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Nursing and Health Sciences (2015), 17, 188–194

Research Article

An observational study of how patients are identified before medication administrations in medical and surgical wards Marja Härkänen, MSc, RN,1,2 Marjo Kervinen, MD,3 Jouni Ahonen, PhD,3 Hannele Turunen, PhD, RN1,3 and Katri Vehviläinen-Julkunen, PhD, RN1,3 1

Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, 2Finnish Doctoral Programme in Nursing Sciences and 3Kuopio University Hospital, Kuopio, Finland

Abstract

The aims of this study were to clarify how a patient’s identity was verified before the administration of medication in medical and surgical wards in a hospital, as well as to study the association between patient identification and the registered nurse’s work experience, observed interruptions, and distractions. The study material was collected during April and May 2012 in two surgical and two medical wards in one university hospital in Finland, using a direct, structured observation method. A total of 32 registered nurses were observed while they administered 1058 medications to 122 patients. Patients were not identified at all in 66.8% (n = 707) of medication administrations. Patient identifications were made more often by nurses with shorter work experience in the nursing profession or in the wards (4 years or less), or if distractions existed during medication administration. According to the results, patient identification was not adequately conducted. There is a need for education and change in the culture of medication processes and nursing practice.

Key words

Finland, medication administration, nursing, observation, patient identification, patient safety.

INTRODUCTION Administration of medication to patients is a general and very important part of nurses’ work. At the same time, it represents one of the largest areas of risk in nursing practice, because the possibility of an error always exists in this complex and multiprofessional process. (Schelbred & Nord, 2007) Many medication administration guidelines are not followed in practice (Kim & Bates, 2013), and deviations from the accepted medication procedures or protocols exist (Hewitt, 2010; Choo et al., 2013). Thus, they have the potential to jeopardize the safety of the medication process (Popescu et al., 2011). In many cases, medication errors are clinically insignificant, but these can also be a serious threat to patient safety, and can cause patient morbidity and mortality in hospital settings (Mansour et al., 2012).

Literature review Most errors in hospitals are medication administration errors (Härkänen et al., 2013; Keers et al., 2013; McLeod et al., 2013). Erroneous medication administration to patients occurs more often than is recognized and reported in health Correspondence address: Marja Härkänen, Department of Nursing Science, University of Eastern Finland, P.O. Box 1627, 70211 Kuopio, Finland. Email: [email protected] Received 23 January 2014; revision received 15 May 2014; accepted 20 May 2014

© 2014 Wiley Publishing Asia Pty Ltd.

care. These errors are usually hard to detect, especially if they do not cause detectable adverse events to patients (Paparella, 2012). Medication administration is usually a complex task (Henneman et al., 2012), and many factors, including interruptions, distractions, and additional stress during medication processes, affect the nurses’ actions and increase the risk of medication errors (Choo et al., 2010; Hewitt, 2010; Westbrook et al., 2011). Limited work experience has also been found to be associated with medication errors by nurses (Westbrook et al., 2011). Although many factors influence medication administration, our understanding of the impact of these factors on medication safety is still limited (Popescu et al., 2011). Accurate identification of patients during the medication process, especially during medication administration, is one important aspect for decreasing the risk of errors (Parisi, 2003; Kelly et al., 2011). This is extremely important in an environment where high-volume and high-risk treatments are implemented (Parisi, 2003). According to previous findings, the identification of patients has been found to reduce the risk of medication errors by 56% (Westbrook et al., 2011). Even so, there is some discrepancy in the previous research concerning the classification of lack of patient identification. In a study by Lisby et al. (2005), lack of identification of a patient was classified as a clinical error. However, in the study by Westbrook et al. (2011), they were classified as procedural failures. doi: 10.1111/nhs.12158

Patient identification

The World Health Organization (2007) recommends that, even if patients are familiar to nurses, the patient should be identified to ensure that the right patient receives the right care. The Institute for Safe Medication Practices recommends that at least two patient identifiers, or the use of barcode verification wherever available, should be used before medication administration (ISMP, 2011). In this study, the identification of a patient means verifying a patient’s identity using the patient’s name, date of birth or the patient’s wristband. Incorrect ways of identifying patients include using the number of the patient’s room or bed, as well as identification by passive agreement such as proposing the name of the patient. Even though there is an extensive literature on patient safety in general, there are only a few empirical studies on patient-identity checking (Smith et al., 2011). Previous observational studies revealed the inadequacy of patient identification during the medication process, but were limited to Denmark (Lisby et al., 2005), Australia (Westbrook et al., 2011), and the UK (Dougherty et al., 2012). Thus, there is a need for additional research evidence about the problem. Our understanding is that there are no previous international studies revealing the factors that are related to patient identification in the hospital, and especially no data for hospitals in Finland.

Study aims The aims of this study were to clarify how patients’ identity was verified before medication administrations in medical and surgical practice in hospital, as well as to study the associations between patient identification and registered nurses’ work experience, observed interruptions, and distractions.

METHODS Design and study setting A cross-sectional study using a structured, direct observation method was conducted. In detecting problems in the medication process, a direct observation method has been found to be a more efficient and accurate method than reviewing charts and incident reports (Flynn et al., 2002). This method was quite similar to a previous structured observation study conducted in Aarhus University Hospital’s medical and surgical wards (Lisby et al., 2005), which also revealed information concerning the lack of patients’ identification. However, unlike that study, we identified work environmental and nurse-related factors that could be associated with patient identification. The study was conducted in one university hospital in Finland, which has 800 beds and provides specialized medical care to 860 000 inhabitants. A total of 1518 registered nurses (RNs) were working in the study hospital during the data collection. Observations of 1058 medication administrations (441 occasions of medication administration with 1–13 medications per occasion) to 122 patients by 32 RNs were made during April and May 2012. Observations were conducted in the hospital’s four different adult wards: two medical

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(cardiology and nephrology) and two surgical (gastroenterology and traumatology) wards. Patient identification is one part of a larger observational study that will be reported in the future. The bar-code technology for patient verification was not used in the study hospital. Only patients with memory problems, showing signs of confusion, or going to surgery were using identification wristbands. There was no clear recommendation in the hospital policy on how patient identification should be carried out. However, every RN in the hospital should have passed continuing education studies of medication. This education included information that patient identity should be verified by asking their name and date of birth, or by using an identity wristband. A web-based errorreporting system was used in the hospital and all health professionals were encouraged to report detected errors and, thus, take an active part in patient safety monitoring.

Ethical considerations A research permit was granted by the hospital, and the ethical statement was granted from the Committee on Research Ethics of the University of Eastern Finland in February 2012. In each ward at least one nursing staff meeting was organized, wherein RNs were informed about the study. The RNs were not allowed to see the observation form and they did not know that patient identification was one of the observed issues, because the aim was that observation would affect the RN’s daily work as little as possible. All kinds of extra distractions and interruptions during observation were avoided. Before observation, RNs were asked about their willingness to participate in the study, and each gave her/his consent. It was ensured that they had enough information before making this decision. They were also told about the possibility of opting out of the study. The RNs were randomly selected on the basis of their work shift, and none of the RNs refused to participate in the study. No personal identifiers of the nurses were gathered during data collection, and thus their anonymity was ensured during data analysis and reporting.

Data collection Two trained observers, with a nursing background and Master’s level education in nursing science, observed the RNs while they administered drugs to patients during day and evening shifts. In each ward, observations were made during seven work shifts on different days. The observer was usually involved in medication rounds (morning, midday, afternoon, and evening), but also some administrations of additional drugs, such as analgesics, were observed. The observers tried to be as unobtrusive and objective as possible. A structured observation form was used for data collection. In this form, the identification of a patient before medication administration was only one of the observed issues. The form was developed for this study because none of the previously used forms met the intended use and purposes of this study. The development process was conducted by a © 2014 Wiley Publishing Asia Pty Ltd.

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multiprofessional (nursing science, clinical medicine, and pharmacy) research team, and was based on the literature. Content and face validity of the observation form was tested by a multiprofessional panel of 12 experts (two physicians, five pharmacists, and five RNs). After the development process based on feedback from the panellists, the content validity index of the form was 0.66. The face validity was at a good level, because every panellist evaluated that the form was measuring medication problems and their related factors. The observation form was tested in a pilot study of every ward before data collection. Inter-rater reliability, using a kappa statistic, was calculated during the pre-test in five different measures. Cohen’s kappa coefficient values and rates of agreement were: Patient 1 (n = 33 observations) – percentage agreement 88%, kappa 0.757, P < 0.0005; Patient 2 (n = 33) – percentage agreement 88%, kappa 0.752, P < 0.005; Patient 3 (n = 31) – percentage agreement 87%, kappa 0.742, P < 0.0005; Patient 4 (n = 27) – percentage agreement 82%, kappa 0.634, P = 0.001; Patient 5 (n = 26) – percentage agreement 92%, kappa 0.846, P < 0.0005.

Data analysis Data analysis included three phases: in the first, observers went through all the observations and classified detected medication problems, reaching their consensus between assessments; in the second, a multiprofessional research team (an observer, a nursing professor, a clinical physician, and a pharmacist) evaluated all of the problems; in the third, the data were analyzed using the SPSS Version 19.0 for Windows software. Associations between patient identification and nurses’ working experience in the wards or in the nursing profession, interruptions, and distractions were analyzed using logistic regression analysis. Associations were regarded as a statistically significant if the P value was less than 0.05. Results are expressed as odds ratios (OR) with a 95% confidence interval (CI).

RESULTS

M. Härkänen et al.

Table 1. Patient identification per medication (n = 1058) and per occasion (n = 441) of medication administration, with 1–13 medications per occasion

Patient identification Yes, using wristband Yes, asking the date of birth Yes, asking the patient’s name Proposing the patient’s name No Not known Total

Per medication (n = 1058), N (%)

Per occasion of medications (n = 441), N (%)

4 (0.4) 2 (0.2)

3 (0.7) 1 (0.2)

272 (25.7)

95 (21.5)

25 (2.4)

12 (2.7)

707 (66.8) 48 (4.5) 1058 (100)

298 (67.6) 32 (7.3) 441 (100)

Patient identification during medication administration In the majority of the 1058 medication administrations (66.8%, n = 707), patients were not identified at all. When comparing identification per occasions of medication administrations (n = 441), including 1–13 medications per occasion, the result was quite similar. In 67.6% (n = 298) of administered medication occasions (n = 441), patients were not identified at all (Table 1). Patients were identified by asking their name in 25.7% (n = 272) of the 1058 medicine administrations, by asking the date of birth in 0.2% (n = 2), or by checking the patient wristband in 0.4% (n = 4). Some identifications were made by proposing the patient’s name (2.4%, n = 25), such as “You are Mr . . .”. In this study, lack of identification of the patient was not classified as an error or procedural failure, because there was no clear recommendation in the hospital on how it should be done. Table 2 shows an example of one observed situation in clinical practice where a near-miss situation occurred, due to the lack of patient identification.

Background information A total of 32 RNs were observed while they administered 1058 medications to 122 patients. The unit of analysis was one administered drug. The RNs’ work experience in the wards ranged from 0 to 30 years, and mean work experience in the unit was 10 years (median 7, mode 5). The RNs’ work experience in nursing ranged from 1 to 32 years, and the mean was 16.3 years (median 15, mode 10). Different types of distractions and interruptions during the medication administrations were observed. The amount of distractions varied from none to six, and the mean amount of distractions during an individual drug administration was 1.83 (median 1, mode 1). The most common distraction was having too many people in the medicine room (66.3%), noise (34.0%), busy atmosphere or time constraints (26.7%), and other distractions (26.4%), which were usually guidance of a student or discussion with relatives during medication administration. © 2014 Wiley Publishing Asia Pty Ltd.

Associations between patient identification and background information The associations between patient identification and nurses’ work experience in the wards, in the nursing profession, and also between distractions were analyzed using logistic regression analyses. In this study, the identifications using patient name, date of birth, or wristband were classified as the patient identity verified class (total 26.3%, n = 278). Identifying patients by proposing the patient’s name was classified as the not-identified class, as well as the not-known class (total 73.7%, n = 780). An association between RNs’ work experience in the ward and identification of patients (P < 0.001) was found. When the nurses with work experience of 4 years or less were compared to nurses with longer experience in the wards, a statistically significant difference was found with every other

Patient identification

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Table 2. An example of patient identification problem detected during observations An example of the notes from clinical practice “RN was administering medicines to patients, when another RN came into room and said that, in another room, a patient was asking for his morning medicines. The RN was in that room before, but she didn’t give any medicines to this particular patient: maybe because the patient had arrived in the ward the previous night. The other RN who dispensed the patient’s drugs during the night shift had put his medicine card and medicines in the wrong place in the medicine tray, and when the nurse administered drugs in the morning, she did not notice that the patient’s medicines were missing. In the morning, during medication administration in that room of four patients, there were a lot of distractions: many nurses in the room, a physician examining one patient and a laboratory technician taking blood samples. There was a hurry to give medicines to all patients before they got their breakfast. Now the RN goes back to the patient’s room, goes to the patient and she is really embarrassed. She gives the drug dose, a jar of pills, to the patient and says that she is sorry for the mistake. No identity checking of the patient was made. When the RN was leaving the room and going back to another, the patient asked: ‘What are these drugs?’ The RN returned to the patient, took a medicine card from the medicine tray and started to tell the names of medicines. The patient did listen to the RN, looked at the drugs and said that he had never had those kinds of drugs. This was a moment when the RN noticed that she was giving another patient’s medicines to this patient. Luckily, this 42 year old patient was attentive and brave enough to ask before he took the medicine.”

group, except that of nurses with work experience of 15–19 years (P = 0.073) in the ward. In the other groups of work experience, the probability that identification was not conducted when compared to nurses with experience of 4 years or less was increased. The highest probabilities that the identification was not conducted were found for nurses with a work experience of 20–24 years (odds ratio (OR) = 18.94; confidence interval (CI) = 9.64–37.22; P ≤ 0.001) and 25 years or more (OR = 11.01; CL = 5.36–22.64; P ≤ 0.001) in wards. An association was also found when the identification was compared to work experiences in the nursing profession (P < 0.001). Statistically significant differences were found in every other nurses’ work experience groups when compared to nurses with experience of 4 years or less. Thus, the identification was more likely not to be conducted by nurses with longer work experience, especially by nurses with experience of 10–14 years (OR = 18.56; CI = 10.87–31.68; P ≤ 0.001) or 20–24 years (OR = 27.92; CI = 15.05–51.80; P ≤ 0.001) in the nursing profession. An association between patient identification and the amount of observed interruptions and distractions was found (P < 0.001). Failure to identify the patient was reported significantly more frequently for nurses who were not distracted or interrupted (95%, reference category) compared with nurses who were distracted or interrupted. Most often the identification was conducted if there were four different dis-

Detected problems Lack of checking that all patients did receive medicines Dispensed drugs were in wrong place in the medicine tray

A lot of distractions during work Poor organization of work Busy work environment

RN’s work environment stressful, possible effect on her concentration No identification control or verification of medications was made The patient was not informed about the names of the medicines being administered No comparison between patient drugs and clinical condition

tractions during medication administration (OR = 0.05; CI = 0.02–0.10; P ≤ 0.001). (Table 3.)

DISCUSSION In this study, patient identification, using the Institute of Safe Medication Practices guidelines (ISMP, 2011) that recommend using two different patient identifiers, was not conducted at all. Identification was made in only one-quarter of all observations, using one patient identifier, usually by asking the name of the patient. Smith et al. (2011) and Dougherty et al. (2012) found that a lack of patient identification appeared to be based on the RNs’ feelings that they knew the patient well enough beforehand. Dougherty et al. (2012) also discussed that a culture in the wards of “knowing the patient” played a large part, and in nurses’ views, patients do not want to repeatedly have to say their name and date of birth. The RNs also tend to think they should know their patients and not need to ask them for detailed information. It is important that patients are aware of why identification is done during every administration of medication and that it is a part of a safe medication practice. The participation of the patient in the medication process should be encouraged to guarantee safety, but the paternalistic view has a long history in health care, and in many cases the patients choose to take the passive role during their hospital stay (Heggland et al., 2013). © 2014 Wiley Publishing Asia Pty Ltd.

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Table 3.

M. Härkänen et al.

Associations between patient identification (n = 1058) and background information (n, %) using logistic regression, P < 0.05 Patient identification

Background information RNs’ work experience in ward (years) 0–4 5–9 10–14 15–19 20–24 25– Total RNs’ work experience in nursing profession (years) 0–4 5–9 10–14 15–19 20–24 25– Total Number of interruptions and distractions during medication administration 0 1 2 3 4 5 or more Total

YES (using wristband, patient name or date of birth), n (%)

NO (not identified, not known or identified by proposing the name), n (%)

TOTAL n (%)

Logistic regression P < 0.05 OR (95% CI) P < 0.001

163 (52.4) 60 (16.7) 14 (28.0) 22 (39.3) 10 (5.5) 9 (9.1) 278 (26.3)

148 (47.6) 300 (83.3) 36 (72.0) 34 (60.7) 172 (94.5) 90 (90.9) 780 (73.7)

311 (100) 360 (100) 50 (100) 56 (100) 182 (100) 99 (100) 1058 (100)

Ref.

An observational study of how patients are identified before medication administrations in medical and surgical wards.

The aims of this study were to clarify how a patient's identity was verified before the administration of medication in medical and surgical wards in ...
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