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Nurses' Perceptions of High‐Alert Medication Administration Safety: A

Qualitative Descriptive Study

Article in Journal of Advanced Nursing · December 2019

DOI: 10.1111/jan.14173

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Received: 8 February 2019 | Revised: 28 June 2019 | Accepted: 5 August 2019

DOI: 10.1111/jan.14173

ORIGINAL RESEARCH:
E M P I R I C A L R E S E A R C H – Q U A L I TAT I V E

Nurses’ perceptions of high‐alert medication administration

safety: A qualitative descriptive study

Laura C. Sessions PhD, RN, CNE, Assistant Professor1 | Lynne S. Nemeth PhD, RN, FAAN,
Professor2 | Kenneth Catchpole PhD, Professor1,2 | Teresa J. Kelechi PhD, RN, FAAN,
Professor, David and Margaret Clare Endowed Chair2

1
College of Health Professions, Towson
University, Towson, Maryland
2
College of Nursing, Medical University of
South Carolina, Charleston, South Carolina
Correspondence
Laura C. Sessions PhD, RN, CNE, College
of Health Professions, Towson University,
8000 York Rd, Towson, MD 21252.
Email: lsessions@towson.edu
Abstract
Aims: The aim of this study was to determine nurses’ perceptions of supports and
barriers to high‐alert medication (HAM) administration safety.
Design: A qualitative descriptive design was used.
Methods: Eighteen acute care nurses were interviewed about HAM administration
practices. Registered nurses (RNs) working with acutely ill adults in two hospitals
participated in one‐on‐one interviews from July–September, 2017. Content analysis
was conducted for data analysis.
Results: Three themes contributed to HAM administration safety: Organizational
Culture of Safety, Collaboration, and RN Competence and Engagement. Error factors
included distractions, workload and acuity. Work arounds bypassing bar code scan‐
ning and independent double check procedures were common. Findings highlighted
the importance of intra‐ and interprofessional collaboration, nurse engagement and
incorporating the patient in HAM safety.
Conclusions: Current HAM safety strategies are not consistently used. An organiza‐
tional culture that supports collaboration, education on safe HAM practices, prag‐
matic HAM policies and enhanced technology are recommended to prevent HAM
errors.
Impact: Hospitals incorporating these findings could reduce HAM errors. Research
on nurse engagement, intra‐ and interprofessional collaboration and inclusion of pa‐
tients in HAM safety strategies is needed.

KEYWORDS
acute care, adult nursing, collaboration, culture of safety, high‐alert medications, medication
errors, nurse engagement, nursing, qualitative descriptive, Swiss Cheese Model

1 | I NTRO D U C TI O N 42 billion dollars annually, almost 1% of total global health expendi‐

tures (World Health Organization, 2017). A medication error is a fail‐
The World Health Organization recognizes that medication error is ure to follow processes designed to assure patient safety from the
the leading cause of healthcare acquired injury, costing approximately time the medication is ordered until the medication is given and may

J Adv Nurs. 2019;00:1–14. wileyonlinelibrary.com/journal/jan

© 2019 John Wiley & Sons Ltd | 1
2 |
or may not result in patient harm (PSNet Patient Safety Network,
2017). In the USA, 7,000 inpatient deaths occur every year due to
medication errors (Flynn, Liang, Dickson, Xie, & Suh, 2012). Research
into the frequency of medication error incidence varies from 5.3%
(Bates, Boyle, Vander Vliet, Schneider, & Leape, 1995) to 22.2%
(Härkänen, Voutilainen, Turunen, & Vehviläinen‐Julkunen, 2016) de‐
pending on concept definitions and study designs. A synthesis of re‐
ports from 91 studies generated a median error rate of 19.6% (Keers,
Williams, Cooke, & Ashcroft, 2013). Up to 50% of medication errors
occur during medication administration, a problem of particular con‐
cern to nursing (Cousins, Gerrett, & Warner, 2012; Institute for Safe
Medication Practices Canada, 2012). The incidence and significance
of medication errors has generated international attention. The
World Health Organization has made reduction in medication errors
by 50% a priority (World Health Organization, 2017). One subset of
medications has been identified as more likely to cause significant
patient harm or death: High‐alert medications (HAM). Additional
medication administration procedures have been implemented in
acute care settings to mitigate this increased risk (Douglass et al.,
2018; Engles & Ciarkowski, 2015; Smeulers et al., 2015).
1.1 | Background
High‐alert medications are defined as medications that have an in‐
creased risk of causing patient harm when used in error (Institute for
Safe Medication Practices, 2018). These drugs include antithrombo‐
litics, antidiabetics, insulin, chemotherapeutics, anaesthetics, seda‐
tives and opioids, among others. Although harm can occur even when
a HAM is used correctly, the risks increase when associated with
a medication error (Institute for Safe Medication Practices, 2018).
HAMs appear in 14–50% of medication error incidents in acute care
settings, 11–29% of which occur during the administration process
(Cabilan, Hughes, & Shannon, 2017; Engles & Ciarkowski, 2015;
Manias et al., 2015). In the US, the National Action Plan for Adverse
Drug Event Prevention (ADE Action Plan) was developed to stem
adverse HAM drug events causing patient harm (U.S. Department
of Health and Human Services & Office of Disease Prevention and
Health Promotion, 2014, p. 1).
The eight common root causes of most medical errors, includ‐
ing medication errors, are: Communication problems, inadequate
information flow, human problems, patient‐related issues, orga‐
nizational transfer of knowledge, staffing patterns and workflow,
technical failures and inadequate policies (Agency for Healthcare
Research & Quality, 2003). These factors are barriers to safe prac‐
tice and have been associated with HAM errors. Examples of spe‐
cific HAM problems include: Task interruptions due to workflow
issues (Engles & Ciarkowski, 2015), frequent transfers from one
ward to another (Manias et al., 2015), failure to implement bar‐code
scanning appropriately (Miller, Fortier, & Garrison, 2011) and insuf‐
ficient HAM knowledge (Engles & Ciarkowski, 2015; Hsaio et al.,
2010; Lu et al., 2013). Education on HAM safety is often omitted in
basic nursing education (Engles & Ciarkowski, 2015; Lo, Yu, Chen,
Wang, & Tang, 2013). This research demonstrates the multifactorial
SESSIONS et al.
nature of HAM error and the influence of systems issues such as
workload, distractions, technological complexities and human fac‐
tors on HAM errors.
Technological and procedural strategies have been developed
to enhance HAM safety (e.g. technology prompts for the HAM in‐
dependent double check procedure, smart pumps) to aid in error
prevention (Douglass et al., 2018; Engles & Ciarkowski, 2015). Four
quality indicators specific to HAM safety—availability of the HAM,
electronic verification of the order, protocols and visual reminders—
have been reported (Smeulers et al., 2015).
2 | TH E S T U DY
2.1 | Aim
Although research on safety practices specific to HAMs has begun
to emerge, there is a gap in the current literature regarding nurses’
perceptions of supports and barriers to safe HAM administration.
The insights of practicing nurses may generate new information on
strategies to prevent HAM administration errors. The purpose of
this research was to answer the question: What are nurses’ percep‐
tions about factors that contribute to safe administration when caring
for patients receiving HAMs?
2.2 | Design
A qualitative descriptive study was conducted. Qualitative de‐
scription is beneficial when attempting to discover the ‘who, what
and where… to provide a comprehensive summary of an event’
(Sandelowski, 2000, pp. 338). This approach aligned with our aim of
identifying the supports and barriers to safe HAM administration.
Examination of a problem as multifaceted as medication errors
is enhanced by a framework that recognizes the systemic factors
contributing to human error. The use of a conceptual framework in
qualitative research helps define research goals and methodolog‐
ical choices and connect to current literature (Collins & Stockton,
2018). Reason's Swiss Cheese Model (SCM) framed this research,
specifically the development of interview questions and the de‐
ductive analysis of data (Reason, 1990, 2000). Reason posits that
errors occur from system failures, when the confluence of protec‐
tive factors used to prevent an error fail at exactly the same mo‐
ment. Thus, error can be visualized as slices of Swiss cheese. When
holes in the cheese align, gaps in the safeguards to prevent an error
are exposed. In this model, human error is believed inevitable;
protective factors prevent latent failures (problems at the orga‐
nizational level that cause errors—blunt end processes) and active
failures (errors that occur from individual slips and mistakes—sharp
end processes) (Reason, 1990, 2000). Blunt end processes are the
organizational systems, policies, procedures and resources that,
when effective, contribute to safety. However, when blunt end
processes fail (latent failures), sharp end processes (the patient–
clinician interaction) must be relied on to prevent error. Active fail‐
ures occur when the individual makes a patient care error. During
SESSIONS et al. | 3

TA B L E 1 Semi‐structured interview guide

Initial questions Follow‐up questions Probe

How would you define HAMs? What HAMs do you use in your practice?
Do you remember when you first heard the Will you describe for me how you learned
term HAM? about HAMs?
What factors help you feel confident to ad‐ Do you feel these safety measures are Describe for me the steps you take when ad‐
minister HAMs safely? adequate to protect patients during HAM minister a HAM on a typical day.
administration? Why or why not?
What policies and procedures are in place at Can you provide an example of how you use Do you feel the policies and procedures at your
your facility to assure patient safety during these protocols? hospital are working to keep patients’ safe?
HAM administration? Why or why not?
What barriers do you think interfere with a
nurse's ability to follow these policies and
procedures?
Can you describe any factors that you feel
interfere with your ability to safely adminis‐
ter HAMs?
What factors can cause a nurse to make a Can you give me an example of a HAM error? What factors do you feel contributed to this
medication error when administering a HAM? error?
Some nurses have ways to ‘work around’ hos‐ Can you give me an example of what work
pital procedures. Are you aware of any ‘work arounds you are seeing in practice?
around’ strategies nurses use in your agency
when giving HAMs?
Imagine that you have to teach a nurse how to
safely administer HAMs. What information
would you consider essential for the nurse
to know?

HAM, high‐alert medication.

the analysis of data, we deductively coded descriptions of partic‐
ipant and institutional practices according to the SCM to identify
fit and outliers.
2.3 | Participants
Eighteen registered nurses (RNs) were recruited from two hospitals
(one urban [251 bed], one suburban [272 bed]) in the mid‐Atlantic
region of the US. Nurses worked on critical care (CCU), intensive
care (ICU), telemetry, emergency department, oncology, medi‐
cal and surgical units. A purposive sampling strategy was used to
attain a diverse (age, sex, race, ethnicity, experience) population
of nurses who worked on units where HAM administration was
common. Nurses self‐identifying as having little experience ad‐
ministering HAMs were excluded from this study. A hospital‐wide
email explaining the study was forwarded to all nurses by the nurse
educators at each hospital. A follow‐up email was sent two weeks
after the initial email. This was the extent of the involvement of the
nurse educators in recruitment. RNs responded directly to the pri‐
mary investigator (LS) by return email. Follow‐up emails confirmed
eligibility, answered participant questions, determined willingness
to participate and established the participants’ preference for in‐
terview time and location. One interview was conducted in a pri‐
vate office at the college; the remaining interviews were conducted
at the participant's hospital in a quiet location. Despite a follow‐up
recruitment email, only seven participants were initially recruited.
A snowball strategy, where participants asked their peers to re‐
spond to the follow‐up email, was used to recruit additional RNs.
Each participant was entered into a raffle for a $50 gift card to ex‐
press appreciation for their participation. One winner was awarded
the gift card.
2.4 | Data collection
The first author (LS) interviewed practicing RNs from 28 June–
12 September 2017. Broad, open‐ended, semi‐structured inter‐
view questions based on the SCM were developed under the
guidance of a senior human factors researcher (KC) (Table 1). The
questions were trialled on two experienced nurses and minor ad‐
justments made to the wording of some questions were made. The
questions focused on supports and barriers to HAM administra‐
tion safety. A senior qualitative researcher (LSN) reviewed early
interviews and provided feedback to LS on interviewing tech‐
nique. The interview format was informal, allowing participants
to lead the conversation to issues they considered relevant. All
interviews were audio recorded. The audio files were uploaded to
a secure server within two hours and the original recordings de‐
leted. All recordings were professionally transcribed by Rev.com.
Personal identifying data were removed and the transcriptions
validated for accuracy by LS. A reflexive journal was maintained.
4 |
Initial and follow‐up memos documented thoughts and ideas to be
explored during data analysis.
2.5 | Ethical considerations
The university Investigational Review Board and both hospitals ap‐
proved this study. Participants responding to a recruitment email
received an information sheet describing the purpose of the study
and risks and benefits of participation. They had the opportunity
to ask questions prior to participating. Participants’ provided verbal
consent and willingness to complete the interview. Transcriptions
and analysis notes were stored on a cloud‐based, secure server. No
personally identifying data were kept in association with the data
used for analysis.
2.6 | Data analysis
A computer assisted qualitative data analysis software program
(NVivo Version 11, QSR International Pty.) aided data organization
and analysis. Content analysis was used to identify, describe and
make inferences about the qualitative data generated by the RNs.
An integrated approach (both inductive and deductive) was used for
data analysis (Bradley, Curry, & Devers, 2007). Starting with an in‐
ductive approach allowed us to immerse ourselves in the data to de‐
termine the concepts and themes most relevant to the participants
(Hsieh & Shannon, 2005). Once the inductive analysis was complete,
we performed a deductive analysis to evaluate the concepts and
themes with the SCM.
Data analysis was conducted by LS under the mentorship of LSN.
As each new interview was conducted, initial ideas about concepts
and themes were documented in memos. The interviews were then
reviewed and areas where the interviewer may have influenced that
questioning were documented in a reflexive journal. This was reviewed
prior to the next interview in a conscious effort to remove interviewer
bias. Each interview was then read word‐by‐word and coded to de‐
termine initial categories. Memos on ideas for initial categories were
created. Findings from new interviews were compared with the old
for consensus and disagreement. Categories were then reanalysed
into meaningful clusters from which concepts and themes were de‐
veloped. At each stage of analysis, findings were discussed by LS and
LSN. Analysis continued until consensus was reached on concepts and
themes. After 13 interviews, no new information was being generated.
An additional five participants were interviewed. Data saturation was
evident. No new volunteers were recruited. After consensus on the
conceptual codes and themes, the authors reanalysed the data through
a deductive process (August 2017–April 2018) to identify if and where
the participant responses aligned with the components of the SCM.
2.6.1 | Rigour
Processes to assure trustworthiness described by Elo et al. (2014)
were incorporated into the preparation, organization and reporting
phases of this study. These methods gave us a systematic strategy
SESSIONS et al.
to objectively gather, quantify and describe the phenomena being
studied, thereby enhancing the validity of the results. The first au‐
thor (LS) collaborated with (LSN) to guide and validate the analytic
methods and findings. Findings were discussed with two experi‐
enced acute care nurse educators to assess credibility of results. The
Table S1 summarizes the data collection and analysis approach and
steps taken to enhance trustworthiness.
3 | FI N D I N G S
3.1 | Participant characteristics
Nineteen RNs volunteered from each of two hospitals (one urban
[N = 12], one suburban [N = 7]). One nurse was excluded for not
meeting participant criteria (paediatric nurse). Most of the RNs
interviewed were female (83%), White (72%) and had a Bachelor
of Science in nursing (56%). Medical or telemetry units were
the majority practice settings. Table 2 summarizes participant
characteristics.
3.2 | Themes
Ten of 18 nurses provided a correct definition of ‘high‐alert medica‐
tions’. Examples of incorrect definitions included medications ‘with
similar sounding names’, ‘with a high‐alert label’ or ‘needing a co‐
signer’. The most common HAMs administered were intravenous
heparin, insulin and hydralazine. Nine nurses learned about HAMs
on the job, six during nursing school, two when caring for ill family
members and one as an ICU technician prior to nursing school.
3.2.1 | Inductive analysis
Nurses described factors that contributed to safe HAM administra‐
tion in three areas: Organizational factors, the nurse's competence
and engagement, and collaboration. Table A1: Selected Statements,
Meanings and the Development of Emergent Themes provides ex‐
amples of the nurse responses that led to the identification of each
theme.
Organizational factors
The nurses felt their organizations demonstrated a commitment
to HAM safety in several ways. Nurses were encouraged to report
HAM errors and were not penalized for doing so. When errors did
occur, information about the causes and prevention were dissemi‐
nated throughout the hospital. Resources were available to support
safe HAM administration (computers, bar code scanning, HAM la‐
belling and smart pumps). Nurses were involved in committees that
developed policies and protocols for HAMs.
Protocols were mentioned by every nurse as essential to safe
HAM administration. The protocol was used to guide judgements
about HAM administration, for example adjusting drug dosing based
on diagnostic data (e.g. glucose and electrolyte levels for insulin), or
patient assessment findings (pain and sedation ratings for narcotics).
SESSIONS et al. | 5

TA B L E 2 Characteristics of participants Micromedex, needed to make judgements about patient care.

Having the medication protocol/nomogram linked to the elec‐
All participants (N = 18) N (%)
tronic medication administration record (eMAR) increased confi‐
Age
dence in their ability to make decisions. When protocols were not
20–30 9 (50) available with a few clicks of the mouse, nurses were left scram‐
31–40 3 (17) bling for information, usually accessing non‐hospital approved
41–50 3 (17) resources for information. Computer alerts reminded nurses of
51–60 2 (11) diagnostic data or assessments needed prior to HAM administra‐
Over 60 1 (5) tion. Bar code scanning and prompts for the independent double
Gender check (IDC) procedure were seen as improving safety. ‘We scan

Female 15 (83) the patient and if that is not the medication that is prescribed for
that patient according to scanning them and then scanning the
Male 3 (17)
medication, we don't give it’.
Race
However, all nurses described ways to bypass these systems and
White 13 (72)
stated that ‘work arounds’ such as having extra patient identification
Black 4 (22)
bands and medication labels to scan at the nurses’ station were com‐
Asian 1 (7)
mon. The IDC procedure was also violated frequently, with nurses
Years of experience signing without checking the medication, or verifying after the HAM
Less than 1 1 (0.6) was started. The nurses provided three reasons for violating IDC
1–5 10 (56) procedures: Emergencies like a code; not having a nurse available
6–10 3 (17) to cosign when the HAM needed to be started; and a sense that the
11–15 2 (11) nurse was competent and therefore, their work did not need to be
26–30 1 (0.6) checked. ‘It's a matter of trust. I know a nurse. I know that [she's] a
More than 40 1 (0.6) high‐quality nurse. I'm not going to be ‘okay let me see that there's

Practice area four units in the vial. I'm gonna trust her’.
The primary organizational barriers identified by all nurses
Medical 7 (39)
were work load and distractions. The number and acuity of pa‐
Critical care 2 (11)
tients assigned left the nurses feeling like they had to rush through
Emergency 2 (11)
important safety checks. ‘If the practice setting is such that it is
Telemetry 7 (39)
incredibly busy, incredibly overwhelming, people who normally
Highest level of education
would have done better… make that compromise, not from a mali‐
ADN 3 (17) cious standpoint, but from a self‐preservation and “I've gotta get
BSN 10 (56) everything done.”’ Nurses described being constantly interrupted
Master's 3 (28) by the patient/family, nursing technicians, physicians, laboratory,
Current student etc. when trying to concentrate on HAM administration. These
Yes 6 (33) distractions interfered with focus. Several nurses lamented about
No 12 (67) their hospital phones:

You're giving medications; you're doing the right

Written protocols supported nurses when advocating for safe
practice:
Maybe a new doctor will not get a PTT [partial throm‐
boplastin time] before heparin and they wanted to go
off the grid, they wanted to do non‐protocol heparin
at the rate they want… and yet they will say, “Just do
it.” I'm like, “Okay, that’s great you’re allowed to do
that but what about a PTT first, the baseline?” “Do we
have to?” “Yes.”
Every nurse described the importance of technology for safe
HAM administration. Computers allowed rapid access to informa‐
tion, such as protocols or medication information databases like
thing…then get a phone call that they need you in
Room 3 for something else. Well, what am I supposed
to do? I'm giving these HAM… and then they want me
to go to Room 3.
Nurses knew they were being ‘timed on responsiveness’ to phone
calls, increasing their perception of a need to rush through HAM
administration.
RN competence and engagement
All nurses talked about competence as having the knowledge and
judgement to make appropriate decisions when giving HAMs. They
reported that administering HAMs was complex and felt many
nurses lacked sufficient knowledge or judgement to be safe:
6 |
I think the clinical judgement is absolutely essential,
because even if you do have the protocols in place,
tell you where to start, what to do, how to change, a
lot of times, they don't give you vital parameters. I'm
not gonna start somebody on a Cardizem drip if their
blood pressure's 80. And, some people don't have
that judgement yet. They don't understand that yet.
Nurses described the importance of working in an environment
where it was safe to ask questions when they were unsure of their
knowledge and they wanted ongoing education to remain current in
their knowledge.
Almost all nurses addressed that not every nurse was engaged
in their patient care. When giving HAMs, these nurses practiced
by rote when completing tasks and were not accountable for un‐
derstanding why they were doing what they were doing. During
report “you'd ask, ‘Oh, they're getting heparin. Why are they
getting heparin?’ ‘I don't know’.” Safe nurses were described as
never complacent; they understood the risks associated with
HAMs and made sure to remain vigilant when caring for patients
on these medications. But, they were concerned when working
with nurses that were not as committed. ‘You can put in policies;
you can put in procedures and everything. If somebody's gonna
dance outside of the box when it comes to safety, then it's not
adequate’.
Collaboration
All nurses reported that they relied heavily on peers (the charge
nurse, the nurse manager, unit specialists and nurse educators) as
sources of information and support during HAM administration.
Collaborative activities described included the IDC and commu‐
nication regarding the correct way to implement HAM protocols.
Conversely, nurses described situations where they did not feel safe
to ask for help. As one nurse stated, ‘if you get that one experience
where, I asked somebody for help, they looked at me like I was stu‐
pid, I'm not going to ask again’.
Nurses also relied on interprofessional collaborations, especially
with the pharmacist, to deliver safe, quality care during HAM admin‐
istration. ‘We have a pharmacist on the floor and she's awesome,
so you can ask her anything about any med. She'll put orders in for
you; she'll double‐check things for you’. Safe HAM administration
required that all members of the interdisciplinary team perform their
roles correctly. Nurses who took responsibility for verifying the
accuracy of the HAM order and medication helped prevent errors.
Nurses’ believed this was part of their role as a patient advocate and
was essential to ensure patient safety.
Five nurses reported that patients sometimes interfered with
safe HAM administration. They described situations where patients
were non‐adherent to the protocol, refusing bloodwork and/or med‐
ications. However, nine nurses emphasized the importance of ed‐
ucating the patient and family about the HAM so that they could
help keep the nurse informed of problems they were experiencing.
These nurses felt that enhanced patient–nurse collaboration could
SESSIONS et al.
help patients adhere to the complex medication regimens associated
with some HAMs.
3.2.2 | Deductive analysis
After completing the inductive analysis, we returned to the data to
determine if the identified concepts and themes aligned with the
SCM. Nurses identified both latent and active factors that had an
impact on HAM administration. Latent factors (organizational) that
supported HAM safety included both the importance of safety as
a value of the organization and processes to enhance safety. The
nurses felt their organizations demonstrated a culture of safety by
supporting an environment with resources for HAM administra‐
tion, where nurses were included in development of policies and
protocols and reporting HAM errors was viewed as an opportunity
to improve practices. Latent factors that contributed to potential
HAM errors were working conditions such as workload, patient
acuity and distractions. These issues contributed to nurse inatten‐
tion and the use of work arounds as nurses rushed to complete
patient care.
Although all nurses described the importance of intraprofes‐
sional and interprofessional collaboration to HAM administration
safety, only two identified a specific organizational (latent) prac‐
tice to enhance collaboration, the unit‐based pharmacist. Nurses
emphasized commitment to their patients as a motivation to take
HAM administration seriously and relied on their clinical judgement
to administer HAMs safely. Nurse competence and engagement
prevented active failures (errors at the patient–nurse level). Despite
this, most described active failures—slips (attention failure) and mis‐
takes (breaking a rule)—that contributed to HAM errors. ‘I've seen
several Heparin mistakes… the nurse didn't change it to the proper
rate. They changed it to the proper rate in the computer, but they
didn't change it to the proper rate on the pump’.
The data demonstrate that the SCM is a useful model for under‐
standing factors that contribute to safe HAM administration and
how latent failures could contribute to active HAM errors. Where
the model falls short is consideration of patient engagement in the
HAM administration process and the definition we use for HAM
errors. Most researchers would include missed doses or failure to
obtain supporting diagnostic data as HAM errors. But is it really
a latent or active failure when the patient refuses to take a medi‐
cation dose, or have their lab work drawn for lab tests needed to
determine response to the medication?
They don't want to be stopped to get a finger stick
every hour. They don't want a BMP [basic metabolic
profile] every two hours. You try to give them a po‐
tassium replacement, they're refusing. After a while
they're just like, "You know what? Just leave me
alone.”
Conflicting nursing responsibilities—patient teaching about the
HAM and why it is important, respecting the patient's autonomy
SESSIONS et al.
and right to refuse the HAM, all while trying to implement the HAM
order and follow hospital policies—can make HAM administration
challenging. It is difficult to determine where these competing du‐
ties fit into the SCM. The answer may lie in the way we define HAM
errors. Table 3 summarizes the barriers and facilitators to safe HAM
administration described by participants.
3.3 | Model generation
Data from this analysis were used to generate a model for HAM safety
to help elucidate the complexities underlying safe patient outcomes
when nurses care for those receiving HAMs. To this end, the authors
proposed a descriptive model of nursing practice to prevent HAM
error: HAM Safety: Nursing, Collaborative and Organizational Influences.
The model proposes that these three interconnected themes are es‐
sential to safe HAM administration. In an organization that prioritizes
a culture of safety, nurses who are engaged in their profession and
have a high degree of competence work collaboratively to implement
safe HAM care. Nurses whose judgement leads them to believe there
is a safety concern with a HAM feel compelled to solve the prob‐
lem because of their professional engagement. Nurses feel safe to
address the issue because the organization makes patient safety a
focus of all care. Nurses can trust they will not be unjustly penalized
for problems outside of their control. Nurses collaborate with their
peers to validate their knowledge and concerns about HAMs. They
access readily available information resources to identify solutions to
problems and collaborate with the pharmacist or health care provider
to remediate the problem. Nurses negotiate organizational functions
to deliver care and when problems develop, participate in remedia‐
tion strategies to develop more effective processes.
4 | D I S CU S S I O N
Our analysis identified three principal themes for HAM safety: An
organization that emphasized a culture of safety, collaboration and
RN competence and engagement. Together, these provided a holistic
view of the multi‐faceted influences on HAM administration safety.
Research specific to safe HAM administration is emerging and while
studies corroborate the findings of this research, our analysis identi‐
fied several gaps in the current literature.
Intraprofessional collaborations with peers as a source of HAM
information were extremely important. The interprofessional collab‐
oration deemed most important for HAM safety was the pharmacist.
Increasing the patient's role in HAM care may also improve safety.
RN engagement was considered essential to safety. Participants felt
that nurses who were dedicated professionals were less likely to by‐
pass safety practices during HAM administration. Nurse representa‐
tion on committees that developed policies affecting HAM practice
was important. It was felt that this would enhance the practicability
of any policy or protocol implemented.
Other findings were supported by current literature. An organi‐
zational culture of safety has been acknowledged as important to
| 7
medication safety. Primary concerns identified by participants in this
study, including inconsistent use of the independent‐double check,
workload and distractions were identified as factors contributing to
medication errors in other studies (Mansour, James, & Edgley, 2012;
Thomas, Donohue‐Porter, & Fishbein, 2017). Establishing a culture
of safety around medication error is complex and requires interdis‐
ciplinary approaches (Hawkins, Nickman, & Morse, 2017). Gimenes
et al. (2016) identified that nurses felt helpless to change prevalent
medication practices in an organizational culture that applied ad‐
ministrative pressures and did not include nurses in identifying solu‐
tions. A ‘Nurses’ Rights of Medication Administration’ could help
assure the responsibility, accountability and authority of the nurse
to intervene to prevent medication errors (Jones & Treiber, 2018).
Organizational processes that support just culture—a work place that
recognizes that errors are inevitable, employees are accountable for
their mistakes, the organization is not unnecessarily punitive and er‐
rors are viewed as an opportunity to improve practice—may improve
HAM safety (Frankel, Haraden, Federico, & Lenoci‐Edwards, 2017).
Research is currently lacking in this area.
Working conditions that include interruptions and distractions
have been identified as factors contributing to HAM errors (Engles
& Ciarkowski, 2015) and medication errors in general (Blignaut,
Coetzee, Klopper, & Ellis, 2017; Brady, Malone, & Fleming, 2009;
Cabilan et al., 2017; Johnson et al., 2017; Keers et al., 2013; Kosits
& Jones, 2011; Raban & Westbrook, 2014; Thomas et al., 2017;
Trbovich, Prakash, Stewart, Trip, & Savage, 22010). As in our study,
others have described the potential of bar‐code scanning to reduce
HAM errors but identified frequent nurse workarounds (failure to
scan the armband or drug), demonstrating a need to continuously
assess and improve processes to support effective use of these tech‐
nologies (Hawkins et al., 2017; Miller et al., 2011).
Research on the IDC, a form of intraprofessional collaboration,
demonstrates this practice is often successful in error detection, but
is routinely performed incorrectly (Hawkins et al., 2017; Miller et al.,
2011) and may contribute to errors when one nurse persuades an‐
other to take an incorrect action (Douglass et al., 2018). Although
this procedure was part of the organization safety plan, our research
demonstrated that nurses routinely used work arounds, risking HAM
error. Collaboration in the form of nurse knowledge sharing has not
been addressed in the literature on medication safety.
The importance of interdisciplinary collaboration to medication
safety has been reported. Research emphasizes the need for better
reporting of errors, consensus on the definition of a reportable error,
communication tools, pharmacists included in rounds, collaborative
medication reviews, workshops and conferences and complexity of
role differentiation and environment (Hawkins et al., 2017; Manias,
2018). The nurses in our study reaffirmed the importance of inter‐
disciplinary collaboration, especially with the pharmacist, to ensure
HAM safety.
Although studies often cite the patient and family as contributing
to distractions, there is little research into the potential advantage
of forming a partnership between the patient/family and nurse to
improve medication safety (Wimpenny & Kirkpatrick, 2010). Several
8 | SESSIONS et al.

TA B L E 3 Barriers and facilitators in safe HAM administration

Themes Barriers Facilitators

Culture of safety
Just culture Fear of retribution Root cause analysis
Fear of confronting physician Rewards and acknowledgment
Fear of admitting a knowledge gap Disciplinary actions for flagrant disregard of safety
policies and procedures
Organizational culture Safety not a priority Safety part of mission and values of organization
Culture inhibits questions Safety is an expectation for all members
Culture inhibits error reporting Support culture of questioning
Routine communications re: errors and prevention
Work flow Cumbersome or overly complex processes Process analysis to improve work flow
Work arounds RNs involved in development of policies that impact
Lack of technology (insufficient number of smart work flow
pumps, computers) Protocols and policies tested before implementation
Technology failure (unable to scan) Needed resources (medications, equipment) easily
Resources hard to access accessible
Distractions Minimize distractions during HAM administration
Information resources Cumbersome or overly complex protocols, policies or Policies and procedures not overly complex or
procedures cumbersome
Information incomplete (missing patient data, policies, RNs involved in development of procedures and
procedures, protocols) protocols
Alerts and warnings inconsistently applied Information resources comprehensive and accurate
Technology failure Technologies efficient, effective and easy to access
Computer algorithms
Computerized provider order entry
eMAR‐associated data link (medication monograph,
patient lab data)
Smart pumps
Availability of technology support
Essential information on medication label
Printed protocols at nurses’ station
Work load Patient acuity Increasing staffing based on patient acuity,
Number of assigned patients cooperation
Patient non‐cooperative Adjusting load during HAM administration
Nurse fatigue and loss of focus
RN competence and
engagement
RN competence Lack of knowledge about HAM HAM education
Inexperience with HAMs Ham simulation experiences
Dosage calculation skills inadequate Competency evaluation
Mixing HAM on unit RN self‐advocacy
Not knowing how to access resources Facility orientation for new hires and agency nurses
Overdependence on computer Continued RN development on HAMs
Lack of institutional specific training Assignments with HAMs based on competency
Staff and agency nurses caring for patient's outside of
their competency
RN engagement Lack of nurse commitment to HAM safety Institutional accountability of evaluation of RN
No personal accountability for knowledge gaps competence
RN not doing what they know needs to be done Rewards and acknowledgment for safety behaviors
Rote administration of HAM
Collaboration
Intraprofessional Not holding peers accountable for HAM safety Peer collaboration encouraged
behaviours Peer resource identified and accessible (team mem‐
Peers complicit in work arounds bers, charge nurse, nurse manager, nurse supervisor)
Trust that peer would not make a mistake Standardized communication strategies employed
Independent double check

(Continues)
SESSIONS et al.
TA B L E 3 (Continued)
Themes Barriers
Interprofessional Lack of interprofessional trust
Lack of standardized safety communication strategies
(CUS)
Verbal orders
Patient–Nurse Patients’ not aware of HAM safety concerns
Abbreviations: eMAR, electronic medication administration record; HAM, high‐alert medication; RN, registered nurse.
nurses in this study identified the potential safety ramifications of
pursuing greater patient–nurse collaboration around HAM safety, a
topic that merits further research (Bucknall et al., 2018).
Accountability for HAM knowledge and clinical judgement were
frequently emphasized in our study and was reflected in the liter‐
ature as well (Engles & Ciarkowski, 2015; Hsaio et al., 2010; Lu et
al., 2013). Nurse competence in terms of overall medication knowl‐
edge and dosage calculation is robustly represented in the literature.
(Brady et al., 2009; Cabilan et al., 2017; Johnson et al., 2017; Keers
et al., 2013; Wimpenny & Kirkpatrick, 2010). Clinical judgement in
any medication administration warrants further research (Rohde &
Domm, 2018).
Research into RN engagement is limited. A correlation between
work commitment (‘an interest or willingness to spend time and en‐
ergy for work’) and medication errors has been reported (Rezaiamin,
Pazokian, Tafreshi, & Naisiri, 2017, p. 3). More research is needed to
address ‘nursing judgement and the concepts of indifference or nor‐
malization of deviance in relation to nurses’ intent to recognize and
report medication errors’ (Hawkins et al., 2017, p. 1921).
4.1 | Limitations
The goal of this research was to identify influences on HAM admin‐
istration errors and identify areas for further research. The results
of this study are not broadly generalizable. Nurses who elected to
participate in this study may have done so due to negative experi‐
ences with HAM administration, which may have skewed the results.
The population lacks participants from rural or under‐resourced hos‐
pitals. Nurses without access to technological and human resources
may have viewed HAM safety differently.
5 | CO N C LU S I O N
This research revealed three areas that influence HAM safety—An
organizational culture of safety, RN competence and engagement
and collaboration. The findings should be used to address current
barriers to safe practice. Nurses need greater input into the develop‐
ment and implementation of policies and protocols that have a direct
impact on their practice. Organizations need to address competing
goals (HAM safety vs. rapidity of response to phone requests) to pri‐
oritize safety. Strategies to improve interprofessional collaboration
around HAM safety are needed. Protocols such as the IDC need to
| 9
Facilitators
Interprofessional collaboration encouraged
Unit‐based clinical pharmacist available during HAM
administration
Patient as partner in safety when receiving HAM
be evaluated for feasibility as well as efficacy. Research is needed on
the impact of nurse engagement on HAM errors and the potential of
patient–nurse collaboration.
C O N FL I C T O F I N T E R E S T
No conflict of interest has been declared by the authors.
AU T H O R C O N T R I B U T I O N
LS, LN: Made substantial contributions to conception and design, or
acquisition of data, or analysis and interpretation of data; LS, LN, KC,
TK: Involved in drafting the manuscript or revising it critically for
important intellectual content; LS, LN, KC, TK: Given final approval
of the version to be published. Each author should have participated
sufficiently in the work to take public responsibility for appropriate
portions of the content; LS, LN, KC, TK: Agreed to be accountable
for all aspects of the work in ensuring that questions related to the
accuracy or integrity of any part of the work are appropriately inves‐
tigated and resolved.
ORCID
Laura C. Sessions https://orcid.org/0000-0001-8526-7182
Lynne S. Nemeth https://orcid.org/0000-0001-8691-1400
Kenneth Catchpole https://orcid.org/0000-0003-4073-3025
Teresa J. Kelechi https://orcid.org/0000-0001-7412-2607
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APPENDIX A

TA B L E A 1 Deductive and inductive framework used to develop model: High‐Alert medication safety: Nursing, collaborative and
organizational influences

Concepts Sub‐Concepts Examples Themes

Latent failures—Fear of confront‐
ing MD, fear of admitting a
knowledge gap, fear of repercus‐
sions for reporting error
Blunt end processes—Culture
of questioning, encouraged to
report errors, routine commu‐
nication about errors made in
organization, information dis‐
semination on error prevention
Sharp end processes—Fear of los‐
ing license, fear of repercussions
Latent failures—Medications in
many locations, pharmacy error,
cumbersome processes, distrac‐
tions, complexity of protocol,
protocols inconsistent, work
arounds, information hard to
find, missing patient data, lack of
technology (insufficient number
of smart pumps), resources hard
to access, technology failure
(unable to scan), patient acuity,
load, patient non‐cooperative,
overwhelmed
Barrier—nursing is hard
Blunt end processes—Protocols,
policies and procedures, RN
involved in policy development,
computer algorithms, medication
reconciliation, adjusting work
load during HAM, staffing
Active failures—Work arounds,
nurse fatigue, loss of focus
Just Culture—‘An environment
in which staff members accept
responsibility for their own ac‐
tions, but know the organiza‐
tion will treat them fairly and
not blame them for something
out of their control’.
(Frankel et al., 2017).
Working conditions
Work flow—Processes that
support safe, quality nursing
practice.
Work Load—Job responsibili‐
ties that place demands on the
nurse’s time and attention.
Overwhelming workload in‐
terferes with attention causing
distraction and loss of focus.
The paper's right there on the com‐ Organizational Culture of
puter, you can look at it. I just point Safety—‘A collective and
to it and they look at it. Sometimes continuous commitment by
they look, sometimes they don't, organizational leadership,
and that's how we go. managers and health care
workers to emphasize safety
over competing goals’.
(American Nurses Association,
2019)
Some of the barriers again are while
you're trying to take care of some of
these things, your phone's ringing
constantly. It's again, it's the inter‐
ruptions and the lack of ability to
focus. And I think that's where a lot
of the mistakes or the errors, or you
know, the reason for not following a
protocol happens.
You've got people that will
cosign but not actually look at
anything. They'll just, "Yeah, okay."
Sometimes it's out of pure busy‐
ness… like I said you're being pulled.
It's not like… Once again, that
doesn't mean you're not a decent
person. You're a human being. You
know what I'm saying? I think peo‐
ple try to do the right thing.

(Continues)
12 | SESSIONS et al.

APPENDIX 1 (Continued)

Concepts Sub‐Concepts Examples Themes

Latent failures—Complexity of Technology We have smart pumps now, which

protocol, protocols inconsistent, Information resources—A I think have contributed to
work arounds, information hard two‐way flow of high‐quality decreasing errors… They're pre‐
to find, missing patient data, lack information to provide safe, programmed, so when you put in a
of technology (insufficient num‐ quality care. medication that is a high risk, it can
ber of smart pumps), resources be set for two RNs to verify it.
hard to access, technology failure There's always some time you're
(unable to scan) going to do a new medication you're
Blunt end processes—Computer not used to. Our ER is very strong
algorithms, computerized pro‐ on pushing protocols and proce‐
vider order entry, ease of access dures at the bedside.
to information, eMAR, associated
data link in eMAR, medication
monograph in computer, smart
pumps, availability of technology,
technology support, essential
information on medication label,
printed protocols at nurses’ sta‐
tion, badge buddies
Active failures—Not utilizing avail‐
able resources
Latent failures—Lack of training, RN Abilities—The knowledge, You also need to have knowledge of RN competence and engage‐
staff and agency nurses caring skills and judgement needed to a bigger picture, a broader picture. ment—Inherent beliefs and
for patient’s outside of their deliver safe, quality care. Not everybody's receiving it [HAM] abilities of the professional
competency for this same reason. Not every nurse.
Blunt end processes—Orientation, person can receive it at the same
continued RN training, compe‐ rate so don't assume.
tency evaluation, assignments
based on competency
Active failures—Lack of knowl‐
edge about HAM, lack of
knowledge, inexperience, dosage
calculation, pulling or mixing dose
in unit, does not know how to ac‐
cess resources, overdependence
on computer
Sharp end processes—RN educa‐
tion, judgement, knowledge,
self‐advocacy
Active failures—Lack of nurse RN engagement—Guides nurses I think some nurses are pretty happy,
integrity, ignore computer alerts, to act with integrity and hon‐ but a lot of them are not happy with
no accountability for knowledge esty as they strive to deliver the work or how things are going
gap, RN not doing what they excellent patient care. and that disquieted, that anger,
know needs to be done, rote that discontent, it shows in the
administration of HAM quality of the work they do, how
Sharp end processes—Self‐ac‐ they treat the patients and their
countability for knowledge gap, relationship with other coworkers. It
self‐advocacy, never complacent, just comes through, even if they try
make no assumptions and hide it.

(Continues)
SESSIONS et al.
APPENDIX 1 (Continued)
Concepts
Active failure—Not holding peers
accountable
Sharp end processes—
Collaboration with nurse peers
(team members, charge nurse,
nurse manager, nurse supervisor),
peer communication, independ‐
ent double check
Active failures—Lack of trust (not
conferring with MD)
Latent failures—Poor communica‐
tion (verbal orders)
Sharp end processes—
Interprofessional collaboration
(pharmacy HCP/MD, lab), RN
verification of orders, patient as
partner
Active failures—Patient non‐coop‐
erative, non‐adherent
Sharp end processes—Patient
education, having patient com‐
municate HAM problems
Sub‐Concepts
Intraprofessional
Collaboration—Two or more
nurses working together to
deliver safe, quality care.
Interprofessional
Collaboration—members of
the health care team work
together to support high‐qual‐
ity patient care.
Patient–Nurse Collaboration—
the patient and family work
with the nurse to achieve a
health outcome.
| 13
Examples Themes
Examples: Collaboration—Two or more
Sometimes I think they think if you're people working together to
checking the medication [they feel] achieve a desired outcome.
like they don't know what they're
doing or because you've been a
nurse longer than they have or
you've been on that unit longer than
they have, like you're doubting their
ability. It's really not about them.
It's about safety for the patient.
On my unit now, we have some
nurses that have been nurses for
about a year and they're doing
charge. When I work with them,
they want to be charge, I'm fine
with them being charge, but they
know I'm there. I'm a resource. If
you have a problem, come to me, I
can help.
Examples:
… in the last year or so that we finally
got clinical pharmacists 24/7 on
the unit. They'll be there in codes.
They'll be there for tPA administra‐
tion, all that kind of stuff, so they're
fantastic. Also, just having some‐
body right next to you to just say,
‘Hey, does this look right to you?’
That's when you appreciate [hav‐
ing a protocol], because then
you come into a situation where
then two doctors don't agree, so
the next day, the day after that
whoever is covering on this non‐
protocol heparin, and that can be
a serious yin‐yang of coagulation.
That's a huge risk I think on this
floor, because you're putting the
person at risk of a stroke from a clot
a PE, something.
You just look at them [the patient]
and you're like, "Well," you got to
use all your good nursing skills to
really tell them, say, "Listen, I know
you're feeling lousy," or they want
to leave AMA. You say, "You can't
leave now. I mean, you're compe‐
tent, you can leave, but you'd just
be right back."
I just don't assume. I might go in
now and say, "I'm giving you this
medication. Do you understand
why you're getting this?" It's always
important for me to have that
understanding from the patient.
14 | SESSIONS et al.

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