Facilitators and Barriers to Safe Medication Administration to Hospital Inpatients: A Mixed Methods Study of Nurses’ Medication Administration Processes and Systems (the MAPS Study)

Abstract

ContextResearch has documented the problem of medication administration errors and their causes. However, little is known about how nurses administer medications safely or how existing systems facilitate or hinder medication administration; this represents a missed opportunity for implementation of practical, effective, and low-cost strategies to increase safety.AimTo identify system factors that facilitate and/or hinder successful medication administration focused on three inter-related areas: nurse practices and workarounds, workflow, and interruptions and distractions.MethodsWe used a mixed-methods ethnographic approach involving observational fieldwork, field notes, participant narratives, photographs, and spaghetti diagrams to identify system factors that facilitate and/or hinder successful medication administration in three inpatient wards, each from a different English NHS trust. We supplemented this with quantitative data on interruptions and distractions among other established medication safety measures.FindingsOverall, 43 nurses on 56 drug rounds were observed. We identified a median of 5.5 interruptions and 9.6 distractions per hour. We identified three interlinked themes that facilitated successful medication administration in some situations but which also acted as barriers in others: (1) system configurations and features, (2) behaviour types among nurses, and (3) patient interactions. Some system configurations and features acted as a physical constraint for parts of the drug round, however some system effects were partly dependent on nurses’ inherent behaviour; we grouped these behaviours into ‘task focused’, and ‘patient-interaction focused’. The former contributed to a more streamlined workflow with fewer interruptions while the latter seemed to empower patients to act as a defence barrier against medication errors by being: (1) an active resource of information, (2) a passive information resource, and/or (3) a ‘double-checker’.ConclusionsWe have identified practical examples of system effects on work optimisation and nurse behaviours that potentially increase medication safety, and conceptualized ways in which patient involvement can increase medication safety in hospitals.

Applying the Theoretical Domains Framework to identify barriers and targeted interventions to enhance nurses’ use of electronic medication management systems in two Australian hospitals

“…Environmental context and resources proved key barriers to nurses’ appropriate use of EMMS. Other studies have highlighted barriers such as design shortcomings [21, 22, 26–28, 30, 66], time pressure and competing demands. The availability, size and characteristics of COWs and log-in time influenced nurses’ likelihood of taking them to the bedside, leaving unattended COWs logged in, or signing off medications before administration.…”

“…It is crucial that ergonomic design improvements are based on assessment of workflow and environment and pilot-tested prior to implementation [29, 32]. McLeod and colleagues reported, for example, nurses preferred a smaller tablet over a COW but found that because the tablet was too small, medications were signed off at the desktop [22]. Previous findings highlight the benefits of point-of-care access to information about test results, medication administration instructions and patient information [68, 69].…”

“…Rather, nurses use ‘workarounds’—practices that differ from organisationally prescribed or intended procedures—to circumvent perceived or actual hindrances to achieving a goal [20]. EMMS workarounds include not taking an electronic medication administration record to the patient [21–23]; preparing medications for multiple patients concurrently [24]; entering medication as administered before having done so [23]; and signing off medication in the EMMS that has been administered by another nurse [22]. While there is little empirical evidence for the impact (negative or positive) of these workarounds on patient safety, not using EMMS appropriately undermines the potential to isolate and measure the impact of EMMS on medication error and may increase the potential for error [21, 25–28].…”

“…To date, examination of these barriers has focused largely on the mismatch between workflow and introduced technology, and on shortcomings in EMMS design, posing barriers to using computers in clinical settings [21, 22, 24, 26–32]. While useful, this research does not directly recognise that patient safety interventions, such as EMMS implementation, require healthcare professionals to change their behaviour.…”

Application of “Six Rights” on Medication Administration by Nurse and Patient Satisfaction

“…Another study of (McLeod, Barber, & Franklin, 2015) on the application of the principle of the six rights in the administration of medications by nurses pointed out that nurses are not applying the principle of the six rights application in medication delivery as a whole. There were 81.4% of nurses are already doing the right dose, 70% of nurses are already doing on time, 5.7% of nurses do not invoke the name of the patient when giving medications, 98.9% of nurses have not been applying the principle of the right way, 10% of nurses is not appropriate documentation and to note that 100% of nurses is not appropriate medication.…”