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Qualitative Research on Medication Safety among Nurses and Pharmacists in

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Article · December 2015

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Ling Yee Wei

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Ministry of Health Malaysia

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Hospital Miri

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Sarawak Journal of Pharmacy 1 (2015) 1-12

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Journal Homepage: http://jknsarawak.moh.gov.my/spj/

Qualitative Research on Medication Safety among Nurses and Pharmacists in Hospital

Miri

Ling Yee Wei1, Tan Hui Min1, Elwin Jong Chai Ming1, Joachim Yeow Bei Sheng1, Kamarudin

Ahmad1

1Miri Hospital Pharmacy Department

Abstract

Medication safety is one of the integral practices for every healthcare provider. It is one of the

major components in health care delivery system because it can cause potential harm to patients

This qualitative study focuses on nurses’ and pharmacists’ experiences and perspectives on

medication safety and hope that this study can contribute in safe medications or and improved

patient care. The findings indicate that both pharmacists and nurses share a responsibility

preventing medication error. Implementing safety practices is paramount and improvement in

clinical knowledge may help in their working circumstances.

Introduction

Medication safety is one of the integral practices for every healthcare provider. It is one

of the major components in health care delivery system because it can cause potential harm to

patients (1). Approximately 106,000 deaths occur annually from medication error and adverse

drug reactions (ADRs). In United States, medication error is the number 4 to 6 leading cause of

death and over 2 million of serious ADRs which defined as requiring hospitalization, causing

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permanent disability and death occurs each year. In 2009, 2572 cases of medications which were

mainly adverse event issues were reported in Malaysia. It has serious direct and indirect result

and usually the consequences of breakdown in a system of care. Not only death or disability, it

causes emotional impact to the patient according to Study conducted by the Institute of Medicine

(1999), entitled “To Err Is Human: Building a Safer Health System”. It is estimated that

medication errors cause over 7,000 deaths annually. In Malaysia, the Malaysian government

does emphasize on the medication safety whereby the government encourages researchers to

conduct research on medication safety (1).

Medication error can lead to patient morbidity or mortality and even cause emotional

impact to patient. Incorrect medication, labeling and negligence when giving medicines are

among the common mistakes that have been detected. Institute for Safe Medication Practice

(ISMP) newsletters are recognized as some mostly updated and comprehensive medical alert

systems are widely used over the world to create awareness on medication safety. In Malaysia,

there were efforts taken to create awareness on medication safety. Few examples like the

arrangement of medicines by colour coding and a “5S management system” which were

implemented in most of the hospitals. There was also the Guide on Handling Look Alike, Sound

Alike Medications, which included the strategies to prevent errors with medicines. A “Know

Your Medicines” programme was introduced to educate the public (2).

Medication safety plays an important role as with the increase in use and grow of the

pharmaceutical industries have brought to the increase in hazards, error and adverse events

which has significant impact on patient outcomes and healthcare costs (3). Besides that,

medications have also become more complex with massive increasing in the number and variety

of medications available and even one single medication that has different routes of delivery.

Furthermore, increasing number of doctors lead to the process of delivering medications to

patients are often shared by a number of doctors and these causes communication failures and

lead to wrong medications given. Doctors have a major role in the use of medicine. Their role

includes prescribing, administration, monitoring for side-effects, working in a team and

potentially a leadership role in the workplace in relation to medication use and improving patient

care. Inadequate knowledge about drug indications, contraindications and drug interactions has

become an increasing problem as the number of medicines in use has increased. It is not possible

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for a doctor to remember all the relevant details necessary for safe prescribing. Therefore, nurses

and pharmacists should work as team with the doctors to identify any medication errors (3).

Knowledge of nurses’ and pharmacists’ experiences and perspectives are important in

modifying safety practices (4). Therefore, this study aimed to know more about nurses’ and

pharmacists’ experiences and perspectives on medication safety and hope that this study can

contribute in safe medications or and improved patient care.

Methods

Setting and context

The study was conducted at Miri General Hospital, Sarawak. This hospital has 340 beds

which have several specialty wards such as Medical, Surgical, Eye, Orthopedic, Gynecology,

Radiology, Anesthesia, and Pediatrics. The ward equip with treatment room where medications

are stored and prepared for administration by nurses. Physicians prescribe medication through a

prescribing medication chart which is handwritten by the prescriber himself. All prescriptions

and administrations are documented in a paper-based medication administration file. Each nurse

has a designated group of patients for whom he/she prepares and administers medications.

Pharmacy Hospital Miri consisted of several main components, such as Procurement and

Supply Service, Outpatient Service, Inpatient Service, Pharmaceutical Production Service, Drug

and Information Service, Ward Pharmacy Service, Clinical Pharmacokinetics Service, and

Cytotoxic Drug Reconstitution Service, and does provide other professional services like

medication therapy adherence service as well.

Participants

We performed a qualitative exploratory study in 4 nurses and 4 pharmacists. To obtain a

broader perspective on the subject from the management as well as the operational level, we

utilized purposive sampling aimed at a high level of heterogeneity. Initially, 2 nursing managers

of U40 and U36 were approached by the two researchers, with requests to participate in a study

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on practices to improve medication safety. Purposeful selection was then applied to select the

remaining 2 other nurses from different departments, varying levels of training and seniority as

well as different attitudes towards medication safety practices. Selection of pharmacists was

similar, with interviewing 2 highly ranked pharmacists of PFU48 with experience in Outpatient

and Inpatient Department, and selection of 2 pharmacists with varying experience and specialties

similar as the method mentioned above. To be included in the study, participants were required

to be registered nurses and pharmacists.

Data collection

A total of 4 pharmacists and 4 nurses were approached, and all participated voluntarily.

All participants received verbal invitation and an email explaining the purpose of the interview,

the process of interview and the guarantee of anonymity. Written informed consent was obtained

from all participants prior to the interview. Participants were reassured that the aim of the study

was to obtain the nurses’ and pharmacists’ personal perspectives and opinions on, as well as their

experiences with, medication safety policies and practices.

Semi-structured individual interviews (n = 8) was conducted, with each interview lasting

approximately 10 minutes or more. The semi-structured interviews allowed the participants to

speak freely with structured guidance from the interviewer using a topic list.

Data Analysis

Dialogues from each interview were fully transcribed verbatim stored electronically as

Word files. After that, the primary analysis was done using a low-technology technique with

printouts, scissors, and crayons. Four of us (YW, HM, El, and JC) were involved in the analysis

using each analyst coding scheme. All quantitative analysis of the coding was done manually or

with a calculator.

Meeting on coding and consensus was performed where the codes were compared,

debated differences of opinion, until consensus on a coding tree was reached, and the most

relevant themes related to nurses’ and pharmacists’ experiences and perspectives regarding

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medication safety were identified. Finally, the text fragments were sorted and analyzed according

to the identified themes. Repeating themes were identified and findings subsequently

summarized.

Current research practice and legislation in Malaysia do not require an ethical approval

process to conduct such a study. The data collection was completely anonymous (in accordance

with the Data Protection Act), and participation was voluntary.

Results

We have interviewed 4 pharmacists and 4 nurses from different level of management in

each department. There were similar responses when it comes to concept of medication safety

but different opinion regarding exposing medication safety to public.

Three specific theme were emerged from the analyzed material: (1) Baseline knowledge

on medication safety in pharmacists and nurses, (2) Pharmacists’ and nurses’ roles and

responsibilities in medication safety and (3) Pharmacists’ and nurses’ ability to work safely in

Hospital Miri

Baseline knowledge on medication safety in pharmacists and nurses

Pharmacists and nurses have the same basic concept on medication safety, which is

providing and serving the correct medication, with the correct dose, frequency, and route.

Sister and staff nurse indicate that they have been following 7R policy as their guidance to

medication safety practice.

“7R include right patient, right medicines, right timing, right dose, right route of

administration, right documentation, and lastly patient’s right to refuse” (SN1) (SN2)

Identifying side effect of medication was also important as indicated by both pharmacist and

staff nurse.

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“Supplying the right medication to the patient, with the correct dose and frequency, and

being aware of possible side effects. So that when the medication is taken, The patient is

able get maximum benefit from the medication but minimal side effect” (P3)

Pharmacists’ knowledge on medication safety in Hospital Miri were mostly build up by

attending medication safety talk organized by DIS (Drug Information Service) department.

“For our pharmacy side, we also have our medication safety talk in our own CPD

(continuous professional development). So to increase the awareness for all the pharmacist

and also the pharmacist assistance” (P2)

On nurses side, their knowledge were based on medication safety courses, where they will

be sending batch of staff nurse at a time for the course which were held 3 times per year, and

also during CNE( continuing nursing education) talk.

“We did one CNE every Thursday, combine from Isolation, Male medical, and Female

medical ward, we will mention about medication safety if we have case.” (SN2)

Pharmacists’ and nurses’ roles and responsibilities in medication safety

Responsibility

Both pharmacists and nurses have the same opinion on our responsibility to have the correct

attitude and being vigilant when handling medication.

“If those PRP or FRP including me are not familiar with medication, we can go and double

check with other colleague to ensure that I’ve dispensed the correct medication” (P2)

“The most important thing is the attitude of staff themselves. We must concentrate at work.

Use the knowledge we have, don’t use short cut.” (SN1)

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Pivotal role

Pharmacist’s role in assisting doctor and nurses especially in ward is well appreciated as

mentioned by the staff nurse.

“It’s very useful actually if there is a pharmacist in the ward. And there is one, so it’s very

useful” (SN4)

But when intervention was not corrected in time, pharmacists indicate that staff nurse can

help in clarifying the dose or route of medication if it’s not appropriate.

“Some of the houseman they prescribe the wrong dose, because the carbon copy of the script

arrived later to Satellite pharmacy, so the wrong dose was actually served to the patient

before it was intervene by pharmacist. So sometimes senior staff nurse can actually play a

role before they serve the medication to the patient.” (P2)

Pharmacists’ and nurses’ ability to work safely

Pharmacists’ and nurses’ ability to work safely were influenced by 1) risk awareness on

medication and 2) circumstances in which they are coping with.

Risk awareness

Awareness on the risk of medication error varies among pharmacist and nurses. Both sides

gain their knowledge from courses attended, incident report, and personal experience. Their

opinion on causes of error was the same: lack of knowledge and experience.

“I feel that experience and knowledge about the medication is very important. If at the first

point I know that fluconazole has two strength and then I won’t supplied the 100mg capsule

to the patient with the 50mg dose, just that I don’t know. That’s why it’s lack of experience

and knowledge about the medication.” (P3)

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Journal Homepage: http://jknsarawak.moh.gov.my/spj/

“If i will say for nurses, maybe lack of experience. The one that are juniors, they are not alert

regarding the dosage, for example the Panadol.” (SN4)

Both professions indicate that the way to overcome this issue is to have more training and to

have senior leading the juniors.

“Sufficient training for the pharmacist and by attending more courses, I believe, these will

improve the condition” (P1)

“One more is when the staff nurse serve medication, a senior must accompany a junior.

That’s why A is to serve, B to witness” (SN1)

Circumstances

Work pressure and work environment influence both pharmacists’ and nurses’ ability to

perform well. They share the same trouble in concentrating on their work when the working

environment become hectic and lack of staff assisting.

“We are still lack of staff in ward. One to follow doctor’s round, one to serve medication.

When doctor ask for help on other procedure, that can also lead to medication error.” (SN1)

“Sometimes we just have a peak hour where people are overload, too busy so they

(pharmacist) tend to make error.” (P2)

Forgot or late administration of medication was perceived to be a medication error

commonly seen in Hospital Miri. Sisters indicate that factor leading to this is the attitude of some

staff nurse when handling the patient’s medication and handing over to the following shift staff

nurse.

“Because during specialist round, they decide to withhold dialysis, then suppose the

medication to be after HD, Then if patient did not went to HD, staff nurse will expect people

in the morning have already served. If ordinary day they serve in morning. But dialysis time

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Journal Homepage: http://jknsarawak.moh.gov.my/spj/

they serve after dialysis. When there is such routine, some staff are not alert. Attitude is the

problem.” (SN2)

As for pharmacists, they share the same concern that similar packaging and location of

similar medication can lead to confusion and ultimately lead pharmacists to medication error.

“Arrangement of the drug is also quite important, because you see like amlodipine 5 and 10,

if you put at the same area, like neighbors, some people will also mislook it, like if you want

to take 10 then you accidentally took the 5.” (P4)

Discussion

Both pharmacists and nurses each plays a pivotal role in this multi-disciplinary team to

provide safety in handling medication, which extends the responsibility beyond supplying,

preparing and administering medication as prescribed. For pharmacists, besides supplying

medication to patients, also takes up the role in identifying drug-drug and drug-food interaction

and educating patients in knowing their medication with the 5R concept. Studies have shown that

through patient education by pharmacist, internal and external ADE reports has decreased

substantially and patients’ adherence to medication improved. (5, 6). However, in relation with

medication prescribed in ward, nurses, apart from clinical pharmacist are crucial in coordinating

the care of patient with their clinical reasoning as they have the closest interaction with patients

and doctors. Others studies also supports the need of nurses’ clinical reasoning and the

coordination of care together with physician and pharmacist in medication management and

safety (7, 8).

In Hospital Miri, both nurses and pharmacists agree that lack of experience and

knowledge is one of the main causes of the medication error. A study conducted at one of the

hospitals in East Malaysia also support their opinion, stating that medication error are more

likely to occur during first 5 years of working (9). Therefore, baseline knowledge of medication

safety in pharmacists and nurses are essential in order to work as a team in medication

management and safety. Evidence from other studies shown that more attention are required to

improve basic as well as continuing education of nurses and pharmacists on medication safety

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Journal Homepage: http://jknsarawak.moh.gov.my/spj/

(10). Both side gain their knowledge and risk awareness through experiences, courses and talk

organized by each profession. Inter-professional collaboration through knowledge sharing and

case-based discussion enable both professions to strengthen their medication safety knowledge.

Knowledge and experience associated with medication administration and error occurred

emphasizes the need to apply safety practice in daily routine. Adherence to medication protocol

is more likely when the medication is perceived high risk, unfamiliar, and causing confusion (11-

13). Therefore, in order to avoid errors, guideline and protocol drafted by Malaysia Ministry of

Health and policy drafted by hospital are implemented. Nurses in Hospital Miri adhere to 7R

protocol in ward and double-checking medication to avoid error during medication

administration. Pharmacists on the other hand follow standard operation protocol on dispensing

developed by pharmacy department and double-checking on medication before supplying

medication to reduce the medication error.

However, error does occur even though both health professions state that the safety

measures (eg double checking) are feasible in Hospital Miri. There are a few papers stating that

some safety measures are not feasible in daily practice even though they have shown to be

advantageous on reducing error (8, 14). Work environment, human attitude, and the work

pressure seem to be the main problem face by both professions. With hectic environment, lack of

staff assisting, high working target set by higher authority, and working pressure build up tends

to cause both professions to lose concentration and affect their ability to perform their work

safely. To improve the environmental aspect of medication safety, nurses state that allocation of

a nurse solely to serve medication and creating awareness of the consequences of interruptions

are necessary.

In the pharmacy, medication with similar wording or packaging place at a close distance

can easily confuse pharmacist, which further affects their ability to perform their role. Adhering

to look-alike, sound-alike guideline and 5S guideline designed by Ministry of Health Malaysia

on arrangement of medication will surely reduce the environmental factor contributing to error in

pharmacy side.

Strength, Limitations and Future Research

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This study has provided a good opportunity to explore and investigate the topic of

medication safety from two of major professions related to it. Valuable pieces of information

were extracted and found consistent with other papers. Nevertheless, the study has been

conducted with no bias. Limitation to our study is that doctors were not recruited. Suggestion for

future research of this topic would be to recruit doctors, nurses, and pharmacists from different

levels, to extract different view of opinions.

Conclusion

Medication error is a substantial problem face by healthcare professional team. This

study shows that both pharmacists and nurses share a pivotal role in preventing medication error.

Other than implementing safety practices, both professions are required to have sufficient

clinical knowledge to be applied in their working circumstances. Management team for nurses

and pharmacists are crucial in creating a safe environment for practice with inter-professional

collaboration and continuing professional development focusing on patient’s medication safety.

Reference:

1. Johari H, Shamsuddin F, Idris N, Hussin A. Medication errors among nurses in

government hospital. J Nurs Health Sci. 2013;1:18-23.

2. Audrey E. Malaysia Health Ministry working to curb errors in medication 24 Feb 2013.

Available from: http://www.thestar.com.my/News/Nation/2013/02/24/Health-Ministry-

working-to-curb-errors-in-medication/.

3. Topic 11: Improving medication safety: World Health Organization; 2011. Available

from: www.who.int/patientsafety/education/curriculum/who_mc_topic-

11.pdf+&cd=2&hl=en&ct=clnk.

4. Smeulers M, Onderwater AT, Zwieten MC, Vermeulen H. Nurses’ experiences and

perspectives on medication safety practices: an explorative qualitative study. Journal of

nursing management. 2014;22(3):276-85.

http://www.thestar.com.my/News/Nation/2013/02/24/Health-Ministry-working-to-curb-errors-in-medication/

http://www.thestar.com.my/News/Nation/2013/02/24/Health-Ministry-working-to-curb-errors-in-medication/

http://www.who.int/patientsafety/education/curriculum/who_mc_topic-11.pdf+&cd=2&hl=en&ct=clnk

http://www.who.int/patientsafety/education/curriculum/who_mc_topic-11.pdf+&cd=2&hl=en&ct=clnk

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Journal Homepage: http://jknsarawak.moh.gov.my/spj/

5. Pedersen CA, Schneider PJ, …