Afaya, A., Konlan, K. D., & Kim Do, H. (2021). Improving patient safety through identifying barriers to reporting medication administration errors among nurses: an integrative review. BMC Health Services Research, 21, 1-10.
In this integrative review, Afaya, Konlan, and Kim Do (2021) conducted a comprehensive analysis to determine what prevents nurses from reporting drug delivery mistakes in hospitals and how doing so might enhance patient safety. According to the authors, these barriers fall into two primary categories: organizational and professional and individual. Organizational barriers include inadequate reporting methods, managerial conduct, and a hazy definition of pharmaceutical mistakes. Fear of management, coworkers, lawsuits, personal reasons, and insufficient understanding of mistakes are examples of professional and personal impediments. Afaya, Konlan, and Kim Do (2021) suggest that an atmosphere devoid of “punitive measures and blame culture” is essential for nurses to disclose drug administration mistakes. They argue that nurses’ capacity to report drug administration mistakes may improve if legislators, managers, and nurses agree on a standard definition of what constitutes a medication error.
The article is an integrative review, which means it compiles material from numerous sources to create a thorough overview of the subject. The role group tasked with implementing quality and safety changes may benefit significantly from this information since it gives them a holistic view of physicians’ obstacles when reporting drug administration mistakes. The World Health Organization (WHO) issued a call to action in 2007 to reduce the severity and avoid medication-related injury by 50% during the next five years. Afaya, Konlan, and Kim Do’s (2021) study are significant because it gives insight into the barriers to reporting medication administration errors that must be addressed to increase patient safety.
Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: a cross-sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC nursing, 19(1), 1-9.
Medication errors are a significant source of preventable suffering in healthcare systems everywhere, the majority of which happens during the administration of medications. Nurses substantially impact the prevalence and avoidability of drug administration mistakes. In this research, Wondmieneh et al. (2020) examine the extent and contributing variables of medicine administration errors among nurses in Addis Ababa, Ethiopia, tertiary care institutions. Sixty-eight percent of nurses admitted to making medication-related mistakes in the previous year. Significant predictors of drug delivery mistakes were insufficient training, the absence of a guideline for medication administration, insufficient work experience, interruption during medication administration, and working during night shifts. Based on these data, the authors hypothesize that providing continual training on the safe administration of drugs, providing a medication administration guideline for nurses to follow, establishing an enabling atmosphere for nurses to prescribe medication properly, and keeping more experienced nurses may be crucial measures for enhancing the quality and safety of drug administration.
Several typical pharmaceutical administration mistakes are highlighted in the research, including the wrong dose, the wrong medicine, and the inaccurate means of administration. In addition, it emphasizes that the most common causes of medicine administration mistakes were a lack of understanding, distraction, and a considerable workload. With its complete grasp of the causes of medication mistakes, this resource can be valuable for the role group responsible for implementing quality and safety improvements in medication administration. The data may be utilized to design effective solutions to reduce pharmaceutical delivery problems in the healthcare system. The research findings may assist in identifying the areas that need improvement to decrease patient safety risk, including boosting knowledge and awareness among nurses, enhancing the work environment, and decreasing the workload.
Schepel, L., Aronpuro, K., Kvarnström, K., Holmström, A. R., Lehtonen, L., Lapatto-Reiniluoto, O., … & Airaksinen, M. (2019). Strategies for improving medication safety in hospitals: evolution of clinical pharmacy services. Research in Social and Administrative Pharmacy, 15(7), 873-882.
The greatest significant avoidable danger to patient safety is associated with drug administration safety risks. Increasing the role of pharmacists in patient care and patient safety work has been a consistent focus of patient safety programs since the early 2000s to mitigate these threats. Following the enactment of the first National Patient Safety Strategy in 2011, Schepel et al. (2019) set out to investigate the breadth and depth of clinical pharmacy services offered by Finnish hospitals to improve patient’s access to safe medications between 2011 and 2016. The research demonstrates that by 2016, pharmacists’ responsibilities have grown to include system-level medication safety duties, including writing medication use instructions, updating medication safety strategies, and analyzing medication error reports to make the drug-use process safer. Additionally, in 2016, there was an increase in the number of pharmacists taking part in long-term continuing education, which was seen as beneficial in expanding pharmacists’ obligations to enhance drug safety.
The resource can undoubtedly be helpful to the role group tasked with achieving quality and safety improvements in drug administration. Based on the experiences of Finnish hospitals, this article presents an in-depth analysis of how clinical pharmacy services may be integrated into established plans for enhancing patient safety in drug administration. This research’s results may serve as a starting point for hospitals seeking to create or improve their clinical pharmacy services to promote patient safety, making it a valuable resource for developing a drug administration safety improvement strategy.
Khalil, H., & Lee, S. (2018). The implementation of a successful medication safety program in a primary care. Journal of evaluation in clinical practice, 24(2), 403-407.
Numerous governments, both in the developed and developing world, have made patient safety an official policy priority. Many pharmaceutical safety measures and programs are mentioned in the literature, but relatively few studies report on their application in primary care. In this paper, Khalil and Lee (2018) outline the procedures necessary to effectively implement a pharmaceutical safety program in rural primary care in Australia. In addition, the authors report on the initiative’s assessment and provide suggestions for future efforts. The study organization’s medication safety program consists of the following steps: collecting data on medication events that have occurred there over the last two years; providing medication safety training to physicians employed by the organization; establishing a medication safety group; and putting into effect the recommendations for medication safety that have been produced. Information on clinicians’ prior and current levels of knowledge, conduct, confidence, and satisfaction was also gathered. The findings demonstrate that physicians’ knowledge, confidence, and satisfaction after drug safety training increase by incorporating the training into their everyday practice.
The article describes the successful implementation of a medication safety program in a primary care setting. Case studies like this one are valuable pieces of evidence for primary care physicians because they show exactly how a drug safety program may be implemented in a real-world situation. A collaborative medication safety endeavor and employee training are two components the research suggests are crucial to a successful medication safety program. This article might serve as an excellent reference for primary care physicians as they work to reduce prescription mistakes and increase patient safety.
Ho, J., & Burger, D. (2020). Improving medication safety practice at a community hospital: a focus on bar code medication administration scanning and pain reassessment. BMJ Open Quality, 9(3), e000987.
In the United States, more than 30 percent of all drug mistakes happen during administration. Less than one percent of non-surgical hospital patients in the United States who are given opioids will have a serious adverse event. Both bedside barcode medication administration (BCMA) and pain reassessments were recognized as areas for quality improvement at Sierra View Medical Center. Ho and Burger (2020) provide a case study of an organization’s efforts to alter its culture to increase the frequency with which medicine prescriptions are scanned, and pain assessments are performed. The research was carried out at Sierra View Medical Center (SVMC), a facility that makes extensive use of automated dispensing cabinets (ADCs) and a fully integrated electronic medical record (EMR) with computerized physician order entry (CPOE) and bars code medication administration (BCMA) capacity. Data openness, weekly dashboards, training, and PDSA cycles based on input from key stakeholders were the tools used to implement this strategy. Barcode medication administration (BCMA) scanning rates increased by 14%, and pain reassessment rates increased by 50% after a series of PDSA cycle implementations. There was a 17% drop in the number of ADEs caused by improper dosing and a 2.6% drop in the number of ADEs caused by opioids.
The resource is published in the BMJ Open Quality journal, which is a well-respected peer-reviewed journal, indicating that the research and findings are credible and trustworthy. The case study methodology used in this investigation lends credibility to the findings by illuminating the difficulties and triumphs of putting drug safety procedures into action in a healthcare facility. In particular, the resource’s advice on adequately deploying bar code medication administration scanning and pain evaluation might be helpful for the role group responsible for implementing quality and safety improvements concentrating on medication administration. It highlights the significance of employee training, key stakeholders’ involvement, and technology’s use in the implementation process. The information provided can be adapted and applied to a variety of healthcare settings, making it an invaluable resource in improving patient safety, particularly in relation to drug administration.
Lee, J. L., Dy, S. M., Gurses, A. P., Kim, J. M., Suarez-Cuervo, C., Berger, Z. D., … & Xiao, Y. (2018). Towards a more patient-centered approach to medication safety. Journal of Patient Experience, 5(2), 83-87.
An ever-increasing focus of high-quality medical treatment is the reduction of adverse drug reactions. Rates of possible interactions, prescription inconsistencies discovered by providers, and hospital readmissions are only a few of the healthcare system-oriented indicators that are often used to describe and evaluate pharmaceutical safety. Patient-reported adverse events or provider mistakes are usually included in these assessments, even though they may not correspond well with patient-centered goals in healthcare. Lee et al. (2018) take a patient-centric measurement approach by describing frequently used health system-oriented pharmaceutical safety indicators for assessing treatments and discussing how they might be reframed to represent the patient viewpoint better. Authors argue for a mixed approach to measuring pharmaceutical safety, with attention paid to both health systems and individual patients. According to Lee et al. (2018), these ideas may be used to improve the quality of patient-centered intervention assessments and to create better treatments overall. This is especially important in the field of pharmaceutical safety, where treatments must be relevant and tailored to individual patients’ requirements to have the most significant impact.
This article is beneficial for enhancing medication administration safety for patients since it provides a fresh viewpoint on the value of patient input into medical safety protocols. The authors point out that most previously published accounts and assessments of pharmaceutical safety center on healthcare system-level indicators. This resource may be seen as valuable by healthcare administrators and other critical actors tasked with implementing quality and safety improvements concentrating on medication administration, as it illustrates the necessity to integrate patient viewpoint into current healthcare-system-oriented measures, which has the potential to lower patient safety risks associated with medication administration.
Bielsten, T., Odzakovic, E., Kullberg, A., Marcusson, J., & Hellström, I. (2022). Controlling the Uncontrollable: Patient Safety and Medication Management From the Perspective of Registered Nurses in Municipal Home Health Care. Global Qualitative Nursing Research, 9, 23333936221108700.
Medication errors account for the vast majority of avoidable medical complications. To ensure that all patients get safe treatment, medical professionals must have a deeper understanding of patient safety as it relates to drug administration in home health care. Bielsten et al. (2022) investigate the topic of patient safety in relation to drug management in home-based care. Based on the research findings, the barriers to patient safety in medication administration in home-based care included difficulties with information transmission, delegation, and sophisticated medical treatments. The problem of information transmission pervaded the research results. The authors argued that for patient safety to be consistent with medication management in home-based care, there must be good communication between care providers to coordinate prescriptions, delegate responsibilities, and offer more comprehensive care.
Extensive studies show that medication delivery mistakes may happen in every area of nursing. The emphasis of Bielsten et al. (2022) .’s research is the factors that contribute to prescription delivery errors in home-based care. Home care workers, like other medical professionals, have an obligation to adopt quality and safety improvements in medicine delivery, and this data might be essential in this endeavor. The article’s emphasis on better drug administration makes it an invaluable resource for lowering the risk of medication-related harm to patients, particularly in home care settings.
Giles, S. J., Lewis, P. J., Phipps, D. L., Mann, F., Avery, A. J., & Ashcroft, D. M. (2020). Capturing patients’ perspectives on medication safety: the development of a patient-centered medication safety framework. Journal of Patient Safety, 16(4), e324.
When it comes to reducing the prevalence of prescription mistakes in primary care, the perspectives and experiences of patients may be invaluable resources. The problem is that there aren’t any models out there to help clinicians dissect the myriad of variables that might contribute to a patient safety event. To better understand medication safety in primary care from the patient and care provider’s point of view, Giles et al. (2020) create a patient-centered contributing factors framework and implementation checklist for addressing drug safety concerns in their article. The results emphasized the value of effective communication, enough drug and equipment supplies, patient and care provider factors, healthcare provider factors, and computer systems and programs in ensuring the proper administration of medications. Access to services and continuity of treatment were cited as two specific factors that were more prevalent among patients receiving primary care.
Contributory factors frameworks may help providers better understand the reasons for medication safety accidents, which are unfortunately widespread in primary care. Seeking patients’ perspectives on pharmaceutical safety might benefit from a framework positioned from their point of view. Medical professionals and other primary caregivers who are tasked with implementing quality and safety improvements related to drug administration may find the patient-centered contributing factors framework provided by this research to be very helpful. Maximizing the reduction of patient safety risks associated with medication administration is possible by integrating the patient-centered contributory factors framework and other existing frameworks.
Chuang, Y. H., Chiu, Y. C., Wu, L. L., Huang, H. C., & Hu, S. (2021). A qualitative exploration of the experiences of doctors, nurses, and pharmacists regarding medication management in an outpatient setting. Journal of Nursing Management, 29(2), 333-341.
In this research, Chuang et al. (2021) want to comprehend how the multidisciplinary team manages drugs and their recommendations for nursing management, as well as to establish a framework for safe medication management in outpatient facilities. To accomplish this goal, the authors conduct face-to-face interviews with doctors, pharmacists, and nurses from eleven different outpatient facilities using a qualitative research strategy. Uncertain professional duties and functions in outpatient medication management; entangled communications; transitioning from data to wisdom; and an uncertain culture of safety were the four themes identified. The resultant paradigm integrates hospital administrative support and information technology into a safety culture, with doctors, patients, pharmacists, nurses, and families working together.
Advancing the role and skills of outpatient nurses in monitoring patient drug safety is crucial. Managerial nurses may benefit from using the “framework of efficient and safe medication administration for outpatients” to evaluate and pinpoint problem areas in care delivery. This article is a helpful resource for nurses interested in enhancing the quality and safety of drug administration by outlining a strategy for doing so. Medication management in the outpatient setting is very crucial but sometimes disregarded. As a result, the article may be crucial in minimizing threats to patient safety associated with medicine administration, especially in the outpatient context.
Khalil, H., & Lee, S. (2018). Medication safety challenges in primary care: Nurses’ perspective. Journal of clinical nursing, 27(9-10), 2072-2082.
Several sources in the literature have pointed to issues that may be associated with medications. Such examples include medicolegal and patient complaints, as well as the systematic tracing of organizational structures and the reporting of incidents by healthcare workers. Few studies discuss the perspectives of community nurses and the barriers they confront in the workplace while trying to adopt drug safety strategies. Khalil and Lee’s 2018 research aims to shed light on the challenges associated with reporting medication errors in community nursing and proposes solutions for enhancing drug safety. The authors highlight various challenges among healthcare practitioners that impede drug safety in primary care, such as cultural differences between hospital and community settings, politics inside the healthcare system, a vague understanding of nurses’ duties, and a lack of incident reporting. Participants also mentioned a lack of education on medication safety, reporting and documentation difficulties, and a lack of clarity or understanding of the processes and procedures of reporting medication events.
Community nurses implementing quality and safety improvements in medication administration may find this resource particularly valuable since it thoroughly reviews the challenges to optimizing medication safety in community care practice. This article is a great resource for enhancing patient safety in medication administration since it identifies the causes of medication mistakes in community nursing. The paper helps drive the creation of the current improvement toolkit since the issues it describes may not be exclusive to community nursing but may exist in other sectors of nursing practice.
Corbett, C. F., Dupler, A. E., Smith, S., E’lise, M. B., & Bolkan, C. R. (2017). Transitional care medication safety: Stakeholders’ perspectives. In Advances in Patient Safety and Medical Liability [Internet]. Agency for Healthcare Research and Quality (US).
The goal of this paper by Corbett et al. (2017) is to identify obstacles to and strategies for enhancing drug safety and decreasing medication risks during patients’ transition from hospital to home. Common variables affecting hospital-home transitional care medication safety were recognized by the stakeholder groups participating in this research. These included patient- and family-level issues such as competence, keeping previous prescriptions, and availability of medicine, and health system-level factors such as communication and care coordination, complicated discharge procedures, and staffing and time restrictions. Solutions to the problem of drug safety during the transition from hospital to home are also identified, including better information management, wider availability of medications, and better use of human resources.
This article is likely more beneficial to nurses as a resource for understanding obstacles to and options for enhancing drug safety and lowering medical risks during the transfer of patients from hospitals to their homes. This article may be a great resource for enhancing patient safety during medication administration by raising knowledge of these challenges and the potential solutions to them. This article has the potential to make essential contributions to the drug administration safety improvement toolkit’s medication safety techniques.
Lindblad, M., Flink, M., & Ekstedt, M. (2017). Safe medication management in specialized home healthcare-an observational study. BMC health services research, 17(1), 1-8.
Problems often arise while administering medications because of how intricate the procedure is. Lindblad, Flink, and Ekstedt (2017) set out to investigate what makes the “medication management process (MMP)” in specialized home care so complicated and how healthcare providers cope with it. This research reveals that MMP in-home care is complicated, with hazy lines of responsibility, insufficient information, and ever-changing norms and expectations. The results also demonstrated that healthcare professionals continually re-prioritized objectives, dealt with communication and information transmission gaps, and developed novel bridging solutions to facilitate a safe MMP. It was also shown that trade-offs and workarounds are required aspects but that they represent a risk to patient safety since they are not routinely examined or accompanied by well-crafted learning mechanisms.
This resource is likely more helpful to nurses as a resource for managing a safe medication process in nursing practice. This resource educates healthcare providers on the need to adjust to changing situations and develop bridging strategies by performing several actions in parallel across time, place, and actors to guarantee patient safety during drug administration. Since it provides a thorough analysis of what comprises the complexity of the medication management process, this resource may be beneficial in creating the safety improvement toolkit related to medication administration.
References
Afaya, A., Konlan, K. D., & Kim Do, H. (2021). Improving patient safety through identifying barriers to reporting medication administration errors among nurses: an integrative review. BMC Health Services Research, 21, 1-10.
Bielsten, T., Odzakovic, E., Kullberg, A., Marcusson, J., & Hellström, I. (2022). Controlling the Uncontrollable: Patient Safety and Medication Management From the Perspective of Registered Nurses in Municipal Home Health Care. Global Qualitative Nursing Research, 9, 23333936221108700.
Chuang, Y. H., Chiu, Y. C., Wu, L. L., Huang, H. C., & Hu, S. (2021). A qualitative exploration of the experiences of doctors, nurses and pharmacists regarding medication management in outpatient setting. Journal of Nursing Management, 29(2), 333-341.
Corbett, C. F., Dupler, A. E., Smith, S., E’lise, M. B., & Bolkan, C. R. (2017). Transitional care medication safety: Stakeholders’ perspectives. In Advances in Patient Safety and Medical Liability [Internet]. Agency for Healthcare Research and Quality (US).
Giles, S. J., Lewis, P. J., Phipps, D. L., Mann, F., Avery, A. J., & Ashcroft, D. M. (2020). Capturing patients’ perspectives on medication safety: the development of a patient-centered medication safety framework. Journal of Patient Safety, 16(4), e324.
Ho, J., & Burger, D. (2020). Improving medication safety practice at a community hospital: a focus on bar code medication administration scanning and pain reassessment. BMJ Open Quality, 9(3), e000987.
Khalil, H., & Lee, S. (2018). Medication safety challenges in primary care: Nurses’ perspective. Journal of clinical nursing, 27(9-10), 2072-2082.
Khalil, H., & Lee, S. (2018). The implementation of a successful medication safety program in a primary care. Journal of evaluation in clinical practice, 24(2), 403-407.
Lee, J. L., Dy, S. M., Gurses, A. P., Kim, J. M., Suarez-Cuervo, C., Berger, Z. D., … & Xiao, Y. (2018). Towards a more patient-centered approach to medication safety. Journal of Patient Experience, 5(2), 83-87.
Lindblad, M., Flink, M., & Ekstedt, M. (2017). Safe medication management in specialized home healthcare-an observational study. BMC health services research, 17(1), 1-8.
Schepel, L., Aronpuro, K., Kvarnström, K., Holmström, A. R., Lehtonen, L., Lapatto-Reiniluoto, O., … & Airaksinen, M. (2019). Strategies for improving medication safety in hospitals: evolution of clinical pharmacy services. Research in Social and Administrative Pharmacy, 15(7), 873-882.
Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: a cross sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC nursing, 19(1), 1-9.
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