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• W2969915384 abstract "The aim of this study was to determine nurses’ perceptions of supports and barriers to high-alert medication (HAM) administration safety. A qualitative descriptive design was used. Eighteen acute care nurses were interviewed about HAM administration practices. Registered nurses (RNs) working with acutely ill adults in two hospitals participated in one-on-one interviews from July–September, 2017. Content analysis was conducted for data analysis. Three themes contributed to HAM administration safety: Organizational Culture of Safety, Collaboration, and RN Competence and Engagement. Error factors included distractions, workload and acuity. Work arounds bypassing bar code scanning and independent double check procedures were common. Findings highlighted the importance of intra- and interprofessional collaboration, nurse engagement and incorporating the patient in HAM safety. Current HAM safety strategies are not consistently used. An organizational culture that supports collaboration, education on safe HAM practices, pragmatic HAM policies and enhanced technology are recommended to prevent HAM errors. Hospitals incorporating these findings could reduce HAM errors. Research on nurse engagement, intra- and interprofessional collaboration and inclusion of patients in HAM safety strategies is needed. 本研究的目的在于确定护士对高危药品(HAM)用药安全有利因素及障碍的看法。 采用了定性描述设计 就高危药品(HAM)用药实践采访了18名急症护理护士。2017年七月至九月,对两家医院护理重症成年患者的注册护士(RN)进行了一对一访问。内容分析用于数据分析。 三个有助于高危药品(HAM)用药安全的主题:组织安全教育、合作、注册护士能力以及参与度。过失原因包括各种干扰、工作量以及敏锐度。绕过条形码扫描和独立复查程序的行为十分常见。调查结果强调了专业内和跨专业合作、护士参与度、以及让患者加入高危药品(HAM)安全。 目前并未贯彻高危药品(HAM)安全策略。建议建立支持合作的组织教育、高危药品(HAM)安全实践教育、高危药品(HAM)实用政策并提高技术避免高危药品(HAM)过失。 采纳这些调查结果的医院能够减少高危药品(HAM)过失。需要对护士参与度、专业内和跨专业合作以及让患者加入高危药品(HAM)安全策略进行研究。 The World Health Organization recognizes that medication error is the leading cause of healthcare acquired injury, costing approximately 42 billion dollars annually, almost 1% of total global health expenditures (World Health Organization, 2017). A medication error is a failure to follow processes designed to assure patient safety from the time the medication is ordered until the medication is given and may or may not result in patient harm (PSNet Patient Safety Network, 2017). In the USA, 7,000 inpatient deaths occur every year due to medication errors (Flynn, Liang, Dickson, Xie, & Suh, 2012). Research into the frequency of medication error incidence varies from 5.3% (Bates, Boyle, Vander Vliet, Schneider, & Leape, 1995) to 22.2% (Härkänen, Voutilainen, Turunen, & Vehviläinen-Julkunen, 2016) depending on concept definitions and study designs. A synthesis of reports from 91 studies generated a median error rate of 19.6% (Keers, Williams, Cooke, & Ashcroft, 2013). Up to 50% of medication errors occur during medication administration, a problem of particular concern to nursing (Cousins, Gerrett, & Warner, 2012; Institute for Safe Medication Practices Canada, 2012). The incidence and significance of medication errors has generated international attention. The World Health Organization has made reduction in medication errors by 50% a priority (World Health Organization, 2017). One subset of medications has been identified as more likely to cause significant patient harm or death: High-alert medications (HAM). Additional medication administration procedures have been implemented in acute care settings to mitigate this increased risk (Douglass et al., 2018; Engles & Ciarkowski, 2015; Smeulers et al., 2015). High-alert medications are defined as medications that have an increased risk of causing patient harm when used in error (Institute for Safe Medication Practices, 2018). These drugs include antithrombolitics, antidiabetics, insulin, chemotherapeutics, anaesthetics, sedatives and opioids, among others. Although harm can occur even when a HAM is used correctly, the risks increase when associated with a medication error (Institute for Safe Medication Practices, 2018). HAMs appear in 14–50% of medication error incidents in acute care settings, 11–29% of which occur during the administration process (Cabilan, Hughes, & Shannon, 2017; Engles & Ciarkowski, 2015; Manias et al., 2015). In the US, the National Action Plan for Adverse Drug Event Prevention (ADE Action Plan) was developed to stem adverse HAM drug events causing patient harm (U.S. Department of Health and Human Services & Office of Disease Prevention and Health Promotion, 2014, p. 1). The eight common root causes of most medical errors, including medication errors, are: Communication problems, inadequate information flow, human problems, patient-related issues, organizational transfer of knowledge, staffing patterns and workflow, technical failures and inadequate policies (Agency for Healthcare Research & Quality, 2003). These factors are barriers to safe practice and have been associated with HAM errors. Examples of specific HAM problems include: Task interruptions due to workflow issues (Engles & Ciarkowski, 2015), frequent transfers from one ward to another (Manias et al., 2015), failure to implement bar-code scanning appropriately (Miller, Fortier, & Garrison, 2011) and insufficient HAM knowledge (Engles & Ciarkowski, 2015; Hsaio et al., 2010; Lu et al., 2013). Education on HAM safety is often omitted in basic nursing education (Engles & Ciarkowski, 2015; Lo, Yu, Chen, Wang, & Tang, 2013). This research demonstrates the multifactorial nature of HAM error and the influence of systems issues such as workload, distractions, technological complexities and human factors on HAM errors. Technological and procedural strategies have been developed to enhance HAM safety (e.g. technology prompts for the HAM independent double check procedure, smart pumps) to aid in error prevention (Douglass et al., 2018; Engles & Ciarkowski, 2015). Four quality indicators specific to HAM safety—availability of the HAM, electronic verification of the order, protocols and visual reminders—have been reported (Smeulers et al., 2015). Although research on safety practices specific to HAMs has begun to emerge, there is a gap in the current literature regarding nurses’ perceptions of supports and barriers to safe HAM administration. The insights of practicing nurses may generate new information on strategies to prevent HAM administration errors. The purpose of this research was to answer the question: What are nurses’ perceptions about factors that contribute to safe administration when caring for patients receiving HAMs? A qualitative descriptive study was conducted. Qualitative description is beneficial when attempting to discover the ‘who, what and where… to provide a comprehensive summary of an event’ (Sandelowski, 2000, pp. 338). This approach aligned with our aim of identifying the supports and barriers to safe HAM administration. Examination of a problem as multifaceted as medication errors is enhanced by a framework that recognizes the systemic factors contributing to human error. The use of a conceptual framework in qualitative research helps define research goals and methodological choices and connect to current literature (Collins & Stockton, 2018). Reason's Swiss Cheese Model (SCM) framed this research, specifically the development of interview questions and the deductive analysis of data (Reason, 1990, 2000). Reason posits that errors occur from system failures, when the confluence of protective factors used to prevent an error fail at exactly the same moment. Thus, error can be visualized as slices of Swiss cheese. When holes in the cheese align, gaps in the safeguards to prevent an error are exposed. In this model, human error is believed inevitable; protective factors prevent latent failures (problems at the organizational level that cause errors—blunt end processes) and active failures (errors that occur from individual slips and mistakes—sharp end processes) (Reason, 1990, 2000). Blunt end processes are the organizational systems, policies, procedures and resources that, when effective, contribute to safety. However, when blunt end processes fail (latent failures), sharp end processes (the patient–clinician interaction) must be relied on to prevent error. Active failures occur when the individual makes a patient care error. During the analysis of data, we deductively coded descriptions of participant and institutional practices according to the SCM to identify fit and outliers. Eighteen registered nurses (RNs) were recruited from two hospitals (one urban [251 bed], one suburban [272 bed]) in the mid-Atlantic region of the US. Nurses worked on critical care (CCU), intensive care (ICU), telemetry, emergency department, oncology, medical and surgical units. A purposive sampling strategy was used to attain a diverse (age, sex, race, ethnicity, experience) population of nurses who worked on units where HAM administration was common. Nurses self-identifying as having little experience administering HAMs were excluded from this study. A hospital-wide email explaining the study was forwarded to all nurses by the nurse educators at each hospital. A follow-up email was sent two weeks after the initial email. This was the extent of the involvement of the nurse educators in recruitment. RNs responded directly to the primary investigator (LS) by return email. Follow-up emails confirmed eligibility, answered participant questions, determined willingness to participate and established the participants’ preference for interview time and location. One interview was conducted in a private office at the college; the remaining interviews were conducted at the participant's hospital in a quiet location. Despite a follow-up recruitment email, only seven participants were initially recruited. A snowball strategy, where participants asked their peers to respond to the follow-up email, was used to recruit additional RNs. Each participant was entered into a raffle for a $50 gift card to express appreciation for their participation. One winner was awarded the gift card. The first author (LS) interviewed practicing RNs from 28 June–12 September 2017. Broad, open-ended, semi-structured interview questions based on the SCM were developed under the guidance of a senior human factors researcher (KC) (Table 1). The questions were trialled on two experienced nurses and minor adjustments made to the wording of some questions were made. The questions focused on supports and barriers to HAM administration safety. A senior qualitative researcher (LSN) reviewed early interviews and provided feedback to LS on interviewing technique. The interview format was informal, allowing participants to lead the conversation to issues they considered relevant. All interviews were audio recorded. The audio files were uploaded to a secure server within two hours and the original recordings deleted. All recordings were professionally transcribed by Rev.com. Personal identifying data were removed and the transcriptions validated for accuracy by LS. A reflexive journal was maintained. Initial and follow-up memos documented thoughts and ideas to be explored during data analysis. The university Investigational Review Board and both hospitals approved this study. Participants responding to a recruitment email received an information sheet describing the purpose of the study and risks and benefits of participation. They had the opportunity to ask questions prior to participating. Participants’ provided verbal consent and willingness to complete the interview. Transcriptions and analysis notes were stored on a cloud-based, secure server. No personally identifying data were kept in association with the data used for analysis. A computer assisted qualitative data analysis software program (NVivo Version 11, QSR International Pty.) aided data organization and analysis. Content analysis was used to identify, describe and make inferences about the qualitative data generated by the RNs. An integrated approach (both inductive and deductive) was used for data analysis (Bradley, Curry, & Devers, 2007). Starting with an inductive approach allowed us to immerse ourselves in the data to determine the concepts and themes most relevant to the participants (Hsieh & Shannon, 2005). Once the inductive analysis was complete, we performed a deductive analysis to evaluate the concepts and themes with the SCM. Data analysis was conducted by LS under the mentorship of LSN. As each new interview was conducted, initial ideas about concepts and themes were documented in memos. The interviews were then reviewed and areas where the interviewer may have influenced that questioning were documented in a reflexive journal. This was reviewed prior to the next interview in a conscious effort to remove interviewer bias. Each interview was then read word-by-word and coded to determine initial categories. Memos on ideas for initial categories were created. Findings from new interviews were compared with the old for consensus and disagreement. Categories were then reanalysed into meaningful clusters from which concepts and themes were developed. At each stage of analysis, findings were discussed by LS and LSN. Analysis continued until consensus was reached on concepts and themes. After 13 interviews, no new information was being generated. An additional five participants were interviewed. Data saturation was evident. No new volunteers were recruited. After consensus on the conceptual codes and themes, the authors reanalysed the data through a deductive process (August 2017–April 2018) to identify if and where the participant responses aligned with the components of the SCM. Processes to assure trustworthiness described by Elo et al. (2014) were incorporated into the preparation, organization and reporting phases of this study. These methods gave us a systematic strategy to objectively gather, quantify and describe the phenomena being studied, thereby enhancing the validity of the results. The first author (LS) collaborated with (LSN) to guide and validate the analytic methods and findings. Findings were discussed with two experienced acute care nurse educators to assess credibility of results. The Table S1 summarizes the data collection and analysis approach and steps taken to enhance trustworthiness. Nineteen RNs volunteered from each of two hospitals (one urban [N = 12], one suburban [N = 7]). One nurse was excluded for not meeting participant criteria (paediatric nurse). Most of the RNs interviewed were female (83%), White (72%) and had a Bachelor of Science in nursing (56%). Medical or telemetry units were the majority practice settings. Table 2 summarizes participant characteristics. Ten of 18 nurses provided a correct definition of ‘high-alert medications’. Examples of incorrect definitions included medications ‘with similar sounding names’, ‘with a high-alert label’ or ‘needing a cosigner’. The most common HAMs administered were intravenous heparin, insulin and hydralazine. Nine nurses learned about HAMs on the job, six during nursing school, two when caring for ill family members and one as an ICU technician prior to nursing school. Nurses described factors that contributed to safe HAM administration in three areas: Organizational factors, the nurse's competence and engagement, and collaboration. Table A1: Selected Statements, Meanings and the Development of Emergent Themes provides examples of the nurse responses that led to the identification of each theme. The nurses felt their organizations demonstrated a commitment to HAM safety in several ways. Nurses were encouraged to report HAM errors and were not penalized for doing so. When errors did occur, information about the causes and prevention were disseminated throughout the hospital. Resources were available to support safe HAM administration (computers, bar code scanning, HAM labelling and smart pumps). Nurses were involved in committees that developed policies and protocols for HAMs. Maybe a new doctor will not get a PTT [partial thromboplastin time] before heparin and they wanted to go off the grid, they wanted to do non-protocol heparin at the rate they want… and yet they will say, “Just do it.” I'm like, “Okay, that’s great you’re allowed to do that but what about a PTT first, the baseline?” “Do we have to?” “Yes.” Every nurse described the importance of technology for safe HAM administration. Computers allowed rapid access to information, such as protocols or medication information databases like Micromedex, needed to make judgements about patient care. Having the medication protocol/nomogram linked to the electronic medication administration record (eMAR) increased confidence in their ability to make decisions. When protocols were not available with a few clicks of the mouse, nurses were left scrambling for information, usually accessing non-hospital approved resources for information. Computer alerts reminded nurses of diagnostic data or assessments needed prior to HAM administration. Bar code scanning and prompts for the independent double check (IDC) procedure were seen as improving safety. ‘We scan the patient and if that is not the medication that is prescribed for that patient according to scanning them and then scanning the medication, we don't give it’. However, all nurses described ways to bypass these systems and stated that ‘work arounds’ such as having extra patient identification bands and medication labels to scan at the nurses’ station were common. The IDC procedure was also violated frequently, with nurses signing without checking the medication, or verifying after the HAM was started. The nurses provided three reasons for violating IDC procedures: Emergencies like a code; not having a nurse available to cosign when the HAM needed to be started; and a sense that the nurse was competent and therefore, their work did not need to be checked. ‘It's a matter of trust. I know a nurse. I know that [she's] a high-quality nurse. I'm not going to be ‘okay let me see that there's four units in the vial. I'm gonna trust her’. You're giving medications; you're doing the right thing…then get a phone call that they need you in Room 3 for something else. Well, what am I supposed to do? I'm giving these HAM… and then they want me to go to Room 3. Nurses knew they were being ‘timed on responsiveness’ to phone calls, increasing their perception of a need to rush through HAM administration. I think the clinical judgement is absolutely essential, because even if you do have the protocols in place, tell you where to start, what to do, how to change, a lot of times, they don't give you vital parameters. I'm not gonna start somebody on a Cardizem drip if their blood pressure's 80. And, some people don't have that judgement yet. They don't understand that yet. Nurses described the importance of working in an environment where it was safe to ask questions when they were unsure of their knowledge and they wanted ongoing education to remain current in their knowledge. Almost all nurses addressed that not every nurse was engaged in their patient care. When giving HAMs, these nurses practiced by rote when completing tasks and were not accountable for understanding why they were doing what they were doing. During report “you'd ask, ‘Oh, they're getting heparin. Why are they getting heparin?’ ‘I don't know’.” Safe nurses were described as never complacent; they understood the risks associated with HAMs and made sure to remain vigilant when caring for patients on these medications. But, they were concerned when working with nurses that were not as committed. ‘You can put in policies; you can put in procedures and everything. If somebody's gonna dance outside of the box when it comes to safety, then it's not adequate’. All nurses reported that they relied heavily on peers (the charge nurse, the nurse manager, unit specialists and nurse educators) as sources of information and support during HAM administration. Collaborative activities described included the IDC and communication regarding the correct way to implement HAM protocols. Conversely, nurses described situations where they did not feel safe to ask for help. As one nurse stated, ‘if you get that one experience where, I asked somebody for help, they looked at me like I was stupid, I'm not going to ask again’. Nurses also relied on interprofessional collaborations, especially with the pharmacist, to deliver safe, quality care during HAM administration. ‘We have a pharmacist on the floor and she's awesome, so you can ask her anything about any med. She'll put orders in for you; she'll double-check things for you’. Safe HAM administration required that all members of the interdisciplinary team perform their roles correctly. Nurses who took responsibility for verifying the accuracy of the HAM order and medication helped prevent errors. Nurses’ believed this was part of their role as a patient advocate and was essential to ensure patient safety. Five nurses reported that patients sometimes interfered with safe HAM administration. They described situations where patients were non-adherent to the protocol, refusing bloodwork and/or medications. However, nine nurses emphasized the importance of educating the patient and family about the HAM so that they could help keep the nurse informed of problems they were experiencing. These nurses felt that enhanced patient–nurse collaboration could help patients adhere to the complex medication regimens associated with some HAMs. After completing the inductive analysis, we returned to the data to determine if the identified concepts and themes aligned with the SCM. Nurses identified both latent and active factors that had an impact on HAM administration. Latent factors (organizational) that supported HAM safety included both the importance of safety as a value of the organization and processes to enhance safety. The nurses felt their organizations demonstrated a culture of safety by supporting an environment with resources for HAM administration, where nurses were included in development of policies and protocols and reporting HAM errors was viewed as an opportunity to improve practices. Latent factors that contributed to potential HAM errors were working conditions such as workload, patient acuity and distractions. These issues contributed to nurse inattention and the use of work arounds as nurses rushed to complete patient care. Although all nurses described the importance of intraprofessional and interprofessional collaboration to HAM administration safety, only two identified a specific organizational (latent) practice to enhance collaboration, the unit-based pharmacist. Nurses emphasized commitment to their patients as a motivation to take HAM administration seriously and relied on their clinical judgement to administer HAMs safely. Nurse competence and engagement prevented active failures (errors at the patient–nurse level). Despite this, most described active failures—slips (attention failure) and mistakes (breaking a rule)—that contributed to HAM errors. ‘I've seen several Heparin mistakes… the nurse didn't change it to the proper rate. They changed it to the proper rate in the computer, but they didn't change it to the proper rate on the pump’. They don't want to be stopped to get a finger stick every hour. They don't want a BMP [basic metabolic profile] every two hours. You try to give them a potassium replacement, they're refusing. After a while they're just like, You know what? Just leave me alone.” Conflicting nursing responsibilities—patient teaching about the HAM and why it is important, respecting the patient's autonomy and right to refuse the HAM, all while trying to implement the HAM order and follow hospital policies—can make HAM administration challenging. It is difficult to determine where these competing duties fit into the SCM. The answer may lie in the way we define HAM errors. Table 3 summarizes the barriers and facilitators to safe HAM administration described by participants. Fear of retribution Fear of confronting physician Fear of admitting a knowledge gap Root cause analysis Rewards and acknowledgment Disciplinary actions for flagrant disregard of safety policies and procedures Safety not a priority Culture inhibits questions Culture inhibits error reporting Safety part of mission and values of organization Safety is an expectation for all members Support culture of questioning Routine communications re: errors and prevention Cumbersome or overly complex processes Work arounds Lack of technology (insufficient number of smart pumps, computers) Technology failure (unable to scan) Resources hard to access Distractions Process analysis to improve work flow RNs involved in development of policies that impact work flow Protocols and policies tested before implementation Needed resources (medications, equipment) easily accessible Minimize distractions during HAM administration Cumbersome or overly complex protocols, policies or procedures Information incomplete (missing patient data, policies, procedures, protocols) Alerts and warnings inconsistently applied Technology failure Policies and procedures not overly complex or cumbersome RNs involved in development of procedures and protocols Information resources comprehensive and accurate Technologies efficient, effective and easy to access Computer algorithms Computerized provider order entry eMAR-associated data link (medication monograph, patient lab data) Smart pumps Availability of technology support Essential information on medication label Printed protocols at nurses’ station Patient acuity Number of assigned patients Patient non-cooperative Nurse fatigue and loss of focus Increasing staffing based on patient acuity, cooperation Adjusting load during HAM administration Lack of knowledge about HAM Inexperience with HAMs Dosage calculation skills inadequate Mixing HAM on unit Not knowing how to access resources Overdependence on computer Lack of institutional specific training Staff and agency nurses caring for patient's outside of their competency HAM education Ham simulation experiences Competency evaluation RN self-advocacy Facility orientation for new hires and agency nurses Continued RN development on HAMs Assignments with HAMs based on competency Lack of nurse commitment to HAM safety No personal accountability for knowledge gaps RN not doing what they know needs to be done Rote administration of HAM Institutional accountability of evaluation of RN competence Rewards and acknowledgment for safety behaviors Not holding peers accountable for HAM safety behaviours Peers complicit in work arounds Trust that peer would not make a mistake Peer collaboration encouraged Peer resource identified and accessible (team members, charge nurse, nurse manager, nurse supervisor) Standardized communication strategies employed Independent double check Lack of interprofessional trust Lack of standardized safety communication strategies (CUS) Verbal orders Interprofessional collaboration encouraged Unit-based clinical pharmacist available during HAM administration Data from this analysis were used to generate a model for HAM safety to help elucidate the complexities underlying safe patient outcomes when nurses care for those receiving HAMs. To this end, the authors proposed a descriptive model of nursing practice to prevent HAM error: HAM Safety: Nursing, Collaborative and Organizational Influences. The model proposes that these three interconnected themes are essential to safe HAM administration. In an organization that prioritizes a culture of safety, nurses who are engaged in their profession and have a high degree of competence work collaboratively to implement safe HAM care. Nurses whose judgement leads them to believe there is a safety concern with a HAM feel compelled to solve the problem because of their professional engagement. Nurses feel safe to address the issue because the organization makes patient safety a focus of all care. Nurses can trust they will not be unjustly penalized for problems outside of their control. Nurses collaborate with their peers to validate their knowledge and concerns about HAMs. They access readily available information resources to identify solutions to problems and collaborate with the pharmacist or health care provider to remediate the problem. Nurses negotiate organizational functions to deliver care and when problems develop, participate in remediation strategies to develop more effective processes. Our analysis identified three principal themes for HAM safety: An organization that emphasized a culture of safety, collaboration and RN competence and engagement. Together, these provided a holistic view of the multi-faceted influences on HAM administration safety. Research specific to safe HAM administration is emerging and while studies corroborate the findings of this research, our analysis identified several gaps in the current literature. Intraprofessional collaborations with peers as a source of HAM information were extremely important. The interprofessional collaboration deemed most important for HAM safety was the pharmacist. Increasing the patient's role in HAM care may also improve safety. RN engagement was considered essential to safety. Participants felt that nurses who were dedicated professionals were less likely to bypass safety practices during HAM administration. Nurse representation on committees that developed policies affecting HAM practice was important. It was felt that this would enhance the practicability of any policy or protocol implemented. Other findings were supported by current literature. An organizational culture of safety has been acknowledged as important to medication safety. Primary concerns identified by participants in this study, including inconsistent use of the independent-double check, workload and distractions were identified as factors contributing to medication errors in other studies (Mansour, James, & Edgley, 2012; Thomas, Donohue-Porter, & Fishbein, 2017). Establishing a culture of safety around" @default.
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• W2969915384 title "Nurses’ perceptions of high‐alert medication administration safety: A qualitative descriptive study" @default.
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• W2969915384 hasConceptScore W2969915384C2779328685 @default.
• W2969915384 hasConceptScore W2969915384C2780765947 @default.
• W2969915384 hasConceptScore W2969915384C33923547 @default.
• W2969915384 hasConceptScore W2969915384C36289849 @default.

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