Journal of Pediatric Nursing (2013) 28, 596–602

Pediatric Emergency Nurses' Self-Reported MedicationSafety PracticesJennifer L. Mattei MSN, CPN, RNa,⁎,Gordon Lee Gillespie PhD, RN, PHCNS-BC, CEN, CPEN, FAENb

aEmergency Department, Cincinnati Children's Hospital Medical Center, Cincinnati, OHbUniversity of Cincinnati, College of Nursing, Cincinnati, OH

0h

Key words:Medication safety;Emergency nursing;National patient safetygoals

Preventable adverse events occur more frequently in areas such as the emergency department withmedication errors as the most frequently reported errors. A cross-sectional survey design was used togather descriptive data of medication safety practices used by pediatric emergency nurses in theMidwest U.S. Participants completed an anonymous survey to identify nurses' understanding,implementation, and barriers to implementing the National Patient Safety Goals (NPSGs) formedication safety. Data were analyzed using descriptive statistics. Participants identified severalbarriers to adopting and implementing the NPSGs. Additional interventions are needed to reduce thebarriers to medication safety practices for pediatric emergency nurses.© 2013 Elsevier Inc. All rights reserved.

EACH YEAR PREVENTABLE drug errors cause morethan 672,000 injuries and 98,000 deaths, with a cost of upto $5.6 million per hospital (Diconsiglio, 2005). Inhospitals, preventable adverse events with serious patientoutcomes are more likely to occur in areas of increasedcomplexity and technology, such as the emergencydepartment (ED) setting. Researchers have indicated thatmedication errors in EDs may be a result of the acute,crowded, and fast-paced nature of care (Pham et al., 2008).Recognizing the need to address medication errors as aserious threat to the health and wellness of the public, thePatient Safety Advisory Committee of The Joint Commis-sion (2010) put forth goals and safety practices aimed atresolving medication errors in hospitals. Medication safetypractices were defined as the actions taken by registerednurses to prevent medication errors, near misses, and otheradverse events resulting from patients receiving an

This study has not been previously presented.⁎ Corresponding author: Jennifer L. Mattei, MSN, CPN, RN.E-mail address: jennifer.mattei@cchmc.org.

882-5963/$ – see front matter © 2013 Elsevier Inc. All rights reserved.ttp://dx.doi.org/10.1016/j.pedn.2013.03.005

incorrect medication, an incorrect dose of a medication,or an incorrect route of administration for a medication.The purpose of this study was to identify the medicationsafety practices of nurses in two pediatric EDs in theMidwest U.S.

Background

Clifton-Koeppel (2008) defines a medication error as“any preventable event that occurs during any stage of themedication [preparation or administration] process thatmay cause or lead to inappropriate medication use orpatient harm” (p. 73). Causes of medication errors aremultifactorial and include: unclear directions, incompleteorders, lack of resources or information, similar drugpackaging, drug names that sound alike, nurse fatigue andnurse interruptions (Richardson, Bromirski, & Hayden,2012). Nurses can administer as many as 50 medicationsper shift placing them at the front line when it comes todrug administration accountability (Mayo & Duncan,

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2004). Nurses also play a critical role in the hospital“safety net” to intercept medication errors before theyreach the patient (Dickson & Flynn, 2012). Through theidentification of nurse-reported barriers to safe medicationadministration, we can develop interventions to removethese barriers and increase patient safety. Being aware ofthe causes for common medication errors and error pronemedication processes gives nurses essential information inwhich to adopt safer medication safety practices (Clifton-Koeppel, 2008).

The ED's fast pace and unpredictability make it ahigh-risk environment for medication errors (Pham et al.,2008). Other characteristics of the ED that increase thepotential for compromised medication safety include ahigh volume of patients being seen for a wide range ofacute and chronic illnesses and injuries, shortages ofhealth care workers, and a complex health care environ-ment (Juarez et al., 2009). Medication errors are the mostfrequently reported errors in the ED, and the volume ofmedications given in the ED setting invites errors (Blanket al., 2011). Nurses working in the fast paced, complexenvironment of an ED must follow the National PatientSafety Goals (NPSGs) and institutional policies for safemedication administration. Medication errors not onlyimpact patients, but also have an effect on nurses as well,in terms of professional and personal status, confidence,and practice (Mayo & Duncan, 2004). Nurses report thatthey experience psychological trauma after a medicationerror, as they worry about the patient and feel upset andguilty. This results in a loss of confidence in their clinicalabilities and anger at themselves, as well as theorganization's lack of a system to prevent medicationsafety errors.

Shaw et al. (2009) conducted a multisite cross-sectional survey study at 21 EDs with a pediatric focusfinding that ED medications were prepared by nursesabout 75% of the time with only about 25% ofmedications prepared by pharmacists. The high frequencyof preparation of medications by nurses can place patientsat risk for a medication error if nurses are distractedduring medication preparation (e.g., talking with othernurses, preparing medications during trauma resuscita-tions) or do not follow the NPSGs for medication safetypractices. Most of the EDs (90%) had protocols requiringmedication orders be double checked by another regis-tered nurse before administration (Shaw et al., 2009),which can help prevent errors in medication preparationprior to their administration.

Medication errors have a direct impact on patient safety,and The Joint Commission has implemented NPSGs tohelp decrease the occurrence of health care errors. A recentcross-sectional study analyzed data from a nationalmedication error reporting system from 496 hospital EDsrevealing that two of the leading causes of ED medicationerrors were not following procedure/protocol (n = 2368,17%) and poor communication (n = 1533, 11%), with

other contributing factors being distractions (n = 1045,7.5%), increased work load (n = 474, 3.4%), inexperiencedstaff (n = 432, 3.1%), and emergency situations (n = 571,4.1%) (Pham et al., 2008). Emergency departmentmedication errors were most likely to occur during theadministration phase of the medication process (n = 5016,36%) with nurses accounting for the highest proportion oferrors (n = 7523, 54%), probably due to their involvementwith medication administration (Pham et al., 2008).

Recommendations of the Institute of Medicine (2000) toimprove safety included the use of information technologyto automate medication delivery systems, collect patientclinical data, and provide clinical decision support. Pointof care technology, which includes electronic healthrecords (EHR), integrates nurse scanning of bar-codedmedications with the patient's electronic medicationadministration record (bar-code/eMAR), and was designedto make medication administration safer by giving nursesan additional safeguard when administering medications(Eisenhauer, Hurley, & Dolan, 2007). Clifton-Koeppel(2008) reported that most technology, especially complexsystems such as bar-code medication administration,requires a strong safety culture to be effective. Nurses inseveral studies identified that EHR use improves patientsafety, as it has built-in safety features to maintain anddisplay essential patient data entry and allergy alertshelping to prevent inadvertent errors (Kossman &Scheidenhelm, 2008). Nurses also found it easier to findpatient information such as the time the last dose of a drugwas given, as well as the most recent lab values which canindicate whether a medication is needed. Nurses reportedfeeling much less ambiguity, frustration, and room forerror with EHR than with handwritten transcriptions ofmedication orders (Eisenhauer et al., 2007). Negativeaspects of using EHR have also been reported, includingthe limiting of team communication, impersonalization,and interference with time spent with patients (Kossman &Scheidenhelm, 2008).

Medication safety involves much more than administer-ing the right medication to the right patient. The literatureshows that safety starts with an organization commitment topatient safety which provides its employees with a culture ofsafety. This culture of safety promotes the non-punitivereporting of medication errors and works to discover theproblems that may lead to errors. As frontline providers,nurses play an important role in the safe delivery of medi-cations. It is important to conduct this study to determine ifthere has been an adoption of medication safety practices, aswell as to discover barriers to the adoption of medicationsafety practices so that future education and interventionscan be developed and implemented. Therefore, the researchquestions for this study were the following: (1) What werethe barriers identified to emergency nurses following theNPSGs? (2) Have recent medication safety changes in theemergency department had an impact on nurses' medicationsafety practices?

598 J.L. Mattei, G.L. Gillespie

Method

Design

This study used a cross-sectional survey design. Permis-sion to conduct the study was obtained from the hospitalInstitutional Review Board.

Setting

This study took place in two affiliated pediatric EDs in theMidwest United States. The first study site was a level Itrauma center situated in an urban setting providingemergency care to approximately 100,000 patients peryear. The second site was a freestanding ED in a rapidlygrowing suburban setting. The second site treats approxi-mately 32,000 patients per year.

Sample

There were approximately 100 registered nurses fromboth EDs eligible to participate in the study. Exclusioncriteria included being a registered nurse in orientation, anintern, and temporary staff “pulled” from another hospitalunit. Age, race, sex, and functional ability were not factorsconsidered for inclusion or exclusion in this study. Studyenrollment included 68 nurses that completed the studyprocedures and an additional 9 nurses that withdrew (did notcomplete the study survey).

Power calculations were determined using G*Power 3.0(Faul, Erdfelder, Lang, & Buchner, 2007). The studyrequired a minimum of 51 participants per comparisongroup to yield 80% power assuming effect size of 0.5 andα = .05. It was acknowledged that the historical sampleonly included data for 41 participants. As a result, overrecruitment took place for the second sample to still yield afinal total sample of 102 participants (41 for the historicalfirst sample and 63 for second and current sample).

Instrumentation

This study used the Emergency Department RegisteredNurse Questionnaire to identify nurses' understanding, im-plementation, and barriers to implementing the NPSGs formedication safety. The instrument was developed by theEmergency Nurses Association for use in a national cross-sectional study (Juarez et al., 2009). Face validity was ob-tained by a panel of 15 content experts who were asked tocomplete the survey and comment on the relevance andclarity of the questions. The feedback was then incorporatedinto the survey.

The original 50-item instrument was adapted by the firstauthor to exclude questions not directly related to medicationadministration for the two EDs in this study. As no additionaldetails related to the validity of the original version of the

instrument were available, content validity of the revised27-item instrument was obtained prior to data collection.

Content validity of the instrument was assessed in January2011 by a panel of 10 content experts in patient safetythrough a content validity index for each item (DeVellis,2003). The Likert-type instrument items were evaluated fortheir saliency and effectiveness to measure medication safetypractices of registered nurses. Each expert was requested todetermine if the items on the instrument were representativeof safe medication administration as well as possible barriersto safe medication administration. Agreement/disagreementby the experts was used to obtain an index of content validity(CVI) (Beck & Gable, 2001). If less than eight experts (CVIb 80%) agreed to the relevance of a particular item, then theitem was reviewed by the study team and either revised ordeleted. Additional items were amended or added based onthe review by the content experts.

Procedures

Subjects for the study received a solicitation e-mail to jointhe study, which included a hyperlink to the Web-based,survey collector. A follow-up reminder was e-mailed weeklyfor 2 weeks to all potential participants.

Human Subjects Protections

Participants were encouraged to contact the investigatorsbefore completing the questionnaire if they had anyquestions. Survey responses were not linked to any namesor employee identification numbers ensuring respondentanonymity. While both investigators were employees in oneof the two EDs where the study was conducted, neither wasin a supervisory position that could be perceived as coerciveto the participants to join the study. Participants wereinformed that participation was voluntary and not a conditionof their employment.

Data Analysis

Research question 1: What were the barriers to emergencynurses following the NPSGs? This question was addressedwith the use of descriptive statistics.

Research question 2: Have recent medication safetychanges in the emergency department had an impact onnurses' medication safety practices? This question wasanswered using descriptive statistics based on responsesfrom the survey that addressed any recent changes in practicethat had been made to improve medication safety.

Findings

Demographics of the participants are outlined in Table 1.The majority of nurses that responded to the survey were

Table 1 Demographics/Sample Description (N = 68).

Demographic Characteristic Frequency %

Age in years (n = 67)20–25 10 14.926–31 20 29.932–37 12 17.938–43 17 25.444–49 4 650–55 4 6Sex (n = 67)Female 58 86.6Male 9 13.4Race (n = 66)Caucasian 63 95.5Non-Caucasian 3 4.5Educational attainment (N = 68)Diploma 7 10.3Associate degree 17 25Bachelor's degree 40 58.8Master's degree 4 5.9Hours worked per shift (n = 56)8 or less 11 19.710 3 5.412 42 75Primary work shift (N = 68)Days 21 30.9Evenings 24 35.3Nights 23 33.8

Table 2 Barriers to the National Patient Safety Guidelines forMedication Safety Practices⁎.

Identifiers and Barriers % (N = 68)

Unique patient identifiers used in the EDPatient name 100Date of birth 100Medical record number 60.3Barriers to taking medication order to medication roomNone/no barriers 25Verbal order not yet in the computer system 20.6Not an expectation in my department 32.4Forgot to take the order set 0No printing device available at computer 10.3Medication preparation area too far from computer 8.8Other 2.9Barriers to taking medication order to the patient bedsideNone/no barriers 25Electronic charting system not able to print the order 26.5Verbal order not yet in the computer system 22.1Not an expectation in my department 0Forgot to take the order set 22.1No longer need to perform due to bar code scanning 5.9Barriers to comparing two unique identifiersNone/no barriers 25Identification bracelet not on the patient 33.8Too difficult to read patient bracelet identifiers 7.4Not an expectation in my department 9No longer needed due to barcode scanning 19.1Forgot to compare the two identifiers 14.7Barriers to maintaining oral dose capsules or tabletsin their original containersNone/no barriers 57.4Not an expectation in my department 0Forget to do it 7.4Only bulk packaged medications available 16.2Too much of a hurry/takes too much time 1.5Not helpful or useful 1.5Other 16Barriers to labeling syringes of oral medications(excluding resuscitations)None/no barriers 55.9Not an expectation in my department 0Forget to do it 5.9Not needed because only have one syringe at a time 11.8Only prepare medications at the patient bedside 13.2Labels are not available 1.5Takes too much time/in a hurry 19.1

⁎ Some columns will add to more than 100%, because participantscould select more than one option.

599Pediatric Medication Safety

female (86.6%) and between the ages of 26 and 43 (73.2%).Most nurses also held at least a bachelor's degree (64.7%)and worked 12-hour shifts (73.2%) with 90% of themworking 32 hours or more per week.

Barriers to Following the NPSGs (Research Question 1)

Summary findings for the first research question areprovided in Table 2. All participants surveyed knew thetwo unique identifiers used in the ED: patient name anddate of birth. Barriers to following the NPSGs wereidentified: 75% of nurses reporting at least one barrier totaking the written or electronic order set with them to themedication storage/preparation area when selecting orpreparing medications. At least one barrier to taking theorder set to the bedside was also high with 75% of nursesreporting this as a barrier. There was a majority (75%) ofparticipants reporting at least one barrier to comparing twounique identifiers on the order sheet or profile screen withthe unique identifiers on the patient's bracelet beforeadministering a medication as well as 44.1% declaring atleast one barrier to labeling the contents of a syringe. Otherbarriers of note were labeling medicine containers on andoff the sterile field (61.8%) and using an oral syringedesigned specifically without a Luer-Lock tip to administeroral liquid medication (26.5%).

Impact to Practice of Medication Safety Changes(Research Question 2)

Summary findings for medication safety education andpractice changes are provided in Table 3. All nurses in thesample received education or training on medication safety,and the majority (86.2%) report discussions of medication

Table 4 Medication Safety Practices Performed by the NurseParticipants.

Medication Safety Practice Mean

Percentage of time order physically taken to themedication room

93.4%

Percentage of time order physically taken to the patient'sbedside

92.7%

Percentage of time that two unique patient identifierscompared prior to medication administration

77.3%

Percentage of time oral unit dose capsules or tabletsmaintained in their original containers untiladministration

90.9%

Percentage of time syringe medication is labeled 92.8%

600 J.L. Mattei, G.L. Gillespie

safety at least every 1–2 months. Nearly all (92.5%) nursesreported making a practice change to improve medicationsafety within the past 6–24 months. These changes includedbarcode scanning medications and intravenous fluids(92.6%), barcode scanning patient wristbands (91.6%),labeling medications (61.8%), using prefilled single dosemedication syringes (80.9%), using an easy form for safetyreporting (58.8%), and making a personal commitment tosafety/culture change (61.8%).

Summary findings for medication safety practices per-formed by the nurse participants are provided in Table 4.Despite the barriers to following the NPSGs, there was highcompliance with the use of emergency nurses' medicationsafety practices. Nurses physically take the written or elec-tronic order set(s) to the medication storage/prep area whenselecting or preparing medications 93.4% of the time. Theelectronic order set(s) are physically taken to the patient'sbedside for use in properly identifying patients prior toadministering medication 92.7% of the time. The percentageof time that two unique patient identifiers were directlycompared prior to administering medication was 77.25%.The percentage of time that all oral unit dose capsules ortablets are maintained in their original containers until atthe patient's bedside was 90.9% of the time. The frequencyof labeling all medicine containers to identify the drug(solution) name and drug concentration, as well as the dateand initials of the person preparing the drug was performed57.8% of the time.

Discussion

Barriers to Following the NPSGs (Research Question 1)

The number of nurses that reported barriers to physicallytaking written or electronic order set(s) with them to themedication storage/preparation area when selecting or

Table 3 Medication Safety Education and Practice Changes.

Received education/training on medication safety (N = 68)Frequency of discussions of medication safety (n = 65)NeverOnce a yearFour times a yearOnce a month or every 2 monthsOnce a week or every 2 weeksImproved personal medication safety practices over the past 6–24 monChanges made to medication safety practices (N = 68)Barcode scanning for medications and intravenous fluidsBarcode scanning of patient identification braceletsLabeling of medicationsUsing prefilled single dose medication syringesPersonal commitment to safety/culture change

preparing medications was 75%. This finding was consid-erably higher compared to that of Juarez et al. (2009) whoreported that only 40% of nurses perceived a barrier. Abarrier that the nurses identified was that the electroniccharting system did not always have the ability to printorders. One reason for this may be that in triage a medicationslip is not generated when a medication order is placed fromseveral of the triage computers. Having a medication slipgenerated every time a medication is ordered from a com-puter may help to eliminate this barrier.

Another barrier that nurses identified to taking the printedorder set to the medication room or patient bedside was thatthe medication order was a verbal order not yet written in thechart or entered in the computerized physician order entrysystem. A reason for this may be that verbal orders are usedin the trauma bay during emergency situations as well asresuscitations, and no written or electronic order set(s) areused. This may be an area where safety can be improvedby implementing a system in which the medication ordersare written out by the physician or a nurse. Developing aneasy to use paper or electronic order form could help ensureproper medication safety.

Frequency %

68 100

1 1.52 3.16 9.225 38.531 47.7

ths (n = 67) 62 92.5

63 92.662 91.642 61.855 80.942 61.8

601Pediatric Medication Safety

Juarez et al. (2009) reported that only 84.7% (n = 111) ofnurses in their study had a system in place for using twounique identifiers when administering medications. In ourstudy, all participants knew the two unique identifiersadopted by the department: name and birthdate. However,the majority of nurses reported barriers to using the twounique identifiers. The primary barrier to comparing twounique identifiers was that the identification bracelet wasnot always on the patient before a medication wasadministered. This increase may be due in part to a changein the style of patient identification bracelets when the EDswitched over to a bar-coding system for patient identifica-tion and medication administration 18 months prior to datacollection. The new bracelets were more difficult to place onpediatric patients and often fell off. Because identifying thecorrect patient is an important step of safe medicationadministration, it is recommended that a new style of patientidentification band be used, and that the identificationbracelets be readily available and easily accessible to helpdecrease this barrier.

Some (19.1%) of the nurses felt like they no longerneeded to compare the two unique patient identifiers becauseof barcode scanning. Similar to the Kossman and Schei-denhelm (2008) study, nurses may feel that the EHR useimproves patient safety, as it has built-in safety features thatmaintain and display essential patient data entry and allergyalerts, helping to prevent inadvertent errors. Although theEHR can help to increase safety, comparing two uniquepatient identifiers prior to medication administration helps toensure safe medication administration. Emergency depart-ment medication errors are most likely to occur during theadministration phase of the medication process, with one ofthe leading causes of ED medication errors being not fol-lowing procedure/protocol (Pham et al., 2008). Further edu-cation on the importance of verifying two unique patientidentifiers may be needed to increase the nurses' complianceto this important step of safe medication administration.

The labeling of contents of a syringe with the drug nameand concentration when preparing a syringe of medicationprior to proceeding to the patient's bedside was also an areathat nurses depicted as a barrier. The majority of nurses notadhering to the expectation of labeling gave the followingreasons: (1) they only had one syringe at a time so they couldremember what they had and (2) they were in too much of ahurry. The NPSGs require labeling all medications, medica-tion containers (syringes, cups, basins, bowls), and othersolutions. Being aware of the causes of common medicationerrors and error prone medication processes gives nursesessential information in which to adopt safer medicationsafety practices (Clifton-Koeppel, 2008). This may be anarea where the safety coaches in the ED need to focus so thatfeedback about practice and compliance can reduce orprevent errors. Engaging the front-line staff in daily efforts toimprove patient's safety, such as a safety coach program, iscritical to the success of building a safety culture (Lindberg,Judd, & Snyder, 2008).

Impact to Practice of Medication Safety Changes(Research Question 2)

The basic principles of medication safety include safety-conscious health care providers and a work environmentfocused on safety (Clifton-Koeppel, 2008). The majorityof nurses said that they participate in discussions ofmedicationsafety every 1 to 2 months and that they had made a practicechange to improve medication safety within the past24 months. Two of the reported changes were (1) using easyform for safety reporting and (2) making a personalcommitment to safety/culture change. During the 2 yearsprior to this study, the EDs developed a user friendly written,safety event form as well as a process in which the informationfrom the forms can be entered into the house-wide system. Thisinformation is used to continuously improve processes andsystems around patient safety in the ED. Safety events arereported throughout the study sites' hospital system, and theresults of the daily safety record are openly posted for everyoneto see. By being transparent about errors and near misses,problems can be identified, carefully analyzed, and then usedto prevent reoccurrences. This process helps to build a cultureof safety, and there is strong evidence that staff members'perceptions and attitudes toward safety in their workenvironment have an effect on their job attitudes andperformance (Shaw et al., 2009).

Although nurses identified multiple barriers to complyingwith the expected safety measures that surround medicationadministration, there was a generally high compliance tomedication safety practices by the participants. These findingsmay be a result of the frequency of medication safety discus-sions that were reported aswell as the increased focus on safetyreporting and building a culture of safety where making apersonal commitment to safety is a priority for staff.

Limitations

The study findings may not be generalizable to all pedia-tric EDs. This limitation is due to the study being conductedat a single pediatric health care system as well as using asmall sample. The sample was predominantly female andCaucasian. This homogeneity of the sample further reducesthe generalizability of the findings to more diverse EDsettings. In addition, the investigators did not validate theparticipants' self-reported compliance to medication safetypractices through direct observation. As a result, it is possiblethat the true medication safety practices of nurses may bedifferent from that reported in this study.

Implications

Implications of the research suggest that there is a needfor changes in practice as well as a need for more staffeducation. Practice changes should include (1) having a

602 J.L. Mattei, G.L. Gillespie

medication slip generated for every medication orderthrough the computer ordering system, (2) designing aquick-to-use paper medication order sheet that can be usedin the trauma bay during emergencies and resuscitations,and (3) improving the quality of patient identificationbracelets to ensure proper placement and secure fit onpediatric patients and have replacement identification bandsreadily available. Education should be focused on (1) checkingthe two unique patient identifiers prior to giving medications,(2) further involving safety coaches to encourage/supportnurses' practice and compliance with error prevention tech-niques such as the labeling of all medication syringes andcontainers, and (3) continuing to encourage safety reportingand building a culture of safety as well as encouraging andsupporting staff in making a personal commitment to patientsafety. Following this education there needs to be a system inplace for the enforcement of the policies by leadership as wellas peer monitoring.

This study indicates that more research is needed tohelp nurses overcome the barriers that they identified tofollowing the NPSGs to safe medication administration.Further research may reveal specific changes that nursescan implement into their practice that will furtherincrease compliance with the NPSGs while minimizingthe barriers.

Conclusions

With the number of U.S. emergency visits increasingand the issue of overcrowding becoming more prevalent,the potential for compromised safety in the ED remains agrowing issue. Because of the broad spectrum of EDpatient needs and the unpredictable, multifaceted nature ofthe ED environment, there continues to be more errorsrelated to medication in the ED setting (Juarez et al., 2009).Nurses need to make the prevention of medication errors apriority in their medication administration practice andfollow the medication safety policies concerning theNPSGs. An environment that supports a personal commit-ment to safety and works to improve a culture of safety isimperative to improving patient safety.

Acknowledgments

The authors wish to acknowledge the Burkardt Consult-ing Center at Northern Kentucky University for conductingthe study's data analysis and Marilyn Schleyer, PhD, MSN,ARNP, for her guidance during the conduct of this study.

This study was not funded by extramural sources.

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