Evaluation of contextual influences on the medication administration practice of paediatric nurses

Aim. This paper is a report of a study conducted to explore the impact of preidentified contextual themes (related to work environment and socialization) on nursing medication practice. Background. Medication administration is a complex aspect of paediatric nursing and an important component of day-to-day nursing practice. Many attempts are being made to improve patient safety, but many errors remain. Identifying and understanding factors that influence medication administration errors are of utmost importance. Method. A cross-sectional survey was conducted with a sample of 278 paediatric nurses from the emergency department, intensive care unit and medical and surgical wards of an Australian tertiary paediatric hospital in 2004. The response rate was 67%. Result. Contextual influences were important in determining how closely medication policy was followed. Completed questionnaires were returned by 185 nurses (67%). Younger nurses aged <34 years thought that their medication administration practice could be influenced by the person with whom they checked the drugs (P = 0·001), and that there were daily circumstances when it was acceptable not to adhere strictly to medication policy (P < 0·001), including choosing between following policy and acting in the best interests of the child (P = 0·002). Senior nurses agreed that senior staff dictate acceptable levels of medication policy adherence through role modelling (P = 0·01). Less experienced nurses reported greater confidence with computer literacy (P < 0·001). Conclusions. Organizations need to employ multidisciplinary education programmes to promote universal understanding of, and adherence to, medication policies. Skill mix should be closely monitored to ensure adequate support for new and junior staff.

Factors influencing paediatric nurses' responses to medication administration

Objective: To evaluate the importance of contextual and policy factors on nurses’ judgment about medication administration practice.---------- Design: A questionnaire survey of responses to a number of factorial vignettes in June 2004. These vignettes considered a combination of seven contextual and policy factors that were thought to influence nurses’ judgments relating to medication administration.---------- Participants: 185 (67% of eligible) clinical paediatric nursing staff returned completed questionnaires.--------- Setting: A tertiary paediatric hospital in Brisbane, Australia.---------- Results: Double checking the patient, double checking the drug and checking the legality of the prescription were the three strongest predictors of nurses’ actions regarding medication administration.--------- Conclusions: Policy factors and not contextual factors drive nurses’ judgment in response to hypothetical scenarios.

Nurses’ willingness to report medication administration errors in Saudi Arabia

Reporting of medication administration errors (MAEs) is one means by which health care facilities monitor their practice in an attempt to maintain the safest patient environment. This study examined the likelihood of registered nurses (RNs) reporting MAEs when working in Saudi Arabia. It also attempted to identify potential barriers in the reporting of MAE. This study found that 63% of RNs raised concerns about reporting of MAEs in Saudi Arabia—nursing administration was the largest impediment affecting nurses' willingness to report MAEs. Changing attitude to a non-blame system and implementation of anonymous reporting systems may encourage a greater reporting of MAEs.

Implementation of individualised medication administration guides for patients with dysphagia: Results from a pilot controlled trial

Introduction Patients with dysphagia (PWDs) have been shown to be four times more likely to suffer medication administration errors (MAEs).1 2 Individualised medication administration guides (I-MAGs) which outline how each formulation should be administered, have been developed to standardise medication administration by nurses on the ward and reduce the likelihood of errors. This pilot study aimed to determine the recruitment rates, estimate effect on errors and develop the intervention to design a future full scale randomised controlled trial to determine the costs and effects of I-MAG implementation. Ethical approval was granted by local ethics committee. Method Software was developed to enable I-MAG production (based on current best practice)3 4 for all PWDs on two care of the older person wards admitted during a six month period from January to July 2011. I-MAGs were attached to the medication administration record charts to be utilised by nurses when administering medicines. Staff training was provided for all staff on the intervention wards. Two care of the older person wards in the same hospital were used for control purposes. All patients with dysphagia were recruited for follow up purposes at discharge. Four ward rounds at each intervention and control ward were observed pre and post I-MAG implementation to determine the level of medication administration errors. NHS ethical approval for the study was obtained. Results 164 I-MAGs were provided for 75 patients with dysphagia (PWDs) in the two intervention wards. At discharge, 23 patients in the intervention wards and 7 patients in the control wards were approached for recruitment of which 17 (74%) & 5 (71.5%) respectively consented. Discussion Recruitment rates were low on discharge due to the dysphagia remitting during hospitalisation. The introduction of the I-MAG demonstrated no effect on the quality of administration on the intervention ward and interestingly practice improved on the control ward. The observation of medication rounds at least one month post I-MAG removal may have identified a reversal to normal practice and ideally observations should have been undertaken with I-MAGs in place. Identification of the reason for the improvement in the control ward is warranted.

Nurses’ views on the implementation of Individualised Medication Administration Guides in patients with dysphagia in care homes

As conditions such as stroke, cancer, Parkinson's disease and Huntingdon's chorea are commonly found in care homes between 15% and 30% of residents in care homes have been found to have difficulties in swallowing their medicines.To address the difficulties associated with administering medicines to patients who cannot swallow (with dysphagia), Individualised Medication Administration Guides (I-MAGs) were introduced by a specialised pharmacist in Care for Elderly wards in a general hospital in East Anglia. The guides contained detailed information about how to administer each medication and they were individualised to the needs of the patient. The I-MAGs were printed in green forms and attached to the medication chart in order to be used in conjunction with it. The ward nurses reported an increase in their confidence when administering medication when I-MAGs were present in the ward. Some patients with I-MAG were discharged to care homes where the I-MAG might have been equally useful. However, the design of such guides is not known to be suitable for care homes environment where they have never been used before. This study aims to explore the opinions of nurses and carers within care homes on the relevance and acceptability of individualised medication administration guides for patients with dysphagia (PWD).

Understanding the information dynamics of medication administration in residential aged care facilities (RACFs): A prerequisite for design of effective ICT systems

Medication information is a critical part of the information required to ensure residents' safety in the highly collaborative care context of RACFs. Studies report poor medication information as a barrier to improve medication management in RACFs. Research exploring medication work practices in aged care settings remains limited. This study aimed to identify contextual and work practice factors contributing to breakdowns in medication information exchange in RACFs in relation to the medication administration process. We employed non-participant observations and semi-structured interviews to explore information practices in three Australian RACFs. Findings identified inefficiencies due to lack of information timeliness, manual stock management, multiple data transcriptions, inadequate design of essential documents such as administration sheets and a reliance on manual auditing procedures. Technological solutions such as electronic medication administration records offer opportunities to overcome some of the identified problems. However these interventions need to be designed to align with the collaborative team based processes they intend to support.

Design challenges for electronic medication administration record systems in residential aged care facilities: A formative evaluation

Introduction Electronic medication administration record (eMAR) systems are promoted as a potential intervention to enhance medication safety in residential aged care facilities (RACFs). The purpose of this study was to conduct an in-practice evaluation of an eMAR being piloted in one Australian RACF before its roll out, and to provide recommendations for system improvements. Methods A multidisciplinary team conducted direct observations of workflow (n=34 hours) in the RACF site and the community pharmacy. Semi-structured interviews (n=5) with RACF staff and the community pharmacist were conducted to investigate their views of the eMAR system. Data were analysed using a grounded theory approach to identify challenges associated with the design of the eMAR system. Results The current eMAR system does not offer an end-to-end solution for medication management. Many steps, including prescribing by doctors and communication with the community pharmacist, are still performed manually using paper charts and fax machines. Five major challenges associated with the design of eMAR system were identified: limited interactivity; inadequate flexibility; problems related to information layout and semantics; the lack of relevant decision support; and system maintenance issues.We suggest recommendations to improve the design of the eMAR system and to optimize existing workflows. Discussion Immediate value can be achieved by improving the system interactivity, reducing inconsistencies in data entry design and offering dedicated organisational support to minimise connectivity issues. Longer-term benefits can be achieved by adding decision support features and establishing system interoperability requirements with stakeholder groups (e.g. community pharmacies) prior to system roll out. In-practice evaluations of technologies like eMAR system have great value in identifying design weaknesses which inhibit optimal system use.

Nurses' perceptions of and satisfaction with the medication administration system in long-term-care homes

The purpose of this study was to explore nurses' perceptions of and level of satisfaction with the medication administration system in long-term care (LTC). The cross-sectional survey design included both quantitative and open-ended questions. Data were collected from licensed registered nurses (RNs) and registered practical nurses (RPNs) at 9 LTC residences in southwestern Ontario, Canada. Using independent sample f tests, the researchers found that RNs were significantly less satisfied than RPNs with their medication administration system, particularly with respect to safety issues. RNs identified a number of related barriers, including time constraints, poor packaging, insufficient drug information, prescription changes, lack of staff competency, and unwieldy medication carts. Implications for practice and policy are discussed, including recommendations for improving medication administration practices and for addressing the workload demands of LTC nurses. © McGill University School of Nursing.

Medication management by graduate nurses: before, during and following medication administration

The purpose of the present study was to explore graduate nurses' perceptions of their medication management activities in the acute care context. A qualitative research design with a semistructured interview schedule was used to elicit information from participants. The sampling population consisted of graduate nurses involved in direct patient care in medical and surgical wards of a Melbourne metropolitan teaching hospital, completing a graduate nurse program. Twelve graduate nurses participated in the interviews. Two major themes emerged: (i) monitoring medications and (ii) interventions for patient care. The findings indicate that graduate nurses are required to address several facets of the medication management role in their daily practice. It is pertinent to examine ward dynamics to ensure that graduate nurses have ready access to experienced health care professionals. Through collegial support, graduate nurses should also be encouraged to critically examine the different possibilities when making clinical judgments about monitoring patient medications.

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 of 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.

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.