The Effect of Nurse Pharmacological Knowledge on Medication Errors

Background

Medication errors can have a negative effect on patient outcomes. Adverse Drug Events (ADE), defined as patient harm caused by a preventable medication error, affect an estimated 5% of hospital patients each day (Patient Safety Network, 2018). These high numbers reflect a significant danger to patients nationwide. While all levels of care including the primary provider, pharmacist, and nurse can be at fault in an ADE as shown by Gaffney, Hatcher & Milligan (2016), the nurse usually plays the final and pivotal role in actually administering the medication or catching the error. Consequently, an understanding of nurse behavior can result in interventions or changes resulting in increased patient safety. Many researchers suggest increasing nurse medication knowledge to prevent ADE (O’Shea, E. 1999). Multiple factors can contribute to a nursing medication error including: being too busy and tired from excess work, few nurses compared to the number of patients, inadequate training, lack of pharmacological knowledge, incorrect medication calculations, and illegible prescriptions. While all of these factors put patients at risk and require intervention in order to ensure patient safety, nurse pharmacological knowledge was identified as the most significant cause for medication errors (Cheragi, Manoocheri, Mahammednejad & Ehsani, 2013). Increased understanding of the role that nurse pharmacological knowledge plays in medication errors can help prevent medication errors.

Significance

The impact of ADE is both expansive and difficult to quantify. Direct harm or death is readily visible, but the rippling effects of either among family and friends often multiples the adverse effects. The quantifiable data that is available suggests that ADE are likely the costliest error in medicine in multiple aspects. ADE are now the third leading cause of death in the United States, surpassing respiratory disease, according to an 8-year study done by John Hopkins University (Makery & Daniel, 2016); only heart disease and cancer take more lives each year. ADE are estimated to affect over 7 million patients, cost $21 billion annually, and result in 1 million emergency room visits each year according to a study published in 2016 by Da Silva and Krishnamurthy. Improving the safety of medication administration was included in the Joint Commission’s first set of national patient safety goals in 2003 and is still a top priority 15 years later. Adjustments to ensure safe medication administration will help ensure better patient outcomes.

Nurses are directly involved in many ADE or in prevented medication errors. In their comprehensive review of twelve studies, Gaffney, Hatcher and Milligan (2016) found that nurses recovered, on average, about one error every shift. This represents a significant impact on patient outcomes. It is of interest that, as noted by Agrawal (2009), the fact that prescription and administration are not a closed loop system means that a nurse recovering a medication error requires an understanding of pharmacology and of patient condition. Facilitating this understanding could be one of the most impactful nursing changes towards eliminating medication errors. The converse can also be true. Cheragi, Manoocheri, Mahammednejad and Ehsani (2013), found that 64% of nurses made medication errors, an average of 7.4 errors were made in three months, and, frighteningly, that 60% of those errors involved intravenous drugs. The frequency of nursing medication errors and the extensive repercussions of those errors demands a deeper understanding of why errors are made and what changes could correct them.

Maslow’s Hierarchy of Needs

A. H. Maslow, in his 1943 paper ‘A Theory of Human Motivation’, outlined an understanding of human motivation that is dependent on viewing actions through a pyramid of priorities, or a hierarchy of needs, that begins with the basic physiologic needs like food, water, sleep, and shelter and culminates in the highest motivations of self-actualization and becoming (Maslow, 1943). The foundational motivations include needs like hunger, thirst, sleep, oxygen saturation, blood PH, and a constant temperature--things upon which life depends. The next priorities outlined are safety and security; these secondary needs are represented by health preservation, employment, property possession, meeting family requirements, and obtaining basic social stability. The third level of needs is connection with others and is represented by needs like friendship, love, and intimacy. Quaternary motivations include self-esteem needs like confidence, achievement, uniqueness, and respect for others. The final tier of motivation encompasses self-actualization, searching for meaning, inner purpose, and traits like creativity and spontaneity. Maslow stated that individual levels are not to be seen as an exclusive stair-step where it is impossible to focus on any need other than those currently present, but rather that only when lower levels of need have been fully satisfied can full attention be given to progressing hierarchical levels (Tay & Deiner, 2011). Maslow’s hierarchy is applicable to the nurse educator, nurse student, and practicing nurse in understanding behavior related to medication decision and administration.

Maslow’s Hierarchy of Needs and Medication Errors

Lack of knowledge can be assumed to be the primary cause of nursing medication errors since basic stipulations of responsible practice assume that nurses are invested in patient care. What priorities other than obtaining sufficient pharmacological education to provide safe patient care motivate student and/or educator? Maslow’s theory explains that some need in a lower level of hierarchy must be the superseding factor eliminating the student’s or nurse’s ability to focus or apply self to the medication task on hand (Maslow, 1943). Preventing medication errors requires either satisfying lower levels of need or increasing the import of knowing and applying pharmacological knowledge in order move the task at hand to a more prominent position on the hierarchy pyramid. ADE are now the third leading cause of death in the United States and, consequently, safe medication administration ought to assume a prominent position in nursing priorities (Makery & Daniel, 2016). Increasing pharmacological knowledge can inform nurses of the potential dangers of medication administration and help ensure that nurses prioritize safety.

Both practicing nurses and student nurses are at risk for ignoring important safety concerns in favor of visible basic needs. The current time spent learning pharmacological knowledge in nursing schools is not proportionate to the time spent in nursing practice performing medication tasks (Simonson, Daehlin, Johansson & Farup, 2014). This could suggest that pharmacological knowledge is not sufficiently emphasized by nursing instructors. Maslow’s theory provides a possible explanation for this lack of focus (Maslow, 1943). Safety concerns, like the proper administration of medication, take back-seat in classrooms focused on ensuring patients are provided with basic needs like food, water, perfusion, and oxygen. Students feeling unsure with their own skills and professors concerned about student competence are at risk for sacrificing essential safety knowledge, level two, in exchange for perceived level one ‘basic needs’ knowledge. Realizing that level two concerns can rapidly become life-threatening, ADE are the third leading cause of death in the United States, will motivate students, nurses, and professors to move medication knowledge and administration towards a level one priority (Makery & Daniel, 2016). The increased awareness will help prevent medication errors and will increase patient safety.

Research Methods

Nurses with increased pharmacological knowledge, as measured by having completed a pharmacology class, make a decreased number of medication errors. Ensuring time spent studying pharmacology during nursing school will result in nurses aware of the significant safety concerns related to dose, duration, route, time, contraindications, and compatibility able to result in life-threating impact on basic needs like respiration, cardiac output, blood PH, and similar essential needs. This understanding will lead to placement of medication administration in a lower level of the hierarchy of needs (Maslow, 1943). Nurses able to connect safety concerns with potential effects on life-sustaining needs, outlined by Maslow’s most basic level of hierarchy, will be motivated to prioritize safe medication administration.

Research Design

A predictive correlational quantitative design will be used for this study. Correlational studies are used to predict the value of a dependent variable based on the value of an independent variable. As quantitative data, variables must be numerically quantifiable and the relationship between them will be compared using linear regression (Grove, Gray & Burns, 2015). A predictive correlational design was used for the study as the hypothesis, ‘Increased pharmacological knowledge, as measured by having completed a pharmacology course, decreases medication errors’, involves the independent variable of having completed a pharmacology class and the dependent variable of the presence or number of medication errors. The information of interest is the presence of a negative relationship. A confidence level of 0.95 will be used to prevent a type I statistical error. The presence of a statistically significant negative relationship between variables will suggest that increasing the number of nursing student required to take a pharmacology class may decrease the prevalence of medication errors.

Research Population

The research population for the study will have the following inclusion criteria: being a current practicing registered nurse, working at least twenty hours a week, and working in the south-east Idaho region in an in-patient facility with over twenty beds. These inclusions ensure a broad spectrum of work experience in the sampling, adequate work experience per week to assume familiarity with nursing role, and a broad sampling to ensure adequate data for ensuring statistical significance. Statistical significance requires 30-500 total responses to ensure significance. Including all in-patient facilities, including long-term care, in the study is appropriate since medication errors can be made by any practicing nurse and errors affect patients at all levels of care.

There are three exclusions from participation in the study. New employees within a year at the facility will be excluded as they are assumed to be unfamiliar with protocols and medications and are, consequently, more likely to commit a medication error. Nurses spending less than twenty hours a week on any given floor or area, such as a float nurse, are assumed to be unfamiliar with protocol and medication and are more likely to commit a medication error. Nurses with English as a secondary language are assumed to be more likely to commit a medication error from lack of language fluency.

Methods and Measurements

Random selection will be used to select twenty facilities in the south-east Idaho area that fit the inclusion criteria of in-patient and over twenty beds. IRB’s will be contacted to obtain permission to survey practicing registered nurses at each facility. Surveys will be distributed via email as overseen by the director of each facility or floor to all practicing registered nurses. The survey will include questions on the number of medication errors committed over the previous twelve months and presence of a completed course in pharmacology. An estimated number of one thousand surveys will be sent out, an average of 50 practicing nurses per facility. The presence of larger hospitals in the study with a greater number of practicing nurses will compensate for proportionately smaller sample size from smaller facilities. Nurses will be motivated to complete the survey by knowing, as informed in the email, that the survey will take under 2 minutes to complete. Assuming at response rate of 2%, a sample size of 60 participants satisfies the requirements for statistical significance of a linear regression test (Grove, Gray & Burns, 2015). Data will be graphed using a linear regression model with a confidence interval of 0.05. A negative relationship between completing a pharmacology class and committing medication errors with a p-value of less than 0.05 will suggest that we are 95% confident that completing a pharmacology class is negatively correlated with committing medication errors. If completing a pharmacology course is negatively correlated with medication errors, it suggests that increased pharmacological knowledge contributes to an awareness of potential life-threatening risks leading nurses to prioritize safe medication administration.

Ethical Considerations

In this study, participants will desire to avoid co-workers or others viewing answers given. This ethical consideration is called privacy (Grove, Gray & Burns, 2015). To address this ethical consideration, researchers writing the surveys will ensure that participants are made aware that the survey is intended to be private by including, as a preface, said information along with a request, if desired, to complete the survey in a private place. The electronic form of the survey will allow for additional privacy, if desired, and could be taken from a personal device or at a private location.

In this study participants will want to be aware of the cost/benefit of completing the survey. This ethical consideration is called justice (Grove, Gray & Burns, 2015). To address this ethical consideration, researchers will include the following information as part of the email; this study is seeking to understand medication errors in order to increase patient safety; this survey will take about two minutes to answer. Understanding that the survey has been designed to take a minimal amount of time will encourage participation and respect the ethical consideration of justice.

In this study participants will want to ensure that they remain anonymous. This ethical consideration is called anonymity (Grove, Gray & Burns, 2015). To address this ethical consideration, researchers will not collect any identifying information in the survey. Participants will be notified in the preface to the survey that all data is completely confidential and will not be shared with anyone—coworkers, employers, and law enforcement included. Each survey received will be assigned a number; consequently, there will be no identifying data and the ethical consideration of anonymity will be respected.

Annotated Bibliography

Latif, A., Rawat, N., Pastavoitau, A., Pronovost, P., Pham, J. (2013). National study on the distribution, causes, and consequences of voluntarily reported medication errors between the ICU and non-ICU settings. Critical Care Medicine, 41(2):389-398. Retrieved from: https://journals.lww.com/ccmjournal/Fulltext/2013/02000/National_Study_on_the_Distribution,_Causes,_and.3.aspx#article-metrics

The five authors are faculty members at The John Hopkins University School of Medicine. The study is a non-directional correlational study. The data used was received through the MEDMARX error reporting system used by >860 facilities in the United States. Univariate and multivariate regression analysis was used to correlate multiple medication error characteristics including general characteristics, types, causes, contributing factors, and categories of harm. ICU and non-ICU data was compared to discover differences. The sample size of the survey was a strength as it assures statistical significance. The fact that all data is self-reported is a weakness of the study as data accuracy is unknown. This is a quality research article because of the amount of data used and the extensive correlational analysis run. This study is significant for nursing as nurses are integrated into the medication administration process and understanding potential breakdown points may improve patient safety. All medical professionals working in an ICU are the intended audience of the study. The study links to the problem as it found that deficits of knowledge and performance were the leading cause of medication errors in all hospital settings supporting the need for additional research in the area.

Patel, N., Desia, M., Shah, S., Patel, P., Gandhi, A. (2016). A study of medication errors in a tertiary care hospital. Perspective Clinical Research, 7(4):168–173. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5079090/#!po=75.4902

Dr. Desia and faculty members of the Department of Pharmacology at B.J. Medical College performed a prospective observational study in the General Medicine and Pediatric ward of Civil Hospital, Ahmedabad over a two-year period to discover the prevalence and types of medication errors made. Chart review, direct observation, and interviews were used to gather data. Medication errors were divided into categories including cause, type, and significance. A strength of the study was detailed information on why medication errors were made including communication, labeling, and improper instrument use. A weakness is the small sample size making the generalization of the findings questionable. The study is significant for nursing as it flags certain types of medications as risks for medication errors. The intended audience is all health care professionals involved in medication administration. This study links to the current problem as it indicates which medications are likely to be improperly administered, thereby informing nurses which medications they must be most familiar with.

Sonnichssen, A., Trampisch, U., Reickert, A., Piccoliori, G., Vogele, A., Flamm, M., Johannsson, T., et al. (2016). Polypharmacy in chronic diseases—reduction of inappropriate medication and adverse drug events in older populations by decision support. BMC 17:57. Retrieved from: https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-016-1177-8 Sennicchssen is a doctor and researcher at the University of Witten/Hardecke and the others are members of his research team including statistical analysis and study design from the university. The study is a multicentre cluster-randomized control trial with a time of two years. 325 general practitioners across 5 study centers in Europe were randomly assigned to two groups and the treatment group was supplied with PRIMA-eds tool, a digital decision-making assistant. After two years the patient outcomes in the two groups were compared as measured by non-elective hospitalization or death. The strength of the study was the large sample size ensuring generalizability. A weakness of the study is the minimal outcome indicators which potentially ignore important, although not life-threatening, changes. This is a quality study because of sample size and effective design. This study is important for nursing because it may indicate the potential for digital assistants preventing medication errors. The intended audience is general care practitioners. This study links to the problem as it indicates additional methods to enhance or double-check nurse pharmacological knowledge.

Meir, F., Maas, R., Sonst, A., Patapovus, A., Muler, F., Plank-Kiegele, B., Pfistermeister, B., et

al. (2014). Adverse drug events in patients admitted to an emergency department: An analysis of direct costs. Pharmacoepidemiology and Drug Safety 24: 176-186. Retrieved from: https://onlinelibrary.wiley.com/doi/epdf/10.1002/pds.3663 Dr. Meier and Maas contributed equally to the research along with their teams from the German Department of Health Management and German Institute of Clinical Pharmacology and Toxicology respectively. The observational study was an analysis of care in a tertiary care hospital using anamnestic data, ED documentation, laboratory findings, and external sources to discover medication errors. Costs of errors in monetary values were determined in relation to length of stay and impacted outcomes as determined by the German health care reimbursement program. The strength of the study was the diversity of the care population studied thus estimating population wide error costs—pediatrics through geriatrics. A weakness of the study was that monetary costs were determined in relation to the German health insurance reimbursement levels which do not necessarily match reimbursement levels or cost of care in other countries. The research quality of this study is moderate because of the small sampling size, one hospital, and the challenge of generalizing the results outside of the German health care system. This study is important because it attempts to suggest the financial incentives of safe medication administration; thus, it is useful for nurses as it incentivizes hospitals and nurses to prioritize safe medication administration. The intended audience is German hospital administration. This study links to the problem since it offers a monetary reason for health care systems to ensure adequate nurse pharmacological knowledge.

Implications

Nursing Knowledge

This study will increase knowledge about the role that nurse pharmacological knowledge plays in nursing medication errors. Knowing the importance of pharmacological knowledge will contribute to the importance that nursing programs attach to having a pharmacology class as part of their curriculum. Currently, associate RN degrees and LPN programs may not include a pharmacology class as part of their curriculum. Increased knowledge about the implications of pharmacological training may encourage a pharmacology class to become an expected part of a nursing degree at any level. This study will also increase knowledge about the role that formal pharmacological training plays in safe medication administration. It may encourage nursing instructors and programs to spend more clinical time and classroom hours on practicing or studying important medications. Increasing knowledge of the importance of pharmacological knowledge will increase patient safety as well as increase awareness for nurses, instructors, and programs of the essential nature of medication knowledge.

Nursing Theory

Maslow’s ‘Hierarchy of Needs’ theory is based on the prioritization of behaviors as those actions relate to levels of need. The most basic level of need, life-sustaining requirements, are the most important and command priority over all other needs (Maslow, 1943). This study supports Maslow’s theory as it suggests that nursing awareness of the potentially life-threating implications of medication administration, as realized during a pharmacology class, will increase the prioritization of safe medication administration. Negative correlation between medication errors and taking a pharmacology class may suggest that nurses who are more aware of the potentially dangerous implications of their actions are better able to exercise clinical judgement directed towards ensuring that a patient’s basic level needs are met. Maslow’s Hierarchy, as it relates to prioritizing safe medication administration, applies to both practicing nurses and to nurse educators. This study increases the focus of all levels of nursing on the potentially serious implications of improper medication administration.

Nursing Practice

This study will contribute directly to the safety of nursing practice. A study showing a negative correlation between pharmacological knowledge and medication errors would incentivize practicing nurses and nurse educators to prioritize pharmacological knowledge in school and in practice. This change would increase awareness of the connection between the basic needs of each patient and the medication that they are receiving. Nurses aware of the implications of the medications they administer would be able to more effectively prioritize as well as more effectively identify potential contraindications or adverse interactions. The resulting changes in nursing practice and the resulting reduction of ADE will help ensure patient safety and increase overall patient outcomes.

Improve Patient Care

This study would improve patient safety as it would present evidence for connections between nurse knowledge and nursing behavior that will result in safer medication administration and increased patient safety. Understanding that pharmacological knowledge is negatively correlated with ADE will encourage nursing education changes. Education changes increasing the importance of pharmacological principles and increased time spent understanding pharmacological principles by nurses will result in greater awareness and help eliminate ADE caused by knowledge deficits. The result will be safer nursing practice as there will be less medication errors.

This study would decrease the costs of patient care. Diminishing the prevalence of ADE would decrease hospitalizations as well as hospital stay time and would represent significant savings for the healthcare community. If medication errors were shown to be negatively correlated with nurse pharmacological knowledge, healthcare systems and nurse education programs could implement changes based on increasing nurse pharmacological knowledge that could result in significant decreases in ADE and decrease the overall cost of patient care.

This study would improve patient outcomes. Nurses are involved in a large number of ADE and those ADE can increase the length of hospitalization or even result in death. A study showing a negative correlation between pharmacological knowledge and medication errors may encourage nurses and nurse educators to prioritize a pharmacology course and pharmacological knowledge as an important part of nurse education. The resulting changes and the increase in pharmacological knowledge will enable nurses to make safer medication decisions and would decrease the number of ADE. Increased patient outcomes would be the result.

Recommendations

Research suggesting a negative correlation between nurse pharmacological knowledge, as measured by having completed a pharmacology course, and medication errors would suggest a need for greater emphasis on nurse pharmacological knowledge. Nurse educators will contribute to this need for emphasis by making a pharmacology course a required part of every nursing program, LPN and associate RN degrees included. Hospitals can contribute to this need for emphasis by offering and encouraging stand-alone pharmacology courses and offering incentives for nurses that have completed pharmacological training. Practicing nurses can contribute to positive change by taking the time to read about and understand the medications that they administer. Efforts in these ways on all levels to increase pharmacological knowledge would help ensure a decrease in nursing pharmacological knowledge deficits and a resulting decrease in medication errors.

While current research, and a discovered negative correlation between medication errors and nurse pharmacological knowledge, suggests that pharmacological knowledge plays a significant role in decreasing medication errors, there is a need for studies on which additional factors may, alongside pharmacological knowledge inadequacies, contribute to the high rate of medication errors. Specifically, a study into nursing use of pharmacological reference books and websites would offer additional data into reasons why nurses may be knowledge deficient. The study will investigate when and why nurses use pharmacological references, what features make the references user friendly, and what changes could be made to pharmacological knowledge references to increase accessibility and ease of use. The results of the study will contribute to a design of more user-friendly references which could allow nurses to access essential medication data in a time sensitive manner. If the study was to include the influence of effective pharmacological references on medication errors and showed a negative correlation, healthcare systems may be incentivized to supply staff with free additional pharmacological resources.

This study is designed to discover a negative correlation between pharmacological knowledge and medication errors. There is a need for more information about what aspects of medication knowledge (effects, contraindications, incompatibilities, etc.) most often are deficient. A follow-up study that implements these important aspects might use a large observational study combined with a structured self-reporting questionnaire to discover which medications are most likely to be erroneously administered and which self-reported causes (lack of specific knowledge, lack of time, interruption, etc.) are correlated with medication specific errors. The resulting data could be generalized across all hospital floors as medication specific deficits are, likely, relatively universal. Just as the original study is directed at a large spectrum of practicing nurses, follow-up research on medication specific concerns would, ideally, be directed at a large spectrum of practice to ensure generalizability. The strength of completing such a study would be the detailed answers to the two important questions of which medications are most at risk and which processes of medication administration are most likely to break-down. Data on additional confounding factors could also be a naturally forthcoming result of open-ended questionnaires.

References:

Agrawal, A. (2009). Medication errors: Prevention using information technology systems. British Journal of Clinical Pharmacology, 67(6): 681–686. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2723209/

Cheragi, M., Manoocheri, H., Mahammednejad, E., Ehsani, S. (2013). Types and causes of medication error from a nurse’s viewpoint. Iran Journal of Nurse Midwifery, 18(3): 228-231. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3748543/

Da Silva, B., Krishnamurthy, M. (2016). The alarming reality of medication error: A patient case and review of Pennsylvania and National data. Journal of Community Hospital Internal Medicine Perspectives, 6(4). Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5016741/

Gaffney, B., Hatcher, T., Milligan, R. (2016). Nurses role in medication error recovery: An integrative review. Journal of Clinical Nursing, 25(7-8): 906-917. Recovered from: https://www.ncbi.nlm.nih.gov/pubmed/26867974

Grove, S. K., Gray, J. R., & Burns, N. (2015). Understanding nursing research: Building an evidence-based practice (6th ed.) (pp. 31-128). St. Louis, MO: Elsevier Saunders.

Institute for Safe Medicine Practices. (2015). List of confused drug names. Retrieved from: https://www.ismp.org/recommendations/confused-drug-names-list

Makary, M., Daniel, M. (2016). Medical error the third leading cause of death in the US. Bmj, 353(2139). Retrieved from: https://www.bmj.com/content/353/bmj.i2139.full

Maslow, A.H. (1943). A theory of human motivation. Psychological Review, 50, 370-396. Retrieved from: http://www.researchhistory.org/2012/06/16/maslows-hierarchy-of-needs/

Meier, F., Maas, R., Sonst, A., Patapovus, A., Muler, F., Plank-Kiegele, B., Pfistermeister, B., et al. (2014). Adverse drug events in patients admitted to an emergency department: An analysis of direct costs. Pharmacoepidemiology and Drug Safety 24: 176-186. Retrieved from: https://onlinelibrary.wiley.com/doi/epdf/10.1002/pds.3663

O’Shea, E. (1999). Factors contributing to medication errors: A literature review. Journal of Clinical Nursing, 8(5):496-504. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/10786520

Patient Safety Network (2018). Medication errors and adverse drug events. Retrieved from: https://psnet.ahrq.gov/primers/primer/23/Medication-Errors-and-Adverse-Drug-Events

Simonson, B., Daehlin, G., Johansson, I., Farup, P. (2014). Differences in medication knowledge and risk of errors in graduating nursing students and working registered nurses. BMC Health Services Resources, 14: 580. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4243274/

Tay, L., Deiner, E. (2011). Needs and subjective well-being around the world. Journal of Personal and Social Psychology, 101(2) 354-365. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/21688922

Bradley Young, BSN

My Work

A Predictive Correlational Study: The Effect of Nurse Pharmacological Knowledge on Medication Errors