Implementation of an intravenous medication infusion pump system: implications for nursing

AIM: To assess perceptions of nurses regarding the implementation of intravenous medication infusion system technology and its impact on nursing care, reporting of medication errors and job satisfaction. BACKGROUND: Medication errors are placing patients at high risk and creating an economic burden for hospitals and health care providers. Infusion pumps are available to decrease errors and promote safety. METHODS: Survey of 1056 nurses in a tertiary care Magnet hospital, using the Infusion System Perception Scale. Response rate was 65.43%. RESULTS: Nurses perceived the system would enhance their ability to provide quality nursing care, reduce medication errors. Job satisfaction was related to higher ratings of the management team and nursing staff. Perceptions verified the pump was designed to promote safe nursing practices. CONCLUSIONS: It is important to consider relationships with job satisfaction, safe nursing practice and the importance of ratings of nursing staff and management teams when implementing infusion technology. IMPLICATIONS FOR NURSING MANAGEMENT: Infusion pumps are perceived by nurses to enhance safe nursing practice. Results stress the importance of management teams in sociotechnological transformations and their impact on job satisfaction among nurses.     

Impact of bar-code medication administration on nursing activity patterns and usage experience in Taiwan

As medication safety is a foremost goal of patient safety, the adoption of bar-code medication administration can help nurses ensure safe medication administration. The aims of the study were to explore the impact on nursing activity patterns of using this device and to understand the nurses' usage of this technology. The data collection was conducted in a medical center in northern Taiwan using work sampling observation and qualitative interviews. A total of 4940 observations were conducted on two groups of nurses who did or did not use the device, and six nurses were interviewed using a semistructured interview guide. The results showed that the nurses who used this device spent less time on medication-related activities and more on indirect care and unit-related activities, especially on the day and night shifts. Three themes were identified from the follow-up interviews: facilitating nursing workflow, improving medication safety, and encountering operational difficulties. Although the technology use could divert the nurses' practice patterns from medication-related activities to indirect care and unit-related activities, their direct care was not compromised. In addition, although the bar-code medication administration use could improve workflow and patient safety, hardware sufficiency and system functionality deserve more attention in the technology adoption process.     

Medication administration errors: understanding the issues.

OBJECTIVE: This paper surveys current literature related to medication administration errors, the role of nurses in such errors, and current initiatives that are underway within New Zealand to address this aspect of patient safety. SETTING: The literature review focused on research that primarily addresses the issues related to medications that arise in tertiary care facilities. PRIMARY ARGUMENT: Medication administration errors are reported to occur in one in five medication dosages. Such events have long been scrutinised, with the primary focus being the practice of nurses and their role in medication error. Analysis of such events frequently identifies the nurse as the deliverer of unsafe practice. However, over the past few years a shift in how medication errors are understood has led to the identification of systems-related issues that contribute to medication errors. CONCLUSION: Initiatives such as the 'Quality and Safe Use of Medicines' raise the opportunity to address some of the safety related issues with a view to enhancing patient safety. A call for nurses to pre-emptively drive and contribute to these initiatives, along with the development of nursing led research, is offered.     

我院护理给药差错管理办法的实施与效果

目的有效控制护理给药差错的漏报率，提高住院病人的安全。方法成立护理给药差错评定小组，强化护理人员的安全意识，扩充有效的给药差错报告渠道，细化奖惩细则及评价标准。结果实施护理给药差错管理办法后，给药差错漏报率有明显降低，差异具有统计学意义（P〈0．01）。结论合理的护理给药差错管理办法能激励当事人和科室管理者主动上报差错的发生情况，使护理给药差错管理纳人良性循环。     

Shifting supervision: implications for safe administration of medication by nursing students

Background. Medication errors made unintentionally by nurses continue to be a major concern in hospitals, medical centres and aged care facilities throughout Australia. While there is a plethora of literature available, which has identified factors that contribute to nurses making errors, few studies have reported on factors that may contribute to errors made by nursing students. Design. A grounded theory approach. Methods. In‐depth interviews with final‐year undergraduate nursing students (n = 28) to explore their experiences of administering medication. Constant comparative analysis was used to identify categories from the data. Results. The central category was identified as ‘shifting levels of supervision’. This describes the process of supervision students received when administering medication. Four levels were identified: ‘being with’, ‘being over’, ‘being near’ and ‘being absent’. The findings suggest that nursing students do not always receive the level of supervision that is legally required. Less than satisfactory levels of supervision were identified by participants as leading to medication errors or near misses. Conclusion. Apart from ‘Being with’, the levels of supervision described by participants have major implications for the safe administration of medication by nursing students and represent the actual or potential cause of error. Relevance to clinical practice. The potential for medication errors pose a major safety issue. Healthcare services have a responsibility to protect patient safety. Appropriate supervision of nursing students when administering education therefore requires urgent attention to ensure best practice is executed.     

Nurses create a culture of patient safety: it takes more than projects

Healthcare organizations are embracing the sciences of safety, improvement, human factors, and complexity to transform their culture into a culture of safety and high reliability. Nurses are the front lines of healthcare delivery, and as such, the front lines of safety and quality processes and outcomes. Nurses are required to both understand and develop the skills needed to improve care processes and to own the work of improvement as a professional responsibility. These changes demand that nurses understand both the complex demands of providing harm-free care and the system dynamics needed to create the conditions for improved outcomes, organizational, and system performance, and intraprofessional development and teamwork. The author presents the challenge of maintaining a safe patient care environment and describes a model that can detect and mitigate the migration of safe nursing care into at-risk and unsafe nursing care. She emphasizes the importance of healthcare organizations performing as high reliability organizations and outlines 'planned practices' steps to introduce new technology and innovation, and concludes by considering the interaction between individual practice and system performance.     

Investigating the safety of medication administration in adult critical care settings

Background: Medication errors are recognized causes of patient morbidity and mortality in hospital settings, and can occur at any stage of the medication management process. Medication administration errors are reported to occur more frequently in critical care settings, and can be associated with severe consequences. However, patient safety research tends to focus on accident causations rather than organizational factors which enhance patient safety and health care resilience to unsafe practice. The Organizational Safety Space Model was developed for high‐risk industries to investigate factors that influence organizational safety. Its application in health care settings may offer a unique approach to understand organizational safety in the health care context, particularly in investigating the safety of medication administration in adult critical care settings. Purpose: This literature review explores the development and use of the Organizational Safety Space Model in the industrial context, and considers its application in investigating the safety of medication administration in adult critical care settings. Search strategies (inclusion and exclusion criteria): CINAHL, Medline, British Nursing Index (BNI) and PsychInfo databases were searched for peer‐reviewed papers, published in English, from 1970 to 2011 with relevance to organizational safety and medication administration in critical care, using the key words: organization, safety, nurse, critical care and medication administration. Archaeological searching, including grey literature and governmental documents, was also carried out. From the identified 766 articles, 51 studies were considered relevant. Conclusion: The Organizational Safety Space Model offers a productive, conceptual system framework to critically analyse the wider organizational issues, which may influence the safety of medication administration and organizational resilience to accidents. However, the model needs to be evaluated for its application in health care settings in general and critical care in particular. Nurses would offer a valuable insight in explaining how the Organizational Safety Space Model can be used to analyse the organizational contributions towards medication administration in adult critical care settings.     

Evaluation of contextual influences on the medication administration practice of paediatric nurses

Title. Evaluation of contextual influences on the medication administration practice of paediatric nurses. Aim. This paper is a report of a study conducted to explore the impact of preidentified contextual themes (related to work environment and socialization) on nursing medication practice. Background. Medication administration is a complex aspect of paediatric nursing and an important component of day‐to‐day nursing practice. Many attempts are being made to improve patient safety, but many errors remain. Identifying and understanding factors that influence medication administration errors are of utmost importance. Method. A cross‐sectional survey was conducted with a sample of 278 paediatric nurses from the emergency department, intensive care unit and medical and surgical wards of an Australian tertiary paediatric hospital in 2004. The response rate was 67%. Result. Contextual influences were important in determining how closely medication policy was followed. Completed questionnaires were returned by 185 nurses (67%). Younger nurses aged <34 years thought that their medication administration practice could be influenced by the person with whom they checked the drugs (P = 0·001), and that there were daily circumstances when it was acceptable not to adhere strictly to medication policy (P < 0·001), including choosing between following policy and acting in the best interests of the child (P = 0·002). Senior nurses agreed that senior staff dictate acceptable levels of medication policy adherence through role modelling (P = 0·01). Less experienced nurses reported greater confidence with computer literacy (P < 0·001). Conclusions. Organizations need to employ multidisciplinary education programmes to promote universal understanding of, and adherence to, medication policies. Skill mix should be closely monitored to ensure adequate support for new and junior staff.     

Medication errors and professional practice of registered nurses

This Australian study identified and described the incidence of medication errors among registered nurses, the type and causes of these errors and the impact that administration of medications has on the professional practice of registered nurses. Mostly, medication errors were attributed to documentation issues, including: illegible handwriting, misunderstanding abbreviations, misplaced decimal point, misreading and misinterpreting written orders. Several human factors were attributed to potential causes of medication errors, including: stress, fatigue, knowledge and skill deficits. Environmental factors, namely, interruptions and distractions during the administration of medications, were also attributed to potential errors. The study found professional nursing practice involving administration of medications had a strong education, patient and ethical focus. Over a quarter of the respondents indicated that further training in medication administration would positively impact on their nursing practice. The registered nurses also highlighted they would appreciate more time to spend with patients when administering medications. Medication errors are not the sole responsibility of any single professional group, therefore, collaboration with other health professionals is central to establishing processes, policies, strategies and systems that will reduce their occurrence. The organisation and those nurses employed within it share an accountability to ensure safe administration of medications to patients. Based on study results, several recommendations are directed towards preventing or reducing medication errors and supporting nurses in providing best practice.     

A critical lens on culture in nursing practice

Increasing evidence demonstrates that the Aboriginal population experience greater health disparities and receive a lower quality of health care services. The Canadian Nurses Association (CNA) code of ethics states that nurses are required to incorporate culture into all domains of their nursing practice and ethical care. The aim of this article is to examine the concepts of cultural competency and cultural safety by way of relational ethics. To address these disparities in health care, cultural competency training programs are being widely advised. Recent research into cultural safety has not only recognized the importance of culture in nursing practice and organizational structures, but also extended the concepts to the culture of the client. In recognizing this diversity, nurses must pay close attention to their relationships with their clients. It is argued that the answers lie in relational ethics, which honors indigenous people's connection to self, others, the environment, and the universe.     

Measuring the impact of an interprofessional multimedia learning resource on Japanese nurses and nursing students using the Theory of Planned Behavior Medication Safety Questionnaire

Interprofessional communication and teamwork are essential for medication safety; however, limited educational opportunities for health professionals and students to develop these skills exist in Japan. This study evaluated the impact of an interprofessional multimedia learning resource on registered nurses' and nursing students' intention to practice in a manner promoting medication safety. Using a quasi‐experimental design, Japanese registered nurses and nursing students (n = 203) were allocated to an experimental (n = 109) or control group (n = 94). Behavioral intentions of medication safety and the predictor variables of attitudes, perceived behavioral control, and subjective norms were measured using a Japanese version of the Theory of Planned Behavior Medication Safety Questionnaire. Registered nurses in the experimental group demonstrated a greater intention to collaborate and practice in a manner that enhanced medication safety, evidenced by higher scores than the control group on all predictor variables. The results demonstrate the potential for interprofessional multimedia learning resources to positively impact the behaviors of Japanese registered nurses in relation to safe medication practices. Further research in other contexts and with other cohorts is warranted.     

Nursing under the influence: a relational ethics perspective

When nurses have active and untreated addictions, patient safety may be compromised and nurse-health endangered. Genuine responses are required to fulfil nurses' moral obligations to their patients as well as to their nurse-colleagues. Guided by core elements of relational ethics, the influences of nursing organizational responses along with the practice environment in shaping the situation are contemplated. This approach identifies the importance of consistency with nursing values, acknowledges nurses interdependence, and addresses the role of nursing organization as moral agent. By examining the relational space, the tension between what appears to be opposing moral responsibilities may be healed. Ongoing discourse to identify authentic actions for the professional practice issue of nursing under the influence is called upon.     

Patient safety to frame and reconcile nursing issues

Canadian nursing leadership is called to advance a national patient safety agenda for the delivery of safe, quality care in professional practice environments. Yet, the nursing discipline is burdened by issues and challenges related to clinical practice and workplace dilemmas that contribute to barriers and obstacles to safe, quality and humane care. We propose that the many clinical challenges faced by nurses in Canada can be more fully understood when framed by a patient safety perspective. Nurse executive leaders and nurse scientists are called to reform clinical practice and conduct research to reconcile patient care safety issues. This paper applies findings obtained from nurses via focus groups led by the Academy of Canadian Executive Nurses (ACEN) and integrates these findings into a patient safety perspective via a conceptual framework.     

Nurses and medication error: a discursive reading of the literature

Medication management is a part of everyday nursing practice. In carrying out this aspect of their role, nurses are subject to a range of practices and procedures, which are dictated through legal, management and medical requirements to ensure safe administration of medications. The literature addresses a range of areas related to the nurse's role in medication management, including knowledge required by nurses, practices and procedures related to administration, procedures for identifying and reducing errors and measuring error rates, and professional and ethical issues. The literature is a part of the discursive ensemble of nursing - as a written text it contributes to how nurses and colleagues construct and view nursing practice. This paper presents a discursive reading of that literature, exploring how nurses are positioned in relation to medication errors. I argue that the voice of nursing is mostly heard through discourses of biomedical science, law and management and draw on the work of Michel Foucault to illustrate some of the ways in which these discourses shape nursing practice.     

Nurses and doctors communicating through medication order charts in critical care.

The structure and content of written forms of communication dynamically interact with the social and historical conditions underlying critical care nursing activities. One important form of documentation regularly used in the critical care area is the medication order chart. This paper considers the ways in which medication order charts are used to structure interactions among nurses and between nurses and doctors. The critical ethnographic study upon which this paper is based involved a research group of six nurses who worked in one critical care unit. Data collection methods involved professional journalling, participant observation and individual and focus group interviews. Data analysis identified four major issues for consideration: imbalance between medical knowledge and legal authority; the nurse as go-between and medication expert; coaching the doctor; and the self policing nurse. The critical care nurse's role extends beyond the traditional passive activity of medication administration. By exploring the power relations underlying this role, there is greater opportunity for improved nursing relationships and patient care.     

Public policy on competency: how will nursing address this complex issue?

The evolving contexts in which nursing care is provided and the complexity of clients being served are raising new questions about the nature of nursing practice, the ways in which nurses can best be prepared for such practice settings, and how current staff can continually update their knowledge, skills, and abilities to provide competent care. It is imperative that the profession be forward looking as it reassesses the implications of assuring the public of a competent nursing work force. The mandate to prepare nurses differently to practice competently in future health care systems also suggests a different system for competency assessment. This article provides an overview of international, national, and state perspectives and approaches in addressing the issue of assuring competency from a public policy perspective, including one state's experience to date.     

The use of medication compliance devices by district nursing services

This article presents a critical review of the literature relating to medication compliance devices and the findings of a survey that examined the use of such devices by district nursing services. The UKCC (1992) does not regard the loading of compliance devices by nurses as safe practice; however, compliance devices continue to be used by district nurses. The evidence base concerning the value and use of medication compliance devices is examined and significant gaps in the literature relating to the use of such devices are identified. There is an absence of studies that focus on the effect of compliance devices on adherence among older patients and the nature and frequency of drug administration errors involving these devices. The survey findings show that nurse-loaded compliance devices are used in over one-third of the sample. Further research is necessary to assess the clinical effectiveness of, and clinical risk attached to, compliance devices for older patients in the community. It is suggested that this is an issue of serious concern for primary care groups considering the principles of clinical governance.     

责任制整体护理模式对患者安全保障体系的作用

目的：探讨责任制整体护理模式在临床护理工作中对患者安全保障体系所产生的作用。方法：通过＂督导式＂的管理模式来指导护理工作;每名护理人员参加主任医师查房,能主次分明、重点突出地了解患者的病情。对于特殊病例、疑难病例通过会议的形式组织学习以提高护理人员的专业知识。还能明确各岗位护士的职责,护理服务内涵、服务目标和工作标准。结果：可提供一个安静、整洁、安全、有序的病房环境;又能很好落实患者的基础护理、安全管理制度,提高了护理质量、服务满意度。结论：责任制整体护理模式既可持续提高护理质量,又能很好的为患者的安全提供保障。     

Nursing services administration in Norway

Despite the importance of nurse administrators to a nation's hospitals and health service, there are few systematic studies analyzing the environmental context of nursing administration and how nurses function to improve the quality of care, control costs and maintain morale. To rectify this situation--which is as true for Norway as for most nations of the world--an in-depth study was conducted of chief nurses in Norwegian hospitals. The aim was to improve understanding of 1) what nursing administration is like, 2) the demands made of nurse administrators in a variety of organizational and geographical contexts, and 3) the skills that are needed to be successful. Below, a report of the study.