Thesis (Mcur)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: A literature study showed that the topics of medication safety and medication error prevention have been studied in depth. Findings from the literature revealed that medication errors are reported to be common in neonatal and paediatric ICUs, that more than half of these errors are preventable and that risk reduction measures protect patients against untoward outcomes or adverse events (Clifton-Koeppel, 2008:72). If and when there is a failure in the process of safe medication administration, it results in a medication error, which is defined as a breach of one or more of the five rights of medication administration (Institute for Safe Medication Practices Alert, 2007:1). Medication administration, which is predominantly a nursing task, is of high risk and high volume in the intensive care unit (ICU). The accuracy of intravenous medication administration is critical for a neonatal and paediatric ICU patient since it can potentially heighten the patient’s vulnerability if further harm is caused. In view of the complexity of medication administration for neonatal and paediatric ICU patients, researchers confirm the diverse role of the registered nurse in safe medication administration practices. The purpose of the study was to describe the perceptions of registered nurses (RNs) regarding the factors that influence IV medication safety practice in the neonatal intensive care unit (NICU); paediatric intensive care unit (PICU); and paediatric cardiac intensive care unit (CSICU) in Saudi Arabia. The study objectives were set to describe the actual factors that have an influence on IV medication safety practices of RNs working in these ICUs; to determine the knowledge of registered nurses in the selected ICUs with regard to safe intravenous medication administration practices and to describe nursing medication administration strategies that are focused on medication error prevention. A quantitative research approach was selected for this study which had a descriptive, survey design. An 85% non-probability purposive sampling method was used to draw a sample (n=103) of the target population of NICU-, PICU- and CSICU-registered nurses (N=121) who were responsible for administering intravenous medication at King Faisal Specialist Hospital and Research Centre in Jeddah (KFSHRC-J). A self-administered questionnaire with closed-ended Likert and open-ended question was designed to describe the objectives under study. A pilot study was conducted to pre-test the questionnaire. A quantitative method was used to analyse the study data. MS Excel was used to capture the quantitative data after which it was analysed using descriptive statistics by means of STATISTICA 9 software. The open–ended questions (indicating “other” and Question 70) were also interpreted quantitatively after exploring the main aspects in the responses. The main findings were that multiple perceived factors influence the intravenous medication safety practices of RN’s working with neonatal and paediatric ICU patients in a particular Saudi Arabian tertiary hospital. It was found that these nurses’ had knowledge regarding safe medication administration practice that constitutes that all five medication rights have to be checked through nursing ‘double-checks’ in the steps of medication administration, as the method of checking as per hospital policy. However, from the findings, it is reflected that RNs perceptions of completely and correctly checking medication rights through complete and independent nursing ‘double-checks’, do not match the steps required by policy and that their knowledge is inadequate. It is evident from the perceptions of RNs that they are aware of the multiple factors influencing IV medication safety practice in this vulnerable patient setting. As perceived by RNs, it is possible to implement more safety strategies. Key recommendations on conclusion of the study include that there are more nursing medication administration strategies that could still be implemented for medication error prevention. These strategies relate to medication safety awareness, the role of the nurse and nursing managers, mandatory staff education, and review of knowledge and skills. / AFRIKAANSE OPSOMMING: Gebaseer op ʼn literatuurstudie blyk dit dat medikasieveiligheid en voorkoming van medikasiefoute reeds in diepte bestudeer are. Bevindings dui daarop dat medikasiefoute algemeen voorkom in neonatale en pediatriese intensiewesorgeenhede, dat meer as die helfte daarvan voorkombaar is, en dat maatreëls om risiko te vermindering pasiënte teen voorkombare uitkomste beskerm (Clifton-Koeppel, 2008:72). Indien en wanneer die proses vir veilige medikasietoediening faal, kom ʼn medikasiefout voor, wat gedefinieer word as die verbreking van een of meer van die vyf medikasieregte (Institute for Safe Medication Practices Alert, 2007:1). Medikasietoediening is hoofsaaklik ʼn verpleegtaak, wat ʼn hoërisiko- en hoëvolume-taak behels. Die akkuraatheid van intraveneuse medikasietoediening is kritiek vir neonatale en pediatriese intensiewesorgpasiënte, aangesien hul weerloosheid verhoog word indien verdere skade veroorsaak word. Omrede medikasietoediening vir neonatale en pediatriese intensiewesorgpasiënte kompleks is, bevestig navorsers dat geregistreerde verpleegkundiges se rol ten opsigte van veilige medikasietoediening veelsoortig is. Die doel van die studie was om die persepsies van geregistreerde verpleegkundiges aangaande die faktore wat medikasieveiligheid in die neonatale en paediatriese intensiewe eenhede in Saoedi-Arabië beinvloed, te beskryf. Studiedoelwitte is gestel om die spesifieke faktore te beskryf wat aanleiding gee tot medikasietoedieningsfoute in die genoemde intensiewesorgeenhede; om geregistreerde verpleegkundiges in die geselekteerde intensiewesorgeenhede se kennis van veilige medikasietoediening te bepaal; en die medikasietoedieningstrategieë wat op die voorkoming van medikasietoedieningsfoute fokus, te beskryf. ʼn Kwantitatiewe navorsingsbenadering is geselekteer vir die studie wat ʼn beskrywende navorsingsontwerp gehad het. ʼn 85% nie-waarskynlike gerieflikheidsteekproef is gebruik om ʼn steekproef (n=103) te selekteer vanuit die teikenpopulasie geregistreerde verpleegkundiges (N=121) wat verantwoordelik was vir medikasietoediening in die geselekteerde intensiewesorgeenhede by King Faisal Specialist Hospital and Research Centre, Jeddah (KFSHRC-J). ʼn Self-geadministreerde vraelys met geslote Likert- en oop-eindevrae is opgestel om die gestelde studiedoelwitte te ondersoek. ʼn Vooraf-toetsing van die vraelys is tydens die loodsstudie uitgevoer. ʼn Kombinasie van kwantitatiewe en kwalitatiewe metodes is gebruik vir die ontleding van die studie-data. Die kwantitatiewe data is op MS Excel ingevoer, waarna beskrywende statistiek deur middel van Statistica 9-sagteware gebruik is om dit te ontleed. Die studie het hoofsaaklik bevind dat veelvuldige faktore die veiligheidspraktyk ten opsigte van intraveneuse medikasie van geregistreerde verpleegkundiges wat met neonatal en pediatriese intensiewesorgpasiënte in ʼn spesifieke tersiêre hospitaal in Saoedi-Arabië werk, beïnvloed. Dit blyk dat hierdie verpleegkundiges se kennis voldoende is aangaande ‘n veilige medikasie toedieningspraktyk wat bestaan uit die kontrolering van al vyf medikasieregte deur verpleegkundige dubbel-kontrolering, soos beskryf is in die hospitaalbeleid. Volgens die bevindinge blyk dit egter dat die verpleegkundiges se persepsie van volledige and korrekte verpleegkundige dubbel-kontrolering, nie met die stappe volgens die hospitaalbeleid ooreenstem nie en dat hulle kennis onvoldoende is. Dit is duidelik dat die verpleegkundiges bewus is van die veelvuldige faktore wat intraveneuse medikasieveiligheidpraktyk vir weerlose pasiënte beïnvloed. Die verpleegkundiges se persepsie is dat daar meer verpleegkundige medikasietoedieningstrategieë is wat geïmplementeer kan word om medikasiefoute te voorkom, insluitende veiligheidsbewustheid ten opsigte van medikasie, die rol van verpleegkundiges en verpleegbestuurders, verpligte personeelopleiding, en hersiening van kennis en vaardighede.

Since 1999 when the report To Err is Human: Building a Safer Health System was released, medical errors have come into focus (Kohn, 2000). In an effort to reduce medication administration errors in prehospital emergency care, an android-based smartphone application simulation was created. The app has components including QR barcode scanning, text to speech for medication cross-checking, weight-based medication dose calculations, and time stamped medication data wirelessly transferring to a database in real-time. Color standard identification was implemented, aiding to a designed systematic process for patient treatment to reduce medication errors. Direct observation was performed of emergency patient calls with Richmond Ambulance Authority’s providers for a preliminary assessment. Device testing was assessed with emergency medical interns and functionally tested in different light environments. Results showed how similar different pharmaceutical vendors created medication labeling and that 58.3% of medical experts would say this device served to reduce medication administration errors.

Abstract The aim of the study was to determine nursing staff’s self-assessment of how they adhere to guidelines on safe medication administration during the medication process in long-term elderly care. In the first phase of this quantitative study, a Safe Medication Management Scale was developed and its reliability was evaluated. A panel of experts (n = 7) determined the scale’s content and the structure of its items. A pilot study was conducted with nursing staff from long-term elderly care wards in one town in northern Finland. The response rate was 24 % (n = 69). In the second phase, a cross-sectional study was conducted among nursing staff from long-term elderly care wards in one hospital district in Finland. The response rate was 39 % (n = 492). The majority of the nurses reported always adhering to guidelines during the medication process. However, one third of the nurses stated that they do not always follow guidelines when preparing medication, and approximately half stated that they do not always follow guidelines when administering medication. Shortcomings were identified in medication documentation, especially in the recording of the effects of medicine and the reason for administration. Routine checks were not always performed at different stages of the medication administration process. Also, patient involvement in the medication administration process was not always completed. Statistically significant associations were detected between the responses and the nurses’ self-assessment of how well they follow recommendations in general, as well as their knowledge of pharmacology and infection control, and their skill in performing medication calculations. A statistically significant association was detected in the age of the nurses; older age groups followed guidelines more thoroughly than younger age groups. When nurses self-assessed their activities in general at a higher level, they seemed to also follow guidelines better. Deviation from instructions and recommendations relating to the administration of medicines often leads to a medication error or creates an opportunity for errors to occur. The results of this study can be used to improve medication safety in long-term elderly care through the development of medication administration processes in organizations as well as the attitudes and competence of nursing staff so that medication is always given in accordance with instructions and recommendations. / Tiivistelmä Tutkimuksen tarkoituksena oli kuvata ja selittää lääkehoidon turvallista toteuttamista ikääntyneiden pitkäaikaishoidossa lääkehoitoon osallistuvan hoitohenkilöstön näkökulmasta. Tämän kvantitatiivisen poikkileikkaustutkimuksen ensimmäisessä vaiheessa kehitettiin lääkehoidon turvallisen toteuttamisen itsearviointimittari ja arvioitiin sen luotettavuutta. Mittarin sisällön validiuden arvioinnissa hyödynnettiin asiantuntijapaneelia (n = 7). Esitestaus tehtiin yhden kuusikkokunnan kunnallisissa ikääntyneiden pitkäaikaishoidon yksiköissä (n = 18). Vastausprosentti oli 24 % (n = 69). Toisen vaiheen perusjoukon muodostivat yhden sairaanhoitopiirin kunnallisten ikääntyneiden pitkäaikaishoidon yksiköiden lääkehoitoon osallistuvat hoitohenkilöstöt. Vastausprosentti oli 39 % (n = 492). Suurin osa hoitajista toteutti lääkehoitoa turvallisesti. Kuitenkin kolmannes hoitajista arvioi, että he eivät aina saata lääkkeitä käyttökuntoon ohjeiden ja suositusten mukaisesti. Lähes puolet arvioi poikkeavansa ohjeista ja suosituksista koskien lääkkeiden antamista ja lääkehoidon vaikutusten seurantaa ja arviointia. Kirjaamisessa havaittiin puutteita erityisesti lääkehoidon vaikutusten ja lääkkeen antamisen syiden kirjaamisessa. Rutiininomaisia tarkistuksia ei aina tehty lääkehoidon prosessin vaiheissa. Potilaan osallistaminen lääkehoidon prosessiin ei arviointien mukaan myöskään aina toteutunut. Mitä paremmin hoitaja koki hallitsevansa farmakologian, infektioiden torjunnan ja lääkelaskennan, sitä paremmin hän myös näytti toteuttavan lääkehoitoa. Hoitajan iällä havaittiin tilastollisesti merkitsevä yhteys lähes kaikkien osa-alueiden kanssa; iältään vanhemmat toteuttivat lääkehoitoa huolellisemmin suosituksia ja ohjeistuksia noudattaen kuin nuoremmat. Mitä paremmaksi hoitajat itsearvioivat toimintansa yleisesti, sitä paremmin he näyttivät vastausten perusteella toteuttavan lääkehoitoa. Kun lääkehoidon ohjeista ja suosituksista poiketaan, aiheuttaa se usein lääkityspoikkeaman tai sen mahdollisuuden. Poikkeama voi aiheuttaa myös lääkehaittatapahtuman. Tässä tutkimuksessa tuotetun tiedon avulla ikääntyneiden pitkäaikaishoidon lääkitysturvallisuutta voidaan parantaa kehittämällä sekä yksikön lääkehoidon toteuttamisen prosesseja, että hoitohenkilöstön lääkehoidon asenteita ja osaamista sellaisiksi, että lääkehoitoa toteutetaan kaikissa tilanteissa ohjeistusten ja suositusten mukaisesti.

The purpose of this body of work was to address medication errors and safe medication administration practices in relation to practicing nurses and nursing students via several different approaches. These different approaches will be presented as three separate papers but interrelated themes. The specific purpose for each paper and the corresponding research questions were addressed individually in each chapter. The approach used in the first paper was a systematic literature search of medication administration errors and the pediatric population; five themes emerged including the incidence rate of medication administration errors, specific medications involved in medication administration errors and classification of the errors, why medication administration errors occur, medication error reporting, and interventions to reduce medication errors. The approach used in the second paper included a systematic literature review and implementation of a survey, both focusing on the assessment strategies for safe medication administration with practicing nurses and nursing students. Results of both the review and the survey indicated a lack of a comprehensive assessment of safe medication administration. The approach used in the third paper was a research study to conduct a psychometric evaluation of the Safe Medication Administration (SAM) Scale with baccalaureate nursing students. Results provided evidence of the validity and reliability of the SAM Scale. This body of work exposed a gap in nursing and demonstrates the importance of having a standardized assessment of safe medication administration with evidence of validity and reliability to demonstrate competency in this area.

<p><strong>Introduktion.</strong> Varje år inträffar misstag inom sjuksköterskors läkemedelshantering. Detta kan leda till vårdskada för patienten. Orsaker till misstag är oftast kända fenomen. Kunskap om hur sjuksköterskor undviker misstag inom läkemedelshantering är därför av största vikt. <strong>Syfte.</strong> Syftet var att beskriva åtgärder för att undvika misstag i sjuksköterskors läkemedelshantering, för god patientsäkerhet. <strong>Metod.</strong> En litteraturstudie utfördes, vilken baserades på fjorton artiklar. Databaserna som användes var CINAHL och PubMed. Artiklarna kvalitetsgranskades med hjälp av mallar.<strong> Resultat.</strong> Två huvudkategorier framkom; Samverkan mellan människor och Samverkan via säkerhetssystem. Följande underkategorier är; Kommunikation -med kollegor och andra i vårdlaget, -med patienter, Söka information och kunskap -lita till eget omdöme och lära av andra, Utföra kontroller, Rapportera misstag och säkerhetsrisker, Minska distraktion och Använda medicinskteknisk utrustning. <strong>Slutsats.</strong> Samverkan framkom som en viktig åtgärd för att undvika misstag inom läkemedelshantering. Det kan ske i form av kommunikation med kollegor och patienter. På detta sätt utväxlas kunskap angående läkemedelshantering. Sjuksköterskan kan även använda olika former av kontroller innan läkemedel tilldelas patienten. Det framkom att diverse utrustning kan hjälpa sjuksköterskan att upprätthålla hög säkerhet i arbetet. Exempel på detta är infusionspump som larmar vid fel, samt rapportering av medicinska misstag via dataprogram.</p>

Adverse drug events, resulting in preventable patient harm or death, are of great concern. To keep patients safe, hospitals have implemented barcode medication administration (BCMA) technology for RNs who have accepted this technology with varying levels of satisfaction. When nurses are dissatisfied with a BCMA system, they may find alternative methods to complete their work. Framed by the Technology Acceptance Model (Davis, 1989), this analytic, cross-sectional study aimed to understand the relationship between BCMA satisfaction and workarounds, perceived ease of use (PEOU) and perceived usefulness (PU) of a BCMA system by 80 hospital-based RNs in northeastern US. Data were collected using the Workaround Usage and Satisfaction with Barcoding Instrument for Nurses (WUSBIN), which was adapted from Hurley's (2006) Medication Administration System-Nurses Assessment of Satisfaction Scale (MAS-NAS) Halbesleben and Rathert's (2010) Workaround Assessment. Results suggested that RNs who were more satisfied with the BCMA system were less likely to use workarounds than nurses who were less satisfied (r2(78)= -.681, p &lt; .05). Significant relationships were noted among BCMA Satisfaction and PEOU (r2(78) = -.725, p &lt; .05), Workaround Usage and PEOU (r2(78) =.943, p &lt; .05) and Workaround Usage and PU (r2(78)=.501, p &lt; .05). RNs perceived the BCMA system to be easy to use (PEOU), but not very useful (PU). BCMA Satisfaction was significantly related to the use of six workarounds, while Workaround Usage was significantly related to five. Significant relationships were also noted among both BCMA Satisfaction (r2(78) = -.393, p &lt; .01), and Workaround Usage (r2(78) = .423, p &lt; .01) with the total number of workarounds used. Significant relationships were found among demographic variables, BCMA Satisfaction, and Workaround Usage. Since admitting to the use of workarounds may be a sensitive matter for RNs, measuring BCMA satisfaction may help understand the state of patient safety related to medication administration. Based on high satisfaction scores and low workaround usage, a profile may be developed to identify nurse champions to improve quality of care. Further research is indicated to fully understand these possibilities. / School of Nursing / Nursing / PhD / Dissertation

Introduktion. Varje år inträffar misstag inom sjuksköterskors läkemedelshantering. Detta kan leda till vårdskada för patienten. Orsaker till misstag är oftast kända fenomen. Kunskap om hur sjuksköterskor undviker misstag inom läkemedelshantering är därför av största vikt. Syfte. Syftet var att beskriva åtgärder för att undvika misstag i sjuksköterskors läkemedelshantering, för god patientsäkerhet. Metod. En litteraturstudie utfördes, vilken baserades på fjorton artiklar. Databaserna som användes var CINAHL och PubMed. Artiklarna kvalitetsgranskades med hjälp av mallar. Resultat. Två huvudkategorier framkom; Samverkan mellan människor och Samverkan via säkerhetssystem. Följande underkategorier är; Kommunikation -med kollegor och andra i vårdlaget, -med patienter, Söka information och kunskap -lita till eget omdöme och lära av andra, Utföra kontroller, Rapportera misstag och säkerhetsrisker, Minska distraktion och Använda medicinskteknisk utrustning. Slutsats. Samverkan framkom som en viktig åtgärd för att undvika misstag inom läkemedelshantering. Det kan ske i form av kommunikation med kollegor och patienter. På detta sätt utväxlas kunskap angående läkemedelshantering. Sjuksköterskan kan även använda olika former av kontroller innan läkemedel tilldelas patienten. Det framkom att diverse utrustning kan hjälpa sjuksköterskan att upprätthålla hög säkerhet i arbetet. Exempel på detta är infusionspump som larmar vid fel, samt rapportering av medicinska misstag via dataprogram.

The general aim was, within psychiatric inpatient care, to explore patient and staff perceptions with regard to medication administration and locked entrance doors. In Study I, medication administration was illuminated according to a mini-ethnographic approach. Nurses and voluntarily admitted patients were observed and interviewed. Two central categories of patient and nurse experiences were identified, get control and leave control. In Study II, patients and nurses were interviewed about patient experiences of forced medication. Identified experiences were related to the disease, being forcibly medicated, and the drug. In Study III, the frequency of and reasons for locked entrance doors on Swedish psychiatric inpatient wards were investigated. Seventy three per cent of the doors were locked on a specific day. According to ward managers, doors were most often locked in order to prevent patients from escaping, provide security and safety, and because legalisation. In Study IV/V, voluntarily admitted patients/mental nurse assistants and nurses were interviewed about advantages and disadvantages about being cared for/working on a psychiatric inpatient ward with a locked entrance door. Most advantages mentioned by patients and staff were categorised as protection against “the outside”, secure and efficient care, and control over patients. Most disadvantages mentioned by patients were categorised as confinement, dependence on the staff, and emotional problems for patients. Most disadvantages mentioned by staff were categorised as extra work, confinement, dependence on the staff, and a non-caring environment. In conclusion, medication administration and locked entrance doors are perceived as connected with staff’s control and restricted freedom for patients. Increased reflection among staff about how medication administration and locked entrance doors are perceived by patients would increase staff’s possibilities to prevent potential experiences of coercion due to these situations among patients in psychiatric inpatient care.

Research suggests that interruptions are ubiquitous in healthcare settings and have a negative impact on patient safety. However, there is a lack of solutions to reduce harm arising from interruptions. Therefore, this research aimed to design and test the effectiveness of interventions to mitigate the effects of interruptions during medication administration. A three-phased study was conducted. First, direct observation was conducted to quantify the state of interruptions in an ambulatory unit where nurses routinely administered high-risk medications. Secondly, a user-centred approach was used to design interventions targeting errors arising from these interruptions. Finally, the effectiveness of these interventions was evaluated through a high-fidelity simulation experiment. Results showed that medication administration error rates decreased significantly on 4 of 7 measures with the use of interventions, compared to the control condition. Results of this work will help guide the implementation of interventions in nursing environments to reduce medication errors caused by interruptions.

Research suggests that interruptions are ubiquitous in healthcare settings and have a negative impact on patient safety. However, there is a lack of solutions to reduce harm arising from interruptions. Therefore, this research aimed to design and test the effectiveness of interventions to mitigate the effects of interruptions during medication administration. A three-phased study was conducted. First, direct observation was conducted to quantify the state of interruptions in an ambulatory unit where nurses routinely administered high-risk medications. Secondly, a user-centred approach was used to design interventions targeting errors arising from these interruptions. Finally, the effectiveness of these interventions was evaluated through a high-fidelity simulation experiment. Results showed that medication administration error rates decreased significantly on 4 of 7 measures with the use of interventions, compared to the control condition. Results of this work will help guide the implementation of interventions in nursing environments to reduce medication errors caused by interruptions.