MEDICATION ERRORS: KNOWLEDGE AND ATTITUDE OF NURSES IN AJMAN, UAE JOLLY JOHNSON 1*, MERLIN THOMAS 1 1 Department of Nursing, Gulf Medical College Hospital, Ajman, UAE ABSTRACT Objectives: This study was conducted to assess the knowledge and attitude of practicing nurses on medication administration and medication errors. Materials and Methods: A questionnaire assessing knowledge on medication errors and attitude of the staff towards medication errors was distributed to 170 nurses working in Gulf Medical College Hospital, Ajman.Analyses were made by appropriate statistical test procedures. Results: In the present study, 67.1% possessed the qualification of GNM (explain) and the remaining were graduates. Twenty one questions were asked to elicit the knowledge regarding medication errors. Mean knowledge score was 15.1±2.6 among participants with graduate level education whereas it was 14.2±2.8 for those with GNM as education level. The years of clinical experience was categorized into five broad groups as less than 2 years, 2-4 years, 4-6 years, 6-8 years, and 8 years and above. Of the 170 nurses in the study, about 35% were with a clinical experience of 8 years and above followed by 22.9% in 2-4 years, 22.4% 4-6 years, 12.9% 6-8 years, and 6.5% with clinical experience less than 2 years respectively. The mean knowledge level of participants with less than 2 years of clinical experience was13.9, whereas in those with more than 2 years of experience the mean knowledge level was 14.8. Conclusion: Knowledge of medication errors is similar across categories of participants with different durations of clinical experience and qualifications. More than 75% of Nurses strongly agrees to the fact that continuous education and up to date information of pharmacology are necessary to avoid medication errors. Keywords: Medication Errors, Knowledge, Attitude, Nurses 1
INTRODUCTION The nursing profession is advancing with high standards and specialized knowledge through research and evidence-based practices. Knowledge changes the attitude and develops confidence for practice. The main responsibility of a nurse is the safety of the patient to whom she is giving care. Medication errors are mistakes associated with drugs that are made during the prescription, transcription, and administration phases of drug preparation and distribution. As a result the patient receives a medication incorrectly, and it may become fatal at times 1. Medication error is one of the major concerns of the nursing professionals internationally. Medication errors that nurses make violate the precept does no harm and may cost a human life. A systematic approach to determine the underlying factors in the occurrence of medication errors is required for the safety of both patients and the staff 2. There are differences in the perceptions of nurses about the causes and reporting of medication errors. All of the potential adverse drug events and approximately two thirds of the actual adverse drug events were judged to be preventable 3. The basic knowledge and attitude of nurses towards the medication errors have to be identified and confirmed before going into systematic approaches to prevent medication errors 4-5. This study was conducted to assess the knowledge and attitude of practicing nurses on medication administration and medication errors. MATERIALS AND METHODS The study was conducted at Gulf Medical College Hospital and Research Centre, Ajman. This 150-bed hospital has almost all specialty units. The study was performed during March to May 2012. Data were collected by the investigatorsand confidentiality was maintained during the data collection process.a self-administered questionnaire on knowledge and attitude towards medication errors was given to the nurses. The tool was developed as per the literature review and was sent for content validity to the experts in the field. It consisted of three parts: Part 1: Socio-demographic data Part 2: Knowledge on medication administration and errors (21 questions were asked as multiple choice questions) Part 3: Attitude on medication administration and errors (20 questions with options such as strongly agree, agree, disagree and strongly disagree were given) Ethics Committee approval was sought before starting the study. After obtaining informed consent, the questionnaire was distributed to the nurses, who were either GNM or BSN qualifiedand were attached to various settings like wards andintensive care areas (both adults and neonatal areas), OT, Emergency room, Maternity wards and OPDs. The data obtained were analyzed using descriptive statistics. The statistical calculations included frequency, mean value and standard deviation. The statistical tests were performed on SPSS 19 version. RESULTS All staff presentaccepted to participate, the response rate consequently becoming 100%. A total of 170 participated and among them 67.1% were with a qualification of GNM, who were the majority of the study population, as compared with the graduates who were 32.9%. 2
Table 1. Mean knowledge score among participants according to their level education Level of education N Mean SD Median B.Sc Nursing 56 15.16 2.66 16.00 GNM 114 14.20 2.81 15.00 Total 170 14.52 2.79 15.00 Table 1 shows that the mean knowledge score among participants with graduate level education was 15.1±2.6, whereas for the participants with GNM as education level the mean score was 14.2±2.8. Thus there is no significant difference in the knowledge level when considering the level of education. Based on the duration, the participants were categorized into five broad groups: less than 2 years, 2-4 years, 4-6 years, 6-8 years, and 8 years and above. Of the 170 nurses in the study, about 35% were with a clinical experience of 8 years and above, followed by 22.9% in 2-4 years, 22.4% 4-6 years, 12.9% 6-8 years, and 6.5% with clinical experience less than 2 years respectively. The mean knowledge level was13.9 among participants with less than 2 years of clinical experience, whereas it was 14.8 with those with more than 2 years of experience.the mean knowledge score details are given in Table 2. Table 2. Mean knowledge score of participants according to duration of experience Duration of experience N Mean SD Median <=2 years 11 13.91 3.18 14.00 2-4 years 39 14.67 2.73 15.00 4-6 years 38 14.90 2.29 15.00 6-8 years 22 14.64 2.97 15.00 >=8 years 60 14.25 3.04 15.00 Total 170 14.52 2.79 15.00 Table 3. Describes the attitude of participants towards medication error Attitude Dimensions Positive Attitude Dimension 3 Strongly agree % Agree % The most important reason for under reporting of medication 27.1 53.5 errors among nurses is fear of reporting When an error occurs nurse should notify the prescriber 74.1 21.2
It is important that nurses need to update their knowledge in 77.1 21.8 pharmacology When there is a confusion with any details of the drug, it should be 32.9 51.2 referred within a colleague Education on medication safety reduces the risk of medication 64.1 31.2 errors During discharge teaching of a patient, the nurse should listen to 77.1 17.1 what patient says and have to explain in detail on medications Reporting a medication error will make others to underestimate 8.2 15.3 one s capabilities Medication error incidents should be noted in the personal file 10.0 52.9 Punishment makes medication errors underreported 10.0 50.0 Environmental factors like other noises in the ward and calling for 23.5 60.6 other work in between can cause medication errors Medication assignment system reduces medication errors 34.1 60.0 Continuous refreshment programs on medication administration and errors should be mandatory for working nurses Negative Attitude Dimension 53.5 43.5 Staying with the patient until an oral medication have been 41.8 44.7 swallowed is a waste of time At times the medication prepared by others also can be 37.6 42.9 administered Mild side effects of drug can be ignored and need not be reported 34.1 60.6 During the administration of IV fluids, maintaining accurate flow 27.6 62.9 rate is not a must for all fluids If a loaded syringe in a tray contains clear fluid in it, assume it as 18.8 73.5 normal saline and can be used for making the IV tubing s patent When a patient refuses injection, make a decision to administer the 28.2 54.1 same medication through a different route Medication error can occur in a facility due to the compliance with 25.3 18.2 policies and procedures Use of abbreviations and dose expressions helps in safe administration of drugs 32.9 21.2 As shown in Table 3, there is no significant difference among the staff with a higher number of years of experience or with different educational qualification; it is purely each individual s attitude and perception of medication errors. When analyzing the statements it was observed that, if the Nurses update their knowledge in Pharmacology and if they educate the patients about the medications and the dosage in detail during the discharge, the risk of medication errors will be reduced which is strongly agreed by the majority (77.1%) of the study population. 4
More than half of the nurses strongly agreed with the fact that education on the medication safety (64.1%) and mandatory refresher programs for the working nurses on medication administration and errors (53.5%) can reduce the risk of medication errors to the maximum extent possible. Other possible ways by which medication errors can be reduced is by making a medication assignment system (34.1%)and by clarifying with the physician if details about the drug are not clear. Other possible reasons for medication errors are the environmental factors such as the noise, dim light, interruptions between work (23.5%) and the under-reporting of medication errors by the nurses (27.1%) Very few of the study population strongly believe that the reason for underreporting is mainly the fear of punishment and the fear that their capabilities might be underestimated.in contrast, 74.1% of nurses strongly believe that if any error occurs it should be notified to the physician. While analyzing the negative attitude dimensions from the 20 questions asked, about 73.5% strongly disagreed that an unlabelled syringe in a tray loaded with clear fluid could be assumed to be normal saline and can be used for making the IV tubings patent. More than half of the study population strongly disagrees with the attitude of ignoring and not reporting the mild side effects of drug (60.6%), not maintaining the accurate flow rate of IV fluid administration (62.9%) and taking own decision regarding the dosage of medication when it is decided to administer through different route (54.1%). About 44.7% of nurses did not agree leaving the patient alone while the oral medicine is not being swallowed and 42.9% did not agree with the administration of medication prepared by another staff. The least number of nurses (18.2%) strongly disagreed with the statement that compliance with policies and procedures can result in medication error and 21.2% strongly disagreed that the use of abbreviations helps in safe administration of drugs. DISCUSSION The aim of the study was to assess the knowledge of nurses on medication errors on the basis of their basic qualifications and the number of years of experience. The study result showed that the mean value of their knowledge was 14.2±2.8 among GNMs, as compared with the 56% of graduate nurses, whose mean knowledge score revealed was 15.1±2.6. On considering the knowledge on medication errors and the number of years of experience, about 35% had a clinical experience of 8 years and above, whose mean knowledge score was found as 14.25. This is followed by 22.9% in 2-4 years with the mean score of 14.66. Out of 22.4% of nurses with clinical experience of 4-6 years also had a mean knowledge score of 14.89, followed by 12.9% with an experience of 6-8 years as 14.63. 5
Another objective of the study was to determine the attitude of nurses on medication errors. 20 questions were answered which contained either positive attitude dimensions or negative attitude dimensions. More than 77% of nurses strongly agreed with the fact that they needed to upgrade their knowledge in pharmacology that they could explain in detail the medications and their dosages clearly to the patient. About 74.1% of nurses wished to notify the prescriber when an error occurred. More than 50% of nurses believe that continuous refresher programs on medication administration and errors are necessary to avoid medication errors. More than 60% indicated that the mild side effects should not be ignored and the accuracy of IV fluid flow rate should be maintained for all fluids. Most nurses disagree with the assumption of the loaded syringe without labeling as normal saline and nearly half reported that nurses should not decide to alter the route of administration on their own. CONCLUSION It can be concluded that there is no significant difference in the knowledge about medication with different levels of education. Additionally, the knowledge level is not related to the number of years of experience. The attitude that matters is the safe administration of medication even though all nurses agree that the updating of knowledge on medication and errors is important.thus the nurses should have a positive attitude towards safe administration of medication and thereby avoid errors. ACKNOWLEDGEMENT Authors would like to thank all the nurses who participated in the study. REFERENCES 1. Bliss Holtz J. Discriminating types of medication calculation errors in nursing practice 1994 December;43(6):373-75. 2. Anderson DJ and Webster CS. A systems approach to the reduction of medication error on the hospital ward. J AdvNurs 2001;35: 34-41. 3. Mayo AM and Duncan D. Nurse perceptions of medication errors: What we need to know for patient safety 2004 September;19(3):209-17. 4. Arndt M. Nurse s medication errors. Journal of advanced nursing 1994 March;19(3):519-26. 5. Gibson T. Nurses and medication error: A discursive reading of the literature 2001 June;8(2):108-17. 6