The main findings regarding registered nurses’ knowledge influencing medication errors in the practice environment under study, as gathered from the empirical findings from this study and from the literature review, are discussed in the sections that follow. Knowledge of RNs may be a latent factor, as cause of a medication error (as depicted by the conceptual framework in paragraph 2.7) since knowledge is also considered as a human factor. This knowledge is tested in the questionnaire items in terms of RN’s knowledge of the research hospital’s policy to check that the right patient receives the right drug (and form of drug), the right dose (strength and rate of the infusion), via the right route, and at the right time (Shane, 2009:546). Their knowledge is also tested in terms of whether ‘double-checking’ these medication rights are performed with a witnessing nurse, as depicted by the institution policy and conceptual framework (KFSHRC-J, 2008a:2).
5.2.2.1 Knowledge of standardisation of IV medication concentrations
According to Hennessy (2007:28), the mandate of the Joint Commission on Accreditation of Health Care Organization (JCAHO) to standardise concentrations of infusions is vital (paragraph 2.10.4). As discussed in question 23 (Table 4.19), the majority of respondents indicated, by ticking off either ‘agree’ (61.4%) or ‘strongly agree’ (32.5%), that standard IV medication concentrations help to provide reliable infusion rates. Since the research hospital is accredited by the Joint Commission International, IV medications are standardised by pharmacy. This situation seems to assist in error prevention. From the findings (see question 19) it also seems possible that a lack of IV medication concentration standardisation is not a cause of dose errors in the NICU, PICU and CSICU.
5.2.2.2 Checking IV medication compatibility
According to De Giorgi et al. (2010:522), the physico-chemical compatibility of drugs makes caring for neonatal and paediatric patients risk-prone (paragraph 2.4). As discussed in question 27 (Table 4.23), the majority of respondents indicated, by ticking off either ‘agree’ (34.1%) or
‘strongly agree’ (58.5%), that routine checks include checking the compatibility with other medication or with the diluting fluid. Based on these findings, it seems possible that the respondents perform this vital nursing double-check before infusions are set to run. It also seems possible that this is also not a cause of dose errors, as discussed in the findings of question 19.
5.2.2.3 Checking identification
By ticking off either ‘agree’ (35.0%) or ‘strongly agree’ (63.0%) (question 30, Figure 4.2), the vast majority of respondents indicated that a double-check must include checking the patient’s identification number and IV medication label against the electronic MAR. . According to Anderson and Townsend (2010:23), the ‘right patient’ ensures prevention of administration errors. Raja et al. (2009:70) also reported that the visual inspection (71%) of a patient's identification tag is a contributing factor to medication errors (paragraph 2.7.5). However, it seems that the respondents in this research setting have adequate knowledge for medication error prevention.
5.2.2.4 Knowledge of an effective double-check method
The vast majority of respondents indicated, by ticking off either ‘agree’ (37.0%) or ‘strongly agree’ (39.0%) (question 33, figure 4.5), that a double-check is performed by asking another registered nurse to check the calculations when he or she is finished with his or her tasks. However, a small number of respondents also indicated, by ticking off either ‘disagree’ (11.0%) or ‘strongly disagree’ (13.0%), that a ‘double-check’ should NOT be carried out in this manner. There is value in a critical, and effective double-check that decreases the margin for risk. Clifton-Koeppel (2008:77) states that medication double-checking is fundamentally a ‘human factors approach’. According to the ISMP Alert, ‘The virtues of independent double checks’ (ISMP, 2003:1), nursing double-checks fail at times because of confirmation bias, namely ‘seeing only what one expects to see and overlooking disconfirming evidence’.
5.2.2.5 Unit-specific training
As per question 9 (Table 4.5) to determine whether insufficient unit-specific training could contribute to medication errors, only 3.1% of respondents indicated that unit-specific training was insufficient. The findings from this question seem to correlate with questions 54 and 55. In question 54 (Table 4.43) the majority of respondents indicated, by ticking off either ‘agree’ (70.7%) or ‘strongly agree’ (18.3%), that new staff receive sufficient unit training related to safe medication administration. As shown in question 55 (Table 4.44), the majority of respondents
indicated, by ticking off either ‘agree’ (64.2%) or ‘strongly agree’ (18.5%), that experienced staff receive sufficient ongoing reviews of safe medication administration. From the findings it is evident that the respondents believed that the educational processes and strategies for medication error prevention are effective. The findings from this study match the recommendations of Sulosaari et al. (2011:465), who reported that nurses need adequate competence to fulfil their role.
5.2.2.6 Standard of nursing practice
By ticking off either ‘agree’ (62.2%) or ‘strongly agree’ (24.4%) (question 22, Table 4.18), the vast majority of respondents indicated that the existing standard of nurses’ practice related to IV medication administration in the ICU was adequate. As also shown in the literature review, they commented that medication errors are prevented if medication administration is safely executed. Safe medication administration practice is seen within the context of the ‘five rights of medication administration’ which aims to ensure that the right patient receives the right drug (and form of drug), the right dose (strength and rate of the infusion) via the right route and at the right time (Benjamin, 2003:768; Elganzouri et al., 2009:424; Elliott & Liu, 2010:300; Shane, 2009:546). According to George et al. (2010:1763), it is essential to evaluate strategies and to address organisational, technical or human issues in attempting to transform the nurse’s practice environment (paragraph 2.2).
5.2.2.7 Registered nurses’ education, practice perceptions and experiences
As discussed in paragraph 5.2, the majority of the respondents (28.2%) had been working in either one of the ICUs only for two years. As discussed in question 50 (Table 4.39), the majority of respondents indicated, by ticking off either ‘agree’ (42.2%) or ‘strongly agree’ (51.8%), that training, experience and skills play a role in safe IV medication administration. Specialised nursing knowledge is required to work in an area of specialty. However Armutlu et al. (2008:58) found that there was no relationship between medication practices or perceived sources of error by years of experience (paragraph 2.7.9), but they mention that there is a need for ongoing education programmes on medication safety for all nurses, regardless of years of experience. It also seems imperative to review nurses’ perceptions regarding medication errors. Mayo and Duncan’s study (2004:215) found that there are differences in nurses’ perceptions about causes of medication errors and the reporting thereof (paragraph 2.7.9). The majority of respondents who participated in this current study agreed that staff perceptions of medication safety can affect nursing practice (92.3%) (question 67).
A disturbing practice perception is the significant number of respondents who agreed that the fear of punishment prevented them from reporting a medication error. They indicated this information by ticking off either ‘agree’ (31.7%) or ‘strongly agree’ (12.2%), which added up to a cumulative number of 43.9% respondents (question 63, Table 4.51). The same trend was found in the literature regarding the voluntary reporting of medication errors. This implies that reliable medication error data is not provided because fear of the manager as well as peer reactions cause barriers to reporting. The situation is often exacerbated by nurses’ perceptions that they are incapable of providing quality nursing care if a medication error has occurred (Carlton & Blegen, 2006:38; Kagan & Barnoy, 2008:360; Lefrak, 2002:80).
Furthermore, the majority of respondents agreed, by ticking off either ‘agree’ (45.0%) or ‘strongly agree’ (55.0%), that safe IV medication administration practice ensures the delivery of quality nursing care. None of the respondents indicated a negative response to this question at all (question 60, Table 4.48). The data indicated that the respondents from the practice environment under study perceived safe IV medication administration practice to link with the delivery of quality nursing care. This finding links with that of Otero et al. (2008:740), namely that the promotion of a unit safety culture (unit-specific culture of medication safety) change can effectively diminish medication errors in neonates and children.
From the above discussion it is clear that registered nurses’ knowledge regarding medication safety influences medication errors because error prevention is ensured through standardised IV concentrations and an effective double-check method.
5.2.3 Nursing medication administration strategies to prevent medication