8/9/2019 NR thesis1

1/39

1

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

8/9/2019 NR thesis1

2/39

2

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

8/9/2019 NR thesis1

3/39

3

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.

8/9/2019 NR thesis1

4/39

4

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

8/9/2019 NR thesis1

5/39

5

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

8/9/2019 NR thesis1

6/39

6

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.

8/9/2019 NR thesis1

7/39

7

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

8/9/2019 NR thesis1

8/39

8

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.

8/9/2019 NR thesis1

9/39

9

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.

8/9/2019 NR thesis1

10/39

10

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)

8/9/2019 NR thesis1

11/39

11

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

8/9/2019 NR thesis1

12/39

12

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

8/9/2019 NR thesis1

13/39

13

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

8/9/2019 NR thesis1

14/39

14

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

8/9/2019 NR thesis1

15/39

15

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).

8/9/2019 NR thesis1

16/39

16

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

8/9/2019 NR thesis1

17/39

17

(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

8/9/2019 NR thesis1

18/39

18

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.

8/9/2019 NR thesis1

19/39

19

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

8/9/2019 NR thesis1

20/39

20

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).

8/9/2019 NR thesis1

21/39

21

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

8/9/2019 NR thesis1

22/39

22

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

8/9/2019 NR thesis1

23/39

23

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.

8/9/2019 NR thesis1

24/39

24

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

8/9/2019 NR thesis1

25/39

25

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.

8/9/2019 NR thesis1

26/39

26

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.

8/9/2019 NR thesis1

27/39

27

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

8/9/2019 NR thesis1

28/39

28

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

8/9/2019 NR thesis1

29/39

29

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

8/9/2019 NR thesis1

30/39

30

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.

8/9/2019 NR thesis1

31/39

31

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.

8/9/2019 NR thesis1

32/39

32

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

8/9/2019 NR thesis1

33/39

33

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).

8/9/2019 NR thesis1

34/39

34

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

8/9/2019 NR thesis1

35/39

35

= 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,

8/9/2019 NR thesis1

36/39

36

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

8/9/2019 NR thesis1

37/39

37

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

8/9/2019 NR thesis1

38/39

38

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

8/9/2019 NR thesis1

39/39

39

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