Occurrence of Medication Errors and Oral Medication Administration Practices of Staff Nurses

 

Arti Devi¹, Sembian N.², Simranjit Kaur³

¹M.Sc. Nursing Second year, Medical Surgical Nursing, M.M. College of Nursing, Mullana

²Associate Professor, Medical Surgical Nursing, UPRIMS and R, Govt. Nursing College, Saifai

³Assistant Professor, Medical Surgical Nursing, M.M. College of Nursing Mullana

 

ABSTRACT:

Introduction: A medication error  is  defined  As  ‘a failure  with the  treatment  program, which may leads to,  or maybe   offers   ones  potential  to help  lead to, harm  for the  patient’. The purpose of this study is to assess the oral medication administration errors done by intensive care unit nurses and to evaluate the effectiveness of safe drug administration programme.

Methodology: In this experimental study, 600 oral medication administration events in medical ICU of MMIMS and R Hospital, Mullana,  Ambala were observed. Event based sampling technique was used to collect the sample. The data was collected by using checklist for assessing the oral medication administration practices and occurrence of medication errors. Reliability of the observational checklist was determined by using inter rater reliability test and it was 0.86. Data analyzes were performed by descriptive statistics and inferential statistics. SPSS-17 software was used and P values less than 0.05 were considered significant.

Result: During oral administration in morning shift, mean of post implementation – I practice scores (20.00) was higher than post-implementation practice score-II (19.56). In evening shift, mean of post implementation – I practice scores(20.98) was higher than post-implementation-II practice scores (20.74) and In night shift, mean of post-implementation-II practice scores (21.50) was higher than post implementation – I practice scores (21.30).

Discussion: The result shows that there was improvement in medication administration practices after implementation of event based teaching programme which was calculated at 0.05 level of significance. So, the concluded that the Event Based Teaching Programme was effective to improve the practices of oral medication administration by staff nurses and reduces the occurrence of medication error.

 

INTRODUCTION:

The concept of patient safety   is a new healthcare discipline.  The item e­mphasizes the reporting, analysis, along with prevention involving medical error. ¹ Nurses have an important role in preventing the medication errors by evidence based practices and by ensuring that they have the knowledge about the correct steps of medication administration. It includes the anatomy and physiology, pharmacology and legal issues. Nurses should maintain medication charts and the charts must be completed accurately because they are legal documents.  And every registered nurse is accountable for the correct methods/steps of medication administration. And after administration of medication the nurse should monitor the patient for the side effects or adverse effects of medications. ² The safety of patient is a major global public health issue. In 2002, the members of WHO was agreed on a World Health Assembly resolution on safety of patient. ³  In  developed countries, as many as 1 out of 10 patients are harmed while admitted in hospital. And, in developing countries, the probability of patients who was admitted in hospitals being harmed higher than in industrialized nations. ⁴ The medical errors  usually are   associated with  inexperienced physicians  in addition to  nurses, new procedures, extremes  of  age,  and also  complex  or perhaps  urgent care.  Poor communication, improper documentation, illegible handwriting, inadequate nurse-to-patient ratios,  and also  similarly named medications  are likewise  known  to  contribute  on the  problem. ⁵ The training for health care professionals should also include the proper storage, handling, and disposal of medications safely. ⁶

 

The word error in medicine is used as a label for nearly all of the problems harming patients. ⁷ Errors are the constituents of our daily life. It is a component of nurse’s performance and plays important role in patient safety. 8  Medication errors are unintentional errors in the prescribing, dispensing, administration or monitoring of a medicine while under the control of a healthcare professional, patient or consumer. ⁹ A medication error is a failure with the treatment program, which may or may results in harm for the patient’. 10 After  administration of medication the nurse should monitor the patient for the side effects or adverse effects of medications. ¹¹ Medication errors are preventable events that lead to medications being used inappropriately. ¹² 

 

A survey was conducted on current nursing practice for patients on oral chemotherapy: in multicenter of Japan. A cross-sectional questionnaire survey was designed and disseminated to 309 cancer centers designated by the Ministry of Health, Labour and Welfare, and 141 general hospitals with more than 300 beds in Japan. The researcher perform two surveys, the first survey was based on a nurse-based questionnaire containing 40 items and the second survey was based on a patient-based questionnaire containing 10 items and adherence-related nursing practices for 249 patients who was taking oral chemotherapy. The researcher had identified factors that were associated with adherence-related nursing practices. A total of 62 nurses (mean age: 41.5 years) from 62 hospitals who consented participated in the both nurse-based survey and patient-based survey about 249 patients. The results of nurse-based survey shows that practices varied and the results of logistic regression revealed that adherence-related nursing practices were associated with the healthcare system-related factors, nurse’s background and type of treatment. ¹³

 

In some hospitals, medication orders, firstly transcribed, dispensed, and after that the medication is administered to the patients. Sometimes or in some settings, the nurses and pharmacists both are involved in transcribing, verifying, dispensing, and delivering the medications to patients. ¹⁴ According to the data of Food and Drug Administration (FDA, 2009) in the United States, 1.3 million injuries occur due to medication error (wrong drug, the wrong dose, the wrong timing of administration, or the wrong route) each year. ¹⁵ Medication errors can lead to the adverse effects of medication like, increased duration of hospitalization, increased mortality and increased medical cost. ¹⁶ The medication errors put a direct impact on patient’s health and health professionals involved. They interfere with patient's safety and results in actual or severe harm to patient’s health. ¹⁷  There are more than 15 types of medication errors: wrong drug, wrong dose, known allergy, wrong choice, missed dose, wrong frequency, wrong time, wrong technique, wrong route, extra dose, drug-drug interaction, failure to act on test, inadequate monitoring, preparation error, equipment failure, and other. ¹⁸

 

The administration of medication is a routine and an important part of nursing practices which requires the special skills, appropriate technique and enough knowledge for attending the patients. ¹⁹ According to a study on medical errors published in the USA, annual deaths from medication errors accounted for 7000 out of the total number of 48000-98000 deaths because of drug complications. ²⁰ In a survey by Institute of Medicine’s July 2006 reported that medication errors harm approximately 1.5 million people in the United States each year which results in increased hospital stay and increased $3.5 billion in extra medical costs. ²¹ Studies have indicated that there is a higher frequency of ME at Intensive Care Units (ICUs). The reason is that ICUs are complex environments in which patients present different severity levels, are submitted to countless procedures and receive a great variety of drugs, including High Alert Medications. ²²

 

MATERIAL AND METHODS:

The methodology of research indicates the general pattern for organizing the procedure for gathering valid and reliable data for an investigation. In this present study a “Quantitative research approach” was used. The research design selected for this study was “Quasi experimental – pre-test post- test design”. Event based teaching programme was independent variable, Medication administration practices and occurrence of medication errors was dependent variable and Time/ shift of medication administration, staff nurses and patient ratio or interference while doing procedure was situational variables. The present study was conducted at MMIMS and R Hospital, Mullana. And the accessible population was staff nurses working in Medical ICU of MMIMS and R hospital. Event sampling technique was used to select the sample of 600 events of medication administration. The events of medication administration only by  the staff nurses in medical ICU, planned/ scheduled medication administration  and medication administration by S.O.S./Stat. were included and Events of the medication administration through other routes i.e. Intravenous, subcutaneous, Intramuscular Route, Intradermal, Nasogastric, Sublingual etc. were excluded. Observational checklist was used to assess the occurrence of medication errors and to observe the medication administration practice. Content  validity of the tool was made and necessary modifications were made according to the expert’s opinion and tool was finalized. The inter-rater reliability was done for observational checklist for oral route with researcher assistance. Inter rater reliability was found to be 0.86 for oral route checklist.

 

Ethical approval to conduct the study was obtained from the institutional ethical committee of MM University, Mullana, Ambala, Haryana and as well as from medical superintendent and nursing superintendent of MMIMS and R Hospital Mullana. Written informed consent was obtained from the study subjects regarding their willingness to participate in the research project. Pre-implementation observation was done for 1-17 days during that period 300 medication administration events of oral route were observed. Event Based Teaching Programme was implemented on 18-19day. After 5 days of implementation Post- Implementation –I observation was done for 24-31 days during this period 150 medication administration events of oral route were observed. After  Post- Implementation –I, Post- Implementation Phase-II observation were done for 26-37 days, during this period 150 medication administration events of oral route medication administration were observed. During this period of data collection, researcher spent 2-4 minutes for oral administration of medication, 8-12 minutes for observing the medication administration practices for each event with the use of checklist for oral routes. According to the objectives the data was organized, tabulated. The data was analyzed by using both descriptive and inferential statistics i.e. frequency and percentage distribution, mean, median, standard deviation,  Unpaired t – test and ANOVA.

 

RESULT:

Situational  variables description- situational variables  were  Time/ shift of medication administration (morning, evening, night), staff nurses and patient ratio (1:1, 1:2, 1:3, 1:4 and 1:5 ) and interference while doing procedure (yes or no).

 

 

 

 

Table 1:Range, mean ,mean difference , median  and standard  deviation of  pre-implementation, post implementation – I and post-implementation-II practice score of medication administration through oral route N=600

Oral route	n	Range of  score	Mean ± Sd	Median
Morning shift Pre implementation Post implementation-I Post implementation-II	300 150 150	14-23 16-26 16-25	17.09±2.301     20.00±2.748 19.56±2.697	16 20 19
Evening shift Pre implementation Post implementation-I Post implementation-II	300 150 150	15-23 16-29 16-26	17.93±2.495 20.74±3.061 20.74±2.905	17 21 21
Night shift Pre implementation Post implementation-I Post implementation-II	300 150 150	14-25 16-28 16-28	17.62±2.502 21.30±3.215 21.50±2.901	16 21 21

Maximum score: 34                                                                         

Minimum score : 0

 

Table 1 depicts that in morning shift, the post implementation – I mean  (20.00) was found higher than pre-implementation (17.09) and post implementation - I(19.56),  in evening shift, the post implementation – I and post implementation – II mean (20.74) was found same and higher than pre-implementation (17.93) and in night shift, the post-post implementation – I mean (21.50) was found higher than pre-implementation (17.62) and post implementation – I (21.30).

 

 

Table 2: Mean , mean difference , standard error of mean difference and “t” value of mean of pre-implementation, post implementation – I and post implementation-II practice score of medication administration through oral route                                                   N=600

Shift	Phase	Mean	MD	SEMD	df	t	p
Morning	Pre implementation        (n=100) Post implementation – I (n=50)   Pre implementation         (n=100) Post implementation-II   (n=50)	17.09 20.00   17.09 19.56	2.91     2.47	0.42     0.45	148     148	6.83     5.84	0.001*     0.001*
Evening	Pre implementation         (n=100) Post implementation – I  (n=50)   Pre implementation         (n=100) Post implementation-II  (n=50)	17.93 20.74   17.93 20.74	3.05     2.81	0.46     0.45	148     148	6.53     6.14	0.001*     0.001*
Night	Pre implementation         (n=100) Post implementation – I  (n=50)   Pre implementation         (n=100) Post implementation-II   (n=50)	17.62 21.30   17.62 21.50	3.68     0.388	0.47     0.457	148     148	7.70     8.48	0.001*     0.001*

‘t’ (148)= 1.96 (p<0.05); *significant  at 0.05 level

 

Table 2 depicts that there was significant difference in pre- implementation, post – implementation-I and post – implementation –II in morning, evening and night shift so the hypotheses were accepted.

 

 

Table 3: Area-wise mean, mean difference , standard error and “t” value of pre-implementation, post implementation – I and post implementation – II  practice score of medication administration through oral route                                                                      N=600

‘t’(148)= 1.96 (p<0.05); *significant  at 0.05 level

Table 3 depicts that there is significant difference in pre- implementation, post – implementation-I and post – implementation –II in morning, evening and night shift in all three areas that are before administration, during administration and after administration. This indicates that Event based teaching programme was effective in improving the medication administration practice of oral medications by staff nurses.

 

 

Table 4: Mean, mean difference, standard error  of mean difference and “t” value for shift-wise comparison of  mean pre-implementation, post implementation – I and post implementation-II practice score of medication administration                                                 through oral route                                                                                                                                                                                 N=600

‘t’(198)= 1.960 (p<0.05); *Significant at 0.05 level

     (98)= 1.980 (p<0.05);^NS-Son significant at 0.05 level

 

Table 4 depicts that there was significant difference in pre- implementation phase was in morning - evening only , in post – implementation-I phase was in all the three shifts i.e. morning-evening, morning-night and evening-night and  in post – implementation –II phase  was in morning-evening and morning-night This indicates that Event based teaching programme was effective in improving the medication administration practice of oral medications in morning and evening shifts by staff nurses.

 

 

 

Table 5: Percentage Distribution of Pre-Implementation, Post Implementation phase-I and  Post implementation Phase-II Practices Score through Oral Route

S. NO	Skill/task	Correctly performed
		Pre-implementation   (N1=300)			Post implementation phase-I  (N2=150)			Post Implementation phase-II (N3=150)
		M (%)	E(%)	N(%)	M(%)	E(%)	N(%)	M(%)	E(%)	N(%)
1.	Identify the right client.	100	100	100	100	100	100	100	100	100
2.	Check the prescription of physician:	100	100	100	100	100	100	100	100	100
3	Medication name	100	100	100	100	100	100	100	100	100
4	Route	100	100	100	100	100	100	100	100	100
5	Frequency	100	100	100	100	100	100	100	100	100
6	Dose	100	100	100	100	100	100	100	100	100
7	Check the expiry date of medication.	8	19	19	42	38	34	44	32	44
8	Explain about the medication to patient.	2	6	4	30	34	32	26	32	32
9	Check the medication three times before administration (taking the medication from trolley, during preparing the medication and during administering the medication).	0	0	0	30	34	42	26	33	40
10	Before the administration of medication assess the patient for allergy from medication.	7	7	2	22	46	44	22	42	42
11	Medication card.	100	100	100	100	100	100	100	100	100
12	Medication.	100	100	100	100	100	100	100	100	100
13	Glass of water.	100	100	100	100	100	100	100	100	100
14	Spoon	0	0	0	16	14	32	14	10	24
12	Medication.	100	100	100	100	100	100	100	100	100
13	Glass of water.	100	100	100	100	100	100	100	100	100
14	Spoon	0	0	0	16	14	32	14	10	24
15	Kidney tray / paper bag	0	0	0	0	0	0	0	0	0
16	Towel	0	0	0	6	6	24	6	14	26
17 18 19 20	Nurse’s record sheet Wash hands Check the medication administration record. Verify the client’s ability to take medication orally.	100 9 100 17	100 26 100 33	100 18 100 30	100 28 100 26	100 26 100 20	100 34 100 38	100 26 100 20	100 28 100 34	100 36 100 30
21	Obtain appropriate medication.	100	100	100	100	100	100	100	100	100
22	Ask client to state his/ her name.	0	0	0	0	0	2	0	0	0
23	Place client in sitting/semi sitting position.	74	87	96	88	88	90	88	86	94
24	Spread the towel on patient’s clothing.	0	0	0	6	6	24	6	14	26
25	Take out the medicine from its cover without touching the medicine and put it in spoon.	0	0	0	18	17	50	66	34	36
26	Hand over the medication to client.	92	98	96	96	98	90	98	94	98
27	Offer glass of water or other liquid (juice).	100	100	100	100	100	100	100	100	100
28	Make sure that client swallows the medication.	20	24	19	34	36	50	36	40	46
29	Replace all the articles.	20	22	21	36	28	32	28	42	42
30	Assess the client for any side effect or hypersensitivity from medicine.	0	3	0	14	14	18	14	16	22
31	Document the procedure.	100	100	100	100	100	100	100	100	100
32	Discard the waste.	20	23	20	36	28	32	28	42	43
33	Replace all the articles.	20	23	20	36	28	32	28	42	43
34	Wash hands.	20	23	20	36	28	32	28	42	43

 

Table 6: Categories of occurrence of medication errors in oral route          

Route	Type of error	Items	Total no. Of errors
			Pre implementation			Post implementation –I			Post implementation –II
Oral	Transcribing		M	E	N	M	E	N	M	E	N
			%	%	%	%	%	%	%	%	%
		Check the expiry date	92	89	89	60	73	76	84	62	54
		Explain about medication to patient	98	94	96	70	66	68	63	82	62
		Check the medication three times	100	100	100	30	66	68	66	73	80
		Check patient for allergy	93	93	98	78	54	66	52	72	72
		Wash hands	91	74	82	72	74	76	67	78	56
		Verify the clients ability to take medication orally	83	77	70	74	80	62	60	64	70
		Ask client to state name	100	100	100	100	100	98	100	100	100
			93.8	89.5	90.7	69.14	73.28	72.14	70.28	75.85	70.51
	Dispensing	Spread towel	100	100	100	94	94	76	94	86	74
		Take out the medicine from its cover without touching the medicine	100	100	100	82	83	50	44	66	64
			100	100	100	88	88.5	63	69	76	69
	Administering	Hand over the medication to patient	8	6	6	4	2	5	8	4	6
		Discard the waste	80	77	80	64	72	68	72	58	57
		Replace the articles	80	77	80	64	72	68	72	58	57
		Wash hands	80	77	80	64	72	68	72	58	57
			62	59.25	61.5	49	54.5	52.25	56	44.5	44.25
	Monitoring	Make sure that patient swallows the medication	80	76	81	34	36	50	36	40	46
		Assess client for any side effects	100	97	100	86	86	82	86	88	78
			90	86.5	90.5	60	61	66	61	64	62

 

Table 5 N  6 depicts that there is decrease in the occurrence of medication administration practices in post implementation – I and post implementation – II after administration of Event Based Teaching program in all the three shifts (morning, evening and night) and increase in the correct medication administration practices of staff.

 

 

Table 7: One way ANOVA/t test showing association between morning, evening and night shifts, oral medication administration routes post implementation-II score with selected situational variables N=600

a – ANOVA test; *Significant (p<o.o5)

b – t test;   ^NS_Non-Significant (p > o.o5)

 

Table 7 depicts that there is significant association between two situational variables among three i.e. I shift (morning, evening and night) and nurse patient ratio (1:3, 1:4 and 1:5).

 

Table 8: Post hoc value showing association of oralpost implementation score medication administration practices with situational variables                                                                                                                                                                                                  N=600

Routes	Situational variables	Mean difference	Standard error	Sig.
Oral	Shift
	Morning                       Evening                                      Night	0.960 0.080	0.312 0.312	0.009* 0.003*
	Evening                        Night	0.120	0.312	0.929 NS
	Nurse patient ratio
	1:3                                 1:4 1:5	0.577 0.954	0.264 0.587	0.092 NS 0.268 NS
	1:4                                 1:5	0.376	0.584	0.812 NS

*Significant (p<o.o5)                                                                                 

^NS_Non-significant (p > o.o5)

 

 

Table 7 depicts that there is significant association between morning-evening shifts and morning- night shifts.

 

DISCUSSION:

The present study indicated that staff nurses had performed poor practices regarding oral administration of medication in Medical I.C.U. and it was reduced after implementation of event based teaching programme. The study finding are consistent with the study conducted by Williams T (2014), to assess the effectiveness of evidence based medication safety interventions on a progressive care unit. The study findings shows that Four types of distractions and interruptions decreased significantly between the two-month pre-implementation and two-month post-implementation periods: those caused by a physician, NP, or physician assistant; those caused by other personnel; phone calls and pages placed or received by the nurse during medication administration; and conversation unrelated to medication administration that involved the nurse or loud nearby conversation that distracted the nurse. The total number of reported adverse drug events also decreased from 10 to four, or by 60%. Thus, medication safety interventions may help decrease distractions and interruptions in high-acuity settings. ²³

 

The present study indicated that staff nurses had poor practices regarding oral administration of medication in Medical I.C.U. The findings of study reveals that mean post implementation phase- II score (21.50) was higher than mean pre implementation phase score (17.09). These findings are consistent with the findings of the study conducted by Hsaio Y-G (2010) to find out the effectiveness of drug education programme provided by pharmacist to critical care nurses in the University of Maryland Medical Systems Hospital. The findings reveals that there was between the mean pre-test score (38.7) and the mean post-test score (66.7). The data further shows that a drug education programme had improved the practices or knowledge of nurses regarding medication administration commonly used in critical care units. ²⁴

 

The present study findings indicate that, in oral route there was significant association between post implementation-II practice score and shift, nurse patient ratio i.e. p value was found 0.001 and 0.048 respectively. The present study findings was consistent with the findings of study conducted by Liu LF (2014), to gain insight into the workload of nurses employed at medical institutions and to determine the relationship between nurse workload and nurse-sensitive patient safety outcome indicators. The findings shows that nurse overtime working hours were positively associated with the following nurse-adverse drug events significantly increased when the patient-nurse ratio exceeded 7:1.²⁵

 

CONCLUSION:

The following conclusions were drawn from the study i.e. the Event Based Teaching Programme was an effective strategy in improving the medication administration practice of staff nurses and after administration of  Event Based Teaching Programme the occurrence of medication error decreased.

 

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Accepted on 16.06.2016        © RJPT All right reserved

Research J. Pharm. and Tech 2016; 9(8):1145-1152.