Nurse’s knowledge and Practice regarding Medication Errors in Critical Care Units: Descriptive study

Al Shaimaa Moustafa Fathy1, Nahla Shaaban Khalil2, Naser Mohamed Taha3, Marwa M.Abd-elbaky4

(1)            B. sc in critical care nursing, Faculty of Nursing, Minia University, Egypt.

(2)            Assist Professor of Critical care Nursing Department, Cairo university

(3)            Professor of Cardiology, Faculty of Medicine, Minia University, Egypt.

(4)            Lecturer of Medical Surgical Nursing, (critical care nursing), Faculty of Nursing, MiniaUniversity, Egypt.

Discussion

Regarding the demographic characteristics of the study subjects, the current study revealed that, the most of the critical care nurses aged was between (20-29) years and their mean average ± SD was (26.7 ± 1.30) years: This may be due to the desire of university's hospital to provide high-quality health care services, through employing new graduates of the faculty of nursing or nursing technical institute in critical units.

 As regards their qualification result found that more than half of them (61.6%) had graduated from technical institute degree in nursing. This may be explained by a little number of faculty's graduates had employed in the university hospital and other work in schools or ministry of health hospital.   On the other hand, the highest percentage of them constituted (96.7%) had from (1-3) years of experience working at critical units.. Finally, more than half of the study group (55%) works in morning shift. This may due to routine and increase work load at this time.

This result come in the line with (Sa’ed et al., 2019) who conducted a cross-sectional study named ''Knowledge about the administration and regulation of high alert medications among nurses in Palestine'' and reported that most of them were between the ages of 25-30 years, But the current study contrasts with the same author who reported that  most of nurses had 5–10 years of total experience.  And the majority of nurses had a bachelor degree in nursing.

Moreover, the current study contraindicated with (Alhashemi, Ghorbani, & Vazin, 2019) who contemplated a case–control study entitled “Improving knowledge, attitudes, and practice of nurses in medication administration through enteral feeding tubes by clinical pharmacists” and detailed that the mean age of nurses was 32 years, and almost two third of them were ladies. By far most of participants in two groups had a four-year college education in nursing. Further, But the current study come in the line with the same author who reported that the mean years of experience among participants in a critical care unit and as a nurse was two and five years.

In addition this outcome comes in concur with (Farag, Eweda, & Elsayed, 2017) who conducted a study titled ''Nurses Knowledge and Practice in Dealing with High Alert Medications'' and reported that short of what one third of the contemplated nurses were from (41 to less than 50) years old, while; of them, one fifth were <30 years old and the experience years of the most were <18 years in the relegated departments.

Regarding Frequency distribution of critical care nurse's knowledge level regarding medication administration errors in CCUs, the present study revealed that most of nurses obtained unsatisfactory knowledge regarding general knowledge & MAEs respectively. This may due to inadequate training in the area, the absence of regular group discussion to refresh their knowledge regarding medication errors , lack of motivation, increased nursing workload which made the delay of nurses abilities and motives to acquire and update their knowledge. On the other hand more (58.3%) only had got satisfactory level regarding medication preparation errors.

 This result comes in the line with (Mansour, 2019) who studied “Effect of Maternity Nurses Knowledge and Practices Regarding the Medication Errors on Laboring Women Safety in Labor Unit” and reported that greater than half of the studied sample had incomplete satisfactory information.

But his result differs with (Samundeeswari & Muthamilselvi, 2018) who studied ''Nurses Knowledge on Prevention of Medication Error'' and reported that one third of the studied nurses are on average in the information of ME. Short of what one third of nurses have poor information, slightly above quarter of nurses have very low level of knowledge and only 8% of nurses had good information on prevention of ME.

Additionally, the current study contraindicated with (Dyab, Elkalmi, Bux, & Jamshed, 2018) who studied “Exploration of Nurses’ Knowledge, Attitudes, and Perceived Barriers towards Medication Error Reporting in a Tertiary Health Care Facility: A Qualitative Approach” and reported that the nurses were knowledgeable about Medication Error Reporting, however there was vulnerability towards detailing innocuous MEs. In addition, (Kaur & Charan, 2018) who conducted “a study to assess the knowledge regarding medication error among staff nurses at SGRD hospital, Amritsar, Punja” reported that almost two third of nurses were on average knowledge followed by less than one third of them having poor score level. 

Regarding critical care nurses mean practice score for medication’s preparation, administration, and after administration .the current study revealed the overall mean practice score of critical care nurse was 23.1+4.58 out of 32. Along these lines, they picked up 13.65+2.97 out of 20 in preparation of drug. While they had low mean score 3.37+0.84 out of 5 in After medication administration.  This may due to lack of continuous educational programs and practice sessions regarding medication administration.  

This result come in accordance with (Abd Elmageed et al, 2020) who delineated that the mean and standard deviation of the nurse's preparation for medication is 50.66±11.85, while in drug administration it was 122.19±14.65 and in nurses’ practices post drug administration, it was 44.17±14.76. In relation to the nurse's total practice for drug administration it scored 267.05±29.62.

Besides, (Wabe, Raju, & Angamo, 2011) who studied “Knowledge, attitude and practice of patient medication counseling among drug dispensers in North West Ethiopia” reported that post medicine practice requires improvement. This finding might be ascribed to the remaining workload that makes the nurses practice described by low-level of performance.

Concerning frequency distribution of critical care  nurses practices level regarding medication administration errors, the present result showed that only more than one-third of them had satisfactory practices in the preparation of medication, only more than one third of them had satisfactory practices during medication administration, the majority of them had satisfactory level of practice after drug administration and only one third of them had total satisfactory performance about drug administration.

This result come in the line with who studied (Abd Elmageed et al, 2020) “Knowledge, Attitude and Practice of Nurses in Administering Medications at Mansoura University Hospitals” that greater than three quarters of the nurses have helpless practice score with respect to drug preparation, trailed by marginally greater than three fifths of them revealed poor practice level regarding medication administration as well. Besides, marginally under two fifths of the nurses have helpless practice post administering drug. Ultimately, around half of the nurses have poor total practice level.

Regarding the correlation matrix between nurses total knowledge with practices sub items regards medication administration, the present study showed that there were a fair positive correlation critical care nurse practice after medication administration with their knowledge about medication preparation errors, their practices in medication preparation, and during medication administration (r= .305, P – Value < .018, r= .458, P – Value < .0001, r= .467, P – Value < .0001 respectively). Likewise, there was reasonable positive relationship between critical care nurse practice during medication administration with their medication preparation (r=.549, P value < .001).This may due to lack of knowledge may have an effect on nurses practice. So they need for courses to update their knowledge and improving their practice  .

This come in accordance with (Bakr Abo El–Ata et al., 2019) who revealed that there were an exceptionally statistical significant correlation between  knowledge and practices in MEs (r=0.26 and p value=0.02). this outcome was upheld by (Abd Elmageed et al, 2020) who reported that there is a measurably  statistically significant relation between nurses’ knowledge, practice and attitude in drug administration.

Regarding the Correlation matrix of nurses total knowledge, practices sub items the present study demonstrated that there were solid positive correlation between total  observation performance of critical care nurse and their performance in preparation of medication and during medication administration (r = .927, P – value < .0001& r = .794, P – value < .0001 respectively), fair positive relationship between critical care nurse  performance during medication administration with their preparation of medication and total  observation performance of critical care nurse with their performance after medication administration  (r = .549, P – value < .0001& r = .646, P – value < .0001 respectively),  and moderate positive correlation between critical care nurse  performance after drug administration with their drug preparation and during drug administration (r = .458, P – value < .0001& r = .467, P – value < .0001 respectively). 

This outcome comes as per (Márquez-Hernández et al., 2019) who studied “Factors related to medication errors in the preparation and administration of intravenous medication in the hospital environment” and revealed that there were measurably huge contrasts found between nurses knowledge and performance.

This result were confirmed by (Bakr Abo El–Ata et al., 2019)who revealed that there was a profoundly positive correlation between practice and knowledge of nurses and there was an indicative positive correlation between their attitude , knowledge and practice. Additionally (Hassan & Ahmed, 2012) detailed a similar result.

Likewise (Shahin, Mohamed, & Sayed, 2012) who studied “'Nurses' knowledge and practices regarding Enteral Nutrition at the critical care”' reported that a profoundly positive correlation between practice and knowledge of nurses. A similar result was outlined by (Abd Elmageed et al, 2020)

With respect to Critical care nurses MCQ responses regards general knowledge of medications administration and preparation errors, the current study showed that more than one third of nurses know the definition of MAEs, slightly less than three quarters of them identified the hazards of MEs and how to prevent them, less than half of them mentioned nursing roles in the MAEs, and only one tenth of them answered correctly patient's rights before medication administration. This result agrees with (Shaikh & Al-Ruzaiqi, 2019) who conducted a study named “knowledge and perception of preventable medical errors in sultanate of Oman” and revealed that the most of participants had heard about the MEs and the majority of them were eager to know the MEs.

Furthermore this outcome was upheld by (Teal, 2019) who studied “Associate and baccalaureate degree nursing students' knowledge of and attitudes toward medication errors and reporting medication errors: implications for curriculum development” and revealed that at nursing students, they failed to define MEs, or to know its types, and causes. This study additionally found that students do not know how to report a ME.

But These results come inconsistent with (Di Muzio, De Vito, Tartaglini, & Villari, 2017) who studied “Knowledge, behaviors, training and attitudes of nurses during preparation and administration of intravenous medications in intensive care units (ICU). A multicenter Italian study” and detailed that the most of the studied nurses were aware of MEs.

Regarding medication preparation errors the current study showed that less than two third of study group had false answer regarding they checked right patient in medication preparation errors while two third of them had true answer regarding they checked right medication, medication name and prescription of medication.

This outcome comes in accordance with (Bucknall et al., 2019) who studied “Nurses’ decision‐making, practices and perceptions of patient involvement in medication administration in an acute hospital setting” and stated that most of the contemplated sample do checking for patient identification, the medication name, checking the dose, the route, and the time as well as patient education about medications, dose calculation, observing the patient while consuming the medications, checking medicine for another nurse in name, dose and route.

Yet, this finding contraindicated with (Abukhader & Abukhader, 2020) who studied “Effect of Medication Safety Education Program on Intensive Care Nurses’ Knowledge regarding Medication Errors” and detailed that the greater part of the contemplated test had agreeable information in regards to following the international patient safety goals and guidelines of intravenous drug administration.

Regarding critical care nurses MCQ responses regards medication administration errors, the present study showed that most of nurses had got false answer related to the time of documentation and the minimum amount of time a client must be observed after taking intravenous drug. On the other hand, three fourth of nurses had given true answers related to recommended route for heparin injections and position the client for suppository medication.

This come in accordance with (Bakr Abo El–Ata, Hassan Ibrahim, Saad Mohamed, & Elsayed Ahmed Allawy, 2019) who studied “Nurses’ Performance Regarding Administration of Inotropic Medications for Critically Ill Patients” and revealed that the most of nurses had an unacceptable degree of knowledge and the majority of studied nurses had unsuitable complete practice with almost the majority of studied nurses had had an uplifting attitude toward administering inotropic drugs.

Likewise, this result come in the line with (Lan et al., 2014)who studied “Medication errors in pediatric nursing: Assessment of nurses' knowledge and analysis of the consequences of errors” and detailed that almost two third of the studied sample had unacceptable level of knowledge regarding drug administration.

The current result were confirmed by (Zarea, Mohammadi, Beiranvand, Hassani, & Baraz, 2018) who studied “Iranian nurses’ medication errors: A survey of the types, the causes, and the related factors” and reported that greater than half of the studied nurses giving medicine to patients later or earlier, greater than one third of them give multiple oral drugs together regardless of their interactions and greater than one third of them administering the postoperative pain relieving drugs without a prescription.

Regarding critical care nurses’ done/not practices done during preparation of medication, the current study revealed that almost two thirds and three fourth of critical care nurses showed that they didn’t check instructions regarding administration of drugs and crushed medicines, the nurse establishes that these have been sanctioned by a medical practitioner or pharmacist. A clean pestle and mortar is used and it is cleaned after each resident with warm water and detergent and wiped with a dry hand towel.. This might be identified with the absence of strategies and roles that controlling drug administration.

outcome comes conflicting with (Mahesh, Hajira Saba, & Gopi, 2016) who studied “Nursing perceptions of medication administration practices, reasons for errors and reporting of errors in a tertiary care hospital, Bangalore” and reported that the majority of nurses consistently checked the composition of the medication before administration. This outcome is affirmed by (Westbrook, Rob, Woods, & Parry, 2011) who detailed that most of the contemplated nurses didn’t aware of drug protocol.

Likewise, the current study showed that the greater part of nurses checked the prescribed route and forms of each medication, checked that there is a valid, clear prescription for each drug, reads the medication prescription without difficulties, checked the prescribed dosage, checked the prescribed time and administered dose accurately.

This outcome comes as per (Mahesh et al., 2016) who detailed that most of the studied sample consistently checked the expiry date prior to administering the drug and consistently practice sterile technique for administering intramuscular and intravenous medications.

Likewise, this outcome was affirmed by (Karttunen, Sneck, Jokelainen, & Elo, 2020) who studied “Nurses’ self‐assessments of adherence to guidelines on safe medication preparation and administration in long‐term elderly care” and revealed that nost members guaranteed to consistently get ready medicine as indicated by the relevant guidelines. (Gilani, 2020) Who studied “Practices of Nurses in Administration of Safe Medication” detailed a similar outcome.

This outcome comes as per (Bucknall et al., 2019) who studied “Nurses’ decision‐making, practices and perceptions of patient involvement in medication administration in an acute hospital setting” and showed that most of the contemplated nurses checking patient identification, the drug name, the dosage,  the route and the scheduled time prior to giving drug.

Regarding critical care nurses’ done/not done practices during administration of drug, the current study showed that two thirds e nurses didn't communicate information sensitively to the resident before and during administration of medicine. This outcome come conflicting with (Bucknall et al., 2019) who expressed that the greater part of the contemplated nurses gives patient with required education about medicine. 

On the other hand most of nurses confirmed the patient's identity before administering medication, three fourth of nurses administered all drugs are personally, and they disposed non administered and squandered drugs or sharps. this outcome comes as per (Karttunen et al., 2020) who stated that over half the participants claimed to administer medication to patients in accordance with the provided guidelines. Also this result come in accordance with (Bucknall et al., 2019) who revealed that the majority of the considered nurse checking patient identification prior to giving drugs.

The present study showed that greater than half of critical care nurses didn't records monitoring data related to administered medication. On the other hand, all nurses reported the abnormal findings to physician. These findings may be related to the work overload or the lack of policy that guide medication administration.  

This finding additionally is in concurred with (Westbrook et al., 2011) whom found that the studied nurses neglect to follow medication rules and record drug. This result come inconsistent with (Kirubakaran & Amirtham, 2017) who studied “Knowledge and practice of intensive care unit nurses on intravenous drug administration” and reported the majority of the contemplated nurses were whined to nursing practice of the medication administration protocol.

Conclusion

The majority of the study participant had un satisfactory level of knowledge and practice.So these results showed that there is a wide gap between nurse's knowledge and their practice regarding medication administration errors.

Recommendations

Based on the findings of the present study and the researcher was suggested that;

• Implementation and dissemination of comprehensive, systematic, and continuous educational programs in order to enhance the knowledge and practices of nurse’s on medication administration practices which will decrease the medication administration errors and using interactive teaching methods and technology in order to increase the efficiency of in-service trainings.
• Drug-related information are required in order to prevent the errors that may arise during practice to ensure quality. Designing safe work environment conducive for patient care delivery and reduce the occurrence of medication administration errors.
• The implications of this research study have relevance to future nursing research as well as other related disciplines in the following ways.