Nurses' medication administration practices at two Singaporean acute care hospitals

Keeping patients safe through medication review and management in the community

BACKGROUND

There are numerous publications on inpatient medication errors. However, little focus is given to medication errors that occur at home.

AIMS

To describe and analyse the types of medication errors among community-dwelling patients following their discharge from an acute care hospital in Singapore.

METHOD

This is a retrospective review of a 'good catch' reporting system from December 2018 to March 2022. Medication-related errors were extracted and analysed.

FINDINGS

A total of 73 reported medication-related error incidents were reviewed. The mean age of the patients was 78 years old (SD=9). Most patients managed their medications independently at home (45.2%, n=33). The majority of medications involved were cardiovascular medications (51.5%, n=50). Incorrect dosing (41.1%, n=39) was the most common medication error reported. Poor understanding of medication usage (35.6%, n=26) and lack of awareness of medication changes after discharge (24.7%, n=18) were the primary causes of the errors.

CONCLUSION

This study's findings provide valuable insights into reducing medication errors at home. More attention must be given to post-discharge care, especially to preventable medication errors. Medication administration and management education can be emphasised using teach-back methods.

Evaluating deviations and considerations in daily practice when double-checking high-risk medication administration: A qualitative study using the FRAM

Background

Double-check protocol compliance during administration is low. Regardless, most high-risk medication administrations are performed without incidents. The present study investigated the process of preparing and administrating high-risk medication and examined which variations occur in daily practice. Additionally, we investigated which considerations were taken into account when deviating from the guidelines.

Methods

Ten Dutch hospital wards participated. The Functional Resonance Analysis Method was applied to construct a model depicting the Dutch guidelines and a ward-overarching model visualizing daily practice. To create the ward-overarching model, eight semi-structured interviews were conducted per ward discussing the preparation and administration of high-risk medication. Work related Efficiency-Thoroughness Trade-Off rules were used to structure subconscious considerations.

Results

In total, 77 nurses were interviewed. Six model deviations were found between the guideline model and ward-overarching model. Notably, four variations in double-check procedures were found. Here, time pressure was an important factor. Nurses made a risk-assessment, considering for patient stability, and difficulty of calculations, to determine whether the double-check would be executed. Additionally, subconscious reasonings, such as trusting their own or colleagues expertise, weighed on the decision.

Conclusion

Time pressure is the most important factor that withholds nurses from performing the double-check. Nurses instead conduct a risk-assessment to decide if the double-check will be executed. The double-check can thus become habitual or unnecessary for certain medications. In future research, insights of the FRAM could be used to make ward-specific alterations for the double-check procedure of medications, that focus on feasibility in daily practice, while maintaining patient safety.

Adherence to medication administration guidelines among nurses in a health facility in South-West Nigeria

Introduction

medication error has become a global problem. Medication administration that is error free is important in achieving positive outcomes in patient's care. This study assessed adherence to medication administration guidelines among nurses in a health facility in South-West Nigeria.

Methods

a cross-sectional descriptive study was carried out on 75 nurses involved in oral medication administration. Data was collected using direct observation method with an observational checklist developed from literature. Data analysis was done using frequency, percentage, Mean and Standard Deviation. Test of relationship was carried out using Kruskal-Wallis Test and Mann Whitney Test at 0.05 (p<0.05) level of significance.

Results

almost an average (49.3%) of participants did not provide information about the medication. More than 1/3^rd (38.7%) did not perform right assessment where necessary. The majority (76.0%) did not serve correct medication. Overall level of non-adherence was 48%. Adherence to medication administration guidelines was significantly related to age (χ² = 9.673, p<0.05), marital status (χ² = 9.426, p<0.05), years of experience (U=404.000 Z=2.7622, p<0.05), type of shift (χ² = 6.314, p<0.05), nurses-patient ratio (χ² = 11.598, p<0.05).

Conclusion

some nurses did not adhere strictly to the guidelines of medication administration. Adherence to medication administration guidelines was related to age, marital status, years of experience, type of shift and nurse-patient ratio. Poor adherence to medication administration guidelines may jeopardize patient safety. There is need for development of a universal medication procedure/protocol and continuous education of nurses on medication administration practices.

Identifying Risk Areas of Medication Administration Process for Developing an Interactive Three-Dimensional Game Intervention

The aim of this study was to describe identified risk areas related to the medication administration process in acute care in order to develop a three-dimensional-game intervention. A secondary analysis was conducted using (1) observed medication administrations (n = 1058) and identified medication errors in 2012 (n = 235), (2) a systematic review including a meta-analysis of previous medication administration educational interventions (n = 14) from 2000 to 2015, (3) incident reports of medication administration errors (n = 1012) from 2013 to 2014, and (4) focus group interviews with RNs' (n = 20) views in 2015. A qualitative content analysis was used to identify risk areas, and the data were organized according to the following main themes: (1) factors related to patients (patient identification, patients' characteristics or symptoms, and patients' allergies and interactions); (2) factors related to medications (medication information, changes in medications, generic substitutes, new drugs, look-alike/sound-alike drugs, demanding drug treatments, medication preparation, and administration techniques); (3) factors related to staffing (workload, skills, interruptions and distractions, division of work, responsibility, attitudes, and guidelines); and (4) factors related to communication (flow of information, communication with the patients, and marking of medication information). Identified risk areas could be used to develop interventions with the aim of increasing the safety of medication administration and nurses' skills.

Feasibility of reusing routinely recorded data to monitor the safe preparation and administration of injectable medication: A multicenter cross-sectional study

BACKGROUND

Reusing routinely recorded data from electronic hospital records (EHR) may offer a less-time consuming, and more real time alternative for monitoring compliance by nurses with a protocol for the safe preparation and administration of injectable medication. However, at present it is unknown if the data necessary to calculate the quality indicators (QIs) are recorded in EHRs, or if these data are suitable for automated QI calculation. Therefore, the aim of this study was to determine the feasibility of monitoring compliance by nurses with a protocol for the safe injectable medication preparation and administration by reusing routinely recorded EHR data for the automated calculation of QIs.

METHODS

A cross-sectional study in 12 Dutch hospitals (October 2015-May 2016). The checks included in the currently prevailing national protocol for the safe preparation and administration of injectable medication were translated into 16 data elements required to calculate the QIs. At each hospital, one interview was conducted using a structured questionnaire to decide whether the data elements were available in EHRs. To present these results, descriptive statistics were used.

RESULTS

In total, 20 health-care professionals were interviewed and four different EHR systems were evaluated. The availability of data elements was comparable between the four evaluated EHR systems. Nine of the 16 required data elements were recorded in EHRs, eight in a structured format. The seven missing data elements were mainly related to checks such as 'gather all materials needed' or 'conduct hand hygiene'. Furthermore, changes were identified in the process for the preparation and administration of injectable medication. These changes are mostly related to the increased use of electronic medication administration registration and barcode medication administration systems.

CONCLUSIONS

Reusing EHR data to monitor compliance by nurses with the currently prevailing protocol for the safe preparation and administration of injectable medication is not entirely feasible. A decision should be made on which checks should be recorded in the EHRs and which checks should be audited in order to minimize the registration burden for nurses. Moreover, the currently prevailing protocol should be revised to bring it in line with work-as-done. Our results can be used as guidance for such a revision and also for designing new QIs that can be calculated by reusing routinely recorded EHR data.

Focus group discussions of registered nurses' perceptions of challenges in the medication administration process

Medication administration (MA) holds a great threat to patient safety, as MA errors remain a global problem. Nurses are key role players in the MA process and can give valuable information from the grassroots level. The aim of the present study was to describe registered nurses' perceptions related to challenges in the MA process. Focus group interviews with registered nurses (n = 20) in two central hospitals in Finland were conducted in 2015. Inductive content analysis was performed. Nurses described multiple challenges during MA, which made the process demanding. These were organized under five themes: (i) medications; (ii) collaboration between health-care professionals; (iii) resources and work environment; (iv) skills and education; and (v) patient-related factors. The MA process is prone to errors, and registered nurses described many challenges related to MA. While nurses are responsible for their various work-related tasks and the maintenance of patient safety through applicable procedures and effective collaboration, health systems and hospital management should be stewards of patient safety by ensuring adequate staffing levels and providing educational resources related to the MA process.

Nurse compliance with a protocol for safe injectable medication administration: comparison of two multicentre observational studies

OBJECTIVES

Medication administration errors with injectable medication have a high risk of causing patient harm. To reduce this risk, all Dutch hospitals implemented a protocol for safe injectable medication administration. Nurse compliance with this protocol was evaluated as low as 19% in 2012. The aim of this second evaluation study was to determine whether nurse compliance had changed over a 4-year period, what factors were associated over time with protocol compliance and which strategies have been implemented by hospitals to increase protocol compliance.

METHODS

In this prospective observational study, conducted between November 2015 and September 2016, nurses from 16 Dutch hospitals were directly observed during intravenous medication administration. Protocol compliance was complete if nine protocol proceedings were conducted correctly. Protocol compliance was compared with results from the first evaluation. Multilevel logistic regression analyses were used to assess the associations over time between explanatory variables and complete protocol compliance. Implemented strategies were classified according to the five components of the Systems Engineering Initiative for Patient Safety (SEIPS) model.

RESULTS

A total of 372 intravenous medication administrations were observed. In comparison with 2012, more proceedings per administration were conducted (mean 7.6, 95% CI 7.5 to 7.7 vs mean 7.3, 95% CI 7.3 to 7.4). No significant change was seen in complete protocol compliance (22% in 2016); compliance with the proceedings 'hand hygiene' and 'check by a second nurse' remained low. In contrast to 2012, the majority of the variance was caused by differences between wards rather than between hospitals. Most implemented improvement strategies targeted the organisation component of the SEIPS model.

CONCLUSIONS

Compliance with 'hand hygiene' and 'check by a second nurse' needs to be further improved in order to increase complete protocol compliance. To do so, interventions focused on nurses and individually tailored to each ward are needed.

Learning outcomes associated with patient simulation method in pharmacotherapy education: an integrative review

STATEMENT

The aims of this systematic integrative review were to identify evidence for the use of patient simulation teaching methods in pharmacotherapy education and to explore related learning outcomes. A systematic literature search was conducted using 6 databases as follows: CINAHL, PubMed, SCOPUS, ERIC, MEDIC, and the Cochrane Library, using the key words relating to patient simulation and pharmacotherapy. The methodological quality of each study was evaluated. Eighteen articles met the inclusion criteria. The earliest article was published in 2005. The selected research articles were subjected to qualitative content analysis. Patient simulation has been used in pharmacotherapy education for preregistration nursing, dental, medical, and pharmacy students and for the continuing education of nurses. Learning outcomes reported were summarized as follows: (1) commitment to pharmacotherapy learning, (2) development of pharmacotherapy evaluation skills, (3) improvement in pharmacotherapy application skills, and (4) knowledge and understanding of pharmacotherapy. To develop effective teaching methods and ensure health care professionals' competence in medication management, further research is needed to determine the educational and clinical effectiveness of simulation teaching methods.

Medication Errors in the Southeast Asian Countries: A Systematic Review

BACKGROUND

Medication error (ME) is a worldwide issue, but most studies on ME have been undertaken in developed countries and very little is known about ME in Southeast Asian countries. This study aimed systematically to identify and review research done on ME in Southeast Asian countries in order to identify common types of ME and estimate its prevalence in this region.

METHODS

The literature relating to MEs in Southeast Asian countries was systematically reviewed in December 2014 by using; Embase, Medline, Pubmed, ProQuest Central and the CINAHL. Inclusion criteria were studies (in any languages) that investigated the incidence and the contributing factors of ME in patients of all ages.

RESULTS

The 17 included studies reported data from six of the eleven Southeast Asian countries: five studies in Singapore, four in Malaysia, three in Thailand, three in Vietnam, one in the Philippines and one in Indonesia. There was no data on MEs in Brunei, Laos, Cambodia, Myanmar and Timor. Of the seventeen included studies, eleven measured administration errors, four focused on prescribing errors, three were done on preparation errors, three on dispensing errors and two on transcribing errors. There was only one study of reconciliation error. Three studies were interventional.

DISCUSSION

The most frequently reported types of administration error were incorrect time, omission error and incorrect dose. Staff shortages, and hence heavy workload for nurses, doctor/nurse distraction, and misinterpretation of the prescription/medication chart, were identified as contributing factors of ME. There is a serious lack of studies on this topic in this region which needs to be addressed if the issue of ME is to be fully understood and addressed.

An observational study of how patients are identified before medication administrations in medical and surgical wards

The aims of this study were to clarify how a patient's identity was verified before the administration of medication in medical and surgical wards in a hospital, as well as to study the association between patient identification and the registered nurse's work experience, observed interruptions, and distractions. The study material was collected during April and May 2012 in two surgical and two medical wards in one university hospital in Finland, using a direct, structured observation method. A total of 32 registered nurses were observed while they administered 1058 medications to 122 patients. Patients were not identified at all in 66.8% (n = 707) of medication administrations. Patient identifications were made more often by nurses with shorter work experience in the nursing profession or in the wards (4 years or less), or if distractions existed during medication administration. According to the results, patient identification was not adequately conducted. There is a need for education and change in the culture of medication processes and nursing practice.