Hrev_master Healthcare in Low-resource Settings 2023; volume 11(s1):11177 A cross-sectional study of the knowledge, skills, and 6 rights on medication administration by nurses at emergency department Linda Wieke Noviyanti,1 Andri Junianto,2 Ahsan1 1Department of Nursing, Faculty of Health Sciences, Universitas Brawijaya, Malang, Indonesia; 2Nursing Practitioner, General Hospital Saiful Anwar, Malang, Indonesia Abstract Introduction: Medication errors occur when a patient is given the wrong drug or receives incorrect pharmacological therapy. Incorrect drug administration can cause fatal errors resulting in the patient’s death. Approximately 44,000-98,000 patients die each year due to medication errors and this condition is found often in the Emergency Room (ER) due to the complexity. Therefore, this study aims to analyze the relationship between nurses’ knowledge, skills, and 6 rights on medication at Emergency Department. Design and Methods: This is an analytical observational study involving 70 nurses randomly selected using consecutive sam- pling and working at the ER department of Saiful Anwar Hospital Malang. Data were collected through a questionnaire and analyzed descriptively to determine the knowledge and skills of nurses and the implementation of the correct principles of medication admin- istration. Results: The results showed that most of the emergency room nurses had good knowledge and skills in applying the correct prin- ciples of medicine. However, the majority could not calculate the drug dose accurately. The spearman rank results showed that there was a relationship between knowledge and the 6 correct drug prin- ciples (p<0.001, α= 0,05; r = 0.491) with a percentage of 44%. This indicates that a higher knowledge results in the correct imple- mentation of the drug. Similarly, there was a significant positive correlation between skills and proper medicine (p<0.001, α= 0,05; r = 0.378). Conclusions: It can be inferred that a higher nurse’s knowl- edge and skill results in a better administration of medicine. Introduction Medication errors can be classified into dispensing, prescrib- ing, and administration.1,2 These errors were detected in 85% of wrong doses with a prevalence rate of 32.1%.3 It is the third lead- ing cause of death in the United States, such that one in every 4 hospitalized patients suffers from harm caused by medication errors.4 Furthermore, more errors were detected during drug administration than in the preparation stage with the successive occurrence of 62.5% and 37.5%. Overall, a total of 43 errors (14.3%) were found to be potentially severe with work conditions, transcription, and pharmacies accounting for 51.5%, 9.9%, and 1.2%, respectively.5 Statistics showed that 38% of medication errors were related to nurses,6 and this is consistent with the reports of the study that the occurrence of errors was significantly associated with their experience and level of education.7 Nurses have a low level of knowledge of the pharmaceuticals they use the most, which leads to a higher rate of medication errors in the ICU.2 Around 84% of nurses have poor knowledge of High Alert Medications (HAMs) administration.8 Some factors that are significantly associated with medication administration errors include poor knowledge and communica- tion, stress, as well as interruption during medication administra- tion. 8,9 Clinicians initially expressed negative attitudes towards existing medication management, citing their dissatisfaction with current policies and procedures, as well as their skepticism about the relevance and utility of potential changes to medication man- agement.10 It is likely that nurses’ lack of information about the drugs, how it is administered, and the legal aspects of their actions will result in errors in drug administration error. In addition, nurs- es’ skills in carrying out action are important due to their impact on the patient’s condition. Nurses with good knowledge will have better behavior (skills) in preventing medication errors. Nurses play an important role in the implementation of drug administration, preventing medication errors, and administering safe drugs. Therefore, before working in real-life care, nursing stu- dents should have adequate competencies regarding medication safety.2 They need to understand the indications, dosage, method of administration, and possible side effects to be able to administer drugs correctly and effectively because of lack of knowledge may result in adverse patient outcomes.8 Nurses in giving drugs to patients have 6 rights on medication administration, these include correct patient, drug, dose, route, time, and documentation. According to several analysts, expanding nurses’ pharmaceutical information can be a critical technique for decreasing medication errors.11 A preliminary study conducted on 6 rights of medication administration at the ER showed that the ER receives approxi- mately 70-100 patients a day for referrals and walk-ins. There is a Article Significance for public health Medication administration contributes to the large literature on patient safety in healthcare settings. It is the complexity inherent in emergency services and the critical factors for enhancing teamwork and work procedures to avoid negligence or unrecorded mistakes. Furthermore, medication safety is a drug control technique that is heavily reliant on good safety culture. It is therefore important to determine nurses’ knowledge and skill to develop and implement strategies for maintaining medication safety. This study describes the correlation between knowledge, skill, and 6 rights medication administration. [Healthcare in Low-resource Settings 2023; 11(s1):11177] [page 57] No n- co mm er cia l u se on ly high complexity of services and risk in the ER due to the pressure of working quickly resulting in negligence or unrecorded errors. Furthermore, the majority of the nurses in the ER could not calcu- late the drug dose and the administration was not timely due to the long length of stay at work. The emergency department (ED) is a hospital setting that poses many patient safety challenges, includ- ing highly unpredictable conditions, and frequent use of high-risk medications, which increases the risk of error.12,13 This study con- tributes to the broad literature on medication management and safety in healthcare settings, especially the ED. It also emphasizes the complexity inherent in emergency services and the important points for improving teamwork and work procedures. In addition, the study evaluates the complexity of emergency services and the high risk of pressure to work quickly, which results in negligence or unrecorded errors. A study showed that the decision errors, crew resource management, inadequate supervision, and organizational climate contained more types of subfactors than other error factors in medication.14 Furthermore, medication safety is both a process and the product of management that relies heavily on strong safety culture. Building a safety culture involves creating an alignment between the individual, group, and institutional values, which impacts attitudes, perceptions, and generally the patterns of clini- cians’ behaviour.15 Therefore, the interest of most study is to exam- ine the relationship between nurses’ knowledge and skills with the implementation of the 6 rights medicine principle. Design and Methods A quantitative, direct, observational study was conducted on the ED nursings, which treat approximately 100 patients a day. This study uses a cross-sectional, non-experimental design to iden- tify the correlation between knowledge, skill, and 6 rights on med- ication administration. An information session was held to create awareness about the study, then the individual nurses were approached to solicit for their participation. After the informed consent, observers closely shadowed nursings for up to 3-hour intervals during day shifts. Specifically, it was hypothesized that a nurses’ knowledge and skill are associated with good medication administration performance. The simple random sampling was used to draw a final sample size of 70 and data were collected using a validated structured pretested self-administered question- naire that was adapted from previous studies. Separate tools were used to collect data regarding the knowledge of nurses on medica- tion administration. The result of construct validit index was between 0.595 – 0.895. Cronbach’s Alpha for knowledge instru- ment was 0.967 and skill instrument was 0.953, while reliability coeficient was 0.468. An observational checklist was developed and used to gather data by observing nurses while medicating patients to determine whether or not they followed the 6 rights of medication administration. Furthermore, the Spearman Rank sta- tistical test was adopted to determine the correlation between the two variables using SPSS for Windows version 16 with a signifi- cance limit of p <0.05. Results and Discussions Based on the data presented in Table 1, the majority of nurses (38) were aged 20-35 years accounting for 54.28%. Based on the gender of the respondents, it was discovered that there were 42 nurses (60%) and the majority (25 nurses) worked in hospitals for 1-5 years with a percentage of 35.71%. As shown in Table 2, based on the p-value < 0.001, it can be inferred that there is a correlation between nurses’ knowledge and implementation of 6 rights medi- cation administration. Furthermore, there was a significant rela- tionship between nurse skills and 6 rights medication administra- tion by nurse (p < 0001, α= 0.05, r = 0.378). The nurse’s level of knowledge Content analysis showed that the most errors include improper dosage, mistaken drug choice, knowledge-based mistakes, skill- based slips, and memory lapses.16 Knowledge, often referred to as cognitive, is obtained from an individual’s or others’ experiences and it helps to determine the activities and obedience of a person. Before individuals can have new behaviour or activities, they must have knowledge first. When the acceptance of this new behaviour is based on knowledge, awareness, and a positive attitude, then it will last long. On the contrary, a behavior that is not knowledge- based will not last long. The results showed that the education level of most ED nurses was Diploma. Education has a significant effect on the learning process because a higher level makes it easy for an individual to receive information. Furthermore, it is needed to increase knowl- edge because an educational model must memorize formulas, def- Article Table 1. Demographics of respondents. Characteristics n % 1. Age group 20-35 years 38 54.28 36-50 years 26 37.14 > 51 years 6 8.57 2. Education High School 3 4.28 Diploma 45 64.27 Bachelor 20 28.57 Master 2 2.85 3. Sex Male 28 40 Female 42 60% 4. Work tenure 1-5 years 25 35.71 6-10 years 12 17.14 11-15 years 8 11.42 16-20 years 7 10.00 21-25 years 13 18.57 > 25 years 5 7.14 Table 2. The relationship between knowledge, skill, and the implementation of 6 rights medication administration. Correlations Sig. Value CorrelationCoefficient Interpretation Knowledge – Implementation of 6 rights medication administration 0.000 0.491 Moderate correlation Skills - Implementation of 6 rights medication administration 0.001 0.378 Weak correlation [page 58] [Healthcare in Low-resource Settings 2023; 11(s1):11177] No n- co mm er cia l u se on ly initions, and how to take action. It can be reached by simulation, which supports skill and improves medication administration knowledge of some concepts. The use of simulation helped to identify a consistent knowledge gap.17 Ensuring that the drug is safe for the patient and monitoring the side effects of its administration is the duty of the nurse. Consequently, nurses or health workers must be equipped with knowledge in carrying out their roles. In this case, education can be used as a parameter to determine a person’s level of knowledge about the implementation of the principle of 6 correct medicines, especially regarding steps towards patient safety and understand- ing of medication errors. In addition, follow-up should be carried out by increasing the manager’s or ER director’s responsibility in providing training, seminars, and facilitating relevant activities in other hospital operations. Based on the results, most ED nurses were aged 20-35 years old with a percentage of 54.28%, this is because the young adult stage is the peak development of the phys- ical condition. In this stage, an individual has cognitive abilities and more complex moral judgments, they use their knowledge to achieve their goals, such as career and family. Therefore, age plays a significant role in implementing the principle of 6 rights medicine. Lack of knowledge may result in inadequate skills, conse- quently develops into a system failure because there is no suffi- cient education regarding drug administration. Previous studies reported that there is a lack of education regarding pharmacology in the basic undergraduate program,18 especially in the field of knowledge.19 Some of the common errors in drug administration include the wrong dose, followed by missed dose, and lack of pre- scription. Furthermore, errors in administering reached the patients more often than prescribed due to shortcomings in knowledge, skills, and abilities, as well as workload. 20 Therefore, it is impor- tant to improve nurses’ knowledge about the preparation and administration of intravenous medications.21 Pharmacology knowledge acquisition and application, as well as lack of opportu- nities in practice to undertake medication administration roles and responsibilities, were major factors.22 Nurse skill level The results showed that the majority of ED nurses have high skills to implement the 6 correct principles of medicine. Skills can be acquired by performing repeated actions frequently to create a condition where skills become a work culture. Furthermore, nurses could make errors due to a lack of adequate access to guidelines or unclear organizational routines.23 Medication management is a complex process that involves prescribing, transcribing, prepara- tion, checks, administering to patients, observation, documenting reactions and side effects, as well as reporting any deviations. Nurses require good educational preparation including a full understanding of pharmacology to ensure safe medication and ful- fill their roles efficiently.24 Regardless of the strategies implement- ed, the formation of a culture that fosters the skills of reporting medication errors, and a systematic, nonpunitive approach to their elimination is where its prevention begins and ends.25 Right patients have the lowest incidence rate with practically no error in the application of the correct principle of medicine. This is because the care system in the ED is divided based on the level of emergency and each level is held by several nurses, there- fore, they memorize their patients’ names. The most common incident at ED is the right dose, which includes precise and accurate calculation. To ensure that the drug is given to the patient at the right dose, the nurse must be able to carry out the calculation accurately and also double-check. Furthermore, the nurse must administer the appropriate amount of medication based on the calculation results to provide the patient with the right dose. The results of this study indicate that for the right dose component, only 25 people (35.71%) had a high appli- cation rate. The existing studies regarding calculating medications indicate that nursing students have poor mathematical and drug dose calculation skills.26 According to the results, strategies were recommended to be adopted for reducing or limiting medication errors, such as improving work conditions, and communication between healthcare workers.5 Correlation between knowledge and the implementa- tion of the 6 rights medication administration In this study, nurses’ knowledge of medication and the princi- ples of drug administration to patients, such as the appropriate drug, right dose, time, patient, and route as well as documentation was examined. The results showed that some nurses in the ED had good knowledge about the implementation of the six rights medi- cation administration. Meanwhile, a small proportion has less knowledge about the implementation of the 6 principles of correct medicine. Nurses’ pharmacological knowledge, inevitable errors, and complications were mentioned in a previous study.27 Knowledge is needed to obtain new informations, such as things that support appropriate action in order to improve the patient’s quality of life. Knowledge influences a person’s decision- making, motivating nurses to behave and participate in improving patient health by providing appropriate treatment measures. Knowledge about medication administration is useful in clinical reasoning for safe medication and also as a precursor of error reporting.28 It is influenced by how much or at least the kind of information obtained by an individual. Nurses who do not have access to information on medication administration and the imple- mentation of the 6 rights will not have the knowledge to apply the principles correctly. Meanwhile, knowledge-based results from prescribing and administration,13 dismissals of policies/procedures or guidelines, and human resources issues.29 Increasing nurse’s knowledge could be through integrated educational interventions that allows nurses to assume a care provider role for patient. Correlation between skill and the implementation of the 6 right medication administration As the largest group of healthcare providers, nurses play a sig- nificant role in the continuity of care by maintaining health at dif- ferent levels of the system. It is therefore expected that the nurse provides the highest level of care based on scientific evidence and acquires the necessary skills and abilities to make clinical deci- sions through the service of control maintenance methods.30 According to a previous study, experienced nurses were more like- ly to practice beyond scope of practice to reduce error.23 Furthermore, overhauling nurses’ information, particularly about unused medicines is an important factor in decreasing medication error.11 The majority of ER nurses’ skills in implementing the principle of 6 correct medicine are still high because the behavior is carried out continuously, subsequently it becomes a culture or habit. The ability of nurses to implement these principles is also a moral responsibility for a profession that must fulfill its obligations. The results of the study showed that nurses’ work tenure significantly affects medication errors based on experience. Statistically, good techniques eliminate the deficiencies in basic math knowledge, problem-solving skills, and correct dosage calculation.31 In the ED, there is a lot of skill mix that will contribute to the implementation of 6 rights medication administration. Hospitals that increase the nursing skill mix and improve the work environment may achieve a reduction in the number of adverse events.32 Article [Healthcare in Low-resource Settings 2023; 11(s1):11177] [page 59] No n- co mm er cia l u se on ly Skill practice programmes like simulation in medication administration are important. According to a study, there was an improvement when the teaching programme was implemented and medication errors were reduced.33 Furthermore, an understanding of the simulation program provides feedback to participants, there- by contributing to the reduction of medication errors.34 Managers should focus on enhancing nursing practices by managing and organizing nurses’ work in a way that creates a feeling of support- iveness, motivation, and security.35 Furthermore, in comparison to single profession education, in which individuals learn in isolation and only in their profession, interprofessional education helps to promote interprofessional collaboration and patient care by pro- moting multiple health professions to increase interprofessional collaboration. Therefore, an interprofessional medication safety education program in ICUs can help to reduce errors and improve patient safety.36 Limitation of the study include single institution, the short term of the observational. Because this study uses cross - sectional, results are not generalizable. Therefore, more studies are needed to assess by increasing the number of observers and other hospital’s emergency department. Conclusions Based on the results, the conclusion drawn is that most of the ED nurses have a high level of knowledge and skill about 6 rights medication administration. The implication of this study for pro- fessional healthcare is to increase the ED nurses’ knowledge of the right medical principles, especially in calculating drug titration and a small part of the incorrect administration of drugs. Therefore, the strategies recommended to be adopted for reducing or limiting medication errors include building a stronger pharmacology knowledge-base in nurses and nursing students, improving work conditions, and communication between healthcare workers.5 The result also showed that there is a significant relationship between information literacy and evidence-based nursing with the knowl- edge and attitude of nurses toward medication error.30 It was, there- fore, suggested that learning by simulation will provide additional support in educational programs for healthcare professionals by increasing knowledge and skill of medication administration.34 References 1. Shitu Z, Aung MMT, Tuan Kamauzaman TH, et al. Prevalence and characteristics of medication errors at an emergency department of a teaching hospital in Malaysia. BMC Health Serv Res 2020;20:1–8. 2. Escrivá Gracia J, Brage Serrano R, Fernández Garrido J. Medication errors and drug knowledge gaps among critical- care nurses: A mixed multi-method study. BMC Health Serv Res 2019;19:1–10. 3. Sutherland A, Canobbio M, Clarke J, et al. Incidence and prevalence of intravenous medication errors in the UK: A sys- tematic review. Eur J Hosp Pharm 2020;27:3–8. 4. Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ 2016;353:1–5. 5. Bagheri Nesami M, Esmaeili R, Tajari M. Intravenous Medication Administration Errors and their Causes in Cardiac Critical Care Units in Iran. Mater Socio Medica 2015;27:442. 6. Al worafi YM. Medication Errors [Internet]. Vol. 48, Nursing. New York: Elsevier B.V.; 2020. 59–71 p. 7. Basil JH, Wong JN, Zaihan AF, et al. Intravenous medication errors in Selangor, Malaysia: prevalence, contributing factors, and potential clinical outcomes. Drugs Ther Perspect 2019;35:381–90. 8. Salman M, Mustafa ZU, Rao AZ, et al. Serious Inadequacies in High Alert Medication-Related Knowledge Among Pakistani Nurses: Findings of a Large, Multicenter, Cross-sectional Survey. Front Pharmacol 2020;11:1–7. 9. Mekonen EG, Gebrie MH, Jemberie SM. The magnitude and associated factors of medication administration error among nurses working in Amhara Region Referral Hospitals, Northwest Ethiopia. J Drug Assess 2020;9:151–8. 10. Bakhshi F, Mitchell R, Nikbakht Nasrabadi A, et al. Clinician attitude towards safety in medication management: a participa- tory action study in an emergency department. BMJ Open 2021;11:e047089. 11. Rodziewicz TL, Houseman B, Hipskind JE. Medical Error Article Correspondence: Linda Wieke Noviyanti, Department of Nursing, Faculty of Health Sciences, Universitas Brawijaya, Jl. Puncak Dieng, Kunci, Kalisongo, Kec. Dau, Malang, East Java Indonesia 65151, Tel.: +62 341 5080686, Fax: +62 341 5080686, E-mail: linda.wieke@ub.ac.id Key words: Nurse, knowledge and skills, 6 rights medication. Acknowledgment: The authors are grateful to all who contributed to this study, particularly the respondents, students of the bachelor program in nurs- ing Faculty of Medicine Universitas Brawijaya, and Universitas Brawijaya. Contribution: All the authors contributed equally to this study. LWN verified the method, the study design, and carried out the study. A served as supervi- sor. AJ also carried out the study, analyzed and interpreted the data. All authors discussed the results and contributed to the final manuscript. Conflict of interest: The author declares no conflict of interest. Funding: This work was funded by the researcher. Availability of data and materials: All data generated or analyzed during this study are included in this published article. Informed consent: Written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be pub- lished in this article. Clinical Trials: This study obtains ethical approval from the Ethics Committee of the General Hospital Dr. Saiful Anwar Malang, (ethical clear- ance letter No. 400/245/K.3/302/2019). Conference presentation: Part of this paper was presented at the 2nd International Nursing and Health Sciences Symposium that took place at the Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia. Received for publication: 3 December 2021. Accepted for publication: 10 May 2022. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11(s1):11177 doi:10.4081/hls.2023.11177 Publisher's note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organiza- tions, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its man- [page 60] [Healthcare in Low-resource Settings 2023; 11(s1):11177] No n- co mm er cia l u se on ly Reduction and Prevention. [Updated 2022 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499956/ 12. Westbrook JI, Raban MZ, Walter SR, et al. Task errors by emergency physicians are associated with interruptions, multi- tasking, fatigue, and working memory capacity: A prospective, direct observation study. BMJ Qual Saf. 2018;27(8):655–63. 13. Cabilan C, Hughes J, Shannon C. The use of a contextual, modal, and psychological classification of medication errors in the emergency department: a retrospective descriptive study. Int J Lab Hematol 2016;38:42–9. 14. Hsieh MC, Chiang PY, Lee YC, et al. An Investigation of Human Errors in Medication Adverse Event Improvement Priority Using a Hybrid Approach. Healthcare (Basel) 2021;9:442. 15. Lee SH, Phan PH, Dorman T, et al. Handoffs, safety culture, and practices: Evidence from the hospital survey on patient safety culture. BMC Health Serv Res 2016;16:1–8. 16. Wolf ZR, Hughes RG. Best Practices to Decrease Infusion- Associated Medication Errors. J Infus Nurs 2019;42:183–92. 17. Myroniak K, Elder S. Improving safe medication administra- tion in new rns using simulation. J Contin Educ Nurs 2021;52:30–3. 18. Sulosaari V, Huupponen R, Hupli M, et al. Factors associated with nursing students’ medication competence at the beginning and end of their education. BMC Med Educ 2015;15:1–12. 19. Di Simone E, Giannetta N, Auddino F, et al. Medication errors in the emergency department: Knowledge, attitude, behavior, and training needs of nurses. Indian J Crit Care Med 2018;22:346–52. 20. Cottell M, Wätterbjörk I, Hälleberg Nyman M. Medication- related incidents at 19 hospitals: A retrospective register study using incident reports. Nurs Open 2020;7:1526–35. 21. Di Simone E, Tartaglini D, Fiorini S, et al. Medication errors in intensive care units: Nurses’ training needs. Emerg Nurse 2016;24:24–9. 22. Cleary-Holdforth J, Leufer T. Senior Nursing Students’ Perceptions of Their Readiness for Oral Medication Administration Prior to Final Year Internship: A Quantitative Descriptive Pilot Study. Dimens Crit Care Nurs 2020;39:23– 32. 23. Björkstén KS, Bergqvist M, Andersén-Karlsson E, et al. Medication errors as malpractice-a qualitative content analysis of 585 medication errors by nurses in Sweden. BMC Health Serv Res 2016;16:1–9. 24. Høghaug G, Skår R, Tran TN, et al. Three-month follow-up effects of a medication management program on nurses’ knowledge. Nurse Educ Pract 2021;51:102979. 25. Weant KA, Bailey A, Baker S. Strategies for reducing medica- tion errors in the emergency department. Open Access Emerg Med 2014;6;45-55. 26. Guneş UY, Baran L, Yilmaz D (Kara). Mathematical and Drug Calculation Skills of Nursing Students in Turkey. Int J Caring Sci 2016;9:220–7. 27. Pazokian M, Zagheri Tafreshi M, Rassouli M. Iranian nurses’ perspectives on factors influencing medication errors. Int Nurs Rev 2014;61:246–54. 28. Kim MS, Kim CH. Canonical correlations between individual self-efficacy/organizational bottom-up approach and perceived barriers to reporting medication errors: A multicenter study. BMC Health Serv Res 2019;19:1–10. 29. Ramadaniati HU, Hughes JD, Lee YP, et al. Simulated medi- cation errors: A means of evaluating healthcare professionals’ knowledge and understanding of medication safety. Int J Risk Saf Med 2018;29:149–58. 30. Azami M, Sharifi H, Alvandpur S. Evaluating the relationship between information literacy and evidence�based nursing and their impact on knowledge and attitude of nurses working in hospitals affiliated to Kerman University of Medical Sciences on medication errors. J Fam Med Prim Care 2020;9:4097–106. 31. Özyazıcıoğlu N, Aydın Aİ, Sürenler S, et al. Evaluation of stu- dents’ knowledge about paediatric dosage calculations. Nurse Educ Pract 2018;28:34–9. 32. Smith JG, Plover CM, McChesney MC, et al. Rural Hospital Nursing Skill Mix and Work Environment Associated With Frequency of Adverse Events. SAGE Open Nurs 2019;5:1–13. 33. Devi A, Sembian N, Kaur S. Occurrence of medication errors and oral medication administration practices of staff nurses. Res J Pharm Technol 2016;9:1145–52. 34. Sarfati L, Ranchon F, Vantard N, et al. Human-simulation- based learning to prevent medication error: A systematic review. J Eval Clin Pract 2019;25:11–20. 35. Nurmeksela A, Mikkonen S, Kinnunen J, et al. Relationships between nurse managers’ work activities, nurses’ job satisfac- tion, patient satisfaction, and medication errors at the unit level: a correlational study. BMC Health Serv Res 2021;21:1– 14. 36. Irajpour A, Farzi S, Saghaei M, et al. Effect of interprofession- al education of medication safety program on the medication error of physicians and nurses in the intensive care units. J Educ Health Promot 2019;8:1–5. Article [Healthcare in Low-resource Settings 2023; 11(s1):11177][ page 61] No n- co mm er cia l u se on ly