The safe administration of medication: Nursing behaviours beyond the five-rights

Improving the quality of medication administration practices in a tertiary Australian hospital: a best practice implementation project

INTRODUCTION

Medication safety is an important health priority that focuses on preventing harm from medication-related events. Unsafe medication administration practices can lead to errors, which can cause avoidable injury (or harm) to patients.

OBJECTIVES

This paper reports on an evidence implementation project conducted in a large tertiary hospital in Australia to improve nursing compliance with best practice recommendations for medication administration.

METHODS

The project was guided by JBI's seven-phase approach to evidence implementation, using audit and feedback and a structured framework to identify barriers, enablers, and implementation strategies.

RESULTS

The project resulted in improved compliance with best practice recommendations. This was achieved through multimodal strategies, including education, improved access to resources, and targeted feedback and discussion sessions to encourage culture and behavior change.

CONCLUSIONS

The project improved nurses' medication administration practices, specifically in performing independent second checks. Collaborative efforts of the project leads facilitated the review of medication administration policy and the development of staff education resources. Patient engagement remains an area for improvement, along with the potential need for further ongoing medication education.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A237.

Pediatric nurses' experiences of implementing the 'ten right principles' in safe medication management: A descriptive phenomenological study

PURPOSE

In medication management, the ten right principles framework is an accepted global nursing standard and an important component of medication safety. Especially pediatric patients have a higher risk of harm in medication administration compared to adults. This study aimed to examine the experiences of pediatric nurses in implementing the ten right principles in safe medication management.

DESIGN AND METHODS

A descriptive phenomenological approach was used in this study. The study was conducted with 16 pediatric nurses in a public hospital's Pediatric Service and Neonatal Intensive Care Unit. Pediatric nurses' medication practices were observed, and semi-structured interviews were conducted with the nurses after the observation. Observations were conducted using an observation tool, and interviews were conducted using a semi-structured interview form. Qualitative data were analyzed using thematic analysis.

RESULTS

In this study, it was observed that although pediatric nurses generally adhered to the ten right principles, they had the most difficulties with the right dose and time principles. As a result of the interviews conducted after the observation, two themes (factors facilitating the implementation of the ten right principles and difficulties in implementing the ten right principles) were formed.

CONCLUSIONS

The findings revealed that pediatric nurses achieved safe and effective medication administration and generally adhered to the ten right principles.

PRACTICE IMPLICATIONS

This study highlights the positive contribution of pediatric nurses to patient safety by using multiple sources of information and clinical reasoning strategies despite the difficulties they experience in drug administration.

Estimating Proportion and Barriers of Medication Error Reporting Among Nurses in Hail City, Saudi Arabia: Implications for Improving Patient Safety

Background

Determining the proportion of nurses reporting medication errors (MEs) and identifying the barriers they perceive in ME reporting are crucial to encourage nurses to actively report MEs.

Objective

This study aimed to determine the proportion of nurses experiencing and reporting MEs, perceived barriers to reporting MEs and their association with nurses' sociodemographic and work-related characteristics.

Methods

A cross-sectional study was conducted among 350 nurses from June to November 2023. Data about sociodemographic and work-related characteristics, and ME reporting, were collected using a validated self-administered questionnaire.

Results

The study found that 34.3% of nurses reported MEs, while 11.1% reported experiencing MEs during their practice. ME reporting was higher proportion among nurses who were older than 40 years (52.1%), males (41.4%), held a master's degree (58.7%), Saudi nationals (37.8%), experienced for more than 10 years (43.1%), working in intensive care units (44.3%), working for 48 hours or more per week (39.7%), working in hospitals with a nurse-to-patient ratio of 1:3 (44.9%) and having a system for incident reporting (37.7%) and with no training on patient safety (44.6%) compared to their counterparts. The rate of experiencing MEs was higher proportion among nurses who were older than 40 years (16.7%), males (17.3%), married (14.8%), Saudi nationals (13.4%), experienced for more than 10 years (15.6%) and with no training on patient safety (15.3%) compared to their counterparts. Lack of knowledge of the person responsible for reporting MEs was the most frequent perceived barrier to ME reporting (66.6%), followed by fears of blame (65.4%).

Conclusion

In this study, nurses reported and experienced MEs during their practice. Most nurses perceive the lack of knowledge and fear of blame or disciplinary actions as barriers to reporting. Healthcare administrators should implement educational programs and workshops to increase nurses' awareness of ME reporting.

Nursing students' and faculty's experiences of first medication administration: A phenomenological inquiry

BACKGROUND

Learning medication administration is essential for nursing students, but the first time can be stressful and shape their clinical development. Previous research primarily focused on student knowledge and technical aspects.

PURPOSE

This phenomenological study helped explore the lived experiences of nursing students and faculty during student's first medication administration in the clinical setting to gain a deeper understanding of their thoughts, feelings, and perspectives.

METHOD

Semi-structured interviews were conducted with female student and faculty informants (N = 12). Using a phenomenological study, data were analyzed using van Manen's hermeneutic six-step research activity method.

RESULTS

Five overarching themes were found: administrating medication, (un)preparedness for complexities in the clinical environment, transformative experience, overcoming fears, and reaping the rewards.

CONCLUSION

First-time medication experiences are greater than an exercise in skill proficiency and may be improved if faculty provides more structured learning experiences and take sufficient time for student preparation in relating medication knowledge to the skill, technology usage, and supporting students' attitudes toward nurse-patient interactions. These are essential aspects of the medication administration learning process as nursing programs shift toward competency-based education. Clinical faculty also need support in their role as educators and to be facilitated to find this time, considering their multiple responsibilities.

Quality indicators for the processing of health products: A mixed-methods study

OBJECTIVE

to analyze the use of quality assessment indicators and their implementation to improve quality in the processing of health products.

METHOD

a mixed-methods study with a multiple case approach using Structure, Process and Results indicators and elaboration of a plan using Appreciative Inquiry, carried out in four central sterile supply departments from hospital units.

RESULTS

the indicators for the Cleaning stage presented 47.8% compliance for Structure and 59.0% for Process: in addition 71.8% of the products were clean. In the Preparation operational stage, 50.0% of the Results indicators were in compliance for Structure and 66.7% for Process. In the Sterilization, Storage and Distribution stage, 43.5% compliance was obtained for Structure, 55.7% for Process and 78.6% for Packaging conservation. Appreciative planning proposed improvements to the physical structure, review of processes and protocols, promotion and appreciation of the work done and strengthening of teaching about processing and service management, highlighting the protagonism of the group and of the leaders.

CONCLUSION

using indicators was positive in materializing reality; however, it was verified that the improvements proposed are related to people. The affirmative and constructive view of Appreciative Inquiry presented itself as a path to changes and quality improvements.

Contemporary challenges for SCPDNs in the provision of end-of-life care

The advancement in the knowledge and skills required by the Specialist Community Practitioner District Nurse (SCPDN) is integral in supporting end-of-life care. An integrated and multi-disciplinary team approach is pivotal for high quality patient care delivery, which involves individuals and their significant others in decision-making at a sensitive time. Advanced care planning and the use of therapeutic communication by the SCPDN can help to support autonomy in individuals during uncertain times, enabling them to express their end-of-life wishes. The SCPDN, guided by the evidence base, must provide holistic care and manage palliation while ensuring the patient is at the centre of all decisions.

Evaluation of intermittent antimicrobial infusion documentation practices in intensive care units: A cross-sectional study

OBJECTIVE

To observe nurse administration of carbapenem antibiotics, in the context of medication safety measures, in intensive care units.

RESEARCH METHODOLOGY/DESIGN

A quantitative study was conducted using observation principles.

SETTING

Three adult private and public Intensive Care Units in the health district of a capital city in KwaZulu-Natal, South Africa.

MAIN OUTCOME MEASURES

Nurse practices were observed for double-checking of the medication order, medication vial, and method of preparation and administration. Infusion bags were inspected for nurse labelling of medication and patient details. Patient medication treatment charts were inspected for nurse signature.

RESULTS

Carbapenem infusion administrations (n = 223) to twenty patients were observed. Adherence to the scheduled time occurred in 34.9% administrations, 5.4% doses were not given, and an incorrect dose given on 1.4% administrations. One hundred and forty-four (64.6%) infusion bags were inspected during the administrations: there was no medication label affixed to 21.5% bags, and only 8.3% of bags were labelled with essential details; the patient's name, drug, dose, date, time, signature of the nurse mixing and administering the dose, and signature of the secondary nurse.

CONCLUSION

There was a lack of compliance with accepted medication risk mitigation measures. Sub-optimal double-checking resulted in the incorrect dose given, missed dose, and non-adherence to scheduled administration time. This has implications for the optimal administration of antimicrobial medications, raising concerns about the efficacy of treatment for critically ill patients.

IMPLICATIONS FOR CLINICAL PRACTICE

Parenteral administration errors pose a challenge in acute care areas. Risk mitigation measures include double-checking of medications. If antimicrobial treatment is not administered at the prescribed dosing intervals, this may have implications for the efficacy of time-dependent broad-spectrum antibiotics such as carbapenems. Medication administration errors involving antimicrobial medications should therefore be considered as high-risk errors, with the potential to contribute towards antimicrobial resistance.

Attitudes of ward nurses towards the administration of ‘as required’ injectable medications for symptom control at the end of life

Background: It is recognised good practice to prescribe ‘as required’ parenteral medication (ARPM) to provide individualised symptom control in the final days of life. The decision to administer the medication and, sometimes, to decide the dose, usually lies with the nurse. Aims: To explore attitudes towards administration of ARPM at end of life (EOL) among hospital nurses. Methods: The views of registered nurses, recruited from wards with high death rates, were explored through questionnaires and semi-structured interviews. Questionnaire responses were coded and statistically analysed. Interviews were recorded, transcribed, manually coded and thematically analysed. Results: Almost 50% of questionnaire respondents (n=62) reported feeling ‘very confident’ in recognising symptoms at the EOL. Only 39% of respondents reported undertaking specific training. Three main themes emerged through the interviews: experience; factors influencing the decision to administer ARPM; and education. Conclusion: Wider accessibility to training may support confident decision making by hospital nurses administering ARPM at the EOL.

Assessment of medication administration of nurses in medical cardiac wards and its relationship with some demographic characteristics: An observational study

BACKGROUND

Unsafe medication administration and medication errors pose a threat to medication safety. Safe medication is one of the most important nursing practices that plays an important role in preventing medication errors. The aim of this study was to assess the medication administration of nurses in cardiac wards and its relationship with some demographic characteristics.

MATERIALS AND METHODS

The present study was conducted as an observational study in 2021 with the 60 nurses who working in the medical cardiac wards of one selected hospital affiliated with the Isfahan University of Medical Sciences. Data were collected using three-part tools (demographic information, medication checklist (55 items), and documentation checklist (8 items). The checklist was completed by the observer after observing the nurses' medication administration. Data analysis was conducted using descriptive and inferential statistics in the SPSS software (version 16, SPSS Inc., Chicago, IL, USA). A P < 0.05 was considered statistically significant.

RESULTS

The mean total score of the principles of injection and oral medication administration were 82.53 ± 10.75 and 75.76 ± 9.62, respectively. The mean score of the principles of injection and oral medication administration in the morning shift was significantly higher than the evening and night shifts (P < 0.001). The relationship between the mean score of the principles of injection medication (r = 0.234, P = 0.067), oral medication (r = 0.222, P = 0.083), and the nurses' work experience no significant. The rate of adherence to the principles of medication administration in the premedication administration stage was higher than during and after drug administration.

CONCLUSION

Although the mean score of medication administration of nurses in the medical cardiac wards was at the desired level, it is necessary to monitor and plan by nursing managers to improve medication administration. Reducing the number of night shifts, adhering to accreditation programs in the hospital, continuous monitoring of nurses in terms of compliance with the principles of medication are among the proposed solutions to improve the safe medication in nurses.

Disciplinary processes for nurses, from organizational supervision to outcomes: A document analysis of a regulatory authority's decisions

AIM

To explore the disciplinary processes for nurses, from organizational supervision to final decisions by the Finnish regulatory authority.

BACKGROUND

Regulatory authorities are responsible for protecting the public, by ensuring that they receive safe, competent and ethical nursing care, but little is known about the disciplinary processes for nurses.

METHODS

A retrospective document analysis of 296 disciplinary decisions by the Finnish regulatory authority from 2007-2016. The data were analysed using a quantitative design with descriptive statistics.

RESULTS

We studied 204 disciplined nurses (81.4% female) with a mean age of 43.5 years. The disciplinary process comprised organizational supervision, complaints, investigations and decisions. Nurses with substance abuse issues were more likely to face criminal investigations and receive temporary decisions. The process lasted from under one month to years and could have profound effects on nurses, colleagues and nurse managers and compromise patient safety.

CONCLUSION

This study identified key factors that could inform the disciplinary processes for nurses. More knowledge is needed about how organizations ensure patient safety when unprofessional conduct is suspected.

IMPLICATIONS FOR NURSING MANAGEMENT

Retaining nursing professionals is vital due to global shortages and more attention should be paid to organizational supervision and support for nurses during disciplinary processes.

Assessing Nursing Students' Self-Perceptions about Safe Medication Management: Design and Validation of a Tool, the NURSPeM

Objective: The objective was to design and validate a tool for assessing nursing students’ self-perceptions about safe medication management. Methods: A descriptive instrumental study was conducted involving construct definition, development of the tool, analysis of the content validity, and psychometric evaluation. Consensus regarding the content was obtained through a two-round Delphi process, and the resulting tool (the NURSPeM) was administered to nursing students to examine its internal consistency, temporal stability, and construct validity, the latter through exploratory factor analysis. Results: Thirteen experts participated in the Delphi process, which yielded a tool comprising two questionnaires: (1) Self-perceptions about safe medication management (27 items) and (2) the frequency and learning of drug-dose calculation (13 items). The tool’s psychometric properties were then examined based on responses from 559 nursing students. This analysis led to the elimination of three items from questionnaire 1, leaving a total of 24 items distributed across seven dimensions. All 13 items in questionnaire 2 were retained. Both questionnaires showed good internal consistency (Cronbach’s alpha = 0.894 and 0.893, respectively) and temporal stability (ICC = 0.894 and 0.846, respectively). Conclusions: The NURSPeM is a valid and reliable tool for assessing nursing students’ self-perceptions about safe medication management. It may be used to identify areas in which their training needs to be enhanced, and to evaluate the subsequent impact of new teaching initiatives.

Omissions and Deviations From Safe Drug Administration Guidelines in 2 Medical Wards and Risk Factors: Findings From an Observational Study

OBJECTIVES

This study aimed to record the type and frequency of errors, with an emphasis on omissions, during administration of medicines to inpatients and to investigate associated factors.

METHODS

This was a descriptive observational study. The medication process in 2 medical wards was observed by 2 observers using a structured observation form. χ2 Test, Kruskal-Wallis test, and regression analysis were used to explore associations between factors and errors.

RESULTS

From the 665 administrations observed, a total of 2371 errors were detected from which 81.2% were omissions and 18.8% were errors of commission. Omissions in the infection prevention guidelines (46.6%) and in the 5 rights of medication safety principles (35.8%) were a predominant finding. In particular, omitting to hand wash before administering a drug (98.4%), omitting to disinfect the site of injection (37.7%), and omitting to confirm the patient's name (74.4%) were the 3 most frequently observed omissions. Documentation errors (13.1%) and administration method errors (4.5%) were also detected. Regression analysis has shown that the therapeutic class of the drug administered and the number of medicines taken per patient were the 2 factors with a statistical significance that increased the risk of a higher number of errors being detected.

CONCLUSIONS

Errors during drug administration are still common in clinical practice, with omissions being the most common type of error. In particular, omissions in the basic infection and safety regulations seem to be a very common problem. The risk of a higher number of errors being made is increased when a cardiovascular drug is administered and when the number of medicines administered per patient is increased.

Medication administration behaviors in prelicensure nursing students: A longitudinal, cohort study

AIM

This longitudinal study identified changes in safe medication administration behaviors in a single cohort of students followed over four semesters of nursing school.

BACKGROUND

Over 40% of a nurse's shift is dedicated to the processes of medication administration, placing them in a position to interrupt costly medication errors. Yet, despite efforts to decrease medication errors, including electronic medical records, smart pumps, and standardized processes, 5% of hospitalized patients experience adverse drug events and the sequela costs billions of dollars annually. One cognitive aid first introduced in nursing school to help nurses administer medications safely is the rights method, including the foundational five (patient, medication, dose, route, and time). However, facility restrictions, complicated electronic health records, and high faculty-to-student ratios are limiting opportunities to apply these rights and develop safe medication administration competency. Although nursing faculty and clinical partners expect competency when initially licensed as professionals, graduating nursing students are not competent and new graduates feel ill prepared to deliver medications safely. Previous studies report findings on safe medication administration in different cohorts of nursing students, but none has followed the same cohort of students throughout nursing school.

DESIGN

Using a non-experimental design, the same cohort of nursing students was followed over four semesters and observed independently administering medications in simulation scenarios.

METHODS

Each semester, this cohort of students self-selected into 10-12 simulation groups. One student from each group was randomized to the role of primary nurse. Guided by the NLN/Jeffries simulation theory and the International Nursing Association for Clinical Simulation and Learning's Standards of Best Practice: Simulation^SM, students participated in four simulations that required the primary nurse to deliver medications as part of clinical care. A single investigator completed an observational checklist during the simulations on verification of the foundational five rights in these students.

RESULTS

Verification of most rights varied each semester, but students consistently did poorly verifying right dose. One hundred percent of students observed in the first semester did not verify all five rights. At the time of graduation, 80% of students observed did not verify all five rights prior to medication administration.

CONCLUSIONS

These concerning findings align with previous research showing that students are not safely administering medications in patient care settings. Educators, administrators, and healthcare systems need to ensure that students receive consistent, high-quality experiences vital to training future nurses for competency in safe medication administration.

Development and Validation of the Safe Parenteral Medication Administration Self-Efficacy Scale

BACKGROUND

This study aimed to develop a valid and reliable measurement instrument for determining the self-efficacy perceptions of nurses concerning safe medication practices.

METHOD

The study was conducted at the hospital of a state university in Istanbul, Turkey, between August and December 2016. The sample consisted of 278 nurses.

RESULTS

The exploratory factor analysis indicated the scale had a single-factor structure that explained 47.92% of the total variance. The remaining 76 items had factor loads ranging from .50 to .87. The item-total correlations varied between .49 and .86, and Cronbach's alpha coefficient for the scale was .98.

CONCLUSION

The results of the analysis show the items constituting the scale have validity and reliability criteria that can measure the self-efficacy of nurses related to parenteral medication administration. [J Contin Educ Nurs. 2021;52(6):267-273.].

A Systematic Review of the Legal Considerations Surrounding Medicines Management

This study explores the legal considerations surrounding medicines management, providing a synthesis of existing knowledge. An integrative systematic review of the current international knowledge was performed. The search encompassed the online databases of PubMed (including Medline), Scopus, CINAHL, and Web of Science using MeSH terms and relevant keywords relating to the legal considerations of medicines management in healthcare settings. The search process led to the identification of 6051 studies published between 2010 and 2020, of which six articles were found to be appropriate for data analysis and synthesis based on inclusion criteria. Research methods were varied and included qualitative interviews, mixed-methods designs, retrospective case reports and cross-sectional interrupted time-series analysis. Their foci were on the delegation of medicines management, pharmacovigilance and reporting of adverse drug reactions (ADRs) before and after legislation by nurses, physicians and pharmacists, medico-legal litigation, use of forced medication and the prescription monitoring program. Given the heterogenicity of the studies in terms of aims and research methods, a meta-analysis could not be performed and, therefore, our review findings are presented narratively under the categories of 'healthcare providers' education and monitoring tasks', 'individual and shared responsibility', and 'patients' rights'. This review identifies legal aspects surrounding medicines management, including supervision and monitoring of the effects of medicines; healthcare providers' knowledge and attitudes; support and standardised tools for monitoring and reporting medicines' adverse side effects/ADRs; electronic health record systems; individual and shared perceptions of responsibility; recognition of nurses' roles; detection of sentinel medication errors; covert or non-voluntary administration of medication, and patient participation.

Recent advances in metallopolymer-based drug delivery systems

Metallopolymers (MPs) or metal-containing polymers have shown great potential as new drug delivery systems (DDSs) due to their unique properties, including universal architectures, composition, properties and surface chemistry. Over the past few decades, the exponential growth of many new classes of MPs that deal with these issues has been demonstrated. This review presents and assesses the recent advances and challenges associated with using MPs as DDSs. Among the most widely used MPs for these purposes, metal complexes based on synthetic and natural polymers, coordination polymers, metal-organic frameworks, and metallodendrimers are distinguished. Particular attention is paid to the stimulus- and multistimuli-responsive metallopolymer-based DDSs. Of considerable interest is the use of MPs for combination therapy and multimodal systems. Finally, the problems and future prospects of using metallopolymer-based DDSs are outlined. The bibliography includes articles published over the past five years.