The Role of Nurses in Medication Administration

Introduction

Medication administration is one of the key roles of a nurse. Once a Nurse receives their registration, they are accountable for any acts of omission and commission involving medication among their patients (Cafazzo et al, 2009). According to Hughes and Blegen, (2008), medication administration is a significant bit of nursing care that must be executed with great thought and professional judgment. This implies that nurses must give strict adherence to all the codes and guidelines of practice, including the NMC code 2015. Graien (2018) also asserts that failure to follow the appropriate medication administration process can have serious detriments such as being struck off the NMC register and consequently the loss of the right to practice as a registered nurse (Kaushal et al, 2001). The incidence and occurrence of medication administration errors (MAE) are not only detrimental to the nurse practitioners but also the patients. MAEs seriously affect patients by contributing to patient mortality and morbidity. Furthermore, MAE has an indirect impact on the families, the patient and health practitioners through cost implications and quality of service delivery through the erosion of patient confidence on the quality of care given (Elliott & Liu, 2010). Particularly, statistics on the cost of MAE in the UK is approximately 1.6 billion pounds per year (Graien, 2018). Similarly, Graien (2018) estimates that in the UK, MAE contributes to at least 22,000 deaths yearly, making it among the most significant ethical and professional issues in the UK’s healthcare practice. This implies that developing solutions for addressing the issue of MAE cam save lives and reduce the economic costs associated with it (WHO, 2016).

According to Lyons et al (2019), medication errors made during stages other than administration are very unlikely to cause harm as they can be identified and corrected. However, a percentage of errors can go undetected and therefore cause harm to patients (JE, 2019). Nonetheless, existing scientific literature indicates that the most common types of medication errors include wrong dose prescription, prescription of wrong medication and prescription to the wrong patient (Tariq and Scherbak, 2018). Consequently, a practice model, the five rights (5R’s Model), was introduced to promote medication safety. According to Federico (2019), the five rights concentrate on how individual performance rather than the human factors can be leveraged on to minimize MAE; and they stand for Right patient, Right drug, Right dose, Right route and Right time. Existing evidence by Barber (2013) and NICE (2017) indicate that the application of the 5R’s model contributes to a reduced rate of MAE Using this is said to prevent medication errors and enhances the practitioner’s adherence to safety regulations for the benefit of both the patient and practitioner. While many studies have evaluated the general impacts of MAE on patient health and quality of care as well as the factors that contribute to MAE in adult care settings, there seems to be a lack of well-organized data for purposes of evidence-based practice. Therefore, the main aim of the current study is to conduct an integrated literature review on the factors that contribute to medication administration errors in the adult care setting. An integrated literature review is deemed to be the most appropriate research methodology for achieving this aim because it provides an opportunity for the researcher to identify, evaluate and synthesise existing evidence on the research topic (Patino and Ferreira, 2018). According to Patino and Ferreira (2018), the integrated literature review help in identifying the latest evidence while comparing them with earlier evidence – all in the spirit of enhancing evidence-based practice.

Research Aim

To investigate factors contributing to medication errors in adult care settings

Research Question

What are the factors contributing to medication errors in adult care settings?

Methodology

This integrative review is based on mix methods, as some articles are of qualitative research and some are off quantitative. The PEO format is used in this integrative review as it will help to formulate an answerable question and to identify the key concepts within it. In this case, factors that causes medication administration errors.

An integrative review is identified as a unique tool in healthcare as it synthesises studies available on a specific matter and helps guide practise based on scientific knowledge (Tavares de Souza et al 2010). According to Palinkas et al (2015), an integrative literature review methodology is a useful secondary research approach for three significant reasons. First, it enables the synthesis of existing research to draw an evidence-based conclusion on the subject under study. Secondly, integrative literature review provides an opportunity for the researcher to identify existing research gaps on a phenomenon and suggest areas of future research. Thirdly, the cost and time effectiveness of integrative literature review has made it a popular approach among present-day scholars. These advantages, therefore, make up a concrete case for the selection of integrative literature review research methodology in the current study. The first step in the integrative review is preparing the guiding question which has been shown in the abstract. The second phase of this review is searching or sampling of the literature. This is when a search in electronic databases and a manual search in journals is carried out, for this review CINAHL was the main database used. This specific database works by searching for keywords to find articles that relate to the chosen question and allows the question to be broken down thus narrowing the results. The keywords used to search up relevant articles on the CINAHL database were: Medication errors, Nurse, Factors, Adults, and administration Errors. After searching this, 136 articles were found however this needed to be narrowed down further. To do this, only research written in English were selected. The selection of studies written in the English language was to ensure that the researcher fully understood the research content for purposes of effective interpretation. Furthermore, the selected studies were limited to those published from 2007 onwards to ensure that the most current and up-to-data data was extracted. Besides, to maintain the focus on the study to adult care settings, the researcher only selected studies conducted within the adult nursing care setting. Not all articles on CINAHL were relevant as a vast majority consisted of secondary research which is not appropriate; therefore PubMed, Medline, Summon and Google scholar were used to search additional articles. This was done by typing in the research question and looking at relevant articles, through these I was able to look into the articles reference list and gain access to related articles. These databases provided relevant evidence-based research, which has been used in this integrative review. Meanwhile, the following table illustrates the inclusion/exclusion criteria with the respective rationale:

After the selection of journal articles based on inclusion/exclusion criteria, the researcher went ahead to extract data from each article using a self-designed data extraction tool. As illustrated in appendix 1, the tool enabled the identification of the demographic, clinical, and geographic characteristics of ach study, as well as their main findings and conclusions. The final phase, phase four of the integrative review, was critically analysing the data collected from the research articles. Once explored and narrowed down, a total of 10 appropriate articles were included to answer the research question. The CASP tool (CASP 2014) was used to analyse details of the articles which allowed the information to be inserted into the data extraction table (Appendix 1). This was to be completed in order to analyse the strengths and weaknesses’ of the studies and identify the key themes that emerged.

Results

Knowledge and Compliance

Parry et al (2015) conducted a narrative review study sought to explore the factors contributing to registered nurse’s medication administration errors. The study included a total of 26 papers, which were analysed thematically; and the results were organized based on the reciprocal determinism framework. (Paulo, 2007) states that a narrative study is good as it provides readers with up to date knowledge regarding specific themes thus is important for the continuing of education, however (Pae 2015) states otherwise and says while narrative reviews of the literature can be useful in some circumstances, meta-analysis is a superior technique for integrating the literature on a topic as it reduces bias and increases validity. The review consisted of 11 studies with respondents drawn from a variety of countries with developed healthcare systems, all of which were based on primary research methodologies that collected data through surveys. There was a clear discrepancy in the studies used as they had different studies. Some made it clear that a lack of experience led to an increased amount of medication errors whilst others disagreed and found that new nurses make fewer errors. Other findings found that experience had no effect. This shows that there is a need for further research to take place which in turn will give consistent results (Paré and Kitsiou, 2017). Harkanen et al., 2014 conducted a cross-section study using direct observations and medication record reviews to observe the levels of seriousness in the medication errors made and to link the contributing factors towards them. N = 32. The validity of this study was strong and is shown as there were twelve expets on the panel who accessed this. Validity refers to the integrity and application of methods used and how accurate the findings reflect the data (Noble and Smith, 2015). Like studies carried out by Parry et al 2015 and Keers 2013, Harkanen et al., 2014 found that a key contributing factor to medication errors was the lack of experience some staff have. However, a study conducted by (Agbor, 2016) states that there was no statistical evidence that shows any relations between medication errors and years of working experience. Smuleurs et al 2014 found similar findings to this study when discovering that the main finding was the lack of knowledge of the risks associated with medication errors was a key factor. Smeulers et al 2014 used semi-structured interviews to conduct a study in order to gain an insight into the nurse’s perspective of preventing medication errors, n=20. This was a piece of qualitative literature which is deemed most appropriate as it allowed the researcher to explore more complex topics (Jane Sutton, 2015) and gain a detailed insight into the nurses’ thoughts. In this study three themes were identified in the results with the use of thematic analysis from the transcribed interviews, these were nurses’ roles and responsibilities in medication safety, nurses’ ability to work safely (risk awareness) and nurses’ acceptance of safety practices. Harkanen et al., 2014 had found similar findings in the theme of knowledge and compliance as in that study showed inadequate knowledge of the risks associated with medication errors was a key finding. A positive aspect of this study was that ethical matters were considered. A general overview of ethical principles will ensure that research is conducted following the best practice (Yip, Sng and Reena Han, 2016), in this particular study the participants were assured that the interviews were confidential and written consent was obtained. A weakness of this study was the small sample size; a small sample can weaken the internal and external validity of a study (Faber and Martins Fonseca, 2014). The sample size was acknowledged by the researcher however said that due to other studies sharing similar results these findings are valid and transferrable. Unfortunately, the researcher did not mention whether they reached a data saturation point.

Keers et al (2013) conducted a systematic mixed methods review that sought to appraise evidence in regards to the causes of medication errors in hospital settings. N = 54 studies. The purpose of a systematic review is to provide a thorough summary of all the primary research available to answer a research question (Clarke, 2011). According to (Yuan and Hunt, 2009) data collected from a systematic review can be misleading if not interpreted correctly. However (Gopalakrishnan and Ganeshkumar, 2013) states that systematic reviews use strategies that help reduce bias and random errors and is, therefore, a beneficial design method to use when carrying out research. (Katikireddi, Egan and Petticrew, 2014) agrees with this statement as he states systematic reviews tend to include studies with the lowest risk of bias, thus providing a stronger piece of literature. This study showed that errors were made due to lack of experience and training, Misidentification or misinterpretation of prescriptions and unsafe acts. This is similar to Parry et al 2015 findings in which the results showed lack of experience is a key factor to medication errors. Popescu, Currey and Botti, 2011 conducted an explorative descriptive study using non-participant observation followed by semi-structured interviews. N = 30. The benefits of using the non-participant method are that it allows the researcher to observe first hand and therefore make their judgements. However, the researchers did not acknowledge the fact that non-participant methodologies expose the results to researcher bias, because they may have lacked some objectivity when interpreting the data, a factor that affects the reliability of the study (Winsor, 2016). However, the disadvantage of this method is that participants may start to act unnaturally; therefore, the researcher’s judgements may not be accurate. Popescu, Currey and Botti, (2011) found that nurses deviated from best‐practice guidelines during medication administration. Shahrokhi, Ebrahimpour and Ghodousi (2013) conducted a descriptive cross-sectional study and data were collected utilising a researcher-made questionnaire. This study was carried out to investigate what influences medication errors from the viewpoint of a nurse. N= 150. The questionnaire was assessed using Cronbach's alpha (r = 0.86) to measure internal consistency. Cronbach's alpha is a tool used in research to determine and compare reliability and validity (Taber, 2018). It is measured by a score between 0 and 1, 0.7 and above is identified as good (Tavakol and Dennick, 2011). The score for this study was 0.86 which shows the content’s internal consistency is good and the results are reliable. Internal consistency is the extent to which all the items in a test measure the same concept (Tang, Cui and Babenko, 2014). Although this is a study which has been carried out in Iran and therefore deemed as hard to generalized due to different healthcare systems, this study was one of the strongest studies when analyzing using the CASP tool. There was a clear structure of the study and the findings were identified. Like Cheragi et al 2013 inadequate knowledge of pharmacology was presented as a factor that effects medication administration. (Dilles et al., 2011) this study was carried out in Belgium which is of a similar healthcare system to the UK and has found similar results.

Cheragi et al 2013 conducted a cross-sectional study using a random sampling method to evaluate the types and causes of nursing medication errors. N = 235. In this study, the inclusion/exclusion criteria were used. Establishing inclusion and exclusion criteria for the participants of research is a standard and is mandatory when designing a high-quality piece of research (Patino and Ferreira, 2018). The inclusion criteria categorise the study population in a consistent, objective manner and the exclusion criteria include characteristics that make the recruited population ineligible to take part in the study (Garg, 2016). Thus using this strengthens the study as you have a set population for answering the particular research question (Garg, 2016). A weakness of the study was that it was conducted in one part of Iran. Not only does Iran have a different healthcare system which can make generalizing quite difficult as mentioned above, but also the fact that it is only conducted in one part of Iran makes it more so. This study found similar findings to other articles such as Shahrokhi, Ebrahimpour and Ghodousi, 2013 and Smuleur et al 2014 who found a lack of knowledge was a key factor to medication errors. This study found that using acronyms of names of drugs causes medication errors. This is a point which hasn’t been mentioned in the other studies however is relevant as this is an ongoing issue globally (Brunetti, Santell and Hicks, 2007).

Environment

Parry et al 2015 identified that clinical workload and interruptions were a key element to the contributing factors of medication errors. These findings were also supported by Keers et al (2013), Tang et al (2007), Harkanen et al., (2014) and Shohani and Tavan, (2018) who had similar findings. Tang et al (2007) carried out a literature review followed by a semi-structured questionnaire to gain nurses views on the factors contributing to medication errors to find ways to improve the medication administration process. A sample of 72 (N = 72) female nurses responded to the semi-structured questionnaire. This study used the snowball sampling method (even though the researchers did not give a clear justification of why they selected the snowball sampling method, it is most likely that they snowballing was the best approach in including participants who had experienced medication errors). The snowball sampling method is when one interviewee provides the researching with the name of another potential interviewee who subsequently will provide another possible interviewee and so on (Kirchherr and Charles, 2018). This method allows the researcher to find the participants needed which he/she was unable to find (Kirchherr, 2018) and allows them to discover details about the desired population which they were not aware off (Naderifar, Goli and Ghaljaie, 2017). However, the data provided from this method is deemed somewhat biased thus limits the validity of the sample (Atkinson and Flint, 2001). One key weakness of this study was the fact that only females were invited to take part, therefore, this cannot be generalized to the population due to gender bias. This study showed three key themes emerged, personal neglect, heavy workload and new staff. These were the same findings of Al-Shara (2011). Al-Shara 2011 conducted a primary study using questionnaires to determine the factors contributing to medication errors and related areas for improvement, as perceived by nurses. N = 126. The questionnaires used in this study were sent out to 5 establishments in Jordan, therefore, the ability to generalize the study is appropriate. However, a key point to make is that this study was carried out in Jordan which has a different health care system to the UK which makes it difficult to generalize. Nevertheless, the findings of this study were a heavy workload, new staff and personal neglect which has been seen in other articles such as Tang et al 2007 and Parry et al 2015, which shows this article is of relevance. Another key point to add is the fact that Al-Shara 2011 looks at the nurse’s viewpoint. The nurses’ opinion could possibly be too subjective and not be the real picture of the situation. However, most of the nurse respondents were of the same opinion, and this implies the results would more likely the case.

Popescu, Currey and Botti, 2011 found that a factor causing medication administration errors was the ward design as the nurses experienced more distractions. A total of 102 distractions were recorded during observation which could potentially result in missed medication during the medication rounds. Observational studies can have the ‘Hawthorne effect’; whereby participants act in an unnatural manner (Parahoo, 2006). Although this study shows an additional factor that causes medication errors, this evidence is deemed weaker than other studies when using the CASP tool. Harkanen et al., 2014 found in the study that the environmental factors that contribute towards medication errors were; Fatigue and distractions which in turn creates feelings such as stress and frustration. These findings were very similar to Popescu, Currey and Botti, 2011, Shahrokhi et al 2013, Shohani and Tavan, 2018, who also found that fatigue and tiredness is a key contributing factor to medication errors. Shohani and Tavan, 2018 conducted a cross-sectional study with a two-part questionnaire to the explore factors affecting the frequency of medication errors from the perspective of nurses in educational hospitals of Ilam, Iran. N = 120. The significant p value obtained from the data in this study was considered under 0.05. A p value of 0.05 is considered not statistically significant (Concato and Hartigan, 2016) thus this study shows that the data collected is of relevance. A clear weakness of this study was the unclear responses in the questionnaires given, detailed information was not obtained thus an observational study would have provided more accurate data (Kawulich, 2005). The key factors found that cause medication errors were fatigue and exhaustion 58.5%, Personal neglect -56%, Heavy workload – 65.6%, Inadequate staffing – 69.7%. These were of similar findings to Popescu, Currey and Botti, 2011, Harkanen et al., 2014, Keers et al 2013 and Parry et al 2013. Like Keers et al 2013 the study carried out by Cheragi et al 2013 shows that inadequate staffing leading to low staff to patient ratio is a key factor to medication errors. The study did not acknowledge its limitations of the study and the findings of the study were quite vague. Cheragi et al 2013 state that the validity of the questionnaire was established from the opinions of experts however he fails to say how many and does not go into detail of how this was done. Overall this study was clearly set out and met the aim of the study however was of poor quality.

Recommendation for Practice Change

The evidence sort from the theme knowledge and compliance suggests that there is a need for further education in the risks associated with medication administration errors. It also highlights that pharmacology knowledge is essential to reduce the risk of medication administration errors. The environment was the other theme identified in this integrative review, distractions and a heavy workload being some of the environmental factors identified. Based on the concept of human factors, it is humans’ nature to make mistakes and errors (Hse.gov.uk, 2019). However, it is up to the individual to identify the error and prevent it from reoccurrence (The Royal College of Nursing, 2019). One clinical practice change which seems realistic is having a checklist on the drug trolley which incorporates the 5 R’s. The 5R model may especially be viable because as highlighted in the current research findings delivering the right medication to the right patient in the right dose, through right route and in the right time reduces the risk of medication administration errors. The checklist is a concept which is currently used in hospitals globally before any surgery or procedure (Pugel et al., 2015). It was launched by the World Health Organization in June 2008 and with considerable involvement from UK clinicians, the checklist was authorized for practice within the NHS in January 2009. This checklist has now become standard practice for institutions nationally and worldwide and has helped reduce the number of deaths and complications by as much as a third (NHS England 2019). Existing evidence have shown the effectiveness of the checklist system in reducing the chance of MAE due to the human factors it gives attention to. Considered one of the safety precautions the healthcare industry has borrowed from the aviation industry, checklists have a potential of improving consistency of teamwork and improved practice, thereby reducing errors in medication administration (Gaeande, 2009). There is growing evidence that checklists can improve patient safety (Ko et al, 2011). While commonly used in surgery (de et al 2010, Hynes et al 2009) and intensive care units Bynes et al (2009), studies by Garbutt et al (2008) have also shown their popularity in medication administration. However, evidence by Narimasu et al (2010) indicates that in practice, the use of checklists varies after adoption, and this may present an obstacle in its effective implementation. For instance, the study by Conley et al (2011) indicate that leaders must be ready to be persuasive on how and why to use it otherwise it may not bring positive results.

The checklist system will be introduced based on Lewin’s change model. The Lewin’s change model is a three-step model that guides managers or any change agent on how to deal with people when implementing change. Ideally, it operates on the principle that the change will be more effective if it is embraced by the people involved, and if they take part in implementing it. Therefore, to effectively implement the checklist system, each department will have a visually displayed checklist next to the practitioner’s desk. The researcher, who will also act as the change agent will participate in printing and sticking the checklists on each departmental office. The checklists will be printed in a light green colour to draw attention and keep the practitioners attracted to it during their normal course of duty. It will display a list of items to adhere to when administering and prescribing any patient medication (Nute, 2014). It will also prompt nurses to think about double-checking thus ensuring patient safety and protecting their pin This implementation for change will be introduced in acute wards to start with within one trust. This will help as once one department begins to follow it, this checklist can be implemented in other areas with the help of nurses supporting the idea. This idea will need to be discussed with the ward manager and chief nurse of the hospital to help formulate it and get the approval.

The main barrier of this checklist is that nurses may just ignore it and see it as an extra workload. Some nurses are stuck in the concept of ‘this is how we do things around here’, and do not accept change (Godfrey et al., 2018). This is not something an organization wants but something that it has, it is a set of values and beliefs that are fixed within that organization. The Francis report (2013) recognized that the negligence of actions and behaviours lead to failures in patient care and safety. Concerning this, The Berwick report (2013) recognized the need for the NHS to embrace a culture of learning and the development of new ideas. To overcome this challenge, the lead change agent will exercise their leadership skills by being persuasive to the practitioners to embrace the change (Conley et al, 2011). This is a small implementation which is cost-effective for the NHS and does not require any training. It is one which can not only benefit the NHS financially but can possibly save lives and ensure the nurses are following the code of conduct and ensuring safety standards for the patients are met.

Conclusion

This integrative review has explored the factors that contribute towards medication administration errors, these errors make a significant number of deaths in the UK and cause serious harm. This review was made up of the analysis of ten articles using the CASP tool to identify key strengths and weaknesses. The two themes that emerged were Knowledge and compliance and environment, from these an implementation of change was sort through a simple checklist which would be in the drug trollies which highlight the 5r’s thus helping reduce medication administration errors. The Strength of creating an integrative review is that it enhances the rigour and is the only approach that allows for the combination of varied methodologies (Whittemore and Knafl, 2005). A limitation of this review is that it only included the most predominant factors that cause medication errors; therefore other factors should also be considered.

References

Byrnes M, Schuerer D, Schallom M, Sona C, Mazuski J, et al. (2009). Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices. Crit. Care Med. 37:2775–81

BMA (2018). Working in a system that is under pressure. England: British Medicine Association, pp.2-5.

Conley DM, Singer SJ, Edmondson L, Berry WR, Gawande AA. (2011). Effective surgical safety checklist implementation. J. Am. Coll. Surg. 212(5):873–79

Cafazzo J., Trbovich P., Cassano-Piche A., Chagpar A., Rossos P., Vicente K., Easty A. (2009) Human Factors Perspectives on a Systemic Approach to Ensuring a Safer Medication Delivery Process. Healthcare Quarterly;12(sp):70–74. doi: 10.12927/hcq.2009.20969.

Frey, L., Botan, C., & Kreps, G. (1999), Investigating communication: An introduction to research methods. (1999). 2nd ed. p.Capter 5.

Garbutt J, Milligan PE, McNaughton C, Highstein G, Waterman BM, et al. (2008). Reducing medication prescribing errors in a teaching hospital. Jt. Comm. J. Qual. Patient Saf. 34(9):528–36

Gawande A. (2009). The Checklist Manifesto: How to Get Things Right. New York: Metrop. Books

Godfrey, M., Young, J., Shannon, R., Skingley, A., Woolley, R., Arrojo, F., Brooker, D., Manley, K. and Surr, C. (2018). Health Services and Delivery Research, The Person, Interactions and Environment Programme to improve care of people with dementia in hospital: a multisite study. 6th ed. Southampton (UK): Nhs.

Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat A-HS, et al. (2009). A surgical safety checklist to reduce morbidity and mortality in a global population. N. Eng. J. Med. 360(5):491–99.

Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat A-HS, et al. (2009). A surgical safety checklist to reduce morbidity and mortality in a global population. N. Eng. J. Med. 360(5):491–99.

Ko H, Turner T, Finnigan M. (2011). Systematic review of safety checklists for use by medical care teams in acute hospital settings—limited evidence of effectiveness. BMC Health Serv. Res. 11(1):211.

Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, et al. (2001) Medication errors and adverse drug events in pediatric inpatients. JAMA;285(16):2114–2120. doi: 10.1001/jama.285.16.2114.

Palinkas, L. A., Horwitz, S. M., Green, C. A., Wisdom, J. P., Duan, N., & Hoagwood, K. (2015). Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Administration and Policy in Mental Health and Mental Health Services Resh, 42(5), 533-544. earc