Self-reported violations during medication administration in two paediatric hospitals

Abstract

Content Violations of safety protocols are paths to adverse outcomes that have been poorly addressed by existing safety efforts. This study reports on nurses' self-reported violations in the medication administration process. Objective To assess the extent of violations in the medication administration process among nurses. Design, Setting, & Participants Participants were 199 nurses from two U.S. urban, academic, tertiary care, free-standing pediatric hospitals who worked in: a pediatric intensive care unit (PICU), a hematology-oncology-transplant (HOT) unit, or a medical-surgical (Med/Surg) unit. In a cross-sectional survey, nurses were asked about violations in routine or emergency situations in three steps of the medication administration process. Main Outcome Measure Self-reported violations of three medication administration protocols were made using a 7-point 0-6 scale from “not at all” to “a great deal.” Results Analysis of variance identified that violation reports were highest for emergency situations, rather than for routine operations, highest by HOT unit nurses, followed by PICU nurses, and then Med/Surge unit nurses, and highest during patient identification checking, followed by matching a medication to a medication administration record, and then documenting an administration. There was also a significant 3-way interaction among Violation Situation, Step in the process, and Unit, which is explained in detail in the Results. Conclusions Protocol violations occur throughout the medication administration process and their prevalence varies as a function of hospital Unit, Step in the process, and Violation Situation. Further research is required to determine whether these violations improve or worsen safety, and for those that worsen safety, how to redesign the system of administration to reduce the need to violate protocol in order to accomplish job tasks.

Macroergonomics in Health Care Quality and Patient Safety

“…For example, studies in anesthesiology (Beatty & Beatty, 2004; de Saint Maurice, Auroy, Vincent, & Amalberti, 2010; Phipps et al, 2008) reveal reasons for safety violations related to the violated rule, the worker, including worker perceptions (Phipps, Parker, Meakin, & Beatty, 2010), and various organizational factors including time pressure, goal conflict, resources and equipment design. These studies, as well as studies in surgery (R. McDonald, Waring, & Harrison, 2006), intensive care nursing (Drews, Wallace, Benuzillo, Markewitz, & Samore, 2012), and pediatric nursing (Alper et al, 2012) also demonstrate that various factors interact to promote violations. For example, a survey of 199 nurses in two pediatric hospitals showed that medication administration process violations depended on a combination of the situation (routine vs. emergency), setting (medical/surgical vs. oncology unit) and task (checking patient identification vs. documenting administration) (Alper et al, 2012).…”

“…Far less attention has been paid to the occurrence and causes of intentional safety violations that affect patient safety largely independent of unintended errors (Amalberti, Vincent, Auroy, & de Saint Maurice, 2006). In the context of patient safety, safety violations (or workarounds) have been defined as deliberate acts that deviate from “rules and standards” (Amalberti, Vincent, Auroy, & de Saint Maurice, 2006, p. i66) or “established protocols of practice” (Phipps et al, 2008, p. 1626), or acts that break “rules, policies, protocols or procedures” (Alper et al, 2012, p. 408). Some note that safety “rules” in health care are incredibly varied, ranging from broad or contested guidelines, to exact and widespread procedures, to institution-specific policies and informal norms, to diagnostic or therapeutic “orders” (Amalberti, Vincent, Auroy, & de Saint Maurice, 2006; de Saint Maurice, Auroy, Vincent, & Amalberti, 2010; Phipps et al, 2008).…”

Prevalência de incidentes relacionados à medicação em unidade de terapia intensiva

“…In this sense, several publications presented satisfactory results in patient safety resulting from redesign of work processes and involvement of healthcare professionals. (11,12) It was observed that medication-related incidents were common in intensive care units. And although a very small fraction caused harm to patients, it is still necessary to manage the risks related to the medication process, considering that critical patients present higher needs for care and are therefore more vulnerable.…”

Toward the modelling of safety violations in healthcare systems

“…A systematic review of violations across a range of industries (including, but not limited to, healthcare) suggests worker-centred design, training, competing goals and rule definition, as predictors as well as individual characteristics 42. For example, in medication administration, violations may be influenced by context, process and hospital location 43. Anaesthesiologists’ decisions to follow or deviate from guidelines are influenced by the beliefs they hold about the consequences of their actions, the direct or indirect influence of others, and the presence of factors that encourage or facilitate particular courses of action 44.…”