions are responsible for the majority of nursing medication errors, while health provider's level of education and work experience have little relevance to nursing malpractice. Moreover, healthcare providers, who work in hospitals with insufficient human resources and are forced to work overtime or consecutive shifts, are more likely to have medical errors (19-21).

Midwives are known as the first providers of maternal and fetal care. Generally, midwifery, as a component of medical care systems and women's health care, is of great importance. Today, with the increasing complexity of the process of reproductive health care, midwifery activities have become more intricate, leading to midwives’ irreparable mistakes in the workplace.

In addition, night work, long shifts, and unpredictable activities of midwives increase the likelihood of fatigue, which can in turn reduce physical function and capacity and increase the possibility of errors (22-24). In fact, according to the announcement by the chief executive of Health and Population Office of the Iranian Ministry of Health, approximately 60% of maternal mortality was due to medical, midwifery, and nursing errors between 1999 and 2005 (13).

In order to offer high-quality care services and achieve the goal of patient safety, i.e., prevention and mitigation of problems and adverse outcomes through healthcare services, it is essential to increase the level of knowledge about the causes of medication errors and determine the reasons against error reporting by employed midwives. Therefore, by eliminating these barriers, optimal services can be offered to mothers. Moreover, identifying the causes of errors can be helpful in eliminating medication errors and the contributing factors, improving the quality of care, and increasing patient safety.

Research on medication errors has been conducted among nurses in nursing wards (19-21). Considering the importance of midwifery in the health of mothers and infants and the scarcity of studies in the field of midwifery (22, 25-28), in this study, we aimed to determine medication errors and the contributing factors among midwives working in maternity units of Mashhad University of Medical Sciences, Mashhad, Iran in 2015.

 Materials and Methods

In this descriptive, cross-sectional research, the study population consisted of 104 employed midwives working in hospitals, affiliated to Mashhad University of Medical Sciences (Imam Reza, Ghaem, Omolbanin, and Hashemi Nezhad hospitals). The inclusion criteria were as follows: 1) employed midwives at maternity wards; 2) six months of work experience (minimum); and 3) bachelor's degree or higher.

If the questionnaires were answered incompletely, they were excluded from the study. The data collection tool was a questionnaire, consisting of four sections, designed according to the study objectives. The first section included nine questions on personal and organizational information, and the second section consisted of 19 items on the incidence of medication errors over the past six months. Each item was scored on a 4-point Likert scale, ranging from "never" to "more than twice"; a score of 0 to 3 was assigned to each item.

The third section contained 14 items about the reasons against reporting medication errors, and the fourth section consisted of 25 items on the causes of medication errors. Items in the third and fourth sections were set on a 5-point Likert scale, ranging from "low importance" to "high importance"; a score of 1-5 was assigned to each item. The content and face validity of the questionnaire were confirmed by a panel of experts.

The reliability and validity of the second and third parts of the questionnaire have been confirmed in a study by Mirzaei et al. (29), while the reliability and validity of the fourth part of the questionnaire have been approved in studies by Yousefi (20) and Nickpayma (30). In this study, the reliability of the second, third, and fourth parts of the questionnaire were re-evaluated, using Cronbach's alpha (0.61, 0.87, and 0.93, respectively).

Informed consent forms were obtained from all the participants. Anonymity of the participants and confidentiality of the data were respected by the researcher. This article was extracted from a postgraduate thesis by the main author, which was approved by Mashhad University of Medical Sciences (code: 930682). Data collection was performed by midwifery and reproductive health students.

Women were asked to complete the self-report questionnaires in a proper setting at an appropriate time. In order to analyze the data related to the causes of medication errors, reasons against medication error reporting, and the contributing factors, linear regression and negative binomial regression analyses were carried out independently, using SPSS version 20 and STATA version 11, respectively. In all statistical tests, confidence interval and significance level were considered to be 95% and 0.05, respectively.

 Results

In this study, the response rate was estimated at 76%; in other words, 79 out of 104 midwives completed the questionnaire. The average age and work experience of the participants were 34.5±9.1 years and 130.4±113.1 months, respectively. In total, 93.7% of the samples had a bachelor's degree, 78.5% were married, 41.8% were full-time employees, and 85.9% worked rotating shifts.

The mean incidence of medication errors for each midwife over the past six months was 2.24±2.89, and the most common medication error was medication administration later or earlier than the stipulated time (0.85±1.13). Among 14 reasons against reporting medication errors, attributing the medication error to individual factors by officials (3.88±1.34) and fear of confrontation with authorities (3.79±1.5) had the highest average scores (Table 1). Also, among 25 causes of medication error, the highest average scores were related to the overcrowding of the ward (4.32±1.01), excessive workload and overexertion (4.19±1.08), and presence of critically ill patients in the ward (4.03±1.18) (Table 2).

The negative binomial regression model

indicated that the ratio of the incidence of medication errors among married subjects was 0.45. Based on the findings, the incidence of medication errors increased as job satisfaction improved in the participants (Table 3). Multiple linear regression analysis showed that lack of medication error reporting was more prevalent among subjects working fixed shifts, compared to those on rotating shift schedules. Moreover, the average incidence of not reporting medication errors decreased as education and job satisfaction improved (Table 4).