Quantitative2-SafetyindrugadministrationResearchonnursingpractice.pdf

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ORIGINALES

Safety in drug administration: Research on nursing practice and
circumstances of errors
Segurança na administração de medicamentos: Investigação sobre a prática de
enfermagem e circunstâncias de erros
Seguridad en la administración de medicamentos: investigación sobre la práctica de
enfermería y circunstancias de errores

Bruna Figueiredo Manzo

1

Célia Luciana Guedes Barbosa Brasil
2

Flávia Felipe Thibau Reis
2

Allana dos Reis Correa
3

Delma Aurélia da Silva Simão
1

Anna Caroline Leite Costa
4

1 Ph.D. Adjunct Professor, Department of Maternal-Infant and Public Health, School,
Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil. [email protected]
2
Nurse. Graduated by the School of the Federal University of Minas Gerais. Belo Horizonte,

Minas Gerais, Brazil.
3
Ph.D., Adjunct Professor, Department of Basic , School, Federal University of Minas

Gerais, MG, Brazil.
4
Undergraduate student in . UFMG School. Belo Horizonte, Minas Gerais, Brazil.

.

http://dx.doi.org/10.6018/eglobal.18.4.344881

Received: 6/10/2018
Accepted: 21/01/2019

ABSTRACT:
Introduction: To provide safe, effective, timely and individualized care is a major challenge in health
care. Currently, the main errors in health care are related to medication errors. These errors can cause
damages, especially in pediatrics, because of organs’ immaturity and variation in the weight and body
surface. In this way, the importance of nursing in this scenario is perceived to guarantee a safe care.
Objective: To investigate the practice of nursing professionals about drug administration process, as
well as the circumstances that lead to errors.
Method: Descriptive, quantitative study with 147 nursing professionals in Neonatal and Pediatric
Intensive Units. To collect data, a questionnaire was used elaborated and based on the
recommendations of the Guideline for Prevention of Intravascular catheter-related infections with
questions related to the practice of drug administration and afterwards a descriptive data analysis was
used.
Results: The professionals pointed out weaknesses in the practice, such as double checking of
medications, administration of medication prepared by the colleague, delays and lack in checking the
prescriptions. The most common errors were derived from the wrong dose and the environmental
factors were presented as a critical point.

mailto:[email protected]

http://dx.doi.org/10.6018/eglobal.18.4.344881

Enfermería Global Nº 56 Octubre 2019 Página 46

Conclusion: The findings interfere in the consolidation of safety practices in drug administration in
pediatrics and neonatology, suggesting the need for team qualification and continuous monitoring of the
work process

Key words: Medication Errors; Safety;

RESUMO:
Introdução: Prestar um cuidado seguro, efetivo, oportuno e individualizado é um grande desafio na
assistência à saúde. Atualmente, os principais erros na assistência à saúde estão relacionados à erros
de medicação. Esses erros podem ocasionar danos, especialmente na pediatria, em decorrência da
imaturidade dos órgãos e a variação de peso e superfície corpórea. Dessa forma, percebe-se a
importância da enfermagem nesse cenário para a garantia de uma assistência segura.
Objetivo: Investigar a prática dos profissionais de enfermagem sobre processo de administração de
medicamento, bem como as circunstâncias que levam aos erros.
Método: estudo descritivo, quantitativo, realizado com 147 profissionais de enfermagem em Unidades
Intensivas neonatais e pediátricas. Para a coleta de dados foi utilizado um questionário elaborado e
alicerçado nas recomendações do Guideline for Prevention of Intravascular cateter-related infections
com perguntas relativas a prática de administração de medicamentos e posteriormente realizado
analise descritiva dos dados.
Resultados: Os profissionais apontaram fragilidades da prática como checagem dupla das
medicações, administração de medicações preparada pelo colega, atrasos e falta de checagem das
prescrições. Os erros mais comuns derivaram de dose errada e os fatores ambientais foram
apresentados como ponto crítico.
Conclusão: os achados encontrados interferem na consolidação de práticas de segurança na
administração de medicação na pediatria e neonatologia, sugerindo necessidade da qualificação da
equipe e monitoramento continuo do processo de trabalho.

Palabras clave: Erros de Medicação; Segurança; Enfermagem.
.

RESUMEN:
Introducción: Prestar un cuidado seguro, efectivo, oportuno e individualizado es un gran desafío en la
asistencia a la salud. Actualmente, los principales errores en la asistencia a la salud están relacionados
con errores de medicación. Estos errores pueden ocasionar daños, especialmente en pediatría, debido
a la inmadurez de los órganos y la variación de peso y superficie corpórea. De esta forma, se percibe la
importancia de la enfermería en ese escenario para la garantía de una asistencia segura.
Objetivo: Investigar la práctica de los profesionales de enfermería sobre el proceso de administración
de medicamentos, así como las circunstancias que conducen a los errores.
Método: Estudio descriptivo, cuantitativo, realizado con 147 profesionales de enfermería en Unidades
Intensivas neonatales y pediátricas. Para la recolección de datos se utilizó un cuestionario elaborado y
basado en las recomendaciones de la Guideline for Prevention of Intravascular cateter-related
infections relacionadas con la práctica de la administración de medicamentos y posteriormente se
realizó análisis descriptivo de los datos.
Resultados: Los profesionales señalaron fragilidades de la práctica como chequeo doble de las
medicaciones, administración de medicamentos preparados por el compañero, retrasos y falta de
verificación de las prescripciones. Los errores más comunes derivaron de dosis erróneas y los factores
ambientales fueron presentados como punto crítico.
Conclusión: Los hallazgos encontrados interfieren en la consolidación de prácticas de seguridad en la
administración de medicación en pediatría y neonatología, sugiriendo la necesidad de la calificación del
equipo y monitoreo continuo del proceso de trabajo

Palavras-chave: Errores de Medicación; Seguridad; Enfermería

INTRODUCTION

One of the major challenges for health services today is to provide safe, effective,
timely and individualized care, since that, with technological and scientific advances
and the inclusion of increasingly complex techniques, the risks for patient safety have
been potentiated.

(1)

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The report To Err is Human: Building a Safer Health System Institute of Medicine of
the United States of America (USA), published in 2000, displayed epidemiological
studies that estimated that from 44,000 to 98,000 annual deaths in the country
occurred due to errors in health care, of which 30% were related to medication error.

(2)

In Brazil, the National System of Toxic-Pharmacological Information (Sintox), reveals
that drugs are in the first place among the agents causing intoxication in humans and
in the second place among the agents causing intoxication.

(1)
Also in Brazil, an

important study carried out in a hospital in Rio de Janeiro showed a 14.3% occurrence
of adverse events caused by drugs, 31.2% of which caused a severe health risk
requiring life support.

(3)

Medication error is defined as an avoidable adverse event, temporary or permanent,
occurring at any stage of the drug therapy and which may or may not cause harm to
the patient. Finding the damage is an adverse event, which is considered an incident
that results in damage to the patient’s health, affecting the recovery, increasing
hospitalization time and costs and leading to death. Medication errors can be classified
in: error from prescription, distribution, omission, schedule, using non-authorized
drugs, dosage, presentation, preparation, administration, monitoring or because of
non-adherence on the side of the patient and the family.

(4)

Estimates show that among all the hospitalized patients, about 3% develop an adverse
event due to the use of some medication. Although the frequency is similar among
children and adults, the potential risk of harm is three times higher among pediatric
and neonatal patients.

(4,5)
The increased risk in children is attributed to the immaturity

of the organs which influences the metabolism of the drugs, as well as to the variation
in weight and body surface. Associated with this fact, we can add that many drugs
used in pediatrics are intended for adults where, as a result of fractioning the doses,
they may lead to errors in the preparation and administration process.

(6,7)

Studies have confirmed that errors occurring during drug administration can be
avoidable, which evidences the important participation of the nursing team in the
system for promoting patient safety.

(6)
This fact is even more striking when it comes to

pediatric care, since a systematic review about medication errors in children has
shown that the medication administration process showed a higher frequency of
errors, among others, with a rate of 72 to 75%, and it is therefore a challenge for every
health institution and team to promote changes in the organizational culture that allow
for the analysis with process restructuring and the creation of safety strategies in order
to reduce, to an acceptable minimum, unnecessary risks and damages associated
with care.

(8)
In the pediatric and neonatal intensive care units, errors range from 22 to

59 errors per thousand doses, and about 2.5% of these children suffer from drug-
related adverse events.

(4)

In this context, the nursing role is highlighted, since in addition to exercising the
leading role in administration and monitoring in drug therapy, the complexity in
pediatrics, demands greater knowledge and commitment of the professional in
conducting the process. However, in spite of the professional practice law proclaiming
that more complex practices be performed by nurses, it has been observed in daily
practice that nurses, technicians and nursing assistants have similar attributions in
drug therapy.

(5)

The lack of quality in this process, with consequent problems and occurrence of
adverse events, can be avoided with proactive and preventive management

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interventions. Among them, educating the nursing team regarding the knowledge
about the drug administration process as an important factor for preventing medication
errors is highlighted, with a view to the patient’s greater safety.

(4,7)

The first step in preventing health error is to admit that it is possible and, from this,
health professionals need to understand the types of adverse events, their causes,
consequences and contributing factors. The notification and registration of adverse
events serve as elements for critical analysis and decision-making, which aims to
eliminate, avoid and reduce these circumstances in daily health care.

(9)

To subsidize and improve the practice, it is necessary to know how the practice of the
nursing team at the administration of drugs in neonatal and pediatric intensive care
units occurs, as well as the circumstances in which the errors occur. This research
may offer subsidies to the professionals for an extended analysis of the practice and of
the problems that permeate this process and, thus, favor the design of actions that
generate a better quality care and safety for all involved.

Thus, this study aims to investigate the practice of nursing professionals in the
medication administration process, as well as the circumstances that lead to errors in
neonatal and pediatric intensive care units.

METHOD

This is a descriptive-exploratory study, with a quantitative approach, performed with
the nursing team of Neonatal and Pediatric Intensive Care Units of a large hospital in
Belo Horizonte, Minas Gerais.

Data collect was performed from August to November 2017, in the morning, afternoon
or evening shifts, on random days, contemplating six shifts per week. All nurses,
technicians and nursing assistants who worked in the respective units were included in
the study, resulting in a sample of 147 professionals. The following exclusion criteria
were considered: professionals who were on vacation, on medical leave or maternity
leave, during the data collect period. A questionnaire was prepared based on the
recommendations of the Guideline for Prevention of Intravascular catheter-related
infections

(10)
and was submitted to the pre-test with three specialist nurses, who

pointed out different suggestions for instrument adjustment.

The instrument was divided in two parts: Part I was related to the characterization of
the socio-demographic profile, where variables such as gender, age, actuation time in
the sector and the profession, postgraduate training for the nurses, work day and work
shift, type of employment contract, participation in courses and lectures on the
medication administration process, were approached. In Part II there were 14
questions considering how often actions are taken during the drug administration
process. For each action, there were four alternatives: always, sometimes, rarely or
never that should be pointed out by the respondent. Regarding the circumstance of
errors, 5 questions with varied answers were included, among them questions about
the types of errors, circumstances that led to errors, doubts in the medication process,
actions regarding errors, and to whom one should turn to for errors.

Data was typed in without spreadsheet in the Microsoft Excel 2010 program, double
typing the data. They were analyzed in the StatisticalPackage for the Social Sciences

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(SPSS) version 19 software, using descriptive statistics with absolute and relative
frequencies for categorical variables and central trend measures (median) and
dispersion measures for numerical variables.

The study observed the recommendations for privacy and confidentiality under
Resolution No. 466, dated October 12, 2012, National Council of Health for Scientific
Research with Human Beings, and was approved by the Ethics and Research
Committee of the Federal University of Minas Gerais and the field of study institution
with the number of written opinion under 1.363.357 and CAAE:
47994215.9.0000.5129. All research’s volunteers were previously oriented about the
objectives of the study and, after agreeing, signed the Free and Informed Consent
Term (FICT) in two counterparts.

RESULTS

This study’s sample was predominantly composed by nursing technicians, aged
between 25 and 68 years old (median=39 years old), mostly women, who had
between 1 and 40 years of training (median=12), acting predominantly in the Neonatal
ICU, in a 12h day/daytime work regime, with a statutory and unique bond.

Of the 24 nurses, two (8.3%) have a master’s degree, and 21 (87.5%) have some
specialization. Among the professionals with specialization, 12 (57.1%) are related to
pediatrics and neonatology, and nine (42.85%) are related to other areas. Data on the
profile of the professionals are displayed in Table 1.

Table 1 – Professional profile for the nursing team of neonatal and
pediatric ICU units (N = 147). Belo Horizonte, MG, Brazil, 2017.

Profile of the professionals N %

Age
Median
(P25-P75)

39 (34-
45)

Time of training
Median
(P25-P75)

12 (9-18)

Time of
performance in
the profession
Median
(P25-P75)

11.5 (8-
18)

Total weekly
working hours
Median
(P25-P75)

36 (30-
40)

Time of
performance in
the institution
Median
(P25-P75)

8 (3-9)

Time of
performance in
the current unit

8 (1.75-9)

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Median
(P25-P75)

Sector of work
in the
institution

ICU, Neonatal 61 41.5%

ICU, Pediatrics 43 29.3%

Pediatric ward 43 29.3%

Gender
Male 6 4.1%

Female 141 95.9%

Profession

Assistant 5 3.4%

Technician 118 80.3%

Nurse 24 16.3%

Working hours
in the
institution

12 hours daytime 75 51.0%

40 hours per week 1 0.7%

12 hours at night 55 37.4%

6 hours daytime 4 2.7%

6 hours afternoon 5 3.4%

Currently
working

Only in this institution 82 55.8%

In this institution and studying 16 10.9%

In this institution and elsewhere 43 29.3%

In this institution, studying and working in
another institution

5 3.4%

Employment
contract

Statutory 103 70.1%

Working under the consolidation of Labor
s

21 14.3%

Contract 23 15.6%

Of the professionals participating in the research, 51 (34.7%) stated that they had
participated in courses or lectures on the medication administration process between
October 2016 and October 2017, while 94 (63.9%) stated that they did not participated
in courses and lectures during this period.

When asked if the nursing team had already made a mistake in the medication
preparation and administration process, 69 (46.9%) of the professionals said yes,
while 71 (48.3%) said they did not. Table 2 displays the descriptive analyses for the
quantitative variables related to errors in drug preparation and administration.

Table 2- Frequency regarding doubts and circumstances of errors in
preparing and administrating drugs. Belo Horizonte, MG, Brazil, 2017.

Circumstances for errors in preparing and administering
drugs

N %

Doubts that
lead to the
error

Compatibility 87 59.2%

Scheduling 35 23.8%

Dilution and diluent 49 33.3%

Stability 67 45.6%

Action of drugs 110 74.8%

Who to turn
to in case
of doubt

Peers 77 52.4%

Doctor 48 32.7%

Pharmacist 49 33.3%

Specialized bibliography 22 15.0%

Printed routine of the sector 51 34.7%

On duty nurse 20 13.6%

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Types of
errors
made

Wrong dose 179 61.3%

Wrong route 53 18.1%

Wrong patient 6 4.1%

Wrong medication 6 4.1%

Wrong diluent 11 7.5%

Wrong schedule 31 21.1%

Conduct in
the face of
error

Solve it by yourself 3 2.0%

Notify nursing coordination 117 79.6%

Notify doctor on call 65 44.2%

Notify hospital risk management 4 2.7%

Factors
contributing
to the error

Insufficient information about the patient 19 12.9%

Insufficient information about the drug 37 25.2%

Communication failures among professionals 67 45.6%

Confusing packaging in drug identification 51 34.7%
Inappropriate dispensing by the pharmacy 27 18.4%
Infusion pumps and equipment without calibration 10 6.8%
Environmental issues: low light, working conditions 86 58.5%

Regarding the professionals’ conduct, when there was a delay in the medication
schedule, 119 (81.0%) professionals claimed that they administered the medication
late, while 2 (1.4%) said they skipped the time and 3 (2.0 %) that they advance the
next time of medication. Also, when they detected an error in the medical prescription,
96 (65.3%) responded that they notify the nurse or the nursing coordination, 90 notify
the doctor on call (61.2%) and 1 (0.7%) participant claimed trying to solve it by
himself/herself. Table 3 displays the analyses regarding the practice of the
professionals during drug preparation and administration.

Table 3 – Frequency of the actions performed by the professionals in the
drug preparation and administration process. Belo Horizonte, MG, Brazil,
2017.

Actions taken by the professionals N %

Interrupted while preparing the drug

Always 54 36.7%

Few times 54 36.7%

Rarely 32 21.8%
Never 6 4.1%

Checks the full name of the patient
receiving the drugs

Always 140 95.2%

Few times 7 4.8%

Checks the dose given with the
prescription

Always 143 97.3%

Few times 1 0.7%

Rarely 1 0.7%
Never 1 0.7%

Checks the route of administration with
the prescription

Always 142 96.6%

Few times 2 1.4%

Never 1 0.7%

Checks and certifies the name of the
drugs with the prescription

Always 143 97.3%

Few times 3 2.0%

Never 1 0.7%

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Checks the medication schedule against
the prescription

Always 145 98.6%

Few times 1 0.7%

Never 1 0.7%

Labels refrigerator medications with
date/time/dilution

Always 143 97.3%

Few times 1 0.7%

Rarely 2 1.4%
Never 1 0.7%

Checks the stabilization time of the drugs
administered continuously in the patient

Always 128 87.1%

Few times 16 10.9%

Rarely 1 0.7%

Checks the dripping on the infusion pump
according to the prescription

Always 138 93.9%

Few times 8 5.4%

Checks the expiration date of the drugs
before preparation and administration

Always 113 76.9%

Few times 21 14.3%

Rarely 5 3.4%

Never 6 4.1%

Always 127 86.4%

Checks on the prescription just after the
drug has been given

Few times 15 10.2%

Rarely 2 1.4%

Never 2 1.4%

Gives medication prepared by another
professional

Always 35 23.8%

Few times 40 27.2%

Rarely 42 28.6%

Never 25 17.0%

Labels collective use drugs Always 109 74.1%

Few times 12 8.2%

Rarely 7 4.8%

Never 17 11.6%

Checks the drugs on the prescription
before being given

Always 19 12.9%

Few times 27 18.4%

Rarely 25 17.0%

Never 72 49.0%

DISCUSSION

The preparation and administration of drugs is a complex process where nursing
professionals have an important role as the last barrier to prevent possible drug-
related harm to the patient. Thus, this study sought to elucidate that, through the
analysis of the practice and circumstances of errors, it is possible to propose more
effective strategies for promoting safety culture for the patient, providing a more
qualified and effective care.

Due to the uniqueness and complexity of the therapy directed to neonatology and
pediatrics, it is extremely important to deepen specific knowledge and frequent

Enfermería Global Nº 56 Octubre 2019 Página 53

trainings in such themes.
(5)

Contrary to this recommendation, this study warned that
63.9% of the subjects in the study stated that they did not participate in courses and
lectures on drug preparation and administration in the last year and that the majority
has doubts regarding the drug action that are resolved with their colleagues and not
with the referral nurse. It is therefore suggested that, for a good quality and safe care,
it is necessary that the work processes be reviewed based on scientific evidence and
that the professionals be trained and qualified, incorporating leaders and those led.
Educational strategies, mediated by focus groups or educational websites and
simulation games, have been shown to be important interventions to reduce incident
rates involving drugs.

(11,12)

The main medication error raised by the study professionals was dose-related error,
corroborating a study conducted in the United States with 120 patients, which showed
that half of the patients were exposed to medication errors, and most were related with
the dose. It should be noted that the main factor contributing to the dose error in this
study is the complexity and specificity of drug therapy in neonatology and
pediatrics.

(9,13)
The literature shows a high prevalence of errors in the medical

prescription, being more prevalent in drugs that require weight-based dosing and,
therefore, making it necessary to elaborate a specific prescription instrument for
pediatrics and neonatology, besides influencing the concordance of the actions taken
when errors have been detected.

(14)

Regarding the reasons contributing to the medication error, the environmental factors
among them, low lighting and adequate physical conditions constituted the largest
percentage of the sample, followed by communication failures, corroborating with
other studies.

(15-16)
It is verified that medication errors are due to the lack of preparation

and knowledge of the professionals, the overload and stress generated in the work
environment and the failure in the multidisciplinary team communication. Furthermore,
it is emphasized that it is common that drugs are suspended and that the doctor who
suspended did not communicate it to the nursing team.

(15)
The Food and Drug

Administration (FDA) evaluated reports on fatal drug errors and identified that 16% of
the causes for such errors were attributed to communication failure. Therefore,
prescription is an important written communication link among health professionals,
seen as the beginning of a series of events within the medication process, which will
result in the safe administration of a dose to the patient.

(17)

Effective communication is another important factor in promoting patient safety in drug
administration, permeating all interpersonal relationships, and it is directly linked as a
cause or contributing factor to most of the incidents. An adequate communication
between professionals and patients/caregivers regarding the administration of the
drugs brought relevant and effective results, thus avoiding the occurrence of new
incidents.

(18)

Regarding error occurrence, it is important to note that, from the error recognition, it is
necessary to analyze the whole process and the components of the medication
system, which may contribute or act as a barrier to the outcome of the error. These
factors can be attributed to the professionals, to failures in the system, to the institution
or even to the presentation of drugs. This analysis is indispensable for understanding
all factors that involve the medication process, not attributing failures to the
incompetence or irresponsibility of the employees.

(1t)

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Regarding the professional’s behavior given the error, most of the interviewees stated
that they notify the nursing coordination, diverging from other studies. A South Florida
survey found that 57.9 percent would not report an error if they did not think it was
dangerous and 25 percent would not report it for fearing the consequence. The
perception of nursing on medication errors is that only 45.6% are notified, the rest is
omitted for fearing the leadership and colleagues.

(19)
The treatment given to error

notifications with a focus on the professional’s performance contributes to the
underreporting of mistakes, since that professionals are afraid to respond to legal and
administrative processes, being labeled as negligent, lose the trust of the manager
and of their team. This is a worrying fact that must be reversed, since underreporting
impedes error analysis and the elaboration of possible measures that minimize their
occurrence and ensure patient’s safety.

Studies that problematize cultural change in approaching patient’s safety incidents
have demonstrated that an intervention specifically focused on this subject for the
practitioners significantly reduces medication errors. In addition, a political change is
needed in the institutions.

(18)

A major problem identified by the participants in this research was the interruption in
drug preparation, which is included in the research as a critical point that leaves
professionals more vulnerable to commit an error, because they are exposed to
distractions. A research performed with pediatric nurses showed that in 88.9% of the
observed interruptions, the outcome was negative. Thus, a study suggests the need to
create restricted areas for preparing drugs, thus preventing interferences.

(20)

Double checking is an effective method for suppressing errors in drug
administration.

(15-16)
In this study, the nursing team reported that this practice is

scarcely or rarely performed. In addition, there was administration of drugs by another
person and lack in conference of drugs with the prescription before being
administered, which contravenes the recommendations of good practices regarding
drug administration.

(10)

In this study, professionals reported that they adhere to some recommended actions in
the safe process of drug administration. However, it should be considered that all
practices that involve patient’s safety in the care process must be fulfilled, and not just
some. Ensuring compliance with the good practices prevents the breaking down of
barriers for …