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Research article
Events related to medication errors and related factors involving nurses’ behavior to reduce medication errors in Japan: a Bayesian network modeling-based factor analysis and scenario analysis  
Naotaka Sugimura, Katsuhiko Ogasawara
J Educ Eval Health Prof. 2024;21:12.   Published online June 11, 2024
DOI: https://doi.org/10.3352/jeehp.2024.21.12
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  • 3 Crossref
AbstractAbstract PDFSupplementary Material
Purpose
This study aimed to identify the relationships between medication errors and the factors affecting nurses’ knowledge and behavior in Japan using Bayesian network modeling. It also aimed to identify important factors through scenario analysis with consideration of nursing students’ and nurses’ education regarding patient safety and medications.
Methods
We used mixed methods. First, error events related to medications and related factors were qualitatively extracted from 119 actual incident reports in 2022 from the database of the Japan Council for Quality Health Care. These events and factors were then quantitatively evaluated in a flow model using Bayesian network, and a scenario analysis was conducted to estimate the posterior probabilities of events when the prior probabilities of some factors were 0%.
Results
There were 10 types of events related to medication errors. A 5-layer flow model was created using Bayesian network analysis. The scenario analysis revealed that “failure to confirm the 5 rights,” “unfamiliarity with operations of medications,” “insufficient knowledge of medications,” and “assumptions and forgetfulness” were factors that were significantly associated with the occurrence of medical errors.
Conclusion
This study provided an estimate of the effects of mitigating nurses’ behavioral factors that trigger medication errors. The flow model itself can also be used as an educational tool to reflect on behavior when incidents occur. It is expected that patient safety education will be recognized as a major element of nursing education worldwide and that an integrated curriculum will be developed.

Citations

Citations to this article as recorded by  
  • Investigating stress dynamics triggers and sleep disturbances among Indian medical students
    Anuj Singh, Anjani Kumar Srivastava, Neha Singh Chauhan, Anjali Singh, Mritunjay Singh Thakur, Vineeta Gupta
    Discover Public Health.2026;[Epub]     CrossRef
  • Explaining the educational needs of nursing students in preventing medication errors: a qualitative study
    Nayereh Baghcheghi, Hamid Reza Koohestani, Linda Graudins
    International Journal For Quality In Health Care.2026;[Epub]     CrossRef
  • Öğrenci Hemşirelerin İlaç Güvenliği Yeterliliklerinin Belirlenmesi
    Ayşe Aydınlı
    Uluborlu Mesleki Bilimler Dergisi.2025; 8(2): 16.     CrossRef

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