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Chapter I THE PROBLEM This chapter aims to discuss the importance of the study. This includes the Introduction on which a brief summarization of the problem is tackled, Statement of the Problem, Scope and Delimitation that will put restriction to the variables of the study and the Significance of the Study, which discusses the importance and benefits of the research to group of people. The references used in Chapter I are enlisted in Notes in Chapter I. Introduction Many issues about the nursing profession have risen since the early ages until this time. One outstanding issue is about medication administration errors. A not-sorecent story was about a Filipina Nurse, a Clinical Instructor , together with her two students were assisting an operation when a surgeon ordered a drug to be given on the female patient. The CI ordered one of the students to get the drug and handed it to the CI. When the surgeon injected the drug, worst thing happened on the patient, death, and for that, the clinical instructor was jailed. Yes, many questions are held up on what are the causes of medication administration errors. Many questions are still hanging without any answers. Let this study answer, if not all, most of the confusions about medication administration. There is much to discuss. The study will be particularly for the BSN III student nurses of Asia Pacific College of Advanced Studies. Before the student nurses of APCAS become registered, they perform the Related Learning Experience. The RLE exposure of the students is mostly on the Provincial Hospital of Bataan, where the masses depend on when times of
health danger occur. Part of their RLE skills in all wards is medication administration. Proper medication administration must be imposed since many lives are in danger. Skills are not learned for only a day, they are founded from experiences. If the foundation is weak, and so will be the structure. Medical treatment involves the use of drugs, whether of any kind. A medication is a substance administered for the diagnosis, cure treatment, or relief of a symptom or for prevention of disease (Berman, 2008). Medication administration errors (MAE) include mistakes on the frequency, dose, route, name and classification of drug, patient, time, assessment, education, evaluation and documentation. That definition of Berman clearly limits that administration errors don¶t include any other error except for those stated. According to Potter and Perry (2004), the physician is responsible for directing medical treatment. Nurses are obliged to follow physician¶s orders unless they believe the orders are in error or would harm the clients. Therefore all orders must be assessed, and if one is found to be enormous or harmful, further clarification is necessary. However, the nurse administering medications is accountable for knowing what medications are prescribed, their therapeutic and non-therapeutic effects, and the client¶s need for medication administration, supervision with administrator, and education about the medication and its effect (Potter, 2001). Medication administration is a complex and time consuming task, occupying to one-third of nurses¶ time. Therefore, there will always be a possibility of error to occur. This study also will give us preventive strategies which will help both nurses and future nurses to avoid mistakes. According to Haw, Dickens and Stubbs (December 2005), during their study period, a total of 123 administration error reports were received. Of these, 88% (108) met
the study¶s definition of an administration error, and a further 3% (4) was considered near misses for a total of 112 error reports. For 103 of 112 errors (92%), sufficient information was available to rate the error severity. Although 86 errors (77%) were rated as grade 1 or 2 (of doubtful importance or having the potential to cause minor adverse effects, 14% (16) were rated as grade 3(having the potential to cause moderate adverse effects), and one (1%) was rated as grade 4(having the potential to cause serious adverse effects). Therefore a further study and research is to be conducted so no growth rate in percentage of the reported medication administration errors will occur. Nurses are here for a purpose not only to give tender loving care, but to help patients live a life worthy of what they deserve. And that is the reason why nurses must not harm the patient in the best of their ability and capacity. The knowledge and skills of every nurse plays a big and significant role in the continuation of life of many people. Nurses have tremendous power (Smith, 2008). They influence patient outcomes in the hospital. In the words of Patch Adams (1998), ³You treat a disease, you win, you lose. You treat a person, I¶ll guarantee you you¶ll win.´ Treat patients properly, and make no mistakes, for lives are at stake. This study will give answers and clarifications on how medication administration errors occur and affect the nursing care to patients and will name important reminders to further prevent such errors on happening. Statement of the Problem This study is structured to note the effects of the causes of medication administration errors (MAE) to the nursing care system among the BSN III students of Asia Pacific College of Advanced Studies.
Specifically, it seeks to answer the following variables: 1. How medication administration errors occur in the following categories
according to the third year nursing students: 1.1 knowledge and skills; 1.2 communication difficulties; 1.3 personal factors? 2. How is nursing care being described in the following categories: 2.1 profession; 2.2 patient¶s safety; 2.3 ethics? 3. How do medication administration errors affect the nursing care system? 4. What are some preventive measures to avoid medication administration errors in the following categories: 4.1 right process of administration; 4.2 Ten Rights of Medication Administration; 4.3 Medication Do¶s and Don¶ts of Nurses? Scope and Delimitation The study¶s central point will be of three major variables. The first variable is the causes of the medication administration errors which will be further subdivided to its variables which are knowledge and skills, communication difficulties and personal factors. The second major variable is the nursing care system¶s description based from its sub variables which are profession, patient¶s safety and ethics. The third major variable is
is the different preventive measures to avoid such errors and is categorized in its sub variables like the right process of administering medications, the Ten Rights of Medication Administration and the Do¶s and Don¶ts of Nurses. As stated, Asia Pacific College of Advanced Studies will be the venue of the study. The school was picked because it is more convenient and significant to the researcher in such a way that the school will benefit from knowledgeable, skillful and competent student nurse about the proper medication administration. All bona fide third year student nurses of the school, both female and male, are the respondents of the study. Significance of the Study The result of the investigation in ³The Effects of the Causes of Medication Administration Errors to the Nursing Care System´ will be significant to the following: To the Student Nurses. This study enables student nurses to recognize different precipitating medication administration errors and ways to shun these. Correct information and ideal skills are presented for the benefit of many students, that they may apply all of this for the proper treatment of their patients in terms of medication administration. This study allows student nurses to know their liabilities and responsibilities in their profession, and aims to help them to have a sense of vigilance over questionable orders. To the Clinical Instructors. This study is conducted for the benefit of the clinical instructors that they may share what is the ideal, enough and right knowledge and
skills to their students. This is also to emphasize that a need for assistance on student nurses is a must. To the Patients of the student nurses. This study also is founded for the benefit of patients that they may become watchful and responsible for what medicine they take. The students also need cooperation and understanding from you. To the Physicians. This thesis would like to make an impact to the way physicians order. The nurses do understand that being a doctor is a tough job, but for the nurses to be efficient and to minimize mistakes there is also a big responsibility for the doctors to do. This study serves to be a constant reminder that mistakes from physicians¶ orders have been one of the causes of errors, and so, a further evaluation on their jobs is a must, especially when writing their orders and doing verbal commands. To the Researcher. This study serves to be a reservoir of knowledge that can be used for recent situations, and future ones and a reminder that learning is an endless process. This gives clear facts to her existing knowledge. This study also emphasizes that the researcher needs to grow to meet the demands of dramatically changing health care system and serves as a reminder that the practice of caring is timeless.
Notes in Chapter I Berman,Audrey.et al.(2008).Fundamentals of Nursing:Concept,Process and Practices,8thEdition.Singapore:Pearson Education Inc.pp.830 Potter, Patricia.et al. (2004). Fundamentals of Nursing, 6th Edition. St.Louis, Missouri: MOSBY Publishing House,pp419 Potter, Patricia. (2001).Fundamentals of Nursing, 5th Edition. St.Louis, Missouri: MOSBY Publishing House,pp899 Haw, Camilla Malyn.et al.(December,2005). A Review of Medication Administration Errors Reported in a Large Psychiatric Hospital in the United Kingdom. www.google.com Smith, Jane. (September, 1995).Nursing Homes.www.google.com Williams, Marsha Garces.et al. (1998).Patch Adams.United States of America.Blue Wolf Productions. http://intghc.oxfordjourals.org/sgi/content/abstract/3/1/11
Chapter II THEORETICAL FRAMEWORK This chapter presents different theories, literatures and studies on which the study is related to. This is divided to Relevant Theories, on which theories are analyzed so the relation to the study is met, Review of Related Literature which sums up each variable in a theory or a principle using published materials, Review of Related Studies on which unpublished materials are used on the other hand, the Conceptual Framework, Paradigm, Hypotheses and Assumptions of the study on which the researcher predicts the outcome of the study. The Definition of Terms follows where different terminologies used in the study are explained thoroughly for the benefit of the readers and the Notes in Chapter II where the references are listed. Relevant Theories Virginia Henderson (1966) defined nursing as ³assisting individuals to gain independence in relation to the performance of activities contributing to health or its recovery´ (Berman et.al 2008). She was one of the first nurses to point out that nursing does not consist of merely following physician¶s orders. Ideally, the nurse would improve nursing practice by using her definition to improve the health of individuals and thus reduce illness. It is a guide that will meet the needs of the patient by using proper knowledge and skills that will make the recovery of the patient faster without inducing other bargains such as on making mistakes. She emphasized that nursing profession is not always about following the physician¶s order since they too, have mistakes. It is always about following what is right.
Using Henderson¶s definition, the study is anchored to a principle that nurses must meet the standards of the profession so as to help patients recover, have a quality life and gain independence. Every nurses and student nurses must take in consideration every time they are giving medication orders that they should put in their minds the sake of the patients. They also must have watchful eyes on physician¶s orders, that when these have mistakes, they would have the right knowledge and skills to decide what to do. Faye Glenn Abdellah (1960) theorized the ³21 Nursing Problems´ on which the third nursing problem is to promote safety (Berman et.al 2008). In Abdellah¶s model, nursing care means providing information to the client or doing something to the client with the goal of meeting needs or alleviating impairment. Nurses, as well as student nurses provide enough and sound information to the patients so their needs are met. This information or knowledge will also be a helpful tool to solve existing problems in their health. Nurses too have the responsibility to give interventions to patients so that any impairment or disability delineating an individual to gain recovery will be moderated. Medication Administration by nurses and student nurses require correct client education. Ample time must be taken so that enlightenment and verification of information will be noted to clients so no adverse effects will occur. Nursing goals are only attained through proper and correct nursing interventions so the patient¶s safety and recovery is promoted. If a nursing consideration is omitted and/or committed, surely, the patient will suffer. His impairment will only be severed and not alleviated.
Imogene King¶s (1971) Goal Attainment Theory described nursing as a helping profession that assists individuals and groups in society to attain, maintain and restore health (Berman et.al 2008). King also viewed nursing as an interaction between the client and the nurse whereby perceiving, setting goals and acting on them, transaction occurs and goals are achieved. King highlighted on her theory that nurses have the responsibility and liability to help patients on restoring their health and not the other way around. She also stated that nurses when interacted with patients and act side by side with them, goals are attained, and good outcomes will follow. The study is based on what right interventions to follow, specifically when administrating medications to patients who trust health care providers with their lives. Health care providers exist for a reason that assisting individuals to adjust to environmental stressor, such as their illness and impairment, will give positive outcomes and not to invade their impaired life with other stressors brought about by errors on medication administration. Proper education, assessment, consultation and intervention with the patient before any administration will definitely minimized if not totally eradicate any mistakes that will make nursing goals unattainable. Review of Related Literature On the Causes of Medication Administration Errors. Cause is defined by The American Heritage Dictionary as the producer of an effect, result or consequence. Several reasons have been proposed for why medication administration occurs. These reasons generally fall into the following category (a) inadequate knowledge and skills, (b)
failure to comply with policy and procedure or lack of procedures, (c) failure in communication, and (d) individual and systems issues. Nurses also described personal factors contributing to errors in medication administration. The Pennsylvania Patient Safety Reporting System(2007) had further mentioned medication errors continue to ranking high, where as unclear and confusing labeling and packaging as well as lookalike or sound alike drug names significantly contribute to medication errors. According to the International Council of Nurses (2002), medication errors therefore result from problems in practice, products or procedures or systems. This first major variable will be divided into knowledge and skills, communication difficulties and personal factors. On Knowledge and Skills. Knowledge is defined by the Oxford English Dictionary as µwhat is known in a particular field or in total, facts and information¶. The term knowledge is also used to mean the confident understanding of a subject with the ability to use it for a specific purpose if appropriate. The nurse uses the knowledge learned from many disciplines when administering medication. It is this knowledge that helps the nurse to understand why a particular medication has been prescribed for a client and how this medication will alter the client¶s physiology so as to exert a therapeutic effect. For example, in physiology, the nurse may have learned that potassium is a major intracellular ion. When clients do not have potassium in their body, they may experience signs and symptoms that are associated with hypokalemia, such as muscle fatigue or weakness. Medications may be prescribed that may restore client¶s potassium level on normal. Another example is knowledge about child development on which may show that children often associate medication administration with a negative experience. The nurse
uses principles from child development to ensure that the child cooperates with the medication experience (Potter, 2004). According to Wolff (2003), nurses must know whether the drugs are compatible with each other when the patient is to receive several kinds of medications. Some drugs are incompatible with certain others and to mix them may be dangerous to the patient or may render the drug ineffective. She should also learn any modifications in the diet are necessary for the drug to function effectively. For example, certain antibiotics cannot be taken with milk. Knowledge about whether the drug is compatible with the patient¶s condition is a must. For example, oral medications are not used for patients who are vomiting. According to Tungpalan (2002), the nurses¶ responsibility in drug administration goes beyond carrying out doctors¶ orders. She decides when or where not to administer a drug. Involving the patient and his family in his plan of care means she is able to explain what drugs he is taking, why he is taking them, for how long and at what intervals, as well as he should stop taking them. The nurse must continually seek to expand her knowledge about drug therapy in order to provide safe and therapeutically effective nursing care. Knowledge of the drug goes beyond knowing its generic name and desired therapeutic effect. The nurse should also know its physiologic actions, its indications, and contraindications, dosage ranges, route of administration and side effects. Knowledge of the patient includes knowing any allergic or drug sensitivity reactions have had in the past. According to the Oxford English Dictionary, a skill is learned capacity to carry out pre-determined results often with minimum outlay of time, energy or both. The nursing student often has limited experience with medication administration as it applies
to professional practice. The clinical experience provides the student with the opportunity to use the nursing process as it applies to medication administration. Since the nurse spends the most time with clients, the nurse is the most appropriate health care worker to administer medications. Wolff (2003) had stated that leaving medications for the patient to take later is considered unsafe practice because the patient may not take the drug. The administration of medications to clients requires knowledge and a set of skills that is unique to the nurse (Potter, 2005). The International Council of Nurses (2002) had stated on their report that types of medication errors falling under extra dose and omission error to be caused by performance deficit and knowledge deficit respectively. Tungapalan, 2002, had stated that nurses see to the patient¶s safety and comfort before, during and after the process of drug administration. A skill in medication administration of a nurse is the responsibility on calculating the flow rate of IV infusions. Too rapid infusion rates result in overloading the intravascular compartment which may lead to cardiac and/or pulmonary conditions while too slow infusion rates result in inefficient fluid and electrolyte replacement. All the methods of parenteral administration involve breaking the skin which is the body¶s first line of defense. As such, the need for aseptic technique cannot be over-emphasized. There is also a need to rotate the injection sites if the patient is receiving a series of injections. The nurse must also be skillful enough to check for patency of the nasogastric tube before administering any food or medications. Another skill is to check for the patency of the IV with dextrose, as such mispatency will result in soft tissue necrosis. A mispatent IV for Sodium Bicarbonate may result on Burns. According to Berman (2008), a skill o medication preparation such
of flicking the upper stem of an ampule several times with a fingernail will help bring all medication down to the main portion of the ampule. Preventing cross contaminations of the needle between bottle to bottle or vial to vial or ampule to ampule will prevent the drug on producing ineffective reactions or lack of reactions. With regards to mixing of insulin, a medication for Diabetes Mellitus, mixing ensures an adequate concentration and thus an accurate dose. Shaking insulin vials can make the medication frothy, making precise measurement difficult. After a skin test is done, ask the child not to rub or scratch the injection site. Rubbing the site can interfere with test results by irritating the underlying tissue. On Communication Difficulties. Communication is a term used to reflect a process of transferring information to another. It is the process of imparting or exchanging thoughts, opinions or information by speech, writing or signs. Nurses are legally responsible for carrying out the orders of the physician in charge of a patient, written or verbally, unless an order would lead a reasonable person to anticipate injury (Taylor, 2004). According to Potter (2004), nursing students should not give any medication without a written medication order. The physician should right all orders and the nurse must make sure that they are transcribed correctly. Verbal orders are not recommended because they increase the possibilities for error (Potter, 2004). When verbal orders are received by the nurse, they should be immediately entered into the client¶s medical record and signed by the nurse, indication the time and the name of the prescriber who gave the order. Most institutions require a prescriber¶s signature within 24 hours after the order is made. Repeat a telephone order back to the physician for confirmation (Taylor, 2004). Very
often that nurse¶s notes are used if at time, lawsuit comes. The nurses¶ assessments and the reporting of significant changes in the assessments are very important factors in defending a lawsuit. Therefore, the nurse should identify the physician contracted, the information communicated and the physician¶s response. Tungpalan (2002) had also mentioned that one of the leading causes of claims against nurses are with errors made with insufficient communication with the patient or with the doctors. Furthermore, the International Council of Nurses (2002) had classified types of error on unauthorized drug to be caused by confusing communication; wrong administration because of inaccurate or omitted transcription and illegible or unclear handwriting to cause for the wrong patient. On Personal Factors. Personality aims to describe aspects of an individual's character, thoughts, and feeling (Buckhalt, 2008).Attributes of a nurse often vary to other nurses, and each personal factor contributes to the success of a nursing intervention. Each nurse¶s station has a place set aside for the nurse to prepare the client¶s medications with minimum distractions and where the equipment she needs are readily available, to insure time and effort (Tungpalan, 2002). Concentrating on the work at hand is very necessary for the patient¶s safety. The leading cause of claims against nurses with personal factors¶-made errors are carelessness and forgetfulness. In many cases, personal life could also affect the attitude at work, so ideally there should be a healthy balance between work and home life (Taylor, 2007).
On Nursing Care System. This variable will tackle its description according to profession, patient¶s safety and ethics. On Profession. The authority for the practice of nursing is based upon a social contract that delineates professional rights and responsibilities as well as mechanisms for public accountability. (www.wikipedia.com).The profession combines physical science; social science, nursing theory, and technology in caring for those individuals. In order to work in the nursing profession, all nurses hold one or more credentials depending on their scope of practice and education. A Licensed practical nurse (LPN) (also referred to as a Licensed vocational nurse, registered practical nurse, Enrolled nurse, and State enrolled nurse) works under a Registered nurse. According to the International Council of Nurses (2002), the nurse assumes the major role in determining and implementing acceptable standards of clinical nursing practice, management, research and education. The nurse is active in developing a core of research-based professional knowledge. The nurse, acting through the professional organization, participates in creating and maintaining safe, equitable social and economic working conditions in nursing. It is a nurse's responsibility to be informed on Nurse Practice Acts which they are licensed to practice. It is critical for students and nurses need to be aware of the legal issues pertaining to the profession. Familiarity with the law and relevant court rulings helps in understanding the scope of practice and responsibilities that come with being a licensed caregiver, as well as providing insight on how to prevent legal problems before they happen (Singleton, 2000). Within the profession, sprout of trust is indeed a must. Nurse-client relationships are referred to as by some as interpersonal relationships
(Berman, 2008). The keys to the helping relationship are development of trust and acceptance between the nurse and the client and an underlying belief that the nurse cares about and wants to help the client. They trust medical practitioners and nurses¶ ability to solve medical problems, and if something went wrong with their bodies as they believe to be caused by errors made by health care providers, the whole system of relationship is held bankrupt. The conflict may arise from differing values, philosophies, personalities and disbelief (Berman,2008). According to Carroll (2006), these conflicts can be solved through exploring alternative solutions, through compromise, negotiation and collaboration. On Patient¶s Safety. Nurses are knowledge workers whose main responsibility is to provide safe and effective care within constantly evolving health care systems. Nurses collaborate with one another, as well as doctors, aides and technicians, to provide holistic care to patients. Although advocating for patient safety is a nurse's role, it is also necessary for the patient to be an active participant in their safety. Patient safety is a collaborative goal that requires concerted efforts from the patient and all members of the health care team. It is also a means to foster communication between the patient and the nurse including other health care members to better patient's health (Blendon et.al, 2002). Due to the increasingly complex nature of the role of nurses, everyday nursing duties are also a challenge in protecting the safety of every patient. Ebright et al. (2005) have stated some important questions regarding medications that patient should ask, and nurses must rightfully answer. The nurses must always check the patient's wrist band before giving medications or treatments. Patients should ask questions about the medications they are receiving when they don't understand something. Ask if there are
any side effects to be aware of and know if the medication will change mental and physical functioning. Other methods to improve safety include: Better lighting and less clutter in work areas where medications are prepared, keeping distractions to a minimum, and keeping noise levels down. Drug companies and health care facilities are also standardizing medication labels and packaging. Medications that can have a particularly dangerous effect are being marked as ³high alert´ (National Quality Forum, 2003). Many hospitals are investing in technology to minimize errors, such as machines that dispense medications for just one patient at a time. Patients are given identification bracelets showing their names and allergies and all medical personnel are required to wear name tags showing their level of training. More severe side effects, also called adverse effects or reactions, may justify the discontinuation of a drug (Berman, 2008).These adverse effects put patient¶s life in danger. According to Tungpalan (2002), these responses may be mild or severe. Reactions include skin rashes, itching, lacrimation, nausea and vomiting, diarrhea, wheezing and shortness of breath and other unexpected outcomes that may jeopardized the health of a patient. These adverse effects may lead to an anaphylactic shock, or a severe allergic reaction which calls for emergency medical intervention. The Department of Health in Taiwan (2005) had defined serious adverse drug reaction that results in death, life-threatening, permanent disability/incapacity, congenital anomaly/birth defect, results in hospitalization or prolongation of an existing hospitalization and may need further management for other possible permanent disabilities.
Previous errors inspire or motivate the health care team members to review and adjust practice for patient¶s safety. As the primary caregivers in hospitals, nurses are best positioned to improve quality and patient safety. However, they are often pulled away from the bedside to conduct tasks that have nothing to do with actually taking care of patients²such as filling out paperwork and other administrative duties. Optimizing nursing staff's time at the bedside is the key to better patient safety (Runy, 2002). On Ethics. Nursing ethics is a branch of applied ethics that concerns itself with activities in the field of nursing. The nature of nursing means that nursing ethics tends to examine the ethics of caring rather than 'curing' by exploring the relationship between the nurse and the person in care ( McHale et.al.,2003). The International Council of Nurses (2002) stated that the nurse carries personal responsibility and accountability for nursing practice, and for maintaining competence by continual learning. The nurse maintains a standard of personal health such that the ability to provide care is not compromised. The nurse uses judgment regarding individual competence when accepting and delegating responsibility. The nurse at all times maintains standards of personal conduct which reflect well on the profession and enhance public confidence. The need for nursing is universal. Inherent in nursing is respect for human rights, including cultural rights, the right to life and choice, to dignity and to be treated with respect. Nurses and health care workers have the responsibility to uphold the rights and worth of all people they encounter regardless of race, sex, ethnicity, age, religion, beliefs, values, socioeconomic status, and sexual orientation. In addition, it is also the
responsibility of patients and their families to mutually respect the dignity of their health care providers and staff (Munson, 2004). Extra precautions to protect dignity such as speaking respectfully to the patient, covering the patient should be used. Also, informing the patient about care needing to be done prior to initiation acknowledges their dignity. A violation in this ethics is negligence. According to Berman (2008), negligence is a conduct that is below the standard. Such conduct places another person at risk for harms. A student is ordinarily responsible for her own act of negligence if injury to a patient results. The nursing student has been considered an employee of the agency in hospital-controlled programs. Patient harmed by nursing students may also bring suit for damages against an instructor-supervisor. If standards of supervision are violated, negligence may be charged. If students feel their assignments are beyond their competency, it is recommended that they call the attention of the instructor (Wollf, 2003). On Different Preventive Strategies .The nurse accepts full responsibility for all actions that are taken; this includes the administration of medications. When a nurse administers a medication to the client, the nurse accepts the responsibility that the medication or the nursing actions in administering it will not harm the client in any way (Potter, 2001). In that view, many different strategic plans earthed as a way on shielding medication errors. Medication errors are preventable; although reducing the error rate significantly will require multiple interventions and close collaboration between the health team and management (International Council of Nurses, 2002).
This major variable will be divided into the right process of medication administration, ten rights and medication do¶s and don¶ts. On the Right Process of Medication Administration. A process is a tool, a step-by-step guide that will emphasize the need for careful planning of an action. Most medication errors occur when a nurse fails to follow routine procedures (Potter, 2001). Berman et.al (2008) named six steps to follow in medication errors which are identifying the client, informing the client, administering the drug, providing adjunctive interventions as indicated, recording the drug administered, and evaluating the client¶s response to the drug. One of the Joint Commission¶s National Patient Safety Goal is to improve the accuracy of client identification, where nurses are required to use at least two client identifiers before administering medications, (Berman, et.al, 2008). According to Berman (2008), if the client is unfamiliar with the medication, the nurse should explain the intended action as well as any side effects that might occur. Listen to the client. Nurses may miss relevant information provided by the client. According to Przybycien (2005), nurses must check three times for safe medication administration. First checking happens on reading the Medication Administration Record and removing from the drawer found at nurse¶s station. Second is while preparing the administration and the last checking happens before the nurse opens the package at the bedside. Clients may need help when receiving medications, they may require physical assistance for example, in assuming positions, and other measures that will enhance drug effectiveness and prevent complications (Berman, 2008). Although most nurses prefer to spend their time interacting with patients rather than writing in a patient¶s records, careful documentation is a crucial legal safeguard for the nurse. Documentation must be factual, accurate, and
complete. The presumption of the law is that if something was not documented, it was not done (Taylor, 2004).According to Berman (2008), the evaluation of the effectiveness of the medication remains the responsibility of the nurse. The kinds of behavior that reflect the action or lack of action of a drug and its untoward effects are as variable as the purpose of drug themselves. Therefore, the nurse must report client¶s response to the nurse manager and primary care provider, i.e., physician, when untoward responses occur. On The Ten Rights of Medication Administration. There are aspects of medication administration that are important for the nurse to check each time a medication is administered. These are referred to as the ³rights´ (Berman, 2008). Right is a term given to a legal, social or moral freedom to act to or refrain from acting, or entitlements to be acted upon or not acted upon. Przybycien (2005) described ten rights which are: Right Medication, Right Dose, Right Time, Right Route, Right Client, Right Client Education, Right Documentation, Right to Refuse, Right Assessment, and Right Evaluation. It is important for the nurse to be aware of how these rights must be practiced. According to Berman (2008), the nurse is expected to respect these rights and responsibilities. On Medication Do¶s and Don¶ts. The central action of medication administration involves actual and complete conveyance of a medication to the patient. However, there is a wider set of practices required to achieve safe, effective patient outcomes and to prepare for and evaluate the outcome of medication administration. Tungpalan (2002) managed to describe different medication do¶s and don¶ts for nurses that will give a concrete framework for the nurse to follow such as: Do not prepare
medications way ahead of the time they are to be administered, Do use sterile technique in the preparation and administration of parenteral medications, Don¶s use medications which are not clearly labeled or solutions which show signs of deterioration, Do ask another nurse or your superior to check your computation before you prepare the drug, and Don¶t administer medications which somebody else has prepared Potter (2001) had mentioned also different do¶s and don¶ts to prevent medication errors such as Do not administer medication ordered by nickname or unofficial abbreviation, Do not confuse equivalents, Do be aware of medications with similar names, Do not attempt to decipher illegible writing, and Do know clients with the same last names. Review of Related Studies Inadequate knowledge and skill generally reflect lack of patient knowledge, patient¶s diagnosis, and the names, purposes, and correct administration of the medication but can also include not knowing how to operate IV pumps/ infusion devices, mistaking IV lines for NG tubes, failure to adequately prepare medications before administration. Monitoring errors may also be included in this category-failure to monitor for side effects because of lack of knowledge according to Haw, Dickens & Stubbs, 2005 on their study A Review of Medication Administration Errors Reported in a Large Psychiatric Hospital in the United Kingdom. Haw, Dickens and Stubbs (2005) had recorded 19 occasions on their study the factors that contributed to errors include busy, noisy ward environments or being short of staff and difficulty reading or understanding physician¶s instructions were reported on ten occasions. Furthermore, they had named some personal factors described by nurses as contributing to errors in 19 instances, including tiredness, poor concentration, inadequate supervision, and lack of support.
Wakefield, Douglas, Holman and Blegen¶s study, Nurse¶s Perception of Why Medication Errors Occur (2008) had stated reasons on why errors occur under the knowledge category as names of many medications are similar with factor loading of .618; many patients on same medications with factor loading of.612, nurses have limited knowledge about adverse effects of medication earned a factor loading of .686, and no easy way to look up medications(.706). According to Wakefield, Douglas, Holman and Blegen¶s study, communication difficulties play a major role in occurrence of medication errors, and named reasons such as doctor¶s medication orders are not legible; doctor¶s medication orders are not clear, orders are not transcribed to chart correctly, nurses do not communicate to other nurses about missed medications to be administered later and chart is illegible. The factor loading for each reasons are .854, .862,.730, .558,.621 respectively. Nurses interrupted while administering medications to perform other duties has been significant player on error occurrence has a factor loading of .584 on the other hand. Communication difficulties between hospital doctors and nurses are well documented. A survey undertaken jointly by medical and nursing administration at Sir Charles Gairdner Hospital in Perth, Western Australia verified difficulties in doctor-nurse communication. Questionnaire responses revealed some impediments in the flow of communication. Both nurses and doctors perceived less frequency of difficulties in communicating with members of their own professional group than with members of the other group as reviewed by McKay, Matsuno, Mulligan(2006). With the study The experiences of final year nursing students in administering medications : shifting levels of supervision, Reid-Searl, Kerry.(2008) stated that ³While
safety measures may be reinforced to students, previous studies have not explained what occurs when students actually administer medications to patients in the clinical setting. Aim - This thesis reports on a study aimed at identifying the experiences of final year undergraduate nursing students in administering medications. A sample of 28 final year nursing students from an Australian university provided the data to permit the development of the theory. Findings - This study identified that supervision was central to the medication administration experiences of students. Students were confronted with registered nurses who presented or provided them with shifting levels of supervision when administering medications to patients. Shifting levels included the registered nurse; being near, being over or being absent. Deans, Cecil on 2005 managed to do her study entitled Medication errors and professional practice of registered nurses and explained why several factors are occurring on contributing on medication errors. 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.
Conceptual Framework The paradigm of the study is made up of two boxes. The common causes of medication errors are contained in the right box where different factors such as knowledge and skills, communication difficulties and personal factors are involved. The left box on the other hand tackles the different results of these errors to the medication administration, as well as to the health care system, which encloses different concepts such as adverse effects, principle of negligence and the effect to patient¶s trust to health care providers. The arrow between the two boxes significantly shows the effects of the other box to the other one. Hypothesis A hypothesis is a proposed explanation of an observable phenomenon. In this study, a Null Hypothesis is utilized. The causes of medication administration errors in this study do not affect the nursing care system. Assumptions of the Study The study assumptions are propositions taken to be true based upon presupposition without preponderance of the facts (Cristobal et.al.2010). The following assumptions are based from the study¶s own major and sub-variables. 1. Medications are used by patients to alleviate and/or treat their existing diseases. 2. The nurse doesn¶t have the sole responsibility in giving medications to patients.
3. In giving medications, nurses and student nurses follow the nursing process to achieve a positive outcome. 4. The student nurses in an affiliated hospital are required to have a set of skills and knowledge. 5. Any errors made should be reported immediately
Paradigm of the Study
Causes of Medication Administration Errors Knowledge and skills Communication Difficulties Personal factors
Nursing Care System Profession Patient¶s Safety Ethics
The Effects of Common Errors in Medication Administration
Definition of Terms Many items or words in this study are of complications. For the better understanding of these terms, they are defined conceptually and/or operationally below: Adverse Effects. More severe side effects (Berman,2008). These are the effects not expected to appear as a manifestation of something went wrong. In this study, the researcher wants to clarify that not all adverse effects are product of medication administration errors of nurses, such may occur with family members assuming the error. Asia Pacific College of Advanced Studies. The school on which the intended BSN III nursing student respondents are enrolled. Cause. The producer of an effect, result or consequence (The American Heritage Dictionary). Operationally, it pertains to the knowledge and skills, communication difficulties and personal factors. Communication. Process of transferring information to another, the imparting or interchange of thoughts, opinions, or information by speech, writing or signs (www.wikipidea.com). The communication used in this study reflects one of the causes of error. Further, it is the giving of orders by doctors, and the environment that takes place as the order is being read, and delivered. Ethics. It is used in this study as a definition of the nursing care system. Knowledge. What is known in a particular field or in total, facts or information (Oxford English Dictionary). As used in the study, knowledge pertains to the information or learning gathered by the student in school and related experiences such as patient
knowledge, patient¶s diagnosis, and the names, purposes, and correct administration of the medication ,how to operate IV pumps/ infusion devices and the like. Medication Do¶s and Don¶ts. It is used in this study as one of the preventive strategies, and are considerations except for the right process and ten rights of medication administration. Negligence. Negligence is generally defined as conduct that is culpable because it falls short of what a reasonable person would do to protect another individual (www.wikipedia.com). It used in this study as the principle being used when lawsuits or punishments for nurses occur. It is one of the effects of administration errors. Nursing students. Defined operationally as the level three students enrolled for the Degree of Bachelor in Science, Major in Nursing of the school and are taking up related learning experiences or hospital exposures in affiliated hospitals. Patient¶s Safety. It is used in this study as a definition of the nursing care system. Personal Factors. Defined operationally to be causing medication errors and conceptually to be the personality and behavior of student nurses. Profession. It is used in this study as a definition of the nursing care system. Related Learning Experiences. It is used in the study as the subject of exposure of nursing students in affiliated hospitals. Right Process of Medication administration. Defined operationally as the preventive strategy and the chronologically arranged process to follow.
Skill. Is a learned capacity to carry out pre-determined results often with minimum outline of time, energy or both (Oxford English Dictionary). In this study, skill is the teachings learned from the subject Related Learning experiences of BSN III nursing students of the school. Ten Rights. Defined operationally to be one of the preventive strategies and the entitlements that nurses must respect. Trust. Assured reliance on the character, ability, strength, or truth of someone or something, one in which confidence is place (Merriam-Webster Online Search).Operationally defined as an effect of medication errors, if patients will change their view in this aspect to health care providers.
Notes in Chapter II Berman,Audrey.et al.(2008).Fundamentals of Nursing:Concept,Process and Practices,8thEdition.Singapore:Pearson Education Inc.pp.59,473,517 833,848-850,852 Potter, Patricia.et al. (2004). Fundamentals of Nursing, 6th Edition. St.Louis, Missouri: MOSBY Publishing House,pp419 Taylor, Carol,et.al.(2004).Fundamentals of Nursing,5th Edition. Philadelphia: J.B. Lippincott Company.pp921-929 Tungpalan,Luz.(2002).Fundamentals of Nursing.Quezon City,Philippines:JMC Press Inc. .pp.446,461,471,472 Potter, Patricia. (2001).Fundamentals of Nursing, 5th Edition. St.Louis, Missouri: MOSBY Publishing House,pp901-902 Przybycien.(2005). Fundamentals of Nursing:Concept,Process and Practices,8thEdition.Singapore:Pearson Education Inc.pp849 Wolff,LuVerne,et.al.(2003).Philadelphia, Pennyslvania:Harper and Raw Publishers Inc. pp.35-36,683 Haw, Camilla Malyn.et al.(December,2005). A Review of Medication Administration Errors Reported in a Large Psychiatric Hospital in the United Kingdom. www.google.com Wakefield,Bonnie.et.al.(2008).Nurses¶ Perception Why Medication Administration Errors Occur.www.google.com Mckay, Ruth.et.al.(2006).Communication Problems Between Doctors and Nurses.www. google.com http://archimedes.ballarat.edu.au:8080/vital/access/HandleResolver/1959.17/13957 http://en.wikipedia.org/wiki/personality/ http://en.wikipedia.org/wiki/Nursing http://hdl.cqu.edu.au/10018/19887 http:ww.icn.ch/ethics.htm http://www.icn.ch/matters errors.htm http://www.icn.ch/icncode.pdf http://intghc.oxfordjourals.org/sgi/content/abstract/3/1/11 http://www.ecri.org/patientsafety/pages/pennsylvannia patient safety reporting system.aspx
Chapter III RESEARCH METHODOLOGY This chapter is evidently composed of the Research Design which describes the research mode in this study; Research Locale, where the research is to be specifically conducted; Respondents of the Study on which the target population and the sample size is described; Instrument of the Study or the means of gathering the information from the respondents; Validation of and Establishing Reliability where strong evidences or proof are presented; Statistical Treatment where the findings are subjected to, and Notes in Chapter III where the references used in the said chapter are listed. Research Design The study is anchored to a Quantitative research design. The aim of this research is to determine the relationship of one thing (an independent variable) and another (a dependent or outcome variable) in a population (Hopkins, 2002). Quantitative type of research gathers empirical evidences, which are rooted in objective reality and gathered through the senses, either directly or indirectly (Cristobal et.al.2010). Specifically, the study will use Survey Studies under the NonExperimental research design. The investigations are conducted through self-report. Survey generally asks respondents to report on their attitudes, opinions, perceptions or behaviors (Cristobal et.al. 2010).
The type of research design was chosen by the researcher because information must be gathered through numerical means to explain the pattern of occurrence of errors. Afterward, conclusions will be made through the findings of the research. Research Locale As the word implies, this sector will define the setting or location on where the study is to be conducted. In the case of this study, it will be held in Asia Pacific College of Advanced Studies in the City of Balanga, Bataan, Philippines. Respondents of the Study The researcher decided to make the BSN third year students enrolled in Asia Pacific College of Advanced Studies as the respondents of the study. There is a total population of 114 from three sections. Through the Slovin¶s formula, 80 will be the total number of respondents. Slovin¶s Formula:
N___ 1 +N e 2
Where: n=sample size N = population size
= margin of error (6 %) 114____ 1+ 114 (.06)2
= = =
114_____ 1+114(.0036) 114_____ 1+.4104
114_____ 1.4104 = 80 Before any actual sampling is to be made, criteria stated by the researcher should be satisfied first by the respondents: they should be enrolled in the said school, no failing grades in both Academics and RLE and should be at least 18 years old. According to Beck (2004), probability sampling is one of the kinds of sampling in which all members of the entire population are given a chance of being selected. Under this probability sampling, the researcher used Simple Random Sampling, where respondents who qualified for the criteria are chosen by chance. Fishbowl method will be implemented, where the names of respondents will be written in a piece of paper and after which, randomly handpicked respondents will be noted. Instrument of the Study The study will use the questionnaire type of data collection technique. It is considered to be the most common technique used. Questionnaires are an inexpensive way to gather data from a potentially large number of respondents (Hodgkins, 2002). Often they are the only feasible way to reach a number of reviewers large enough to allow statistically analysis of results. A set of questionnaire is to be prepared which consists of the variables used in the study. The first part is about the common causes of medication errors,
followed by different preventive strategies. The last part of the instrument is about the effects of these errors. Rating scale of such will be implemented: Value 5 4 3 2 1 Interpretation Totally Agree Partially Agree Either Agree or Disagree Partially Disagree Totally Disagree
TA- Totally Agree (when you perceive the indicators 81-100%of the time) PA- Partially Agree (when you perceive the indicators 61-80%of the time) EA/ED- Either Agree or Disagree(when you perceive the indicators 41-60%of the time) PD- Partially Disagree(when you perceive the indicators 21-40%of the time) TD- Totally Disagree (when you perceive the indicators 0-20%of the time) Validity and Reliability of the Instrument The instrument of the study, which uses the major variables and sub variables and different indicators from the related literature, is to be tested to ensure its validity and reliability. Validity represents how well a variable measures what it is supposed to (Hodgkins, 2002). A reliable instrument yields the same rank for each individual who take the test more than once (Cristobal et.al.2010) The first validity that will satisfy this study is Face Validity. Face validity tells us nothing about what a test actually measures. It refers to how test takers perceive
the attractiveness and appropriateness of a test. If test takers consider the test to have face validity, they may offer a more conscientious effort to complete the test. If a test does not have face validity they might hurry through a test and take it less seriously. Another validity that will be used is Content Validity. One of the simplest ways to obtain evidence for the validation of a test is to examine the content of the test. Content validity then is the extent to which the questions on a test are representative of the trait, behavior, or attribute that is being measured. It focuses on the questions of the test. The questionnaire will be reviewed by at least three experts, whom have their masteral degree in nursing and preferably to be head and/or chief nurses. The experts will be asked to validate the indicators and variables, and to recommend improvements. With their knowledge and wisdom gained by their practices, their suggestions will be highly accepted, after which, the questionnaire will be improved for the submission of it to the adviser before the dissemination to the respondents of the study. The following were the experts who validated the instrument: Ma.Theresa Sy.Miguel,RN,MAN, Meliza Servera,RN,MAN and Raquel Leongson RN,MAN. The instrument was disseminated to the students and had used the Internal Consistency to establish its reliability. Internal consistency is the extent to which tests or procedures assess the same characteristic, skill or quality. It is a measure of the precision between the observers or of the measuring instruments used in a study. This type of reliability often helps researchers interpret data and predict the value of scores and the limits of the relationship among variables (Howell, 2010). Under this consistency, a more specific type called Split-half will be utilized. It is, according to Cristobal, 2010, a method of establishing internal consistency wherein a test is given only once to the
respondents. The respondents sample size will be split into a first and second half. The scores of these two halves are then correlated using the Spearman-Brown prophecy formula. __2r__ 1+r Where: r-correlation coefficient computed or split halves r1- the estimated reliability of the entire test Statistical Treatment The study¶s statement of the problems will be answered through the following formula. 1-2. The weighted mean refers to the set of data taken from the average of the population (Broto, 2006). Formula: WM=fxN Where: WM-wighted mean fx-sum of the products of the frequency with weights N-sample size 3. The Pearson product moment coefficient of correlation formula is used to test whether the three constructs are correlated. ______ Formula: r= ¥Nxy - xy [nx2-(x)2][ny2-(y)2 Where r=coefficient of correlation x and y = scores N=size of sample r1 =
Notes in Chapter III Hodgkins,Wil.(2002) www.google.com Cristobal,Amadeo et.al.(2010).Guidebook in research Writing:Preparing the Nursing Thesis Proposal.Quezon City,Philippines:C & E Publishing Inc.pp.84,89,98,100,109,120,127,130 Howell, Jonathan. (2010).www.google.com http://www.sportsei:org/jour/001/wghdesign.html http://www.cc.gatech.edu/classes/cs675197 winter/topics/quest.design/ http: www.slideshare.net/songoten 77/presentation-validity-reliability
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