EVIDENCE BASED PRACTICE in NURSING MODULE (EBPiN)
This case study provides an example of the assignment summarising and critically evaluating the current evidence related to medication errors during medicine administration in adult patients.
This case study is brief and not exhaustive or complete. When writing your report greater breadth, depth, references and accuracy are required. You must refer to the assessment criteria, guidelines and Frequent Asked Questions (FAQ) for an outline of the structure of your report together with specific details. All can be found on the module blackboard site.
This assignment example or case study should be used in conjunction with the e-Workbook and when preparing for the timetabled group seminars.
To explore the frequency and cause of medication errors during drug rounds.
The purpose of this report is to explore the frequency and causes of medication errors during drug rounds. The Background section will provide a clear rationale for the need to examine this area with nursing research evidence used to support the rationale. The literature search section will ……………………………………………………………………….
Medication administration is a process which includes the involvement of many healthcare professionals (Cloete, 2015) and remains one of the most common causes of harm to patients in hospital (Roughead et al., 2013). The Nursing and Midwifery Council (2010) state the medication process to be complex in nature, high risk and involving multiple interactions. Adhering to the “9 Rights” during medicine administration requires much cognitive attention (Elliott & Lui, 2010) especially when multiple medications are being administered (Rohde & Domm, 2018). Work interruptions or a break in the activity being performed in order to carry out a secondary task are ever present in nursing practice (Hopp et al., 2005). Hedberg and Larsson (2004) suggest nurses are interrupted 2.8 times per hour while Alvarez and Coiera (2005) state 14 times per hour. Nurses are therefore rarely able to complete any activity without being interrupted. While many interruptions may be amid benign care delivery, other intrusions such as during medicine administration, can severely compromise patient safety (Raban & Westbrook, 2014).
In reviews by Brady et al. (2009) and Parry et al. (2015) it is stated medication errors are a significant cause of morbidity and mortality in hospitalized patients. This creates an imperative to reduce medication errors in order to deliver safe and ethical nursing care. Most medication administrators are nurses and therefore when errors occur, nurses are frequently determined to be accountable (Burke et al., 2005). Hayes et al. (2015) recommend further exploration into the way nurses learn to manage interruptions and distractions during medication administration as they are a serious threat to patient safety. In a review of medication errors by Cousins et al. (2012) it is stated 526,186 errors occurred in England and Wales with 16% causing actual harm and 0.95% severe harm or death. Moreover, the cost to the NHS in litigation in 2007 was £770 million (Frontier Economics, 2014). Furthermore, failure to report any medication errors can have serious professional and psychological consequences for all involved (Vrbnjak et al., 2016).
Reid-Searl et al. (2010) suggest errors in medication administration can occur when junior staff have not received direct and appropriate supervision. However, Popescu et al. (2011) suggests interruptions during medicine rounds from other nurses is a main cause as drug administration frequently occurs in open clinical spaces where nurses may be viewed as more accessible to ask questions or seek advice on care delivery. Westbrook et al. (2011) examined type and severity of intravenous (IV) administration errors and established IV administrations had a higher risk and severity for error above other medication administration. Also, the errors uncovered for IV administration suggested nurses’ had skill and knowledge deﬁciencies. In a survey of nurses regarding errors by Picone et al. (2008), the greatest causes of medication error were omissions errors (49%) due to lack of administration (54%) or transcription errors (documentation) (38%). In a Swedish study by Bjorkstnn et al. (2016) medication errors over an 11 year period were examined with the most common errors being wrong dose (41%), wrong patient (13%) and omission of drug (12%). In 95% of the errors, approximately 1.4 individual contributory factors were established with the most common being negligence, forgetfulness or lack of attentiveness (68%), incorrect protocol (25%), lack of knowledge (13%) and practice beyond scope (12%).
Jones (2009) states the main causes of medication errors to be person-centred factors – lack of calculation ability, poor adherence to protocols and system factors (distractions, time pressures). Likewise, Brady et al. (2009) states the ability to acquire and maintain mathematical competency to be an important issue in the prevention of medication errors although Parry et al. (2015) suggests more attention should be given to the environment in which errors occur. A further study by ……………………………….………………………………………………………………………
This literature review will therefore examine medication errors to establish …………………………………………….
(TIP – approximately 1½ pages (BSc) 2 pages (MA) in length to effectively demonstrate the issue requires examining. Present much NURSING evidence in support as it is a NURSING review).
To explore the frequency and cause of medication errors during drug rounds.
A well designed research question often has four components frequently based on the PICO framework to identify the: patient problem or population (P); intervention (I); comparison (C); and outcome(s) (O) (Khodabux, 2016). However, the PICO framework has been criticised in relation to its application to ‘real-world clinical questions’ (Huang et al., 2006 p.4). A derivative of this simple method of question formation is the PEO framework (Bettany-Saltikov, 2012; Khodabux, 2016). Here P-population/ patient, E-Exposure and O-Outcome are employed. Both methods are similar although the PEO has no comparison section and therefore only three components (use of comparison not always appropriate or necessary) –
Population (Which patients or populations of patients are we interested in? How can they be best described? Are there subgroups that need to be considered?)
Exposure (Which is the intervention, treatment or approach that should be used/ suggested?)
Outcomes (What is important for the patient – safe, accuracy, 9 rights, non-maleficence [obligation to avoid causing harm], etc.)
Application of PEO framework
|Patient problem and /or population||Exposure||Outcomes|
|Adult, child or mental health patients||Medication errors during drug rounds||Uncover cause of errors during medication administration.
Explore possible relationship between errors and interruptions/ ability/ time/ reduced staff.
Reduction in medication errors
Evidence to support practice can be drawn from four areas – research, clinical experiences of health professional, patients’ experiences and local information such as guidelines and policies (Aveyard & Sharp, 2017; Rycroft-Malone, 2004). However, research evidence will be used in the reviewed papers for its objectivity (Davis, 2016). Research studies were identified by searching two health databases MEDLINE and CINAHL because they contain articles that evaluate health care interventions and include a wide range of topics such as medication errors (Rowles & McNaughton, 2017). Studies published between January 2008 and December 2018 were included as searching for the last 10 years is generally accepted as the most pertinent method in gaining contemporary research evidence (Aveyard & Sharp, 2017). Opportunities in clinical practice when working with mentors and time spent with other health care professionals were used to discuss medication errors and gain associated documentation. The Trust intranet, Library and ward resources were accessed in order to identify local policies, protocols and guidelines in relation to medicine administration and error reporting. All information was carefully noted and categorised (Wright, 2010; Wright & Ferns, 2010). To undertake the database search the topic was broken down into keywords that were linked together (Davis, 2016). The example below relates to the keywords used and how the search terms were linked. Any keywords from the studies uncovered were also used. An example of the search strategy retrieved from CINAHL is provided on page 6 in the e-Workbook and should be placed in the assignment Appendix.
|Child/ adult/ mental health patients||Hospital||Medication|
|Child health||Wards||Medication errors, nurs*, drugs.|
|Mental health||Clinical area||Mistakes, near miss, observations, discrepancies|
|Adult Health||Acute setting||Interruptions, patient safety, distractions.|
(TIP – the subject and quality of an assignment can be quickly gained by a glance at the reference list – a markers first task. Ask someone to look at the reference list and if the topic is not immediately apparent and good quality NURSING journals/ research in limited supply – reconsider)
Various search strategies were used such as truncation ….., wild cards….. and the use of Boolean operators…..and this had the effect of …………….. This is resulted in …. articles being identified. Inclusion and exclusion criteria were then applied ……. and the abstracts were read. The flow chart (hypothetical example) identifies how the final …….. (number) of articles were gained and ….. (dates) supports this is a sufficient quality and quantity of articles for undergraduates to deal with in assignments at Level 6 BSc (Hons) (Aveyard, 2014). For MA, students many more than n=10 research papers is anticipated.
Summary of the evidence
The …. (number) research papers included in this review all relate to the frequency of medication errors during drug rounds. Studies were undertaken in a total of …….….. countries with an overall …… observations of medicine administration viewed and a total number of surveys as ………. and nurse participants……….. The total level of medication errors established was………… Table 3 (Characteristics of Studies) below provides a succinct overview of all the studies included in the review.
Four research papers are quantitative observational studies (Berdot et al., 2012; Härkänen et al., 2015; Kelly & Wright, 2012; Palese et al., 2009) undertaken in four different countries although all concerning adult patients in the acute hospital setting. A study undertaken in America (Fasolino, 2012) used a mixed methods approach (qualitative and quantitative methods) and examined the similarities/ differences between medical-surgical nurse characteristics, practice environment, team member effectiveness and medication errors in an attempt to identify any significant links. Three research papers involved a survey of nurses (Fathi et al., 2017; Kim et al., 2011; Unver et al., 2012) with one research paper using a validated medication errors questionnaire (Unver et al., 2012) whereas Fathi et al. (2017) and Kim et al. (2011) simply asked nurses for their experience of errors and error reporting. Four studies used ……………………….. Six studies were ………………. Four studies were ………………………………….. The final two studies were ………
Characteristics of Studies Table (Incomplete as not all studies listed)
|Author (s), date and country of origin (STUDIES LISTED IN AUTHOR ALPHABETICAL ORDER)||Aim of
|Determine incidence, type and clinical importance of drug administration errors and to identify risk factors.||Disguised observation on four wards (800 beds). Pharmacist shadowed nurses and witnessed 3 drug rounds over 6 days. 28 nurses caring for 108 patients observed. Main outcomes – number, type and clinical importance of errors and associated risk factors.||Among 1501 chances for error, 415 administrations with one or more errors were detected (28%). 312 wrong time errors, ten together with another type of error, resulting in error rate without wrong time error of 8%. No potentially life-threatening errors witnessed although 6% of errors were classified as having important impact on patients (mainly omission).|
|Examine link between clinical contextual factors and medication administration errors.||A mixed-methods, correlational design. Associations examined among medical-surgical unit nurse characteristics, practice environment, team member effectiveness versus medication errors. Questionnaires distributed to n=248 RNs with n=163 returned.||Statistically signiﬁcant relationship between RN age and experience/ medication errors. Fewer medication errors made by older and more experienced RNs. They were able to effectively use thinking skills to evaluate medication records and identify possible mistakes.|
|Examine prevalence and types of medication errors as well as barriers to reporting.||n=500 nurses surveyed using non-validated questionnaire regarding main causes of errors together with barriers in reporting errors.||Error occurrence 17%. Most common errors were administering medications at the wrong time (24%), incorrect dosage (17%), and wrong patient (14%). A heavy workload and high number of patients considered main causes. 45% did not report their errors.|
|Describe frequency, types, and severity of medication errors in medical and surgical inpatients as well as the relationship between medication errors and other factors.||A cross-sectional study using direct observations and medication record to assess 32 registered nurses administering 1058 medications to 122 inpatients in 4 medical and surgical wards. Observations recorded using structured observation form and patients’ medication record (n = 122) before and after observations were conducted.||At least one error found in 22% of administered medications. 63% were medication administration errors and 18% documentation errors. Of the medication administration errors, 59% involved an incorrect administration technique. 3% of errors caused harm to patients.|
|Assess severity of medicine administration errors to older patients.||Undisguised observational study of n=62 nurses administering oral medicines to n=625 patients. Data collected on preparation and administration of oral medicines.||n=65 drug rounds observed. n=2129 drug administrations made to 625 patients, of which 817 doses (38%) were given incorrectly. The number and severity of errors observed high compared with previous studies.|
|Identify Korean nurses’ perceptions of medication errors.||A cross-sectional convenient sample survey of n=330 nurses from 7 hospitals. Participants asked to identify contributing factors of medication errors, reporting and strategies to prevent errors.||64% of participants had been involved in medication errors once or more in the past month. Factors contributing to medication errors (45%) ‘advanced drug preparation and administration without rechecking’. Only 14% informed patients and their families of errors with 28% submitting an incident report. Medication errors occurred most often during day-shift.|
|Examine frequency and perceived risk of interruptions to nurses during drug rounds.||Observational study to a) follow n=56 randomized drug rounds, n=8 for each ward, and b) n=28 of the nurses observed interviewed.||n=298 interruptions observed (one for every 3.2 drugs given). Ten different categories of interruption emerged. The highest risk of error from interruptions perceived by nurses related to the management of telephone calls.|
|Investigated perspectives of newly graduated and experienced nurses concerning medication errors.||n=169 nurses surveyed where n=87 were new graduates and n=82 experienced nurses. Modiﬁed Gladstone’s Scale of Medication Errors used to collect data on rates, causes and reporting of errors.||Two highest perceived causes of errors were nurse exhaustion and distraction. Most medication errors were preventable. Reasons for errors and failure to inform co-workers of errors examined further.|
Quality appraisal and discussion
Evidence Based Practice
Sackett et al. (1996) defined evidence-based practice as “the conscientious, explicit and judicious use of current best evidence’ to inform practice” (p.2). It is recognised, however, the quality and reliability of some evidence may vary when subjected to the Hierarchy of Evidence (Aveyard, 2014; Evans, 2003). However, the application of the Hierarchy of Evidence was based on the assumption that research, in particular quantitative research, forms the best available evidence although many would disagree with this (Noyes, 2010). Moreover, Holland and Rees (2010) found the Hierarchy of Evidence requires professionals to accept whatever research is classed as ‘best evidence’ over their personal expertise. A number of authors explain evidence based practice is more concerned with the integration of expert knowledge, research evidence plus experiences and perspectives of the patients (Craig & Smyth, 2012; Holland & Rees, 2010).
Identifying best practice is important because not all research evidence is appropriate or applicable to all clinical practice (Parahoo, 2014). For example, the results of this review in adult nursing may not be appropriate in adult community nursing or in an adult mental health setting. The need for evidence based practice is highlighted across Government Policies and professional guidance (Nursing and Midwifery Council, 2015) specifically directing nurses to deliver the best available practice in order to provide high quality care. To be able to do this, nurses must have the ability to confidently read and critically appraise published research papers in order to assess, understand and determine its effectiveness and applicability to practice (Mould et al., 2017).
To assist in the appraisal of research, many differing assessment tools are available (Hawker et al., 2002) and are very useful to the novice appraiser (and experienced appraiser) as they provide insight to help consider and question research papers in a structured and consistent manner (Aveyard, 2014). Tools such as the Critical Appraisal Skills Programme (CASP) (Public Health Resource Unit, 2006) are commonly used although CASP can be quite advanced and undergraduate students may find it too complex (Caldwell et al., 2005). To overcome this, Caldwell et al. (2005) developed an appraisal tool specifically aimed at the needs of undergraduate students and will be used in this review. Although Caldwell et al. (2005) provides a number of questions to consider, only the aspects pertinent to the specific papers will be highlighted as opposed to a ‘tick box’ or ‘checklist’ approach as this was never the intention of the Caldwell et al. (2005) tool. The tool merely highlights areas for ‘potential’ appraisal.
Appraisal of the Evidence
(TIP – Critical appraisal is one of the most important aspects in all assignments at Level 6 and beyond (see marking guide). The majority of issues of appraisal are frequently rooted in the research papers’ Methodology sections or Clinical Application. Keep any description of the research papers succinct, as it is appraisal of the research that is central in this section. The ability to build a ‘brief picture’ of the research undertaken together with succinct strengths/ weaknesses is important as it demonstrates your ability to think critically and analytically.
Many students when first undertaking critical appraisal take one paper separately in one paragraph then the next paper in another paragraph and so forth. However, students with more experience of critical appraisal may group several studies together and appraise over-arching aspects such as sample size, etc. Both methods are acceptable although the example below appraises one paper per paragraph as it is a simpler approach. In either case, it is helpful to use sub-headings to logically introduce the papers e.g. Qualitative research studies, Quantitative research studies, etc. A brief and succinct description starts each paragraph to enable a coherent introduction of the research undertaken followed, crucially, by some aspects of appraisal (underlined here to help demonstrate). Try to appreciate the difference between mere description (often always available in the original paper) and critical appraisal (largely absent from the original research paper)).
Quantitative Research Studies
In a French study by Berdot et al. (2012) a pharmacist accompanied nurses to witness the preparation and administration of medicines’ to patients during three drug rounds for six days on a total of four wards. Overall n=28 nurses caring for n=108 patients were observed and any errors documented. However, the study did not gain ethical approval as it was deemed an audit. However, nurses involved in the observations were requested to sign a consent form. When undertaking an audit, consent forms are not normally employed (Grant et al., 2013; Twycross & Shorten, 2014). Moreover, observation of the nurses was disguised although no explanation is provided to how the disguise was undertaken in the midst of four clinical environments totalling 800 beds. A positive aspect to the study was just one observer was used (clinical pharmacist) who received 1 months’ training from a senior pharmacist before the start of the study and a standardised form used to record potential errors. Using just one observer avoids issues of inter-rater reliability (Parahoo, 2014; Salmon, 2015) (multiple observers possibly recording different scores) and a standard form allows for quick , simple and standardised categorisation (Timmins, 2015b; Upton & Upton, 2006).
Fasolino (2012) examined the possible link between clinical environment and medication administration errors by recording nurse characteristics, practice environment, team member effectiveness versus medication errors. A non-validated questionnaire was distributed to n=248 Registered Nurses in one American hospital concerning team member effectiveness, nurses’ ability and unit type. This rating was then compared to medication errors in the individual units when the questionnaires were completed. However, the error rates for some clinical units were not available and nurses’ perceptions of team member effectiveness was only very weakly positively related to medication errors. Very weak correlations can have little clinical impact (Malone & Coyne, 2017). Moreover, although data identified the weaknesses in individual units, the hospital managers refused to release the information, as public sharing of care quality was regarded as too sensitive. Ultimately, the findings were not therefore used in the clinical environment to improve medication error rates. When undertaking research in sensitive areas managers can sometimes refuse to allow the data to be distributed, used or published (Lee, 2009). The whole purpose of this study is therefore questionable.
A total of n=500 nurses from seven with at least 1 year of practical work experience in the hospital setting were surveyed using a questionnaire designed to ascertain the main causes of medication errors together with barriers in reporting (Fathi et al., 2017). The main errors were identified as administering medications at the wrong time, dosage errors and to the wrong patient. However, the study states no significant association between the frequency of medication errors and nurses’ age, marital status, socioeconomic status, level of educational attainment or years of experience. This is quite an erroneous finding as no justification for examining such demographic data was provided in the Background information and no academic support given to pursuit such figures. Participants were therefore asked to complete survey items for which there was no theoretical justification (Kelley et al., 2003; Polit & Tantano Beck, 2014), that is, demographic details versus medication mistakes. This is often referred to in informal research terms as ‘fishing’.
In a further survey by Härkänen et al. (2015) undertaken in Finland ………………………………
From the n=20 studies in the literature review three clear themes emerged – interruptions, staff ability/ knowledge and workload/ staff shortage. Each theme will be discussed below and the relevant evidence used to support the established findings.
In an observational study by Lemos et al. (2012) distractions could not be linked directly to medication errors although 100 factors causing distraction during medication administration were identified – telephone/ mobile phone ringing, interruptions from healthcare professionals, changes to medical prescriptions, overlapping tasks concerning medication times, lack of formal care planning, etc.. Reed et al. (2018) established 39% of medication errors were due to interruptions and nurses were likely to delay the medication task to attend to the interruption task or multitask or delay responding to the interruption until the medications were completed. Johnson et al. (2017) stated interruptions occurred repeatedly during medication preparation (99%) leading to errors and the primary source of the interruptions came from other nurses. Nurses continually had to stop medication preparation or administration to address the interruption (mean 2.5 minutes). Blignaut et al. (2017) uncovered 296 medication errors mostly concerning wrong-time or omissions and interruptions were significantly related to wrong-dose and wrong-route errors. Palese et al. (2009) established error rates were high when nurses were interrupted by telephone calls and recommended improved organisation of work and the creation of a calm atmosphere for drug administration. Westbrook et al. (2010) discovered ………….
2) Staff ability/ knowledge
3) Workload/ staff shortage
Effective dissemination is essential if information about healthcare developments and practice are to be adopted and is a key element of evidence-based practice (Timmins, 2015a). Sharing findings from this literature review will enable nurses to make decisions regarding care based on current information about medication errors. A range of strategies will be used to disseminate the findings including developing information for the clinical area (Hewitt-Taylor, 2006), journal clubs (Mattila et al., 2013; Wilson et al., 2015), discussing findings with the clinical managers (Grol & Grimshaw, 2003), presenting at the university student conference (Alexandrov & Hennerici, 2013) and preparing the report for submission for consideration for publication (Bourne, 2005; Gennaro, 2012; Happell, 2012; Oermann et al., 2010). A poster presentation for the clinical environment can be of good use in an easy-to-read format (Wood & Morrison, 2011), informative and well-designed (Bingham & O’Neal, 2013; Corkill, 2012). Viewing posters around the Trust or the Higher Education Institute (HEI) to gain ……………………………………………..
Barriers to implementation
The main aim of an evidenced based approach is to use evidence to improve clinical nursing practice (Hewitt-Taylor et al., 2012). Disseminating evidence is not sufficient on its own. A main barriers often quoted are lack of time (Tan et al., 2012) and knowledge (Fink et al., 2005) or not having the authority to change practice (Kocaman et al., 2010). Ubbink et al. (2013) suggests ………………………………………..
This report examined medication errors and …..(succinctly reiterate main points from each section).
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