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Chapter I
THE PROBLEM
This chapter aims to discuss the importance of the study. This includes the
Introduction on which a brief summarization of the problem is tackled, Statement of the
Problem, Scope and Delimitation that will put restriction to the variables of the study and
the Significance of the Study, which discusses the importance and benefits of the research
to group of people. The references used in Chapter I are enlisted in Notes in Chapter I.
Introduction
Many issues about the nursing profession have risen since the early ages until
this time. One outstanding issue is about medication administration errors. A not-so-
recent story was about a Filipina Nurse, a Clinical Instructor , together with her two
students were assisting an operation when a surgeon ordered a drug to be given on the
female patient. The CI ordered one of the students to get the drug and handed it to the CI.
When the surgeon injected the drug, worst thing happened on the patient, death, and for
that, the clinical instructor was jailed. Yes, many questions are held up on what are the
causes of medication administration errors. Many questions are still hanging without any
answers. Let this study answer, if not all, most of the confusions about medication
administration. There is much to discuss.
The study will be particularly for the BSN III student nurses of Asia Pacific
College of Advanced Studies. Before the student nurses of APCAS become registered,
they perform the Related Learning Experience. The RLE exposure of the students is
mostly on the Provincial Hospital of Bataan, where the masses depend on when times of
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health danger occur. Part of their RLE skills in all wards is medication administration.
Proper medication administration must be imposed since many lives are in danger. Skills
are not learned for only a day, they are founded from experiences. If the foundation is
weak, and so will be the structure.
Medical treatment involves the use of drugs, whether of any kind. A medication is
a substance administered for the diagnosis, cure treatment, or relief of a symptom or for
prevention of disease (Berman, 2008). Medication administration errors (MAE) include
mistakes on the frequency, dose, route, name and classification of drug, patient, time,
assessment, education, evaluation and documentation. That definition of Berman clearly
limits that administration errors dont include any other error except for those stated.
According to Potter and Perry (2004), the physician is responsible for directing medical
treatment. Nurses are obliged to follow physicians orders unless they believe the orders
are in error or would harm the clients. Therefore all orders must be assessed, and if one is
found to be enormous or harmful, further clarification is necessary. However, the nurse
administering medications is accountable for knowing what medications are prescribed,
their therapeutic and non-therapeutic effects, and the clients need for medication
administration, supervision with administrator, and education about the medication and
its effect (Potter, 2001). Medication administration is a complex and time consuming
task, occupying to one-third of nurses time. Therefore, there will always be a possibility
of error to occur. This study also will give us preventive strategies which will help both
nurses and future nurses to avoid mistakes.
According to Haw, Dickens and Stubbs (December 2005), during their study
period, a total of 123 administration error reports were received. Of these, 88% (108) met
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the studys definition of an administration error, and a further 3% (4) was considered near
misses for a total of 112 error reports. For 103 of 112 errors (92%), sufficient information
was available to rate the error severity. Although 86 errors (77%) were rated as grade 1 or
2 (of doubtful importance or having the potential to cause minor adverse effects, 14%
(16) were rated as grade 3(having the potential to cause moderate adverse effects), and
one (1%) was rated as grade 4(having the potential to cause serious adverse effects).
Therefore a further study and research is to be conducted so no growth rate in percentage
of the reported medication administration errors will occur.
Nurses are here for a purpose not only to give tender loving care, but to help
patients live a life worthy of what they deserve. And that is the reason why nurses must
not harm the patient in the best of their ability and capacity. The knowledge and skills of
every nurse plays a big and significant role in the continuation of life of many people.
Nurses have tremendous power (Smith, 2008). They influence patient outcomes in the
hospital. In the words of Patch Adams (1998), You treat a disease, you win, you lose.
You treat a person, Ill guarantee you youll win. Treat patients properly, and make no
mistakes, for lives are at stake. This study will give answers and clarifications on how
medication administration errors occur and affect the nursing care to patients and will
name important reminders to further prevent such errors on happening.
Statement of the Problem
This study is structured to note the effects of the causes of medication
administration errors (MAE) to the nursing care system among the BSN III students of
Asia Pacific College of Advanced Studies.
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Specifically, it seeks to answer the following variables:
1. How medication administration errors occur in the following categoriesaccording to the third year nursing students:
1.1knowledge and skills;1.2communication difficulties;1.3personal factors?
2. How is nursing care being described in the following categories:2.1profession;2.2patients safety;2.3ethics?
3. How do medication administration errors affect the nursing care system?4. What are some preventive measures to avoid medication administration errors in
the following categories:
4.1right process of administration;4.2Ten Rights of Medication Administration;4.3Medication Dos and Donts of Nurses?
Scope and Delimitation
The studys central point will be of three major variables. The first variable is the
causes of the medication administration errors which will be further subdivided to itsvariables which are knowledge and skills, communication difficulties and personal
factors. The second major variable is the nursing care systems description based from its
sub variables which are profession, patients safety and ethics. The third major variable is
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is the different preventive measures to avoid such errors and is categorized in its sub
variables like the right process of administering medications, the Ten Rights of
Medication Administration and the Dos and Donts of Nurses.
As stated, Asia Pacific College of Advanced Studies will be the venue of the study.
The school was picked because it is more convenient and significant to the researcher in
such a way that the school will benefit from knowledgeable, skillful and competent
student nurse about the proper medication administration.
All bona fide third year student nurses of the school, both female and male, are the
respondents of the study.
Significance of the Study
The result of the investigation in The Effects of the Causes of Medication
Administration Errors to the Nursing Care System will be significant to the following:
To the Student Nurses. This study enables student nurses to recognize
different precipitating medication administration errors and ways to shun these. Correct
information and ideal skills are presented for the benefit of many students, that they may
apply all of this for the proper treatment of their patients in terms of medication
administration. This study allows student nurses to know their liabilities and
responsibilities in their profession, and aims to help them to have a sense of vigilance
over questionable orders.
To the Clinical Instructors. This study is conducted for the benefit of the
clinical instructors that they may share what is the ideal, enough and right knowledge and
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skills to their students. This is also to emphasize that a need for assistance on student
nurses is a must.
To the Patients of the student nurses. This study also is founded for the benefit
of patients that they may become watchful and responsible for what medicine they take.
The students also need cooperation and understanding from you.
To the Physicians. This thesis would like to make an impact to the way
physicians order. The nurses do understand that being a doctor is a tough job, but for the
nurses to be efficient and to minimize mistakes there is also a big responsibility for the
doctors to do. This study serves to be a constant reminder that mistakes from physicians
orders have been one of the causes of errors, and so, a further evaluation on their jobs is a
must, especially when writing their orders and doing verbal commands.
To the Researcher. This study serves to be a reservoir of knowledge that can be
used for recent situations, and future ones and a reminder that learning is an endless
process. This gives clear facts to her existing knowledge. This study also emphasizes that
the researcher needs to grow to meet the demands of dramatically changing health care
system and serves as a reminder that the practice of caring is timeless.
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Notes in Chapter I
Berman,Audrey.et al.(2008).Fundamentals of Nursing:Concept,Processand Practices,8thEdition.Singapore:Pearson Education Inc.pp.830
Potter, Patricia.et al. (2004). Fundamentals of Nursing, 6th Edition. St.Louis, Missouri:MOSBY Publishing House,pp419
Potter, Patricia. (2001).Fundamentals of Nursing, 5th Edition. St.Louis, Missouri:MOSBY Publishing House,pp899
Haw, Camilla Malyn.et al.(December,2005). A Review of Medication AdministrationErrors Reported in a Large Psychiatric Hospital in the United Kingdom.www.google.com
Smith, Jane. (September, 1995).Nursing Homes.www.google.com
Williams, Marsha Garces.et al. (1998).Patch Adams.United States of America.Blue WolfProductions.
http://intghc.oxfordjourals.org/sgi/content/abstract/3/1/11
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Chapter II
THEORETICAL FRAMEWORK
This chapter presents different theories, literatures and studies on which
the study is related to. This is divided to Relevant Theories, on which theories are
analyzed so the relation to the study is met, Review of Related Literature which sums up
each variable in a theory or a principle using published materials, Review of Related
Studies on which unpublished materials are used on the other hand, the Conceptual
Framework, Paradigm, Hypotheses and Assumptions of the study on which the
researcher predicts the outcome of the study. The Definition of Terms follows where
different terminologies used in the study are explained thoroughly for the benefit of the
readers and the Notes in Chapter II where the references are listed.
Relevant Theories
Virginia Henderson (1966) defined nursing as assisting individuals to
gain independence in relation to the performance of activities contributing to health or its
recovery (Berman et.al 2008). She was one of the first nurses to point out that nursing
does not consist of merely following physicians orders.
Ideally, the nurse would improve nursing practice by using her definition
to improve the health of individuals and thus reduce illness. It is a guide that will meet
the needs of the patient by using proper knowledge and skills that will make the recovery
of the patient faster without inducing other bargains such as on making mistakes. She
emphasized that nursing profession is not always about following the physicians order
since they too, have mistakes. It is always about following what is right.
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Using Hendersons definition, the study is anchored to a principle that
nurses must meet the standards of the profession so as to help patients recover, have a
quality life and gain independence. Every nurses and student nurses must take in
consideration every time they are giving medication orders that they should put in their
minds the sake of the patients. They also must have watchful eyes on physicians orders,
that when these have mistakes, they would have the right knowledge and skills to decide
what to do.
Faye Glenn Abdellah (1960) theorized the 21 Nursing Problems on
which the third nursing problem is to promote safety (Berman et.al 2008). In Abdellahs
model, nursing care means providing information to the client or doing something to the
client with the goal of meeting needs or alleviating impairment.
Nurses, as well as student nurses provide enough and sound information to
the patients so their needs are met. This information or knowledge will also be a helpful
tool to solve existing problems in their health. Nurses too have the responsibility to give
interventions to patients so that any impairment or disability delineating an individual to
gain recovery will be moderated.
Medication Administration by nurses and student nurses require correct
client education. Ample time must be taken so that enlightenment and verification of
information will be noted to clients so no adverse effects will occur. Nursing goals areonly attained through proper and correct nursing interventions so the patients safety and
recovery is promoted. If a nursing consideration is omitted and/or committed, surely, the
patient will suffer. His impairment will only be severed and not alleviated.
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Imogene Kings (1971) Goal Attainment Theory described nursing as a
helping profession that assists individuals and groups in society to attain, maintain and
restore health (Berman et.al 2008). King also viewed nursing as an interaction between
the client and the nurse whereby perceiving, setting goals and acting on them, transaction
occurs and goals are achieved.
King highlighted on her theory that nurses have the responsibility and
liability to help patients on restoring their health and not the other way around. She also
stated that nurses when interacted with patients and act side by side with them, goals are
attained, and good outcomes will follow.
The study is based on what right interventions to follow, specifically when
administrating medications to patients who trust health care providers with their lives.
Health care providers exist for a reason that assisting individuals to adjust to
environmental stressor, such as their illness and impairment, will give positive outcomes
and not to invade their impaired life with other stressors brought about by errors on
medication administration. Proper education, assessment, consultation and intervention
with the patient before any administration will definitely minimized if not totally
eradicate any mistakes that will make nursing goals unattainable.
Review of Related Literature
On the Causes ofMedication Administration Errors. Cause is defined
by The American Heritage Dictionary as the producer of an effect, result or consequence.
Several reasons have been proposed for why medication administration occurs. These
reasons generally fall into the following category (a) inadequate knowledge and skills, (b)
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failure to comply with policy and procedure or lack of procedures, (c) failure in
communication, and (d) individual and systems issues. Nurses also described personal
factors contributing to errors in medication administration. The Pennsylvania Patient
Safety Reporting System(2007) had further mentioned medication errors continue to
ranking high, where as unclear and confusing labeling and packaging as well as look-
alike or sound alike drug names significantly contribute to medication errors. According
to the International Council of Nurses (2002), medication errors therefore result from
problems in practice, products or procedures or systems.
This first major variable will be divided into knowledge and skills,
communication difficulties and personal factors.
On Knowledge and Skills. Knowledge is defined by the Oxford English
Dictionary as what is known in a particular field or in total, facts and information. The
term knowledge is also used to mean the confident understanding of a subject with the
ability to use it for a specific purpose if appropriate. The nurse uses the knowledge
learned from many disciplines when administering medication. It is this knowledge that
helps the nurse to understand why a particular medication has been prescribed for a client
and how this medication will alter the clients physiology so as to exert a therapeutic
effect. For example, in physiology, the nurse may have learned that potassium is a major
intracellular ion. When clients do not have potassium in their body, they may experience
signs and symptoms that are associated with hypokalemia, such as muscle fatigue or
weakness. Medications may be prescribed that may restore clients potassium level on
normal. Another example is knowledge about child development on which may show that
children often associate medication administration with a negative experience. The nurse
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uses principles from child development to ensure that the child cooperates with the
medication experience (Potter, 2004). According to Wolff (2003), nurses must know
whether the drugs are compatible with each other when the patient is to receive several
kinds of medications. Some drugs are incompatible with certain others and to mix them
may be dangerous to the patient or may render the drug ineffective. She should also learn
any modifications in the diet are necessary for the drug to function effectively. For
example, certain antibiotics cannot be taken with milk. Knowledge about whether the
drug is compatible with the patients condition is a must. For example, oral medications
are not used for patients who are vomiting.
According to Tungpalan (2002), the nurses responsibility in drug
administration goes beyond carrying out doctors orders. She decides when or where not
to administer a drug. Involving the patient and his family in his plan of care means she is
able to explain what drugs he is taking, why he is taking them, for how long and at what
intervals, as well as he should stop taking them. The nurse must continually seek to
expand her knowledge about drug therapy in order to provide safe and therapeutically
effective nursing care. Knowledge of the drug goes beyond knowing its generic name and
desired therapeutic effect. The nurse should also know its physiologic actions, its
indications, and contraindications, dosage ranges, route of administration and side effects.
Knowledge of the patient includes knowing any allergic or drug sensitivity reactions have
had in the past.
According to the Oxford English Dictionary, a skill is learned capacity to
carry out pre-determined results often with minimum outlay of time, energy or both. The
nursing student often has limited experience with medication administration as it applies
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to professional practice. The clinical experience provides the student with the opportunity
to use the nursing process as it applies to medication administration. Since the nurse
spends the most time with clients, the nurse is the most appropriate health care worker to
administer medications. Wolff (2003) had stated that leaving medications for the patient
to take later is considered unsafe practice because the patient may not take the drug. The
administration of medications to clients requires knowledge and a set of skills that is
unique to the nurse (Potter, 2005).
The International Council of Nurses (2002) had stated on their report that
types of medication errors falling under extra dose and omission error to be caused by
performance deficit and knowledge deficit respectively.
Tungapalan, 2002, had stated that nurses see to the patients safety and
comfort before, during and after the process of drug administration. A skill in medication
administration of a nurse is the responsibility on calculating the flow rate of IV infusions.
Too rapid infusion rates result in overloading the intravascular compartment which may
lead to cardiac and/or pulmonary conditions while too slow infusion rates result in
inefficient fluid and electrolyte replacement. All the methods of parenteral administration
involve breaking the skin which is the bodys first line of defense. As such, the need for
aseptic technique cannot be over-emphasized. There is also a need to rotate the injection
sites if the patient is receiving a series of injections. The nurse must also be skillful
enough to check for patency of the nasogastric tube before administering any food or
medications. Another skill is to check for the patency of the IV with dextrose, as such
mispatency will result in soft tissue necrosis. A mispatent IV for Sodium Bicarbonate
may result on Burns. According to Berman (2008), a skill o medication preparation such
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of flicking the upper stem of an ampule several times with a fingernail will help bring all
medication down to the main portion of the ampule. Preventing cross contaminations of
the needle between bottle to bottle or vial to vial or ampule to ampule will prevent the
drug on producing ineffective reactions or lack of reactions. With regards to mixing of
insulin, a medication for Diabetes Mellitus, mixing ensures an adequate concentration
and thus an accurate dose. Shaking insulin vials can make the medication frothy, making
precise measurement difficult. After a skin test is done, ask the child not to rub or scratch
the injection site. Rubbing the site can interfere with test results by irritating the
underlying tissue.
On Communication Difficulties. Communication is a term used to
reflect a process of transferring information to another. It is the process of imparting or
exchanging thoughts, opinions or information by speech, writing or signs. Nurses are
legally responsible for carrying out the orders of the physician in charge of a patient,
written or verbally, unless an order would lead a reasonable person to anticipate injury
(Taylor, 2004). According to Potter (2004), nursing students should not give any
medication without a written medication order.
The physician should right all orders and the nurse must make sure that
they are transcribed correctly. Verbal orders are not recommended because they increase
the possibilities for error (Potter, 2004). When verbal orders are received by the nurse,
they should be immediately entered into the clients medical record and signed by the
nurse, indication the time and the name of the prescriber who gave the order. Most
institutions require a prescribers signature within 24 hours after the order is made.
Repeat a telephone order back to the physician for confirmation (Taylor, 2004). Very
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often that nurses notes are used if at time, lawsuit comes. The nurses assessments and
the reporting of significant changes in the assessments are very important factors in
defending a lawsuit. Therefore, the nurse should identify the physician contracted, the
information communicated and the physicians response.
Tungpalan (2002) had also mentioned that one of the leading causes of
claims against nurses are with errors made with insufficient communication with the
patient or with the doctors.
Furthermore, the International Council of Nurses (2002) had classified
types of error on unauthorized drug to be caused by confusing communication; wrong
administration because of inaccurate or omitted transcription and illegible or unclear
handwriting to cause for the wrong patient.
On Personal Factors. Personality aims to describe aspects of an
individual's character, thoughts, and feeling (Buckhalt, 2008).Attributes of a nurse often
vary to other nurses, and each personal factor contributes to the success of a nursing
intervention. Each nurses station has a place set aside for the nurse to prepare the clients
medications with minimum distractions and where the equipment she needs are readily
available, to insure time and effort (Tungpalan, 2002). Concentrating on the work at hand
is very necessary for the patients safety. The leading cause of claims against nurses with
personal factors-made errors are carelessness and forgetfulness. In many cases, personallife could also affect the attitude at work, so ideally there should be a healthy balance
between work and home life (Taylor, 2007).
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On Nursing Care System. This variable will tackle its description
according to profession, patients safety and ethics.
On Profession. The authority for the practice of nursing is based upon a
social contract that delineates professional rights and responsibilities as well as
mechanisms for public accountability. (www.wikipedia.com).The profession combines
physical science; social science, nursing theory, and technology in caring for those
individuals. In order to work in the nursing profession, all nurses hold one or more
credentials depending on their scope of practice and education. A Licensed practical
nurse (LPN) (also referred to as a Licensed vocational nurse, registered practical nurse,
Enrolled nurse, and State enrolled nurse) works under a Registered nurse.
According to the International Council of Nurses (2002), the nurse
assumes the major role in determining and implementing acceptable standards of clinical
nursing practice, management, research and education. The nurse is active in developing
a core of research-based professional knowledge. The nurse, acting through the
professional organization, participates in creating and maintaining safe, equitable social
and economic working conditions in nursing.
It is a nurse's responsibility to be informed on Nurse Practice Acts which
they are licensed to practice. It is critical for students and nurses need to be aware of the
legal issues pertaining to the profession. Familiarity with the law and relevant court
rulings helps in understanding the scope of practice and responsibilities that come with
being a licensed caregiver, as well as providing insight on how to prevent legal problems
before they happen (Singleton, 2000). Within the profession, sprout of trust is indeed a
must. Nurse-client relationships are referred to as by some as interpersonal relationships
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(Berman, 2008). The keys to the helping relationship are development of trust and
acceptance between the nurse and the client and an underlying belief that the nurse cares
about and wants to help the client. They trust medical practitioners and nurses ability to
solve medical problems, and if something went wrong with their bodies as they believe to
be caused by errors made by health care providers, the whole system of relationship is
held bankrupt. The conflict may arise from differing values, philosophies, personalities
and disbelief (Berman,2008). According to Carroll (2006), these conflicts can be solved
through exploring alternative solutions, through compromise, negotiation and
collaboration.On Patients Safety.Nurses are knowledge workers whose main responsibility is
to provide safe and effective care within constantly evolving health care systems. Nurses
collaborate with one another, as well as doctors, aides and technicians, to provide holistic
care to patients. Although advocating for patient safety is a nurse's role, it is also
necessary for the patient to be an active participant in their safety. Patient safety is a
collaborative goal that requires concerted efforts from the patient and all members of the
health care team. It is also a means to foster communication between the patient and the
nurse including other health care members to better patient's health (Blendon et.al, 2002).
Due to the increasingly complex nature of the role of nurses, everyday
nursing duties are also a challenge in protecting the safety of every patient. Ebright et al.
(2005) have stated some important questions regarding medications that patient should
ask, and nurses must rightfully answer. The nurses must always check the patient's wrist
band before giving medications or treatments. Patients should ask questions about the
medications they are receiving when they don't understand something. Ask if there are
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any side effects to be aware of and know if the medication will change mental and
physical functioning.
Other methods to improve safety include: Better lighting and less clutter in work
areas where medications are prepared, keeping distractions to a minimum, and keeping
noise levels down. Drug companies and health care facilities are also standardizing
medication labels and packaging. Medications that can have a particularly dangerous
effect are being marked as high alert (National Quality Forum, 2003).
Many hospitals are investing in technology to minimize errors, such as machines that
dispense medications for just one patient at a time. Patients are given identificationbracelets showing their names and allergies and all medical personnel are required to
wear name tags showing their level of training.
More severe side effects, also called adverse effects or reactions,
may justify the discontinuation of a drug (Berman, 2008).These adverse effects put
patients life in danger. According to Tungpalan (2002), these responses may be mild or
severe. Reactions include skin rashes, itching, lacrimation, nausea and vomiting, diarrhea,
wheezing and shortness of breath and other unexpected outcomes that may jeopardized
the health of a patient. These adverse effects may lead to an anaphylactic shock, or a
severe allergic reaction which calls for emergency medical intervention.
The Department of Health in Taiwan (2005) had defined serious adverse
drug reaction that results in death, life-threatening, permanent disability/incapacity,
congenital anomaly/birth defect, results in hospitalization or prolongation of an existing
hospitalization and may need further management for other possible permanent
disabilities.
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Previous errors inspire or motivate the health care team members to
review and adjust practice for patients safety. As the primary caregivers in hospitals,
nurses are best positioned to improve quality and patient safety. However, they are often
pulled away from the bedside to conduct tasks that have nothing to do with actually
taking care of patientssuch as filling out paperwork and other administrative duties.
Optimizing nursing staff's time at the bedside is the key to better patient safety (Runy,
2002).
On Ethics.Nursing ethics is a branch of applied ethics that concerns itself
with activities in the field of nursing. The nature of nursing means that nursing ethicstends to examine the ethics of caring rather than 'curing' by exploring the relationship
between the nurse and the person in care ( McHale et.al.,2003).
The International Council of Nurses (2002) stated that the nurse carries personal
responsibility and accountability for nursing practice, and for maintaining competence by
continual learning. The nurse maintains a standard of personal health such that the ability
to provide care is not compromised. The nurse uses judgment regarding individual
competence when accepting and delegating responsibility. The nurse at all times
maintains standards of personal conduct which reflect well on the profession and enhance
public confidence. The need for nursing is universal. Inherent in nursing is respect for
human rights, including cultural rights, the right to life and choice, to dignity and to be
treated with respect.
Nurses and health care workers have the responsibility to uphold the rights
and worth of all people they encounter regardless of race, sex, ethnicity, age, religion,
beliefs, values, socioeconomic status, and sexual orientation. In addition, it is also the
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responsibility of patients and their families to mutually respect the dignity of their health
care providers and staff (Munson, 2004). Extra precautions to protect dignity such as
speaking respectfully to the patient, covering the patient should be used. Also, informing
the patient about care needing to be done prior to initiation acknowledges their dignity.
A violation in this ethics is negligence. According to Berman (2008),
negligence is a conduct that is below the standard. Such conduct places another person at
risk for harms. A student is ordinarily responsible for her own act of negligence if injury
to a patient results. The nursing student has been considered an employee of the agency
in hospital-controlled programs. Patient harmed by nursing students may also bring suitfor damages against an instructor-supervisor. If standards of supervision are violated,
negligence may be charged. If students feel their assignments are beyond their
competency, it is recommended that they call the attention of the instructor (Wollf, 2003).
On Different Preventive Strategies .The nurse accepts full responsibility
for all actions that are taken; this includes the administration of medications. When a
nurse administers a medication to the client, the nurse accepts the responsibility that the
medication or the nursing actions in administering it will not harm the client in any way
(Potter, 2001). In that view, many different strategic plans earthed as a way on shielding
medication errors.
Medication errors are preventable; although reducing the error rate
significantly will require multiple interventions and close collaboration between the
health team and management (International Council of Nurses, 2002).
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This major variable will be divided into the right process of medication
administration, ten rights and medication dos and donts.
On the Right Process ofMedication Administration. A process is a
tool, a step-by-step guide that will emphasize the need for careful planning of an action.
Most medication errors occur when a nurse fails to follow routine procedures (Potter,
2001). Berman et.al (2008) named six steps to follow in medication errors which are
identifying the client, informing the client, administering the drug, providing adjunctive
interventions as indicated, recording the drug administered, and evaluating the clients
response to the drug. One of the Joint Commissions National Patient Safety Goal is to
improve the accuracy of client identification, where nurses are required to use at least two
client identifiers before administering medications, (Berman, et.al, 2008). According to
Berman (2008), if the client is unfamiliar with the medication, the nurse should explain
the intended action as well as any side effects that might occur. Listen to the client.
Nurses may miss relevant information provided by the client.According to Przybycien
(2005), nurses must check three times for safe medication administration. First checking
happens on reading the Medication Administration Record and removing from the drawer
found at nurses station. Second is while preparing the administration and the last
checking happens before the nurse opens the package at the bedside. Clients may need
help when receiving medications, they may require physical assistance for example, in
assuming positions, and other measures that will enhance drug effectiveness and prevent
complications (Berman, 2008). Although most nurses prefer to spend their time
interacting with patients rather than writing in a patients records, careful documentation
is a crucial legal safeguard for the nurse. Documentation must be factual, accurate, and
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complete. The presumption of the law is that if something was not documented, it was
not done (Taylor, 2004).According to Berman (2008), the evaluation of the effectiveness
of the medication remains the responsibility of the nurse. The kinds of behavior that
reflect the action or lack of action of a drug and its untoward effects are as variable as the
purpose of drug themselves. Therefore, the nurse must report clients response to the
nurse manager and primary care provider, i.e., physician, when untoward responses
occur.
On The Ten Rights ofMedication Administration. There are aspects of
medication administration that are important for the nurse to check each time a
medication is administered. These are referred to as the rights (Berman, 2008). Right is
a term given to a legal, social or moral freedom to act to or refrain from acting, or
entitlements to be acted upon or not acted upon. Przybycien (2005) described ten rights
which are: Right Medication, Right Dose, Right Time, Right Route, Right Client, Right
Client Education, Right Documentation, Right to Refuse, Right Assessment, and Right
Evaluation. It is important for the nurse to be aware of how these rights must be
practiced. According to Berman (2008), the nurse is expected to respect these rights and
responsibilities.
On Medication Dos and Donts. The central action of medication
administration involves actual and complete conveyance of a medication to the patient.
However, there is a wider set of practices required to achieve safe, effective patient
outcomes and to prepare for and evaluate the outcome of medication administration.
Tungpalan (2002) managed to describe different medication dos and donts for nurses
that will give a concrete framework for the nurse to follow such as: Do not prepare
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medications way ahead of the time they are to be administered, Do use sterile technique
in the preparation and administration of parenteral medications, Dons use medications
which are not clearly labeled or solutions which show signs of deterioration, Do ask
another nurse or your superior to check your computation before you prepare the drug,
and Dont administer medications which somebody else has prepared Potter (2001) had
mentioned also different dos and donts to prevent medication errors such as Do not
administer medication ordered by nickname or unofficial abbreviation, Do not confuse
equivalents, Do be aware of medications with similar names, Do not attempt to decipher
illegible writing, and Do know clients with the same last names.
Review of Related Studies
Inadequate knowledge and skill generally reflect lack of patient
knowledge, patients diagnosis, and the names, purposes, and correct administration of
the medication but can also include not knowing how to operate IV pumps/ infusion
devices, mistaking IV lines for NG tubes, failure to adequately prepare medications
before administration. Monitoring errors may also be included in this category-failure to
monitor for side effects because of lack of knowledge according to Haw, Dickens &
Stubbs, 2005 on their study A Review of Medication Administration Errors Reported in a
Large Psychiatric Hospital in the United Kingdom. Haw, Dickens and Stubbs (2005) had
recorded 19 occasions on their study the factors that contributed to errors include busy,
noisy ward environments or being short of staff and difficulty reading or understanding
physicians instructions were reported on ten occasions. Furthermore, they had named
some personal factors described by nurses as contributing to errors in 19 instances,
including tiredness, poor concentration, inadequate supervision, and lack of support.
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Wakefield, Douglas, Holman and Blegens study, Nurses Perception of
Why Medication Errors Occur(2008) had stated reasons on why errors occur under the
knowledge category as names of many medications are similar with factor loading of
.618; many patients on same medications with factor loading of.612, nurses have limited
knowledge about adverse effects of medication earned a factor loading of .686, and no
easy way to look up medications(.706). According to Wakefield, Douglas, Holman and
Blegens study, communication difficulties play a major role in occurrence of medication
errors, and named reasons such as doctors medication orders are not legible; doctors
medication orders are not clear, orders are not transcribed to chart correctly, nurses do notcommunicate to other nurses about missed medications to be administered later and chart
is illegible. The factor loading for each reasons are .854, .862,.730, .558,.621
respectively. Nurses interrupted while administering medications to perform other duties
has been significant player on error occurrence has a factor loading of .584 on the other
hand.
Communication difficulties between hospital doctors and nurses are well
documented. A survey undertaken jointly by medical and nursing administration at Sir
Charles Gairdner Hospital in Perth, Western Australia verified difficulties in doctor-nurse
communication. Questionnaire responses revealed some impediments in the flow of
communication. Both nurses and doctors perceived less frequency of difficulties in
communicating with members of their own professional group than with members of the
other group as reviewed by McKay, Matsuno, Mulligan(2006).
With the study The experiences of final year nursing students in administering
medications : shifting levels of supervision, Reid-Searl, Kerry.(2008) stated that While
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safety measures may be reinforced to students, previous studies have not explained what
occurs when students actually administer medications to patients in the clinical setting.
Aim - This thesis reports on a study aimed at identifying the experiences of final year
undergraduate nursing students in administering medications. A sample of 28 final year
nursing students from an Australian university provided the data to permit the
development of the theory. Findings - This study identified that supervision was central
to the medication administration experiences of students. Students were confronted with
registered nurses who presented or provided them with shifting levels of supervision
when administering medications to patients. Shifting levels included the registered nurse;being near, being over or being absent.
Deans, Cecil on 2005 managed to do her study entitledMedication errors and
professional practice of registered nurses and explained why several factors are
occurring on contributing on medication errors. Mostly, medication errors were attributed
to documentation issues, including: illegible handwriting, misunderstanding
abbreviations, misplaced decimal point, misreading and misinterpreting written orders.
Several human factors were attributed to potential causes of medication errors, including:
stress, fatigue, knowledge and skill deficits. Environmental factors, namely, interruptions
and distractions during the administration of medications, were also attributed to potential
errors. The study found professional nursing practice involving administration of
medications had a strong education, patient and ethical focus. Over a quarter of the
respondents indicated that further training in medication administration would positively
impact on their nursing practice.
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Conceptual Framework
The paradigm of the study is made up of two boxes. The common causes
of medication errors are contained in the right box where different factors such as
knowledge and skills, communication difficulties and personal factors are involved. The
left box on the other hand tackles the different results of these errors to the medication
administration, as well as to the health care system, which encloses different concepts
such as adverse effects, principle of negligence and the effect to patients trust to health
care providers. The arrow between the two boxes significantly shows the effects of the
other box to the other one.
Hypothesis
A hypothesis is a proposed explanation of an observable phenomenon. In
this study, a Null Hypothesis is utilized.
The causes of medication administration errors in this study do not affect
the nursing care system.
Assumptions of the Study
The study assumptions are propositions taken to be true based upon
presupposition without preponderance of the facts (Cristobal et.al.2010). The following
assumptions are based from the studys own major and sub-variables.
1. Medications are used by patients to alleviate and/or treat their existing diseases.2. The nurse doesnt have the sole responsibility in giving medications to patients.
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3. In giving medications, nurses and student nurses follow the nursing process toachieve a positive outcome.
4. The student nurses in an affiliated hospital are required to have a set of skills andknowledge.
5. Any errors made should be reported immediately
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Paradigm of the Study
Figure 1
The Effects of Common Errors inMedication Administration
Causes of MedicationAdministration Errors
Knowledge and skills CommunicationDifficulties
Personal factors
Nursing Care System
Profession
Patients Safety
Ethics
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Definition ofTerms
Many items or words in this study are of complications. For the better
understanding of these terms, they are defined conceptually and/or operationally below:
Adverse Effects. More severe side effects (Berman,2008). These are the effects
not expected to appear as a manifestation of something went wrong. In this study, the
researcher wants to clarify that not all adverse effects are product of medication
administration errors of nurses, such may occur with family members assuming the error.
Asia Pacific College of Advanced Studies. The school on which the intended
BSN III nursing student respondents are enrolled.
Cause. The producer of an effect, result or consequence (The American Heritage
Dictionary). Operationally, it pertains to the knowledge and skills, communication
difficulties and personal factors.
Communication. Process of transferring information to another, the imparting or
interchange of thoughts, opinions, or information by speech, writing or signs
(www.wikipidea.com). The communication used in this study reflects one of the causes
of error. Further, it is the giving of orders by doctors, and the environment that takes
place as the order is being read, and delivered.
Ethics. It is used in this study as a definition of the nursing care system.
Knowledge. What is known in a particular field or in total, facts or information
(Oxford English Dictionary). As used in the study, knowledge pertains to the information
or learning gathered by the student in school and related experiences such as patient
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knowledge, patients diagnosis, and the names, purposes, and correct administration of
the medication ,how to operate IV pumps/ infusion devices and the like.
Medication Dos and Donts. It is used in this study as one of the preventive
strategies, and are considerations except for the right process and ten rights of medication
administration.
Negligence.Negligence is generally defined as conduct that is culpable because it
falls short of what a reasonable person would do to protect another individual
(www.wikipedia.com). It used in this study as the principle being used when lawsuits or
punishments for nurses occur. It is one of the effects of administration errors.
Nursing students. Defined operationally as the level three students enrolled for
the Degree of Bachelor in Science, Major in Nursing of the school and are taking up
related learning experiences or hospital exposures in affiliated hospitals.
Patients Safety. It is used in this study as a definition of the nursing care system.
Personal Factors. Defined operationally to be causing medication errors and
conceptually to be the personality and behavior of student nurses.
Profession. It is used in this study as a definition of the nursing care system.
Related Learning Experiences. It is used in the study as the subject of exposure
of nursing students in affiliated hospitals.
Right Process ofMedication administration. Defined operationally as the
preventive strategy and the chronologically arranged process to follow.
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Skill. Is a learned capacity to carry out pre-determined results often with
minimum outline of time, energy or both (Oxford English Dictionary). In this study, skill
is the teachings learned from the subject Related Learning experiences of BSN III
nursing students of the school.
Ten Rights. Defined operationally to be one of the preventive strategies and the
entitlements that nurses must respect.
Trust. Assured reliance on the character, ability, strength, or truth of someone
or something, one in which confidence is place (Merriam-Webster Online
Search).Operationally defined as an effect of medication errors, if patients will change
their view in this aspect to health care providers.
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Notes in Chapter II
Berman,Audrey.et al.(2008).Fundamentals of Nursing:Concept,Processand Practices,8thEdition.Singapore:Pearson Education Inc.pp.59,473,517833,848-850,852
Potter, Patricia.et al. (2004). Fundamentals of Nursing, 6th Edition. St.Louis, Missouri:MOSBY Publishing House,pp419
Taylor, Carol,et.al.(2004).Fundamentals of Nursing,5th Edition. Philadelphia: J.B.Lippincott Company.pp921-929
Tungpalan,Luz.(2002).Fundamentals of Nursing.Quezon City,Philippines:JMC Press Inc..pp.446,461,471,472
Potter, Patricia. (2001).Fundamentals of Nursing, 5th Edition. St.Louis, Missouri:MOSBY Publishing House,pp901-902
Przybycien.(2005). Fundamentals of Nursing:Concept,Processand Practices,8thEdition.Singapore:Pearson Education Inc.pp849
Wolff,LuVerne,et.al.(2003).Philadelphia, Pennyslvania:Harper and Raw Publishers Inc.pp.35-36,683
Haw, Camilla Malyn.et al.(December,2005). A Review of Medication AdministrationErrors Reported in a Large Psychiatric Hospital in the United Kingdom.www.google.com
Wakefield,Bonnie.et.al.(2008).Nurses Perception Why Medication AdministrationErrors Occur.www.google.com
Mckay, Ruth.et.al.(2006).Communication Problems Between Doctors and Nurses.www.google.com
http://archimedes.ballarat.edu.au:8080/vital/access/HandleResolver/1959.17/13957http://en.wikipedia.org/wiki/personality/ http://en.wikipedia.org/wiki/Nursinghttp://hdl.cqu.edu.au/10018/19887http:ww.icn.ch/ethics.htmhttp://www.icn.ch/matters errors.htmhttp://www.icn.ch/icncode.pdfhttp://intghc.oxfordjourals.org/sgi/content/abstract/3/1/11http://www.ecri.org/patientsafety/pages/pennsylvannia patient safety reporting
system.aspx
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Chapter III
RESEARCHMETHODOLOGY
This chapter is evidently composed of the Research Design which
describes the research mode in this study; Research Locale, where the research is to be
specifically conducted; Respondents of the Study on which the target population and the
sample size is described; Instrument of the Study or the means of gathering the
information from the respondents; Validation of and Establishing Reliability where
strong evidences or proof are presented; Statistical Treatment where the findings are
subjected to, and Notes in Chapter III where the references used in the said chapter are
listed.
Research Design
The study is anchored to a Quantitative research design. The aim of this
research is to determine the relationship of one thing (an independent variable) and
another (a dependent or outcome variable) in a population (Hopkins, 2002). Quantitative
type of research gathers empirical evidences, which are rooted in objective reality and
gathered through the senses, either directly or indirectly (Cristobal et.al.2010).
Specifically, the study will use Survey Studies under the Non-
Experimental research design. The investigations are conducted through self-report.
Survey generally asks respondents to report on their attitudes, opinions, perceptions or
behaviors (Cristobal et.al. 2010).
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The type of research design was chosen by the researcher because
information must be gathered through numerical means to explain the pattern of
occurrence of errors. Afterward, conclusions will be made through the findings of the
research.
Research Locale
As the word implies, this sector will define the setting or location on
where the study is to be conducted. In the case of this study, it will be held in Asia Pacific
College of Advanced Studies in the City of Balanga, Bataan, Philippines.
Respondents of the Study
The researcher decided to make the BSN third year students enrolled in
Asia Pacific College of Advanced Studies as the respondents of the study. There is a total
population of 114 from three sections. Through the Slovins formula, 80 will be the total
number of respondents.
Slovins Formula:
n= N___1 +N e
2
Where: n=sample size
N = population size
e = margin of error (6 %)
n= 114____1+ 114 (.06)2
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= 114_____1+114(.0036)
= 114_____1+.4104
= 114_____1.4104
= 80
Before any actual sampling is to be made, criteria stated by the researcher
should be satisfied first by the respondents: they should be enrolled in the said school, no
failing grades in both Academics and RLE and should be at least 18 years old.
According to Beck (2004), probability sampling is one of the kinds of
sampling in which all members of the entire population are given a chance of being
selected. Under this probability sampling, the researcher used Simple Random Sampling,
where respondents who qualified for the criteria are chosen by chance. Fishbowl method
will be implemented, where the names of respondents will be written in a piece of paper
and after which, randomly handpicked respondents will be noted.
Instrument of the Study
The study will use the questionnaire type of data collection technique. It is
considered to be the most common technique used. Questionnaires are an inexpensive
way to gather data from a potentially large number of respondents (Hodgkins, 2002).
Often they are the only feasible way to reach a number of reviewers large enough toallow statistically analysis of results.
A set of questionnaire is to be prepared which consists of the variables
used in the study. The first part is about the common causes of medication errors,
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followed by different preventive strategies. The last part of the instrument is about the
effects of these errors. Rating scale of such will be implemented:
Value Interpretation
5 Totally Agree
4 Partially Agree
3 Either Agree or Disagree
2 Partially Disagree
1 Totally Disagree
TA- Totally Agree (when you perceive the indicators 81-100%of the time)
PA- Partially Agree (when you perceive the indicators 61-80%of the time)
EA/ED- Either Agree or Disagree(when you perceive the indicators 41-60%of the time)
PD- Partially Disagree(when you perceive the indicators 21-40%of the time)TD- Totally Disagree (when you perceive the indicators 0-20%of the time)
Validity and Reliability of the Instrument
The instrument of the study, which uses the major variables and sub
variables and different indicators from the related literature, is to be tested to ensure its
validity and reliability. Validity represents how well a variable measures what it is
supposed to (Hodgkins, 2002). A reliable instrument yields the same rank for each
individual who take the test more than once (Cristobal et.al.2010)
The first validity that will satisfy this study is Face Validity. Face validity
tells us nothing about what a test actually measures. It refers to how test takers perceive
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the attractiveness and appropriateness of a test. If test takers consider the test to have
face validity, they may offer a more conscientious effort to complete the test. If a test
does not have face validity they might hurry through a test and take it less seriously.
Another validity that will be used is Content Validity. One of the simplest ways to obtain
evidence for the validation of a test is to examine the content of the test. Content validity
then is the extent to which the questions on a test are representative of the trait, behavior,
or attribute that is being measured. It focuses on the questions of the test.
The questionnaire will be reviewed by at least three experts, whom have
their masteral degree in nursing and preferably to be head and/or chief nurses. The
experts will be asked to validate the indicators and variables, and to recommend
improvements. With their knowledge and wisdom gained by their practices, their
suggestions will be highly accepted, after which, the questionnaire will be improved for
the submission of it to the adviser before the dissemination to the respondents of the
study. The following were the experts who validated the instrument: Ma.Theresa
Sy.Miguel,RN,MAN, Meliza Servera,RN,MAN and Raquel Leongson RN,MAN.
The instrument was disseminated to the students and had used the Internal
Consistency to establish its reliability. Internal consistency is the extent to which tests or
procedures assess the same characteristic, skill or quality. It is a measure of the precision
between the observers or of the measuring instruments used in a study. This type of
reliability often helps researchers interpret data and predict the value of scores and the
limits of the relationship among variables (Howell, 2010). Under this consistency, a more
specific type called Split-half will be utilized. It is, according to Cristobal, 2010, a
method of establishing internal consistency wherein a test is given only once to the
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respondents. The respondents sample size will be split into a first and second half. The
scores of these two halves are then correlated using the Spearman-Brown prophecy
formula.
r1= __2r__1+r
Where: r-correlation coefficient computed or split halves
r1- the estimated reliability of the entire test
StatisticalTreatment
The studys statement of the problems will be answered through the
following formula.
1-2. The weighted mean refers to the set of data taken from the average of thepopulation (Broto, 2006).
Formula: WM=fxN
Where: WM-wighted mean
fx-sum of the products of the frequency with weights
N-sample size
3. The Pearson product moment coefficient of correlation formula is used to test
whether the three constructs are correlated.
______Formula: r= Nxy - xy
[nx2
-(x)2
][ny2
-(y)2
Where r=coefficient of correlation
x andy = scores
N=size of sample
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Notes in Chapter III
Hodgkins,Wil.(2002) www.google.com
Cristobal,Amadeo et.al.(2010).Guidebook in research Writing:Preparing theNursing Thesis Proposal.Quezon City,Philippines:C & E PublishingInc.pp.84,89,98,100,109,120,127,130
Howell, Jonathan. (2010).www.google.com
http://www.sportsei:org/jour/001/wghdesign.html
http://www.cc.gatech.edu/classes/cs675197 winter/topics/quest.design/
http: www.slideshare.net/songoten 77/presentation-validity-reliability
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