Nurses' Medication Errors in the Pediatric Emergency

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Manal Fehade Al- Wahbi Al- Harbi Correspondence: Manal Fehade Al- Wahbi Al- Harbi RN, PhD Assistant Professor & Chairperson of Maternity & Child Health Department Research Center Member at College of Nursing -KSU Diriyah Female Campus 1st Office. 3rd Flr. Bldg.12 P.O. Box 642, 11421 Riyadh- Saudi Arabia Tel: +966 118058533 Email: Maalwahbi@ksu.edu.sa; Manalalharbi7@gmail.com

Abstract Purpose: Medication errors have been identified as a major concern in the healthcare industries. The purpose of the current study was to assess nurses' perceived contributory factors of medication errors perceptions on the use medication technology as a strategy to reduce its occurrence. Methods: A descriptive cross-sectional design was used to describe the perception of nurses and examine their relationship with the profile characteristics. 200 registered nurses were conveniently selected from the two of the major tertiary healthcare facilities in Riyadh which were equipped with pediatric emergency department. Findings: This study highlights the significant role nurses play in the medication administration process. It has been found out that the 3 top rank factors contributing to medication errors were interruptions during medication pass (M= 2.32), shortage of nursing staff (M= 2.13), and caring for high acuity patients (M= 2.11). Whereas, hostile work environment (M= 1.56) was the least among all factors. Moreover, all four types of medication technologies: barcode medication administration (M= 1.79), computerized physician order entry (M= 1.9), automated medication dispensing (M= 2.28), and smart infusion pumps (M= 2.34) were perceived as very helpful in reducing medication errors. Lastly, the several demographic characteristics, years of clinical experience (p= 0.01), and the years of attending pharmacology courses (p= 0.04) were found significantly related with medication errors. Results of this study have implications for the staff nurses, hospital administration, and the health care system in planning for interventions which reduce medication error and promote establishing of a safety culture. Conclusion: Based on the findings of the current study, a multidisciplinary approach with administration and research, is needed to solve the problems of medication errors in the pediatric departments. Key words: Pediatric nurses, medication, medication errors, emergency department, patient safety, Saudi Arabia

Clinical relevance
Studies on medication errors are scarce in developing countries, and the present study was one of the first few relevant studies which explored medication administration errors in the pediatric wards in Saudi Arabia. Therefore, the study will ignite awareness concerning medication safety in Saudi Arabia and also encourage and ignite interest for future relevant studies. which promote medication safety.

Introduction
Medication errors (MEs) are the most common type of faults in the clinical environment. Each year, hospitalized patients experience 1.5 million preventable MEs related injuries and hospitals incur an additional $3.5 billion in costs. Several organizations now support measures to study and improve the safety of administering medications to promote patient safety (1) . MEs may be classified according to where they occur in the medication use cycle, i.e. at the stage of prescribing, dispensing, or administration of a drug (2) . One of the most important healthcare workers' last line of defense to protect against MEs are the nurses. Aside from checking the prescription and dispensing of drugs which are crucial, nurses ensure the right calculation, measurement and medication administration. A study from the nurses in America reported that potential adverse drug events in pediatric population were three times more than in adults. Thus, the risk of MEs tend to be higher in pediatric patients and more likely to lead to serious or fatal consequences as compared to adults (3) . Among all MEs, cases involving pediatric patients attract special attention due to their high incidence and injury rates. The Lan study reported that insufficient knowledge on pharmacology is the leading obstacle nurses encountered when administering medications, which are commonly due to inaccurate doses (4) . Thus, providing continuing education and double-checking dosages among nurses is highly recommended(1) .
For healthcare providers working in the emergency departments (EDs), rapid and accurate measurement of a child's height and weight upon arrival is critical for accurate medication dosing (5) . A misplaced decimal point can result in a tenfold dosing error. In addition, the weights of pediatric patients can change dramatically, thus frequent recalculation of drug doses is required. Children are a vulnerable group and have limited communication skills to warn their healthcare providers of the adverse effects that they experience. In addition, all children, especially neonates, have limited internal reserves that are vital for buffering (6) . The risk of medication errors tends to be higher in pediatric patients than in adults. Pediatric dosage of medicine is usually calculated individually according to the child age, weight, and body surface area as well as his/ her clinical condition. Even though many errors are caught before a drug is administered, MEs when not intercepted by nurses can result in adverse events. Because nurses are the ones who predominantly administer medications, they are often the last potential barrier between a medication error and harm. Nurses must ensure that patients receive the right medication, right dose, right route, right time and right evaluation for therapeutic and possible adverse events (6). Many hospitals have check and balance systems to promote patient safety during medication administration, however, there are still possibilities for error. The issues in MEs requires an examination of the causes and identifying methods for improving nurse competency and the administration process (7,8). Furthermore, the process of medication administration takes many steps, and in any of them, the nurse may commit MEs which are psychologically devastating to the nurse and harmful to the patient.

Nowadays with different accreditation bodies for hospitals, attention been given to different aspects of patient safety including medication administration and medication errors. MEs have been under-reported in the Middle Eastern regions including in Saudi Arabia since 1999 (9). Recently, safety issues in medication administration have started to gain attention by different nursing scholars and academics. A retrospective study was conducted among pediatric physicians' medication orders in Saudi Arabia and results showed MEs occur frequently with dosage error (10) . Tobaiqy and Stewart's study(11) showed wrong medications, wrong dose, inappropriate prescribing, inappropriate route, prescription duplication, and equipment failure were some of the reported MEs in Saudi Arabia. An Iranian MEs study identified that the rate of medication errors was found to be much more than what had been reported by nurses( 12) . Studies on MEs as perceived by nurses are scarce in developing countries and this present study is just one of the few studies to be conducted on medication administration errors by pediatric nurses in the kingdom. Therefore, this study would serve to ignite awareness and encourage relevant studies to be conducted in the region. Thus, this study aimed to describe the factors which contribute to MEs in pediatric EDs and their perceptions toward the use of medication technology in reducing medication error.

Methods
Research Design. A descriptive cross sectional approach was utilized to describe the perception of nurses regarding MEs, the use of technology for medication administration, and to establish correlation between variables and the demographic data of the respondents.
Settings. The study was conducted in the tertiary health care facilities in Riyadh which were equipped with pediatric EDs. The selection of the setting was done in two phases: a primary survey to assess the availability of such pediatric EDs and the number of working staff nurses. There were 7 hospitals with pediatric EDs in Riyadh city and only two were selected based on the number of admissions and number of nurses working in the pediatric ED.

Subjects. The eligible respondents passed the following inclusion criteria: (1) working in pediatric emergency units in Riyadh, (2) experience of ? 3 months (3) voluntarily participation as respondent. A convenience sampling technique was utilized since the population was generally homogeneous, or individual units which were accessible to the researcher. A power analysis was utilized through Raosoft Incorporated which was used to calculate the sample size of 200 with an Alpha of .05, power of .80, and effect size of .50.

Data collection instrument. A self-administered questionnaire was used for data collection which was developed by the researchers. Part one of the instrument focused on demographic characteristics such as gender, age, nationality, marital status, economic status, highest level of education, years of clinical experience, time since attending pharmacology course and their relationship with their family and with other health care professionals. The other parts of the questionnaire were designed after reviewing literature to assess pediatric emergency nurses' perceptions of medication errors and their barriers to report the medication error. Therefore, the second part was questions on factors contributing to MEs and designed after using the Haddon Matrix as a commonly used matrix in injury prevention to look at factors related to personal attributes, agent attributes and environmental attributes; before, during and after an injury(13). These items were dose calculation, depth of medication knowledge, interruptions during the medication process, usefulness of policies and procedures related to medication administration, nursing workload, patient acuity, overtime hours per day and week, incomplete medication orders, lack of clinical expertise in the area one is working, newness to nursing practice, hostile or tense feelings during medication administration. The third part were items about the number of medication errors made by the nurse or a colleague that resulted in harm to a patient over the past year, or did not harm the patient and evaluated the number of medication errors that were reported in the past 12 months including those that caused harm to a patient and those that did not cause harm. The fourth part of the instrument assessed technologies used in decreasing MEs. Technology included in questions were: bar coded medication administration, computerized physician order entry, automated medication dispensing, and smart infusion pumps. In part five, eight items were developed to address pediatric nurses' perceptions for barriers to reporting (focus on the individual rather than the system, thinking colleagues will feel the nurse is incompetent, feeling the error is not important to report, fear of blame, reporting is time consuming, afraid of a reprimand, afraid of consequences, and feeling a near miss is not an error). Part six included factors which might increase the likelihood of medication error reporting. Seven statements were developed about violation of any of the "five rights" of medication administration, anonymous reporting process, safety of the patient has been compromised, benefits of reporting are identified by nurse, no fear of retaliation in the workplace, positive relationship with supervisor, and positive relationship with physicians the nurse works with on the unit. The last part was about communication errors and the items were about reporting the medication error to the patient, or to a family member if appropriate, and use of medication error report cards. All scales throughout the survey were developed in closed format using Likert-type responses utilizing several responses which included: "Never to Always", "Major Barrier to Not a Barrier", "Highly Likely to Highly Unlikely", "Strongly Agree to Strongly Disagree", and "Very Helpful to Not Helpful.

Validity. Face validity of the instrument was established via a comprehensive review of the literature in the area of medication administration errors and was established by reviewing previously published survey instruments on MEs. To establish content validity, the questionnaire was sent to an expert panel (n = 4) of reviewers that had strong expertise in survey research and medication error knowledge based on their publication success and minor changes were recommended.

Reliability. A convenience sample of 25 registered nurses working in the Riyadh area was considered for pilot testing to test the internal consistency of the items. The instrument was given to the nurses on two separate occasions. Internal consistency reliability was tested using Cronbach alpha on appropriate sections of all returned surveys.

Data Collection Method. After getting the approval from the selected hospitals' ethical committees, data were collected between January to June, 2012. Posters, as advertisements were posted in the units and interested respondents were advised to contact the researcher. The researcher oriented the respondents about the objectives of the study, and confidentiality of their responses and the benefits. Written informed consent was obtained from each respondent.

Ethical Considerations. Ethical approval was secured from the Institute Review Board of the university. Confidentiality of the information obtained was maintained to the best of the researcher 's ability. The names of the nurse respondents were not solicited or written down. No record other than informed consent documents, were kept of the nurse respondents ' identities. Efforts were taken to minimize the likelihood that any data could be tied to the identity of any participant.

Data Analysis. Analysis of data was done using SPSS 17.0 statistical software. Descriptive statistics such as frequencies, range of frequencies, percentages, means, and standard deviations was used to describe demographic data of respondents. In addition, independent t-tests, and analysis of variance (ANOVA) was calculated with appropriate post-hoc tests to determine if there were significant differences between the means. A significance level of .05 was used for all of the analysis.

Results
Demographic profile of the respondents. Table 1 shows that majority were females (93%), belonged to 30-39 age group (41%), non-Saudi (72.5%), married (66%), in good economic status (70%), bachelor degree graduate (60.5%), working as a nurse for >10 years (69%), and (60%) has attended pharmacology courses for 1-2 years.

Table 1: Demographic profile of the respondents

f- frequency, %- percentage

Factors Contributing to MEs. Table 2 shows that interruption during medication pass (M= 2.32, SD= 0.67) is considered the main factor causing most medication errors, followed by shortage of nursing staff (M= 2.13, SD= 0.74), and caring for high acuity patients (M=2.11, SD= 0.73). The least reason to contribute to medication error is when ED pediatric nurses perceived the working environment as hostile (M= 1.56, SD= 0.64).

Click here for Table 2: Primary factors of medication errors as perceived by the nurses

Barriers of reporting and communication of medication errors. The major barrier for nurses is shown in Table 3. The item of that the nurse will be blamed got the highest mean (2.83), followed by that nurses are afraid of the consequences if they report a medication error with a mean (2.75) and nurses are afraid of a reprimand if they report a medication error that had a mean of (2.71). In contrast, nurses think that Reporting is too detailed and time consuming is a minor barrier in reporting the medication error as the mean for this item (2.48). For communication of medication errors Table 4 shows that the majority of nurses overwhelmingly agreed that medication errors should be communicated to the patient (70.0%). Nurses also agreed that the patients' family should be notified of an error when the patient is not capable of understanding (69.0%). In addition, over one-half (58.0%) of the nurses surveyed, felt the hospital should publish medication error report cards for the public to review.

Click here for Table 3: Perceived Barriers to Reporting Medication Errors by nurses working at emergency paediatric department

Table 4: Distribution of the sample according to importance of communication of medication errors


Use of Medication Technology in Reducing Medication Error Rate
Looking in Table 5, the majority of nurses perceived that smart infusion pumps (M= 2.34), automated medication dispensing (M= 2.28), computerized physician order entry (M=1.90), and barcode medication administration (M= 1.79) all were helpful in decreasing MEs. In addition, around (20%) to (39%) of the sample said that most solutions suggested to reduce medication error, is not available at their hospital.

Click here for Table 5: Perception of Medication Technology associated with Decreasing Medication Errors

Relationship between MEs and Demographic Profile
As shown in Table 6, nationality (p= <0.001, p= 0.001), economic status (p= 0.02, p< 0.01), and age (p = 0.01, p=0.01) were significantly correlated to medication error whether not causing harm or harmed the pediatric patient. The number of years of clinical experience (p= 0.01), and years of attending pharmacology course were found to be significantly (p= 0.04) correlated with MEs which harmed the patients in the pediatric EDs.

Click here for Table 6: Chi square test result between relationship with medication error

Discussion
Several characteristics of the ED nurses were associated with the MEs which either cause harm or did not cause harm to the pediatric patients. Similar with the findings, the age of the ED pediatric nurses has been linked to MEs. According to Davis (14( , age is an essential factor on how pediatric nurses closely followed the policies in medication administration. Age was also found to be significantly correlated with medication administration errors among nurses coming from 2 regional hospitals in Riyadh Saudi Arabia(15). The correlation of nationality to MEs can be attributed to communication errors as non-Saudi nationals may be caring and giving medications to a Saudi national patient. In Saudi Arabia nursing care is a mixture of different nationalities. The cultural diversity of those nurses implies concern about their ability to communicate between themselves and with their patients, Alharbi's study identified that most of the nurses had used another language to give nursing care due to cultural diversity (16). According to Albougami(17), current literature of MEs in Saudi Arabia imply that communication and language maybe linked. The author added that the errors in health care service delivery in the kingdom may be attributed to communication challenges between non-Saudi and Saudi healthcare personnel as well as between non-Saudi and Saudi patients, however, the direct effect has not been comprehensively studied. No scientific literature can support the correlation of the economic status of the ED pediatric nurses to the probability of committing MEs. However, this present study identified that most of the ED nurses with lower salaries are the newly hired or novices who still lack working experience compared to those with higher salaries who have been promoted to a higher rank. The economic status of the ED pediatric nurses is parallel to the length of working experience. The correlation of years of working experience and MEs in this study was congruent with the study of Aboshaiqah(15) with nurses working in Saudi Arabia and in contrast with the study of Chang which showed that there was no significant relationship between number of errors and years of experience for either errors causing harm or "no harm"(18) .

Nurses need pharmacology knowledge for accurate medication administration, patient assessment, patient education, and for some nurses for prescribing; however, less time was spent in pharmacology education during the college program(19). Thus, the theory-practice gap leads to a number of identified anxieties related to insufficient preparation. In a clinical audit by Morrow-Frost (2006), the more experienced nurses are more knowledgeable than the nurses with less working experience. However, the less experienced nurses were more willing to admit that they cannot provide concrete and correct answers(20) . Also, new nursing interns and staff nurses have been found to have poorer mathematical skills than physicians and pharmacists(6) .

Factors that are contributing to medication errors
The reasons for MEs among ED pediatrics nurses were similar to the findings from other studies carried out in USA, Australia and Turkey. They identify the factors that contribute to errors such as work load, high patient: nurse ratio causes work-load time pressure leading to calculation errors and the medication could not be administrated at the right time. In the present study, the ED pediatric nurses perceived interruptions as the topmost reason for MEs. This finding agrees with international studies wherein pediatric nurses perceived interruptions or distractions as contributory factors to medications errors among pediatric patients(21,22). Interruption distracted the attention of the nurses during the preparation and administration of the medications and caused calculation errors. Correspondingly to previous studies, the high nurse to patient ratio and workload stress renders nurses unable to carry out their professional role (7) and will more likely contribute to MEs by the ED pediatric nurses (14,21,22,23,24. In nurse staffing, the high nurse to patient ratio will consequently lead to increased workload which commonly occurs in the tertiary health care facilities in Saudi Arabia. With the chronic shortage of nurses, the kingdom has been suffering from shortage of nurses and low production of Saudi nursing graduates with increasing turnovers of expatriate nurses. Furthermore, the shortage consequently demands an increasing number of hours by the other staff nurses as a compromise to staffing issues. Thus, overtime schedules become prevalent which is a determinant of burn-out and low work performance which contributes to MEs among pediatric nurses (25). Also, the finding that high acuity pediatric cases contribute to MEs was similar to the finding of Davis(14) which explained that due to the complexity of cases in pediatric patients, higher incidence of MEs was noticed compared to than adult patients. Several studies (22,26,27) showed that the overall experience of pediatric clients who are sensitive to drug reactions will more likely contribute to errors.

Barriers of reporting and communication of medication errors
The top three barriers to reporting errors identified in the current study were: nurses are afraid, the nurses will be blamed, and a reprimand if they reported medication error. Thesefindings are congruent with a study(28) which revealed that fear was found to be barrier for reporting MEs in addition to knowledge, burden of work, and excusing the error. Another study(29) identified four major subscales in relation to barriers to reporting medication errors, which included: disagreement over whether it was an error, reporting effort, fear, and administrative response. The barriers identified in the current study were included under the subscales, fear and administrative response. As most of the accreditation of healthcare organizations has required disclosure of adverse outcome as an ethical obligation(30). In the current study nurses agreed overwhelmingly that medication errors should be communicated to the patient or to the family if the patient is not capable of understanding what has occurred. In addition, the reporting systems dependent on the nurse's ability to recognize an error has occurred, belief that the error warrants reporting, belief that she-he has committed the error, and willingness to overcome the embarrassment and fear of retaliation for having committed a medication error (3,31,32). Furthermore, the majority of nurses felt that hospitals should publish medication error report cards for the public to review.

Medication technology as helpful in reducing medication errors
Four interventions with the use of technology that could reduce MEs were ranked by the ED pediatric nurses. Infusion pumps ranked first which has been proven to reduce intravenous MEs. In Pang's study infused drugs with pumps and the frequency of MEs post-intervention were compared with the MEs in the pre-intervention period (33). The study concluded that the use of a specific infusion pump resulted in significant reductions in the number and clinical significance of intravenous MEs in administration. Second, the automated dispensing has been perceived as the least to resolve the MEs in this present study. Automation dispensing has been shown by James' study(34) to improve dispensing efficiency and reduce unwanted incidents which are common during periods of high workload or busy periods, which were attributed to fatigue among staffs. Third among the ranked is the use of computer systems. In a review study(35) the computer systems were reviewed as the most commonly used intervention to minimize MEs among pediatric and neonatal patients. The review showed that the ME rates decreased after a Clinical Decision Support System (CDSS) is used with a Computerized Physician Order Entry (CPOE). Lastly, Barcode medication administration (BCMA) system which was perceived as the least to resolve MEs was shown to be effective in the reduction of MEs (36). The study used prospective, observational, cohort study of a BCMA as a tool to reduce MEs and adverse drug events in a neonatal intensive care unit. Results showed that the intervention significantly reduced ADEs, controlled MEs, and the associated risks. The use of technology has been implicated as solution to a faster and accurate way of delivering healthcare services(37,38). The review of the literature on safety systems demonstrated the use of medication administration technology showed that no particular safety system or practice has been identified as best to prevent MEs. However, information technology interventions have great potential for reducing the frequency of errors. The magnitude of the benefits may be even greater in pediatrics than in adult medicine because of the need for weight-based dosing (39,40).

Although the current study contributed to the gap in the literature by describing the surveyed nurses' perceptions at one point in time, it was limited by its essence as a descriptive study that only described various aspects of the MEs (phenomena). Another limitation is the fact that external factors such as training and each nurse's work environment were not reviewed. Some nurses may have had a better orientation and training experience, leading them to perceive that different factors impact medication administration errors than their cohorts with the same amount of ED experience. The study could be influenced by subjectivity as the researchers developed the questionnaires which limited the participant's answers. This study was limited to Saudi Arabia, which could have influenced the results. A final limitation may be that the surveyed nurses represent numerous EDs.

Conclusions
The results of the current study have implications for patient well-being and how to minimize MEs. Based on the findings, a multidisciplinary approach between the organization and research is needed to solve the problems of MEs among pediatric nurses working in the emergency pediatric units. In the clinical environment, institutional responsibility to prepare and implement educational strategies and the system can be strengthened by embedding training from orientation and continuing at all levels to meet the needs of the nurses. A quality review system to review drug use and MEs, and implementing computerized physician order entry (CPOE) or other technological innovations which is recommended by the American Academy of Pediatrics be implemented to reduce errors. An integrative approach such as increased communication through education forums, the presence of a clinical pharmacist as a team leader and no-punitive approach by medical and nursing leadership could be alternative changes that can positively affect patient outcomes. For future studies, identifying types of interruptions which may cause MEs and strategies to decrease errors to be used during medication preparation and administration, is recommended.

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