Nursing Essay: ReductionOfMedication Administration Errors Among Nurses
Question
Task: Examine the evidence supporting this clinical topic below and critically appraise the evidence to underpin the evidence-based practice, including a discussion of factors that may inhibit the implementation of the evidence base.
Question To Be Answered Through This Nursing Essay
What factors could reduce medication administration errors among nurses in hospitals.
Answer
MEDICATION ADMINISTRATION ERROR
Introduction
This research paper prepared within this nursing essay aims to understand what medication administration error is and how it can be reduced amongst nurses in the hospital. Based on various articles, a comprehensive study will be provided. Medication error as the word implies means error in prescription of the drug, dosage, or administration of the drug to the patient. Any error that implies that the patient has received anything different from what was prescribed will be known as a medication error. Such error can have a grave impact on the health of the patient in terms of side effects or mortality. Medication error is one of the most important criteria of nurse practice and the risk occurs when there is a discrepancy between what drug was prescribed and what drug was administered to the patient. Evidence-based practice (EBP) is the use of expertise and experience of the nurses for their patient’s complete health care.
Research Question
The research question which will be addressed in this paper is, what are the factors that could reduce medication administration errors among nurses in the hospitals Almost 30% of hospital patients suffer from a medication error, which results in major side effects or death. It is believed that in the leading cause of death in many nations, medical error positions third. Immunity to a medication error is not even accounted in a single health care facility. It is very difficult to figure out the exact number of medication error cases due to the lack of reporting system. A nurse's role in a patient's medication procedure involves prescribing, preparing and dispensing, and giving the prescription. The errors are most likely to occur during this process but medication administration is considered a final checkpoint at which the error can be found out and rectified (Alomari, et al. 2021).
Many new ways have been introduced to avoid errors like computerized medication entry, automatic medication dispensers, dosage value meter, bar code administration system, and smart pumps. Even then medication errors remain an issue. The chances of unrecorded error exist because no proper channel is available to record the accuracy of medication administered. Medication error is a matter of great concern on the patient’s health and safety and research into the causes of errors and strategies for improvement is the need of the hour (Wheeler, et al. 2018).
Methodology
The approach for this essay is to curate an analytical to draw out conclusive information. First of all, the search term is decided based on the inclusion/exclusion criteria. Then theoretical and academic perspective is sought to provide better insight into the topic. The whole understanding is implemented through quantitative analysis.
Search Term
The search terms used for the purpose of this paper were ‘meaning of medication administration error and its factors’. The keywords used were nursing errors, medication administration, and factors leading to medication errors, prevention of medication errors. 8 articles were selected and properly scrutinized for reference purposes.
Quality Appraisal
Under this section the following 8 articles will be critically appraised for the purpose of this paper.
In the first article by Karen H. Frith et al. 2012, the relationship between the nurse staff and the occurrence of medication errors was examined. Using a retrospective design, researchers analyzed secondary data from one from the hospital’s database which contained 801 weekly staffing intervals and 31,080 patient observations. The study revealed that increasing the number of registered nurses hours and decreasing the licensed practical nursing hours can be a strategy to reduce medication errors. The article explained the most frequent type of errors. Wrong medication, Wrong dose, Wrong method of administration, Wrong order, and Drug omission. Wrong order of administration is generally most likely to occur by first time nurses.
Physicians, pharmacists, or nurses can make medication error, and such errors can be made at any step in the process. Although it is believed that error can occur by any of the above set of professionals but the nurse is most usually the final line of defense between the patient and the mistake. Failure in calculating the dosage and no active knowledge of pharmacy are to be critically examined.
The second article by Patterson et al. 2002 provides for options in terms of technology in the health care facilitates to avoid medication errors. The study in this particular article was based on introducing barcode method into the complex , sociotechnical setting. Under this method the software is installed in all hospital computer systems and they are fixed to the medication carts. The software has all the data of the patient who have been admitted along with all the details of the medication. The nurse can scan the barcode printed on the wristband of the patient and the nurse log will automatically appear on the screen along with pending medication and dosage. In case of any error or discrepancy, a pop-up will appear which the nurse cannot ignore. The purpose of scanning a bar code is to ensure that the drug, dose, route, and administration time correspond to the patient's prescription. This procedure acts as a backup for all hospital documentation. The BCMA is seen to be very successful in streamlining everyday procedures, making the system more efficient and making it simpler to predict and identify incorrect behaviors.
One of the disadvantages of the bar code medication administration software is the degraded coordination between the physician and the nurse. Earlier the nurses had to be in constant contact with the physician regarding the medication of the patient but with the introduction of BCMA, there are sometimes chances of some discrepancies occurring. Failure to notice erroneous medicine orders, verifications, or administrations, failure to renew automatically ceased prescriptions, and failure to prioritize an emergency medication are all examples of poor coordination. The BCMA provided only 7 days of the history of a patient in the software where it is difficult for rotation nurses to understand the medication. Many times the barcode on the wristband was difficult to scan due to printing issues, removal of wristband if the patient had limb issues, or if the patient is asleep. Most nurses try to avoid disturbing the patients who are asleep, particularly if that patient has no oral medication prescribed. Often the nurses feel that once they scan the barcode from the wristband, patients often distract the nurses by requesting information regarding their health. The nurses uniformly believe that typing or writing a patient identification code along with medication is less time consuming. One of the greatest challenges faced by BCMA is how to manage the software and the data in case of power loss or system maintenance downtime. Many hospitals have come up with backups for such situations. Printing the patient data everyday and filing them, creating backup my logging into separate computers, and providing health summaries every few hours in stand alone computers with power backups (Patterson, Cook and Render, 2002).
With the advancement in technology, the BCMA can be seen as a technology to reduce errors in health care facilities. Several features are added into the software which is designed to allow nurses and physicians to view the patients medications at a glance, view multiple patient data simultaneously, colour code the data which need special care or are critical patients. Nurses might have faster access to pending and stopped drug information, making it easier for them to anticipate orders and spot mistakes. Even though BCMA cannot fully decrease medication errors, it can reduce the severity of the errors. The BCMA is believed to reduce the following errors; 1) order of administration of injectable, 2) pharmacy medication description, 3) dose omission 4) dose error.
In the third article by Tan et al. 2017 it is considered that preparation and administration of medication in the ICU are the main reason for medication errors. Under this article the emphasis was on medication education, types of medication preparation, adherence to good practice and drug infusion practice. A survey was conducted with regards to concentration of drug infusion by nurses and it was observed that education intervention played a significant role and it also improved the good practice adherence. The risk of medication error is considered to be the highest in the ICU (Intensive care unit) as compared to the general ward, for many reasons. The ICU patients are already in a critical condition following which they receive multiple medications simultaneously where the chances of error are high. These patients are ordinarily weak or sedated and hence are less likely to detect any error in the medication. The ICU patients are vulnerable and more prone to any side effects caused due to medication error due to the severity of their illness. Another issue that tends to create more error is the manual infusion of the drug to the patient. It is a common practice in almost all the hospitals, all of the world that nurses prepare drugs next to the patient which may sometimes lead to error in the concentration of the drug. Many nurses lack the information and calculations skills essential for the medicine preparation and administration. Incorrect preparation is also considered one of the common types of error. Reportedly 57% of the drug doses are prepared incorrectly as a result of incorrect diluent, inaccurate measurement, or insufficient mixing. Skill and technique to prepare the medication are of vital importance and mostly the errors are found in the volume and calculation measurement of the drug. The primary reason for such error is improper training, less staff, or distractions during the preparation. To avoid such errors it is important to provide admixtures or ready to use injections One more type of error is the incorrect administration rate, which implies inducing the injections too quickly. Time pressure and heavy workload are the reasons for such errors. Administering a drug too quickly than the prescribed time can result in shock or cardiac arrest. The best way to avoid such errors is to provide infusion pumps next to the bedside of the patient. One of the errors which is the most common of all is preparing and administering drugs using aseptic techniques, i.e. without basic hand hygiene. This practice is seen in mostly three countries, UK, Germany, and France. Not following basic hygiene leads to infusion contamination, which could result in blood infection or death. Poor hygiene knowledge is the primary reason for such error.
According to Macias, et al. 2018, there are various kinds of errors that can occur while administrating patients while allocating the barcode for each of them. He conducted an experiment to identify and categorize the kind of errors that could arise. He collected comprehensive data and evaluated the errors before and after the allocation of the barcode. The whole dataset was characterized into different segments such as age, automated or manual prescription. The paper also mentions a specific dataset to find the impact of barcodes on solid tumour patients. So, the study concluded that with the presence of a barcode system, MAEs and errors in the treatment and record of the patient can be reduced.
An article by Almori, et al. 2020, emphasized the rate of medication error in patients per 1000 patients. The total medication error stated by the study was 48.4% in 2014, 39.6% in 2015, and 26.5% in 2016. The overall change from 2014 to 2016 is reduced by 45.2%. Medication error is also a big concern. In 2014, there were 26,960 prescribed medication errors. Similarly, in 2015, it was 48,629 and 33,510 in 2016.
In the fourth article by Santiago et al. 2020 the emphasis was on electronic medication management system which can ensure and reduce errors as compared to traditional paper based approaches. A survey was conducted in four ICU’s and the study showed that introduction of electronic management system increased the nurses’ view on safety and satisfaction. Even though the system was not considered more efficient than paper based approach it was surely user friendly and complied to the bar code scanning when administering medication. Before the bar code medication administration system, the hospitals used paper-based system. The doctor handwrote diagnosis and medication and the nurse would send the copy to the pharmacy and the medications were put on record and sent to the ward stock. The medications were double checked by the nurse. One copy would be in the pharmacy computer. The nurses documented all these papers, patient wise. This procedure had its drawbacks. 1) Incorrect patient identification 2) Incorrect drug prescription 3) Incorrect volume prescribed 4) failure to document.
According to article five, by Alomariet al.2020, a study was conducted to assess a set of interventions designed and implemented by the nurses with the goal of lowering the medication administration errors and improving nurses nurse’s medication administration practice. The study was three-phase quantitative study. The first phase aimed to build an overall picture of medication practice. Phase Two aimed to develop and implement targeted interventions. The interventions were evaluated in Phase Three. Implementing a multidimensional approach reduced a number of medication errors. The research was successful in raising awareness amongst nurses regarding their medication practice. It was believed that the primary duties of a nurse are maintaining patient records and administration of medication, which are often, interrupted by either other staff members, shortage of doses, or other patient care needs. In such cases, nurses tend to omit steps, apply shortcuts, or deviate from the regular standard procedure to get the work done. It is the nurses who are given the final responsibility of administering the drug to the patient and so in case of any error it is the nurses who are held responsible. The nurses are the overall incharge of the doses and act as surveillance on the whole process. Such responsibilities can make the nurse feel vulnerable and burdensome and this can lead to error. Even though they may not have been a part of prescription writing or dispensing the medication from the pharmacy still are held responsible. It is therefore very important that nurses contribute to the nursing training and knowledge and extend their expertise in their field. 40 hours of duty in a week can create a likelihood of medication error on the part of the nurse. Long working hours create tiredness and fatigue among the nurses leading to medication error. Apart from basic patient duties, the nurses have to handle a lot of other responsibilities too. On the other hand, nurses who are fresher and possess no experience are likely to create more medication errors. Studies show that only many years of experience in the health care field can prevent medication errors.
According to article six by Flynn et al. 2016 , the high frequency of interruptions during the administration of medication , the chances of medication errors are high. A study was conducted in the cardiac units to evaluate the impact of limiting the interruption on medication administration. Due to the evidence based strategies the interruptions decreased tremendously. It is observed that it is dependent on the teamwork of the staff to reduce the interruption.
According to article seven by Macias et al. 2018 a study was conducted to determine the impact of barcode medication administration and to understand the errors in the program. The study was conducted in the onco-hematology unit in Spain. The study proved that the program was useful in reducing the severity of errors and it helped the nurses in spending time on the direct patient care. The program showed that the errors were reduced in dose omissions, dose errors, order of administration, and pharmacy. Barcode medication administration has been a boon for the hospitals and with its software getting updated every now and then the BCMA has been effective in reducing a lot of medication errors. Even then the BCMA technology has to be improvised in detecting high potential errors and dose administration system.
According to article eight by Berg et al. 2021, a study was conducted to understand the aspects of nurse medication administration from the perspective of key variables and to measure how an external factor or intervention might influence the occurrence of errors. An agent based modeling approach was used to understand the frequency of errors both in literature and clinical cases. The medication agent is a systematic approach that that interacts with nurses during the administration. It calculated the probability of the medication and provides inputs in the form of missed dose or received dose.
The health-care business has tried a variety of approaches to improve labour efficiency and minimize the number of mistakes. Computer modeling is one such approach that aids in health-care operations such as workflow and patient data, resource planning, and staff evaluation. Agent based modeling is the new class of computer modeling that combines the standard form of system, which interacts with any entity whether animate or inanimate, or even conceptual entities. Under the healthcare system, it helps in decision support system, planning, process stimulation, and analysis and data management.
Summary And Synthesis Of Paper
Having educated health care providers is the most important element in eliminating medication errors. Many nurses neither possesses full knowledge nor experience of providing injectable to the patient. The errors caused by nurses can include wrong dosage, or improper injectable, wrong time or frequency, and under severe circumstances providing medication to wrong patient. There are high chances of errors with injections than oral medications. The primary concern is the infection in the blood due to wrong dose or aseptic use. Wrong route of administration or frequency can cause shock or cardiac arrest in some cases.
Factors associated with health care professionals:
Absence of practicum
Inadequate medication understanding and information
An insufficient acquaintance of the patient’s history and allegories
Elements associated with the patients:
Patient factors, which includes nature, age, education, and language issues)
Multiple health complications
Aspects associated with the work atmosphere
Workload and time constraints
Distraction and interruptions
Lack of protocol and instructions
Low resources
Individual irresponsibility leads to system failure, which can result in a variety of tragedies. Many studies show that nurses who have full knowledge of the drug can avoid such errors. Many medication mistakes occur as a result of a heavy workload and an inconsistent nurse-to-patient ratio. There is evidence to show that physicians and pharmacists make medication errors. Some of the causes of prescription errors are:
1. Failure to have full knowledge of the content of the drug
2. Multiple drugs which should not be mixed
3. Wrong dosage
4. Failure to review medication history of the patient
5. Wrong instruction to consume the dose.
Each pharmacy ought to have a prescribed procedure set up to prevent error, and it is the pharmacist’s obligation to check medicines if there is any uncertainty about the specific prescription the physician prescribes.
It is the duty of the doctor as well as the physician to ask their patients routine questions like,
Are you taking any medication
Are you allergic to any medicine
Have you had any reaction from any medicine earlier
The consequences of these errors can be serious and can fetch legal liabilities for the hospitals. According to one of the research medical errors have become the third leading cause of death in the USA. For the nurses, the consequences of these errors can be emotionally traumatic and weakens their self-confidence. When the consequences of error are grave like the patient goes into a coma or dies, the nurses tend to feel guilty and depressed and they experience emotional distress. Many times they fear that reporting the error can lead to litigation cases and that’s why they do not report the case.
On average, hospitalized patients are thought to experience at least one drug mistake every day. Prescription reconciliation is the process of compiling the most accurate and comprehensive list of a patient's current medications and comparing it to the patient's medication order. It is basically preparing a list of all the medication that the patient has been taking. The process of conciliation is done to avoid any medication error such as omissions, wrong dose, or volume of drug. The process of reconciliation must be done at very step where the physician prescribes a new medication. Any sort of change in physician, dosage, medication, or reaction to medication must be recorded.
The process of reconciliation included 5 steps:
1. Preparing a list of current medication
2. List of new medication prescribed
3. Comparison of two lists
4. Forming a decision based on the comparison
5. Communicate the list to the guardian and the patient
Medication reconciliation is a step to prevent such errors as much as possible and to perform reconciliation at very step. The intention is to avoid drug error, duplication or omission at any step.
The medication reconciliation list must be comprehensive and should include prescriptions, injectable, vitamins, supplements, drugs, vaccines, blood readings, dietary supplements and any other important medication related report. The medication reconciliation steps are simple as it involves documenting the newly admitted patient’s medical history, new prescription and any tests if needed. During the discharge the documents would include dietary precautions, home medications, follow up routines.
Issues Of Implementation
The promoting action on research implementation in health services (PARIHS) is designed to understand the frameworks of the article including research, clinical experience, local information.
According to Alomari, et al. (2020), there were five interventions that were implemented while reducing the error rates in medication administration. These five interventions were – ‘AstrisLifeCare mobile trolleys for administering medication, query about parental involvement, safety and quality meetings to be taken every month, increasing time-space before the end of shift, and updating medication policy. The interventions were applied and medication errors were reduced and yet there was a substantial setback in engagement and consultancy. Another thing that was noticed was that the study did not measure the impact of each intervention singularly. The analysis of a single trait could have been influential to implement the extent of each intervention. There were elements of biasing which makes the analyzed data a bit more non-trustable.
The other most influential element that determines the issues in implementation is the lack of right and appropriate knowledge. The parameter of education intervention, specifically for parenteral medication is quite tough to carry out. The study designed by Tan, et al. (2017) did not completely utilize the sample size for evaluating parental medication post intervention. Secondly, the implications of research have been directed to multiple errors. During administering the methods of the study, there were situations when errors were severe and researchers had to intervene. This would have hampered the observation process. Thus, it is also considered as one of the prominent issues that circumstantial interference can hamper the data measurements (Tong, et al. 2017).
The presence of agents in the form of nurses or medical staff is also an umbrella notation for medical professionals who would carry out medical administration. The primary objective of the study was to carry out steps that could reduce the errors during medication, but the implementation of an agent is another human entity that is supposed to reduce the error. Even the model created by a study has proved the effectiveness of the agents for reducing medication error, but again, they are human themselves and there is a possibility that error can be caused by them. To resolve this concern, these agents are needed to be trained specifically beyond the role of nurse and caretaker. This was the most prominent issue identified in the study that is to make sure that these agents carry out their tasks properly and with diligence (Berg, et al. 2021).
Another research conducted by Frith, et al. (2012), focused on another parameter that can be identified as a prominent issue in implementing a strategy to reduce medication error. The issue is the cost of nurse staffing. This research identified a basic and important parameter that is to train and staff the nurses in optimum quantity to ensure the truthfulness and error - free medication (Latimer, et al. 2017). A study presented in the study has shown that many medical institutions have spent a larger amount of money to reduce the errors than the actual impact on cost the error would have incurred. In order to reduce or resolve the administered error, a huge investment is required, otherwise, it won’t be of any use to anyone. Thus, administering the error rate is a continuous process that will be supported by the implementation of the required infrastructure to reduce it.
A study conducted with the objective of reducing the interruptions to reduce the medication error was proposed. The main aim was to identify all the kinds of interruptions that could occur during medication administration and how they can be reduced. The research had a lesser number of participants and thus, the uniformness in the representativeness of the sample was compromised (Khalil, et al. 2017). The research also restricted its domain to 3 speciality units which have prevented the generalized findings of medication administration. The data collected for the model was done after developing a baseline on initial data which cannot be considered as a benchmark. Thus, due to several restrictions and boundaries of the research such as limiting the medical administration to general physicians has restricted the implementation of the study for every department in the medical sector (Flynn, et al. 2016).
One study has conducted research on medication errors and developed a model named BCMA (BarCode Medical Administration). The limitation of the study was to mark the reduction in the frequency of predefined failures along with identifying the beneficial sides. The BCMA has given another aspect of administering the procedure of medication but these are limited to general and nursing wards. As this could be risky and quite tricky to be used in Intensive care units due to multiple reasons. Thus, it is crucial to understand that the role of human intervention and administration is extremely important in the cases of ICUs and that’s why BCMA based administration cannot be implemented. This was the identified issue of implementation of BCMA in medication administration (Patterson, Cook and Render, 2002). The use of electronic medication management systems is supposed to provide a complete assessment and support mechanism for nurses. This will provide them with an option to evaluate their administration and make sure that errors are as least as possible. The use of electronic systems is the only concern for the people or medical staff who are not well aware or equipped with technical knowledge or how to use those machines. The unfamiliarity of machines can cause delays which could ultimately lead to the occurrence of errors. Therefore, it is still not a perfect mechanism to be utilized for the assistance of nurses and the reduction of medication errors. Thus, one could say that the electronic system is not user friendly which creates a huge setback for the research (SANTIAGO, et al. 2020).
In one study, again BCMA was considered as an option for supporting the medical staff to reduce the administration error. But it was found that these BCMA were facilitated in a setting that could present certain barcodes and cannot be generalized for others. Thus, the study was overall based on a particular field of implementation, not a general one. There were delays in the data collection post - intervention and this has become the subject matter for further studies. This means that BCMA has its issues with implementation and more research is needed to find its impact on the medication errors (Trakulsunti, Antony and Douglas, 2020).
Conclusion
Medication errors are a common issue in the healthcare system. It is a globally prevalent issue which may lead to various disasters like allergic reactions, therapeutic failure, longer hospital stays and in some cases death. The medication errors can take place while providing prescriptions, documenting, dispensing, administering. The most common type of drug error is omission, wrong time, wrong sequence, and volume of administration of the drug. The last and final check between the medication and patient is the nurse and hence the burden lies upon the nurse to act as a barrier for any error. A lot of factors have been put forward in the nurse medication administration error like workload, experience level, lack of training, work culture, interruption, etc. As the nurses are the last checkpoint between medicine and patients the burden falls upon the nurses to avoid any sort of error. Barcode medication administration has been a boon for the hospitals and with its software getting updated every now and then the BCMA has been effective in reducing a lot of medication errors. Even then the BCMA technology has to be improvised in detecting high potential errors and dose administration system.
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