ABSTRACT
Drug administration is a core responsibility of nurses.
Medication error occurring during the drug administration process can be
attributed to varied effects on patients’ safety, ranging from the errors going
undetected to prolonged hospital stays, discomfort and death. It is relevant to
identify the extent of drug administration error in the district hospitals in
the Central region of Ghana. A quantitative, cross-sectional study was
conducted among nurses nursing patients admitted to selected district hospital
in the Central Region of Ghana. Primary data was gathered from 168 nurses using
a pre-tested questionnaire and a review of incident books on the wards.
Logistic regression was done to assess possible factors contributing to drug
administration error. The majority of the respondents (61.9%) were below 29
years and had worked between one and four years (72.2%). Most common types of
error committed include pre-administration error (mean=2.67) and administration
technique error (mean=2.67).The majority of these errors occur during the night
shift (65%). Lack of understanding of medication jargons (mean = 3.89),
“feeling uncomfortable to wake patient up’ (mean = 3.78) and nurses eagerness
to go home (mean = 3.67) were the most predisposing factors to drug administration
error. Increasing internal environment constraints corresponds with increasing
drug administration error commitment by a factor of 0.228. Lack of emphasis
placed on medication error as a measure of quality of care and non-existence of
channels for reporting drug administration error were the main barriers to
reporting drug administration error.
CHAPTER ONE
INTRODUCTION
Background to the Study
The effect of medical errors on the safety and quality of
patient care in health facilities cannot be overemphasized. Studies shows that,
patient safety is one of the most pressing health care challenges in the world
(Institute of Medicine (IOM), 1999). Patient’s safety is freedom from
accidental injury while a patient is receiving care in the health facility
(IOM, 1999). Patient safety encompasses a variety of patient care processes and
outcomes, including the safe use of surgical equipment during procedures,
medications, physical restraints, and prevention of harmful events, such as
patient falls and suicide (Wakefield, Uden-Holman & Wakefield, 2005).
Emmanuel, et al (2009) stated that the level of a patients’ safety in health
facilities affects the recovery rate of clients. The Patient Safety Curriculum
Guide Report (2011), explains that it is the responsibility of every healthcare
provider to render the best medical services with minimal or no medical errors
to patients.
Medications are therapeutic interventions envisioned to
reduce patient suffering, promote healing and improve health and quality of
life; however, all medications have potential adverse effects (Metsala &
Vaherkoski, 2014). Among patient safety issues, medication safety has been considered
a major indicator of health-care quality (Joint Commission on Accreditation of
Healthcare Organizations, 2006). The use of medicines to address the health
challenges of patients in the world has increased considerably(Avian, 2009).
However, the increase in the use of medication is accompanied by medication
error. Medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the
medication is in the control of the healthcare professional, patient, or
consumer (Williams, 2007).
Medication errors may occur in any phase of the medication
use process (Mrayyan, Shishani, & Al-Faouri, 2007). The medication use
process extends from procuring the medication by the procurement officers;
selecting, transcribing and ordering of the medication by the doctors,
preparing, dispensing and educating on the medication regimen by the pharmacy attendants;
administering and monitoring on the effect of the medication by the nurse and
the patient or the consumer who is receiving the medication. Some stages of
errors comprise manufacturing, prescribing, transcribing, dispensing,
administration of a medication and monitoring of its effects (Dabaghzadeha, et
al, 2013).
Empirical evidence shows that medication error continues to
place the patient in serious danger (Rozich, Haraden, & Resar, 2008).
According to estimates by the IOM, patients who are admitted into hospitals
experience approximately one medication error per day of their stay (Institute
of Medicine, 2006). It has been estimated that between 10% and 18% of all
reported medical errors can be attributed to unsafe medication use with varied
effects, ranging from the errors going unnoticed to causing death and other
disabilities to patient (Choo, Hutchinson & Bucknall, 2010).
The increase in the incidence of medication error may be due
to the complex nature of the medication use process which extends from
medication prescription, transcription, dispensing and the administration
stage. It could also result from lack of professional competence or system
failures (Ndosi & Newell, 2008). Increases in new products as well as advances
in technology also increase the risk of medication error.
Globally, empirical evidence shows that researchers are
concerned by the increased rate of medication error. A report from the IOM,
(1999) stated that 7,000 deaths could be associated with medication errors
annually in the United States. Similarly, Ammenwerth, et al (2008) estimated
that nearly 100,000 individuals per year in the United States (US) die of
preventable medication errors. Aside from death, poor patient safety practices
are responsible for the increasing hospital admissions and cost, prolonged
hospital stays, use of additional resources, extra cost of litigation, lowering
patient satisfaction and undue discomfort (Montesi & Lechi, 2009). It is
therefore important to promote safety in the medication process because of the
significant consequences associated with medication error.
Medication error is particularly common in hospitalized
patients, especially elderly people, critically ill, pediatric patients and
those that require multiple forms of pharmacological therapies (Mirkuzie,
Tesfahun and Zeleke ,2014). The above categorization places adult clients on
admission at risk of medication error. A study by the US Food and Drug Administration
(FDA) evaluated reports of fatal medication errors over five years’ records
that almost half of the fatal medication errors occurred in people at the age
of 60 years and above (Stoppler,2006). This indicates that older people are at
greatest risk for medication errors because they often take multiple
prescription medications (Stoppler, 2006).
In health facilities, the drug administration process is the
last stage of the medication use process. The process involves: obtaining
medication in a ready-to-use form, counting or calculating, labelling,
storing and preparing in some way. It also involves checking for allergies;
giving the right medication to the right patient, in the right dose, via the right
route, at the right time; and documenting and monitoring of patient for effects
of the drug (World Health Organisation (WHO), 2011). In the same vein, the
Nursing and Midwifery Council (NMC) in the UK argues that the drug
administration process is not a robotic task that should be performed by
strictly following the prescriber’s orders but demands that the nurse thinks
through and exercises professional judgement as well (NMC, 2007). There is
potential for a drug administration error to occur with each dose of medication
due to the complex nature of the medication administration process. It is
therefore imperative that drug administration errors are detected and reported
by nurses (Ferner, Ferner, & McDowell, 2009). A study by Anderson and
Townsen, 2010 (as cited in Jo, Marquard, Clarke, & Henneman,2013) expounds
that approximately 38% of medication errors occur during medication
administration process and are termed drug administration error.
Drug administration error is any discrepancy between the drug
therapy received by the patient and that intended by the prescriber (Chua, Tea
& Rahman, 2009). About 71.5% of medication errors are due to nurse
administration and 16.4% result from the prescribing stages (Westbrook and
Woods, (2009) & Redley and Botti, 2012). A recent systematic review of drug
administration error prevalence in healthcare settings found that nursing
administration error is the most common type of medication error in health
facilities, reporting an estimated median of 19.1 % of total opportunities for
error in hospitals (Keers, Williams, & Cooke, 2013).
Many policies and guidelines have been devised to help
prevent drug administration error from occurring. Most nurses are familiar with
the five rights of medication administration: the right patient, drug, dose,
route and time (Eisenhauer, Hurley, and Dolan, 2007).These medication rights
are designed to ensure patient safety and prevent harm (Malcolm, Yisi, 2010).
However, quality in medication administration is not simply a matter of
adhering to these five rights (Cox, 2000).
Just like medication error classification, different types of
drug administration error can occur owing to the stage of the drug
administration process at which an error occurs. For instance, Seki &
Yamazaki (2009) describe that error of omission can occur when a drug is
prescribed but was not administered by the nurse to the patient. Wrong patient
error occurs when a different medication is administered to the patient other
than the one prescribed. Drug administration error can also occur during any
shift (morning, afternoon and night shifts). Likewise, various classifications
of medication like antibiotics, intravenous infusions, diuretics,
anti-diabetes, anti-hypertensive medications and analgesics can be involved in
drug administration error (Ferner et al., 2009).
A study by Clifton-Koppel (2008) shows that nurses can reduce
drug administration error and improve patient safety by implementing important
changes to their individual practice. These changes include reporting
medication errors, reducing distractions, independent implementation of safe
medication double checks before medication administration, and promoting a
safety culture (Handler et al., 2008). It appears that nurses are not reporting
drug administration error when they occur. Meanwhile, error reporting is important in reducing drug administration error. Informal
reporting and documentation of drug administration errors can prevent
healthcare authorities from knowing the rates of specific types of medication
errors that occur (Garner, 2012). It will also prevent the authorities from
understanding the underlying cause of drug administration error and from
appropriately prioritizing the opportunities to correct and prevent the errors,
both within and across facilities.
Drug administration errors are less likely to be prevented
than prescription and dispensing errors because it occurs in the last stage of
the medication use process and result in direct harm to the patient (Van den
Bemt, Robertz, De Jong, Van Roon, & Leufkens, 2007).
Statement of the Problem
The increase in the use of drugs has also brought about an
increase in associated medication errors (Avian,2009). A study of anonymous
errors reported via a national, confidential medication error-reporting program
in the US across 496 emergency departments recorded a total of 13,932
medication errors over a 4-year time span (Pham, et al, 2011). This value
translates to an error rate of 78 reports per 100,000 patient visits. The
groups most frequently responsible for these errors were nurses (54%) and the most
common errors that occurred were in the drug administration phase (36%) (Pham,
et al., 2011).
Likewise, Dabaghzadeh, et al (2013), in a study on medication
errors in a large teaching hospital in Tehran (US) showed that 19% of drug
administrations contained at least one error. The most recorded errors were
made by nurses (44.5%), most commonly during the drug administrating stage (63.6%). Most of these drug administration errors were
responsible for one-third of medication errors leading to poor patient
recovery, death, decreased client satisfaction, and other forms of harm to
patients (Westbrook & Woods 2009; Redley & Botti, 2012). Similarly,
Alsulami et al. (2013) in systematic review study on medication errors in the
Middle East countries revealed that the most frequent types of reported
medication incidents errors were drug administration related errors.
The case is not different in Africa. A prospective
observational study carried out in Ethiopia revealed that a total of 196 (89.9
%) administration errors were identified from 218 observations made over a
period of 13 days (Feleke & Girma, 2010). This indicated that at least 15
administrative errors were committed each day in the hospital.
Studies by Ahado, (2007) and Degley (2013) in Ghana using
questionnaires and an observational method recorded 32.9% and 49%
administration errors respectively. These findings suggested that drug
administration error also occurs in Ghanaian hospitals but little is known
about the frequency of these drug administration errors. WHO (2009) also
estimated that the risk of patient harm as a result of medication error may be
greater in Ghana, due to inadequate infrastructure facilities, technological
advancement, and skilled human resources in hospitals.
According to Barker, et al, (2002), identifying errors is
fundamental to error prevention. Thus, for a hospital to be able to minimize
drug administration error, it is important to explore the various factors that
contribute to drug administration error in the facility. The questions that
remain unanswered are what types of drug administration error occur in health facilities in Ghana, what contributes to those errors and how
do these medication errors compromise in-patient safety? These questions remain
unanswered in the two empirical studies on medication errors carried out in
Ghana.
Likewise, it was revealed that some studies were done on drug
administration error in specialty wards (theatre, emergency department,
psychiatric and intensive care unit), but little has been done among the
general adult, medical and surgical ward which was the focus of the researcher.
To address this gap in literature, the study aimed to profile drug
administration errors and explore nurses’ perception on the effects of drug
administration error on patient safety in the health facilities in Central
Ghana.
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