The other main finding regarding factors that have an impact on IV medication errors as gathered from the empirical findings from this study as well as from the literature review is the variations in medication administration practice.
Variations in medication administration practice will be inevitable if all staff working in the practice environment do not consistently adhere to the safety precautions for medication administration. Bates et al. (2005:203) contend that a significant and unnecessary variation in IV medication practice is associated with increased risk of patient harm. Thomka (2007:24) argues that senior nurses may take risks as a result of their comfort or familiarity with the medication process, and junior nurses (newly oriented staff) may feel pressured to emulate the practices of senior nurses, thereby quickly fitting into the unit safety culture (paragraph 2.7.9).
As discussed in question 20 (Table 4.16), the majority of respondents indicated, by ticking off either ‘agree’ (33.7%) or ‘strongly agree’ (65.0%), that routine double-checks can reduce the risk of IV medication administration errors. This finding reveals that the respondents were adequately aware of medication safety and medication error prevention. Question 28 (Table 4.24) revealed that the patient’s assigned nurse as well as a second registered nurse must be involved in checking the five medication rights together by BOTH registered nurses performing the calculations independently. The respondents indicated this viewpoint by ticking off either ‘agree’ (33.0%) or ‘strongly agree’ (62.2%). Once again, it seems evident that the respondents were adequately aware of medication safety and medication error prevention. However, compared with the findings from question 8 (medication errors caused by missing one or more of the medication rights and the RN does not perform a double-check), it seems evident that there is non-compliance with this safety precaution.
Question 32 was formulated to test the opposite, namely that ONE registered nurse performs the calculation, as opposed to the stipulation that the patient’s nurse AND a second registered nurse should check, as tested previously in question 28. As tested in question 32 (Figure 4.4), the concern is that a majority of respondents indicated, by ticking off either ‘agree’ (33.0%) or ‘strongly agree’ (26.0%), that a double-check is performed by one registered nurse checking the dose and concentration calculation of the medication. However, a significant number of respondents also indicated, by ticking off either ‘disagree’ (22.0%) or ‘strongly disagree’ (19.0%), that a double-check should NOT be carried out by one registered nurse checking the dose and concentration calculation of the medication. It is possible that the respondents who
agreed and strongly agreed to this question, did not read the question well, or that the registered nurses were not following safety precautions that stipulate that two registered nurses should check the medication dose and calculation prior to the administration of IV medication. It is also possible that registered nurses do not properly understand how to check medications independently with another registered nurse. These findings seem to be in line with the recommendation from Johnson and Young (2011:134) that checking of the five rights prior to medication administration should be emphasised during orientation programmes.
According to the findings from question 8 (Table 4.4), registered nurses did not believe calculation skills to relate to medication errors. This finding is determined because a small number of respondents indicated that medication errors are caused by incorrect dosage calculations (6.8%) and the nurse’s lack of concentration (6.7%). Dosage calculation is a routine ICU nursing task, and this nursing skill is tested through mandatory nursing examinations that are written by all newly recruited nursing staff in their nursing orientation period. According to Bates et al. (2005:203), a significant and unnecessary variation in IV medication practice is associated with increased risk of patient harm. Hicks and Becker (2006:20) found that the leading underlying cause of error omission involved clinician performance deficit, like calculation errors (paragraph 2.8). Interestingly, the findings in this study (Table 4.15) identified dose errors and not calculation errors per se as a leading cause of IV medication errors (paragraph 5.2.1.1). Another practice variation which could affect the occurrence of a medication error was noted. As discussed in question 31 (Figure 4.3), the vast majority of respondents indicated, by ticking off either ‘agree’ (33.0%) or ‘strongly agree’ (54.0%), that a double-check includes checking the pump settings with another registered nurse and tracing the IV tubing to the injection site before the infusions are started. However, a significant number of respondents (13.0%) indicated that the pump settings are NOT checked with another registered nurse, despite this aspect being a policy requirement and therefore tested in the questionnaire. It is possible that the potential could be created for latent errors to exist in the practice environment if this safety precaution is not followed. The question arises: if the majority of respondents indicated that checks were performed by two registered nurses, why did medication errors still occur? When this information is linked with question 15 (IVs are accidentally switched) and question 19 (errors that occur are due to wrong dose), it seems evident that double-checks were NOT effectively performed.
From the above discussion it is clear that variations in medication administration practice cause medication errors. The analysis of this study’s findings provided an understanding of the factors that nurses encounter as a cause of medication errors. Since it takes one medication error to cause harm to a patient, nurses need to take pro-active action to reduce or eliminate the potential for medication errors in the practice environment.
5.2.2 Knowledge of registered nurses related to safe IV medication