Identifying the "right patient" : nurse and patient perspectives on how to verify patient identity during medication administration

In this paper, we report on a research project funded by the Australian College Mental Health Nurses’ and Bristol Myers Squibb Research Grant in 2007. We examined ways in which mental health nurses could correctly identify patients during medication administration that promote medication safety and that are acceptable to both consumers and nurses.

Central to the safe practice of medication administration are the “five rights”- giving the right drug, in the right dose, to the right patient, via the right route, at the right time. In non-psychiatric settings, such as medical and surgical inpatient units, the use of identification aids, such as wristbands, are common. In most Victorian psychiatric inpatient units, however, standardised identification aids are not used. Anecdotally, consumers dislike some methods of patient identification, such as wearing wrist bands, and some nurses perceive consumers' rights are infringed through wearing personal identifiers.

In focus groups, mental health consumers and mental health nurses were invited to discuss their experiences of patient identification during routine psychiatric inpatient medication administration. They were also asked their opinions of, and preferences for, different ways of verifying “right patient” during routine medication administration. In our paper, we will present the findings of a qualitative research project in which we explored the experiences, opinions, and preferences of mental health consumers and mental health nurses towards methods of correctly identifying patients during medication administration.

Medication administration via enteral tubes : a survey of nurses' practices

Aim: This article is a report of a study examining the practices of acute care nurses when administering medication via enteral tubes. Background. Administering medication via enteral tubes is predominantly a nursing responsibility across countries. It is important to establish what nurses actually do when giving enteral medication to inform policy and continuing education development.

Method: In 2007, a survey was conducted using a random sample of acute care nurses at two large metropolitan hospitals in Melbourne, Australia. There were 181 Registered Nurses who participated in the study; 92 (50Æ8%) practised in intensive care units, 52 (28Æ7%) in surgical areas, 30 (16Æ6%) in medical areas and 7 (3Æ9%) were from combined medical–surgical areas. The questionnaire was developed by the researchers and a pilot study was conducted in August 2006 to test reliability, face validity and user-friendliness of the tool.

Results: Nurses reported using a range of methods to verify enteral tube position prior to administering enteral medication; some were unreliable methods. A majority reported administering enteric-coated and slow or extended release forms of medication, and giving solid forms of medication when liquid form was available. Nearly all (96%) reported flushing a tube after giving medication, 28% before, and 12% always flushed between each medication.

Conclusion: Enteral medication administration practices are inconsistent. Some nurses are using unsafe practices and may therefore compromise patient care.

Multifactorial influences on and deviations from medication administration safety and quality in the acute medical/surgical context

Background and Aims: Although numerous factors influence medication administration, our understanding of the interplay of these factors on medication quality and safety is limited. The aim of this study was to explore the multifactorial influences on medication quality and safety in the context of a single checking policy for medication administration in acute care.

Approach: An exploratory/descriptive study using non-participant observation and follow-up interview was used to identify factors influencing medication quality and safety in medication administration episodes (n = 30). Observations focused on nurses’ interactions with patients during medication administration, and the characteristics of the environment in which these took place. Confirmation of observed data occurred on completion of the observation period during short semi-structured interviews with participant nurses.

Findings: Findings showed nurses developed therapeutic relationships with patients in terms of assessing patients before administering medications and educating patients about drugs during medication administration. Nurses experienced more frequent distractions when medications were stored and prepared in a communal drug room according to ward design. Nurses deviated from best-practice guidelines during medication administration.

Implications: Nurses’ abilities and readiness to develop therapeutic relationships with patients increased medication quality and safety, thereby protecting patients from potential adverse events. Deviations from best-practice medication administration had the potential to decrease medication safety. System factors such as ward design determining medication storage areas can be readily addressed to minimise potential error.

Conclusions: Nurses displayed behaviours that increased medication administration quality and safety; however, violations of practice standards were observed. These findings will inform future intervention studies to improve medication quality and safety.

Oncology nurses' perceptions about involving patients in the prevention of chemotherapy administration errors

To explore oncology nurses' perceptions and experiences with patient involvement in chemotherapy error prevention.

Recommended guidelines for medication administration in schools /

Mode of access: Internet.

Caracterização dos incidentes na administração de medicamentos num serviço de Medicina Interna

RESUMO - O problema do erro de medicação tem vindo a adquirir uma importância e um interesse crescentes nos últimos anos. As consequências directas no doente que condicionam frequentemente o prolongamento do internamento, a necessidade de utilização adicional de recursos e a diminuição de satisfação por parte dos doentes, são alguns dos aspectos que importa analisar no sentido de se aumentar a segurança do doente. No circuito do medicamento em meio hospitalar estão envolvidos diversos profissionais, estando o enfermeiro no final da cadeia quando administra a medicação ao doente. Na bibliografia internacional, são referidas incidências elevadas de eventos adversos relacionados com o medicamento. Em Portugal, não existem estudos disponíveis que nos permitam conhecer, nem o tipo de incidentes, nem a dimensão do problema do erro de medicação. Efectuamos um estudo descritivo, prospectivo, exploratório, utilizando a técnica de observação não participante, da administração de medicamentos. Os objectivos são, por um lado, determinar a frequência de incidentes na administração de medicação num Serviço de Medicina Interna e, por outro, caracterizar o tipo de incidentes na administração da medicação e identificar as suas possíveis causas. A população em estudo foi constituída pelos enfermeiros que administraram medicamentos aos doentes internados no Serviço de Medicina Interna seleccionado, durante os meses de junho a agosto de 2012, sendo observadas 1521 administrações. Foi utilizada uma grelha de observação, que incluiu os seguintes elementos: doente certo; medicamento certo; dose certa; hora certa; via certa; técnica de administração correcta (assépsia); tempo de infusão; monitorização correcta. Constatou-se que em 43% das doses administradas apresentavam pelo menos um erro, num total de 764 erros. Não foi observado nenhum erro de doente, de medicamento, de dose extra, de via, de forma farmacêutica, nem a administração de medicamento não prescrito. Detectaram-se 0,19% de erros na preparação, 0,72% de erros de dose, 1,7% erros de omissão, 1,97% de erros de administração, 13,52% de erros de monitorização, 28,73% de erros de v horário. O tempo de infusão da terapêutica parentérica não foi cumprida em 27,69% das oportunidades, tendo sido sempre administrado em tempo inferior ao preconizado. Não encontramos relação entre as interrupções durante a administração de terapêutica e os erros. Pelo contrário constatou-se haver relação entre o número de doses com erro e o turno em que ocorreram, sendo mais frequentes no turno da noite. Constatamos também que aos fins de semana os erros eram mais frequentes e o risco da ocorrência de um erro na administração de medicação aumenta 1,5 vezes quando o número de enfermeiros é insuficiente.

Errors in the administration of medication in inpatient hospitals: A systematic review of the research literature on commercial computerized physician order entry systems

Errors in the administration of medication represent a significant loss of medical resources and pose life altering or life threatening risks to patients. This paper considered the question, what impact do Computerized Physician Order Entry (CPOE) systems have on medication errors in the hospital inpatient environment? Previous reviews have examined evidence of the impact of CPOE on medication errors, but have come to ambiguous conclusions as to the impact of CPOE and decision support systems (DSS). Forty-three papers were identified. Thirty-one demonstrated a significant reduction in prescribing error rates for all or some drug types; decreases in minor errors were most often reported. Several studies reported increases in the rate of duplicate orders and failures to remove contraindicated drugs, often attributed to inappropriate design or to an inability to operate the system properly. The evidence on the effectiveness of CPOE to reduce errors in medication administration is compelling though it is limited by modest study sample sizes and designs. ^

Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people

Introduction: Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes. Methods: A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement. Results: The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff’s high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems. Conclusions: That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.

Reported medication errors after introducing an electronic medication management system

Aims and objectives
To explore the effects of introducing an electronic medication management system on reported medication errors.
Background
Computerised medication management systems have been found to improve medication safety; however, introducing medication management system into healthcare environments can create unanticipated or new problems and opportunities for medication error.
Design
Descriptive analysis of medication error reports.
Methods
This was a retrospective analysis of 359 incident reports drawn from the period of 1 May 2005–30 April 2006 across two hospital sites of a single not-for-profit private health service located in metropolitan Melbourne. Site A used a conventional pen and paper system for medication management, and Site B had introduced a computerised medication management system.
Results
Most medication errors occurred at the nurse administration (71·5%) and prescribing (16·4%) stages of delivery. The most common medication error type reported at Site A was omission (33%), and at Site B was wrong documentation (24·2%). A higher proportion of errors at the prescribing phase, and less nurse administration errors, were detected at Site B where the medication management system was in use. The incidence of other, less frequent errors was similar across the two hospital sites.
Conclusions
This examination of medication error reports suggests there are differences in the types of medication errors that are reported in association with the introduction of electronic medication management system compared to pen and paper system systems. The findings provide a new insight into the effects of introducing an electronic medication management system on the types of medication errors reported.
Relevance to clinical practice
The findings provide a new insight into the types of medication errors that are reported during implementation of an electronic medication management system. Extra support for physicians prescribing practices should be considered.

Self-administration of medication in hospital: patients' perspectives

Background. Little information is available about patients' perspectives on self- or nurse-related administration of medication.

Aim. The aim of the study was to determine patients' perspectives about self-medication in the acute care setting.

Methods. A qualitative approach, using in-depth semi-structured interviews, was taken. Ten patients with a chronic medical illness who had experienced multiple hospital admissions for treatment were interviewed about their experiences of medication administration in the acute care setting. Participants were recruited from two cardiovascular wards in a private, not-for-profit hospital in Melbourne, Australia. Data collection occurred between August and September 2002.

Findings. Four major themes were identified from the interviews: benefits of self-administration, barriers to self-administration, assessing appropriateness of self-administration and timing of medication administration. Seven participants had previously experienced self-administration of medications and six were in favour of this practice in the clinical setting. Nine managed their own medications at home, and one self-administered with some assistance from his family. Participants were very concerned about how nurses' heavily regulated routines affected delivery of medications in hospital and disrupted individualized plans of care maintained in the home setting.

Conclusions. In planning and implementing self-administration programmes, it is important to consider patients' views. Medication regimes should be simple and flexible enough to adapt to patients' lifestyles and usual routines. Nurses should also take advantage of opportunities to support and facilitate patient autonomy, to enable more effective management of health care needs when patients return home.

Nursing administration of medication via enteral tubes in adults : a systematic review

Background Enteral tubes are frequently inserted as part of medical treatment in a wide range of patient situations. Patients with an enteral tube are cared for by nurses in a variety of settings, including general and specialised acute care areas, aged care facilities and at home. Regardless of the setting, nurses have the primary responsibility for administering medication through enteral tubes. Medication administration via an enteral tube is a reasonably common nursing intervention that entails a number of skills, including preparing the medication, verifying the tube position, flushing the tube and assessing for potential complications. If medications are not given effectively through an enteral tube, harmful consequences may result leading to increased morbidity, for example, tube occlusion, diarrhoea and aspiration pneumonia. There are resultant costs for the health-care system related to possible increased length of stay and increased use of equipment. Presently what is considered to be best practice to give medications through enteral tubes is unknown.

Objectives The objective of this systematic review was to determine the best available evidence on which nursing interventions are effective in minimising the complications associated with the administration of medications via enteral tubes in adults. Nursing interventions and considerations related to medication administration included form of medication, verifying tube placement before administration, methods used to give medication, methods used to flush tubes, maintenance of tube patency and specific practices to prevent possible complications related to the administration of enteral medications.

Search strategy The following databases were searched for literature reported in English only: CINAHL, MEDLINE, The Cochrane Library, Current Contents/All Editions, EMBASE, Australasian Medical Index and PsychINFO. There was no date restriction applied. In addition, the reference lists of all included studies were scrutinised for other potentially relevant studies.

Selection criteria Systematic reviews of randomised controlled trials (RCTs) and RCTs that compared the effectiveness of nursing interventions and considerations used in the administration of medications via enteral tubes. Other research methods, such as non-randomised controlled trials, longitudinal studies, cohort and case control studies, were also included. Exclusion criteria included studies investigating drug–nutrient interactions or the bioavailability of specific medications.

Data collection and analysis Initial consideration of potential relevance to the review was carried out by the primary author (NP). Two reviewers independently assessed study eligibility for inclusion. A meta-analysis could not be undertaken, as there were no comparable RCTs identified. All data were presented in a narrative summary.

Results There is very limited evidence regarding the effectiveness of nursing interventions in minimising the complications associated with enteral tube medication administration in adults. The review highlights a lack of high quality research on many important nursing issues relating to enteral medication administration. There is huge scope for further research. Some of the evidence that was identified included that nurses should consider the use of liquid form medications as there may be fewer tube occlusions than with solid forms in nasoenteral tubes and silicone percutaneous endoscopic gastronomy tubes. Nurses may need to consider the sorbitol content of some liquid medications, for example, elixirs, as diarrhoea has been attributed to the sorbitol content of the elixir, not the drug itself. In addition, the use of 30 mL of water for irrigation when administering medications or flushing small-diameter nasoenteral tubes may reduce the number of tube occlusions.

A systematic review of nursing administration of medication via enteral tubes in adults

Aim. This systematic review aimed to determine the best available evidence regarding the effectiveness of nursing interventions in minimising the complications associated with administering medication via enteral tubes in adults.
Background. Giving enteral medication is a fairly common nursing intervention entailing several skills: verifying tube position, preparing medication, flushing the tube and assessing for potential complications. If not carried out effectively harmful consequences may result leading to increased morbidity and even mortality. Until now, what was considered to be best practice in this area was unknown.
Design. Systematic review.
Methods. CINAHL, MEDLINE, The Cochrane Library, Current Contents/All Editions, EMBASE, Australasian Medical Index and PsychINFO databases were searched up to September 2005. Reference lists of included studies were appraised. Two reviewers independently assessed study eligibility for inclusion. There were no comparable randomised-controlled trials; data
were presented in a narrative summary.
Results. Identified evidence included using 30 ml of water for irrigation when giving medication or flushing small-diameter nasoenteral tubes may reduce tube occlusion. Using liquid medication should be considered as there may be less tube occlusions than with solid forms in nasoenteral tubes and silicone percutaneous endoscopic gastrostomy tubes. In addition, nurses may need to consider the sorbitol content of some liquid medications, for example elixirs, as diarrhoea has been attributed to the sorbitol content of the elixir, not the drug itself.
Conclusion. The evidence was limited. There was a lack of high-quality research on many important issues relating to giving enteral medication.
Relevance to clinical practice. Nurses have the primary responsibility for giving medication through enteral tubes and need knowledge of the best available evidence. Some of the nursing considerations and interventions relating to this skill have been researched in the clinical area and have implications for practice. There is a need for further studies to strengthen these findings.

Nurses' role in medication safety

Aim To explore the nurses role in the process of medication management and identify the challenges associated with safe medication management in contemporary clinical practice.
Background Medication errors have been a long-standing factor affecting consumer safety. The nursing profession has been identified as essential to the promotion of patient safety.
Evaluation A review of literature on medication errors and the use of electronic prescribing in medication errors.
Key issues Medication management requires a multidisciplinary approach and interdisciplinary communication is essential to reduce medication errors. Information technologies can help to reduce some medication errors through eradication of transcription and dosing errors. Nurses must play a major role in the design of computerized medication systems to ensure a smooth transition to such as system.
Conclusion The nurses roles in medication management cannot be over-emphasized. This is particularly true when designing a computerized medication system.
Implication for nursing management The adoption of safety measures during decision making that parallel those of the aviation industry safety procedures can provide some strategies to prevent medication error. Innovations in information technology offer potential mechanisms to avert adverse events in medication management for nurses.