Safety in medication use

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Purpose: To explore how safety measures function with a view to preventing the use of incorrect medication and adverse drug treatment in nursing homes. The data collection started parallel with the introduction of the Norwegian Coordination Reform, and was conducted over a three year period.

Data analysis was carried out by coding and categorising meaning. There was also little correlation between tasks, staffing and medication competence. There was little focus on systematic competence building, and training in handling medication was not taken sufficiently seriously. Conclusion: This study has shown that safety measures do not function adequately, and that there is an increasing need for personnel with relevant pharmaceutical expertise in nursing homes.

An important question is how nursing competence can be utilised to improve patient safety in respect of medication. Medication errors are among the most common adverse events in the health and care services. The need for greater efforts to ensure patient safety has been documented in national guidelines 1, 2, 3 and in the Official Norwegian Report 4. This highlights the considerable need to develop systems and cultures in order to learn from errors. This programme is carried forward in — The Coordination Reform entails that nursing homes have greater responsibility for treatment and not only responsibility for nursing and care.

Care for patients in a nursing home is demanding and requires that the nurses have wide-ranging competence 6. Because nursing home residents use many medications at the same time, this increases the risk of interactions between drugs, side effects and incorrect medication 7. In order to prevent medication errors, a variety of safety measures are often implemented, for example training, and control of the prepared drugs by two members of staff. Nevertheless, a report from the Norwegian Board of Health Supervision in reveals serious deficiencies in medication management in 51 out of 67 nursing homes that were investigated 8.

Pressure of time, poor coordination between work tasks, staffing and competence as well as inadequate training are common, while following the introduction of the Coordination Reform, the complexity of nursing tasks has grown 9. Despite this, a survey showed that tasks such as cleaning and preparing food as well as poor ICT solutions stole time and attention from the care of patients The nurses state that they need better knowledge of pharmacology and age-related physiological changes Alteren 12 found that student nurses lacked knowledge and experience of handling medication.

Another study 13 showed that by assuming responsibility for a nursing home ward, third-year students gained experience of handling medication. Brenden et al. International studies show that medication errors represent a considerable problem 15— However, we must question how effective current systems are in dealing with non-conformance, particularly in terms of whether error reporting systems and organisational measures promote learning and improvement Research has revealed that there are conspicuous organisational barriers in the case of adverse events 16, Interruptions when preparing medicines, a lack of knowledge and few opportunities to follow up the effects and side effects are factors that influence medication error 18, A survey of four American nursing homes on limiting medication error showed that the reporting systems were difficult to access.

There was no information about medication error reporting forms and the follow-up of reported non-conformances was poor Guidelines and standard procedures that could reduce incorrect use of medication often did not exist in nursing homes An international study found that lack of time and training as well as a punitive culture were reasons for the failure of health personnel to report medication error. The study also showed that a culture of learning and fairness helped to increase reporting Procedures, guidelines and training are safety measures that are encompassed in the structural aspect of patient safety.

According to Hjort 25 , errors in the health service are mainly the result of systems errors such as time pressure, lack of guidelines, poor routines and the working environment. The systems approach entails analysing underlying causes and establishing systems that detect adverse events before they have serious consequences While single loop learning involves adjusting behaviour within the same mind-set, double loop learning questions the basic perceptions underlying actions Patient safety in terms of medication is an area that has not been adequately researched in Norwegian nursing homes.

The purpose of this study is to shed light on how different safety measures function with regard to preventing medication errors. Safety measures are understood as interventions at the structural and processual level ensuring correct handling of medicines. The study has a qualitative design with focus group interviews as the main method of data collection.

The focus group interview is a quick and non-resource-intensive method that can provide an insight into how nurses think and act to safeguard patient safety, and thus gives a deeper understanding of medication use in nursing homes. Using targeted group discussions, the participants can exchange perceptions and experiences Individual learning logs are included as additional data. Learning logs are a tool used in programmes of professional study, and students use them to log their experiences of their clinical practice We started collecting data by means of focus group interviews with nurses in , the same year as the Coordination Reform was initiated.


With the implementation of the reform, students, teachers and the field of practice paid considerable attention to challenges associated with handling medication. According to Morgan 28 , there should be a sufficiently large number of focus groups to provide adequate data to shed light on the research question. We conducted therefore two focus group interviews with students in and in addition to collecting the learning logs. All informants received information in writing about voluntary participation, and we obtained written consent. The Norwegian Centre for Research Data approved the project.

We obtained permission to conduct the study at two nursing homes. One was a large urban nursing home with over places distributed among three large wards. The other was situated in a rural municipality and had approximately 60 places distributed among five small wards. The focus groups of nurses and a social educator were randomly made up of the staff on duty the day we carried out the interviews and who had the same formal competence in handling medication. We wanted to ensure that factors related to position levels did not affect the interaction Hereinafter, we will refer to the special educator as part of the group of nurses for reasons of anonymity.

The seniority of the participants varied from 6 months to 24 years of practice.

Medication Safety Alerts

We carried out two focus group interviews at the large nursing home and one at the small nursing home, and two focus group interviews with students at the same nursing homes. The focus group material incorporates the experiences of 16 nurses and 13 student nurses. The learning logs also come from the same nursing homes in addition to a third nursing home that took part in the teaching project.

Altogether 18 out of 69 learning logs included the handling of medication as a self-chosen topic. The interview guide had three main themes:. This article is limited to structural factors with special focus on safety measures table 1.

Safe Practices for Medication Use (Take Charge of Your Medicines!)

A previous data collection conducted at a hospital in connection with a related topic of research used the same methods and a similar interview guide, and resulted in relevant data generation. In the nursing home project, some of the discussions were limited and were more akin to a group interview When we compared the data, the nursing home interviews provided considerable information about structural factors, but less information about relational conditions and culture.

The content of the learning logs varied. Some gave detailed information about the handling of medication while others contained more superficial descriptions. In five focus groups, the participants discussed the same topic guided by questions in a semi-structured interview guide. In the analysis of the discussion, key topics largely paralleled the topics in the interview guide. By coding pieces of text, the general topics of discussion emerged. Categorisation took place by further condensing the data material through unifying several codes under one topic see table 2.

Those interviewed are regarded as informants or witnesses who provide reliable information The learning logs are treated as individual interview data. They were coded and categorised in the same way as the focus group interviews, and supplemented the data material.

International Medication Safety Network

Since information about medication error may be sensitive, it was vital to be aware of ethical aspects in connection with the project When researching patient safety, a conflict of interests may arise. On the one hand, confidentiality must be safeguarded and a relationship of trust with the interviewees upheld. On the other hand, it is incumbent on us to warn of any risk to patient safety or treatment that is not professionally sound 32, The interviews did not give rise to any such ethical dilemmas.

Several nursing homes in the region were asked to participate but only two of them found it possible to allow several nurses to leave the ward at the same time to participate in an interview. This restricted the breadth of the data. The students who took part assumed responsibility for a nursing home ward for two weeks. They had the same functional area as the nurses, apart from the handling of drugs, which was always checked by a nurse. The students had less experience than the nurses but their strength was their critical external gaze and their attention to theory.

When we read through the body of material, it emerged that the nurses and students had similar experiences.

Both groups are defined as health personnel, and in light of the principle of responsible conduct, prior learning and work experience is decisive for what tasks they can perform in connection with the handling of medication Experiences of how safety measures functioned with regard to medication management in nursing homes were divided into three main topics table 2 :.

Verification by two members of staff was a well-established safety procedure. Two nurses checked the selection or preparation of medicines. If only one nurse was on duty, a practitioner for example, a care worker or a nursing assistant could help to check. The medicines were placed in a pill dispenser one week in advance, and were most often distributed by a nursing assistant. Two nurses mixed the drugs used in the infusion pump, but only one changed the pump.

The informants said that after a near-accident, the staff had discussed whether there should also be two present when changing the pump. At one of the nursing homes, there was a computer-controlled medicine cabinet with inbuilt control of the withdrawal and selection of medication. Secure practice relied on there being no interruptions to the work on preparing the medication. It was pointed out that the cabinet was too cramped, it was difficult to get a full overview and it quickly became very untidy.

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Written regulations on medication management were well implemented. However, according to the informants, there were many examples of non-compliance with the safety procedures. Due to time pressures, sometimes they skipped a step in the documentation routine. For example, they might forget to sign for the medicines administered, or they might sign for medicines that had not been handed out. A detailed example of a forgotten signing-off of a blood-thinning drug was described in a learning log. Up And Away Out of reach and out of sight.

Medication Safety Basics. Program Focus.

Additional Resources. Featured Initiatives. Up And Away Program external icon. Hospitals commonly have electronic databases for medications. Smart phone users can consult drug reference applications to research unfamiliar medications. Professional development classes at local community colleges or online classes strengthen a nurse's understanding of pharmacokinetics and pharmacodynamics.

Nurses have a duty to the patient to know the actions and indications of all medications they administer, including safe dosage ranges, adverse reactions, monitoring parameters, and nursing implications.

Medication Safety Alerts

Misperceptions are at the root of many medication errors. For example, a nurse using the medication dispensing system to obtain hydralazine retrieves the wrong drug because a pharmacy technician had inadvertently filled the drawer with hydroxyzine instead. The nurse incorrectly perceives that the correct drug was retrieved because that was what the nurse expected to find in that drawer. Another example of an error based on perceptual factors is when hydralazine and hydroxyzine appear on the screen of the automated dispensing system in alphabetical sequence and, because the drug names are so similar, the nurse inadvertently selects the wrong drug.

The mind can easily be fooled by the illusion created by familiarity, expectancy, similarity, and experience; this phenomenon is known as confirmation bias or inattentional blindness. Examples of confirmation bias that contribute to medication errors include look-alike and sound-alike drugs, decimal point placement, units of measurement, size and type of font, incorrect drug calculations, frequency of administration, similar packaging, and the use of unapproved abbreviations.

The nurse may see the drug name on the label, drug, or dose but interpret it incorrectly. Errors result from poor attention span, inadequate communication, faulty reasoning, reduced memory, insufficient training, fatigue, and inexperience. Above all, nurses should never prepare medications for more than one patient at the same time.

Drug calculation errors fall into this category as well. Nurses who aren't confident in their math abilities should confirm any drug calculations by asking a peer to double-check the calculation, verifying the correct dosage with the pharmacy, or consulting a drug book to validate a safe dose range.

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  • Nurses should follow institutional policy regarding the need to seek independent verification of dosage calculations for those medications deemed to be high risk in their practice setting. For medications given as a continuous infusion, most infusion pumps have safety features such as preprogrammed drug libraries with alerts established for doses considered dangerous or ineffective. Nurses shouldn't ignore or disable these important safety features. Equally important is ensuring the previous nurse programmed the rate correctly based on the designated protocols for titration. Healthcare professionals often fail to clarify orders, prescriptions, directions, and reporting parameters.

    Components of a medication order include patient, drug, dose, frequency, route, parameters, and any necessary labs for monitoring if indicated. For example, if a nurse is administering vancomycin, the patient's renal function studies must be assessed before starting therapy and periodically during therapy. If these results aren't available, the nurse must know to request these lab test results from the healthcare provider. The quality of team communication and improved clinical outcomes are related, making it essential for a nurse to clarify ambiguous communication.

    The medication administration process involves multiple decision points that increase the potential for error. Patients are admitted to the hospital with increasingly complex medical conditions and medication regimens that create a very dynamic medication administration record. Brady et al. Medication management systems, computerized provider order entry, bar coding, electronic medical records, and workstations-on-wheels improve efficiencies and minimize the potential for error by giving nurses access to information in real time.

    Advances in technology, however, create a whole new set of risks and error potentials. Initially, computer processes may be time consuming, but ultimately they can improve patient safety. When a system issue interferes with safe medication administration, nurses must report the problem so improvements can be implemented. Nurses can also ensure a safe environment by reducing distractions, improving lighting, and minimizing noise levels. To improve safety, a medication room should have only one medication dispensing system.

    Medication rooms with more than one medication dispensing system become high-traffic areas, increasing the risk of distraction resulting in a medication error. To ensure a safer environment for medication preparation and administration, the first step is for nurses to examine their work environment and reflect on their current practice of medication administration. Streamlining the medication error reporting process can facilitate reporting actual or potential errors.

    Error reporting addresses complex system issues and improves patient outcomes by minimizing the likelihood of the same event being repeated. To reduce the risk of human error, nurses must be attentive, support each other when mistakes occur, and stop tolerating workarounds and other risky behaviors. Heightened awareness of error-prone conditions and recognition of contributing factors in the medication administration process are essential to patient safety. You may be trying to access this site from a secured browser on the server. Please enable scripts and reload this page.

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