research article registered nurses experiences with the...

Research ArticleRegistered Nurses’ Experiences with the MedicationAdministration Process

Hanna Pirinen,1 Lotta Kauhanen,1 Riitta Danielsson-Ojala,1 Johan Lilius,2

Ilona Tuominen,2 Natalia Díaz Rodríguez,2 and Sanna Salanterä1

1Department of Nursing Science, University of Turku, Lemminkaisenkatu 1, 20520 Turku, Finland2Turku Centre for Computer Science (TUCS), Department of Information Technologies, Abo Akademi University,Joukahaisenkatu 3-5 A, 20520 Turku, Finland

Correspondence should be addressed to Lotta Kauhanen; [email protected]

Received 21 May 2015; Revised 26 August 2015; Accepted 27 August 2015

Academic Editor: Ann M. Mitchell

Copyright © 2015 Hanna Pirinen et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. Registered nurses (RNs) have a role in themedication administration process (MAP)multiple times per day in a hectichospital environment.This requires a great deal from the RNs in order to accomplish the demanding task of avoiding adverse drugevents. However, the process has not been widely studied from the nurses’ perspective. Aim. The aim of this study was to describethe different stages of MAP from the RNs’ perspective.Methods. A qualitative descriptive research design, with a purposive sampleinvolving thematic interviews of 20 RNs and questions to them in a paper form, was conducted in two medical units. Data wasanalyzed by using deductive content analysis. Results. The results revealed that RNs confront numerous problems such as equivocalprescriptions, problems with information technology (IT), unavailability or incompatibility of the medicines, a substantial amountof generic substitutions, and changing medicine brands. Disruptions and distraction run through each stage of the MAP, excludingprescribing.The RNs desire support in all stages of the MAP. Conclusion. There are areas to improve in each stage of the MAP fromthe RNs perspective. Real-time and ubiquitous documentation, along with software including the data and knowledge required inmedication management, is needed.

1. Introduction

The medication administration process (MAP) is a complexand multistage practice in hospital settings. MAP plays acentral role in nursing and is mostly managed by nurses,except prescribing that is conducted by the physicians.However, nurses are in some way involved in each stageof the MAP, including prescribing, documenting (transcrib-ing), dispensing, administering, and monitoring. MAP isa time-consuming task, taking an estimated up to 40% ofnurses’ work time [1] where interruptions and distractionsare common [2] which is not facilitated by the continuouslyincreasing number of new medicines and generics [3].

In this paper, by nurse we mean registered nurses (RNs)that do not have the prescription authority. However, nurseshave an essential role in prescribing. By “RNs’ role inprescribing” we mean the work that nurses conduct in inter-preting and understanding the prescriptions. Nurses’ role in

prescribing might also include suggesting medication andasking the physician to check patient’s medication or to domedication changes. In addition, nurses have a responsibilityto prevent, evaluate, and report drug effects, side effects, andadverse drug events. In the participating hospital nurses alsoprogram the drug administration times and document theminto to the medicine software.

The complexity of the MAP exposes risks to medicationerrors that are surprisingly common and costly [4]. Thereport To Err Is Human: Building a Safer Health Systemestimated that, in the United States, 44,000 to 98,000 patientsdie annually because of medication errors, with an estimatedcost of 17–29 billion dollars [5]. Many of these errors are [6–8] thus preventable. Moreover, developing medication safetyis one of the main political objectives recognized in theEuropean Commission [9].

Medication errors occur in all stages of the MAP in hos-pital settings, most frequently at administration, prescribing,

Hindawi Publishing CorporationAdvances in NursingVolume 2015, Article ID 941589, 10 pageshttp://dx.doi.org/10.1155/2015/941589

2 Advances in Nursing

or dispensing [10]. According to the Institute of Medicine(IOM), approximately one medication error occurs perpatient per day in hospital care [4]. Nurses have an essentialpart in the MAP and can be considered as administratorsof safety for being in the front line when medications areadministered. Therefore, health-care personnel perspectivesshould be used when developing safer practices in hospitals[11].

2. Background

Medication administration is not simply a part of nurses’work but rather constitutes most of their daily work. Inhospital settings, one patient may require multiple scheduledand unscheduled medication doses per day. Unscheduleddoses, for example, PRN (pro re nata, as needed), occur atunplanned times and thereby create discontinuities in work.Furthermore, nurses face a complex mixture of demandsrelated to medication administration (demands from insti-tutional policies, technical devices, patients, the physicalenvironment, and medications themselves) that need tobe completed within the temporal structure of their shift[12]. Meanwhile, meeting these demands, nurses have animportant role promotingmedication safety as part of patientsafety. This includes, for example, risk identification duringthe process, responsibility to prevent and report adversedrug events (ADEs), and learning from experience [13].The generally regarded “five rights” principle (right patient,medication, dose, route, and time) of the MAP providesa basic standard for safe medication practice. However,focusing on the individual nurse’s performance during thefinal stage of the process does not reflect the responsibilityand accountability associated with medication administra-tion or multidisciplinary approaches to medication manage-ment [14]. Administering medicines requires theoretical andclinical medication competence [13]. In-depth knowledge ofmedicines includes pharmacodynamics, therapeutic use, sideeffects, adverse events, and appropriateness of administeringthe medication considering the patient’s current response totreatment [15].

The MAP is well recognized in previous studies. Theyhave focused, for example, on nurses’ requisite knowledge ofthe MAP, such as clinical reasoning and practices [16], phar-macological knowledge [15], and medication competence[13]. Adverse drug events [12, 15, 17] and interruptions duringthe MAP [18–23] are also broadly studied. Few studies havefocused on studying the MAP from the nurses’ perspective,examining either the factors causing medication errors [6–8, 24–26] or barriers for safe medication management innursing homes [27, 28]. One recent study [29] has focused onnurses’ experiences in medication safety practices. Smeulerset al. showed that nurses experience having an important rolein conducting medication safety and that clinical reasoningis essential in nurses’ work for safe practices [29]. However,little attention has been given to nurses’ experiences in theprocess focusing on the problems in a broader viewpoint thansafety during all stages of MAP. We also wanted to studythe desired support in the MAP from RNs perspective inhospital settings. Studying the MAP from this perspective

gives important information that should be considered whendeveloping the process or applying new innovative technolo-gies to support the process and make it run smoother andsafer.

The aim of this study was to describe the MAP fromthe registered nurses’ (RNs’) perspective. Both the problemsconfronted and support desired in the MAP are presented,thus providing new empirical knowledge of RNs imple-menting the MAP on a daily basis and an insight of thepossible developmental areas in theMAP.This study is part ofthe “Smart Medication Management” project, which aims todevelop the MAP by applying new IT to support medicationmanagement. Other publications from the “Smart Medica-tionManagement” project are focusing on the “smart dosing”application that has been developed by the research groupunder the “Smart Medication Management” project [30, 31].

3. Material and Methods

A qualitative descriptive research design including thematicindividual interviews and questions in a paper form wasconducted.

Participants were chosen using a purposive samplingmethod from the population of RNs in two medical units.The inclusion criteria were participation in the MAP on thedata collection day and RNwilling to give a written informedconsent. The eligible sample size was estimated to be 20participants, large enough for data saturation. Saturation wasreached when new data confirmed previous data withoutreally adding new insights [32]. The final sample size of thestudy was 20 participants.

The settings for data collection were from two differentfields of medical units in one university hospital in Finland.Both units have patientswith high daily consumption ofmed-ication. Patients in these units are often elderly with chronicdiseases and they come to specialized care with a needfor painkillers and antiemetics in addition to the treatmentmedication and their regular medication. The description ofthe MAP in the units is shown in Figure 1. Both units usedCGIs (Consultants to Government and Industry) Uranussoftware, where the Miranda medicine system is applied.In addition, units have nonelectronic medicine cabinets,where medicines are not single-packaged. Both units use themedicine brand names in the MAP.

3.1. Data Collection and Analysis. The data was collected inJanuary 2013, within a two-week period, using semistruc-tured theme interviews and questionswhichwere filled by theparticipants in a paper format. Both interviews and questionswere employed as a single measure in Finnish and, thus, thecitations used are translations. As no validated interviews orquestionnaires relevant to the topic of interest were available,the themes of the interview and the questions were developedby the research group, based on previous scientific literature.The methods of this study were founded on the followingstages of the MAP: prescribing, documenting, dispensing(filling themedication trays), and administering (to patients).The researchers visited both units prior to the data collection

Advances in Nursing 3

Medical round Unscheduled time

Documenting

Physician places order(s)

RN programs administration time(s)

RN prints the updated medicine list(s)and tray chart(s) and places them in the

medicine room

Dispensing

RN dispenses medicines according tothe tray charts into the colored cups(indicating time of administration)

Double checking of dispensed medicinesby another RN or pharmacist

Administering

The dispensed medicine(s) topatient(s) in colored cups

Narcotics aredispensed separately

RN documentsnarcotics to a separate

card and to the software

PRN medicines aredispensed when needed

RN documents PRNmedicines to the software

Prescribing∗

Figure 1: Medication administration process on the units according to the hospital policies. ∗RNs role in prescribing is to interpret and tounderstand the prescriptions, suggest changes to medication if needed, and evaluate and report drug effects.

to present the study and inform the staff about the study.Subsequently, the staff had an opportunity to ask questionsand receive answers concerning the study.

The interviews (Table 1) contained seven questions, eachrepresenting a specific theme exploring the stages of MAP.The interviews were conducted as individual in-personinterviews over the participant’s shift in the unit, underan environment as calm as possible, lasting 15 minutes onaverage. Participants were able to influence the time theinterview was done. Participants’ responses were typed on alaptop during the interviews.

The questions in a paper form were handed out to theparticipants at the beginning of their shift and they wereasked to complete, after the medication administration, andreturn them to the researcher. The completed answers werekept safe from other participants.The questions surveyed theRNs’ actions during the MAP. The questions were as follows:(1) how often do you need help in finding the wanted drug

from the medicine cabinet?, (2) from what source do youcheck the generic substance or the changed brands of themedicines?, and (3) how often do you need to use PharmacaFennica when filling the medication tray?

We used bothmethods (questions in a paper form and in-person interviews) to enrich the data and to get more realisticdescriptions of the actions during the MAP without theinterviewer bias [33]. Interview is a more personal form thanindependently conducted questionnaire or survey, and thus,even though the questions in the paper form could have beenasked during the interview, we wanted to divide the questionsinto a personal interview and nonpersonal paper form. Onereason for this was also the practical arrangements: the ques-tions about the actions during the MAP were supposed to befilled straight after the medication administration to ensurethe best recall outcome.The interviews were conducted whenthe participating nurse had time.


Table 1: The themes and questions of the theme interview.

Themes Questions

Prescribing and documentingHow do you experience your role as a nurse in prescribing and documentation of the medicine?How does the medication software support safe medication administration?What sort of problems have you confronted in the following situations: prescribing medicine anddocumenting medicine?

Dispensing and administering

How do you experience dispensing (filling the medication trays)?What sort of problems have you confronted when filling the medication tray and administering themedicines to the patient?What kind of support would you like to have when filling the medication tray and administering themedicines to the patient?

Medication administration process What sort of help would you like to have to facilitate the medication administration process?

Table 2: The nurses’ roles in prescribing and documenting medication.

Stage Role Specification

Prescribing events

An advocate ofpatients

Informing patient of medicationsTaking responsibility in(i) prescribing situations based on their understanding of the patient’s condition,(ii) suggesting changes if needed in patient medications (dosing/choice of medication)

An active attendee

Monitoring physician orders(i) ensuring the validity of prescriptions,(ii) considering patient medications as a whole (following up interactions, extra/unnecessarymedications),(iii) reminding physician of medications that need to be discontinued,(iv) informing of patients prevailing condition that needs to be considered with upcomingprescriptions,(v) guiding/suggesting physician to prescribe specific medicines/increase of doses

A passive attendee Executing orders

Documentingprescriptions

A programmer Programming administration times to the softwareA personresponsible/in charge Responsible for the entire documenting process

The qualitative data was analyzed using deductive contentanalysis, where the themes and questions (the phases ofMAP) guided the analysis. The analysis progressed withthe following stages: preparation, organizing, and reporting.Preparation included making sense of the entire data set,selecting the unit of analysis as a unit of meaning, andanalyzing the manifest content. Organizing entailed bothsearching relevant expressions relative to study questionsand reduction of the expressions. Subsequently, groupingand abstraction of the data followed [34]. In the analysisof the questions in the paper form, quantified analysis wasused to visualize the actions RNs conduct during the MAP,for example, the frequency of the use of Pharmaca Fennica.Reporting was implemented with the aid of applying Coreq’schecklist [35].

3.2. Ethical Considerations. The study was licensed andapproved by the authorities of the Hospital District ofSouthwest Finland.The study complied with a good scientificpractice [36] and the ethical principles [37]within each phase.Prior to the data collection, each participant received aninformation leaflet and an informed consent. The data col-lected was handled confidentially and reported in a mannerassuring anonymity.

4. Results

The results of the theme interviews show that RNs confrontvarious problems, in each stage of the MAP, which interferewith their work, and have several areas they desire supportin (Figure 2). The results of the perceived experiences, prob-lems, and support desired in each stage of the MAP aredescribed in Figure 2.

4.1. RNs’ Role in Prescribing Events. RNs had different types ofexperienced roles in prescribing events and in documentingmedications (Table 2). Mainly RNs experienced their roleas substantial in prescribing events. In documenting pre-scriptions, RNs cited physicians as being accountable forthe documenting process and RNs being accountable forprogramming administration times in accordance with theunit’s policies. Being responsible for the whole documentingprocess was experienced as extremely time consuming, slow,and a task demanding accuracy, especially as orders areoccasionally equivocal and ambiguous.

The problems RNs experienced in prescribing wererelated to prescriptions, admissions, or discharges. Prescript-ion-related problems included equivocal and erroneous pre-scriptions, nonprescribed orders, crucial factors not taken


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Figure 2: Nurses experienced problems and support desired in different stages of the medication administration process.

into account, and lack of information. Equivocal prescriptionsconsisted of telephone and verbal orders (e.g., mentionedwhen bypassing), including both incomplete prescriptions(e.g., missing strength/dose/dosing/formulation) and unclearorder expiration dates (real time with last administrationversus the printed medicine chart in the medicine room).RNs also experienced prescription process complicated when

physicians documented medications to a wrong place inthe software. That is why it was sometimes difficult for thenurses to notice new or changed prescriptions. Erroneousprescriptions comprehend errors in prescribed medicinestrength or dose and prescriptions that were documentederroneously (e.g., PRN medicines prescribed to scheduledmedications). Nonprescribed orders, meaning prescriptions


that should have, but had not, been implemented by physi-cians (e.g., premeditations or medicines on hold that shouldbe prescribed to continue), were experienced as problem-atic. Prescriptions were also experienced as difficult whencrucial factors, such as interactions of prescribed medicineswith patients’ other medications and duplicate orders, werenot taken into account, or when RNs were uninformed ofnew prescriptions. Verifying the correctness of medicationadministration records (MARs) at admission or dischargewas experienced as problematic and time consuming. Itwas confusing for RNs to find out patients’ currently activemedications, latest updates, and the expiration dates of eachmedicine: “. . .every time a new patient arrives in the unit,you need to print the patient’s medicine chart and find out ifit’s accurate. . .you’re finding out what medicines the patientis actually taking, what dosage and when. . .” or “. . .whendischarging a patient nobody goes through the patient’s wholemedication list. . .nurses are the ones askingwhat about this andthat medicine. . ..”

The support desired in prescribing was that the prescrip-tions were at accurate times and an updated printout wasplaced in themedicine rooms. Furthermore, RNs desired thatthe softwarewould enablemore precautions (e.g., notificationof erroneous dosing) and getting collective directions forphysicians when entering in prescriptions (e.g., complyingwith unit policies).

4.2. Documenting. In documenting, RNs experienced prob-lems related to programming, software, and environment.Programming was problematic due to defective error iden-tification and an unyielding structure or inflexibility of themedicine software. RNs reported that the medicine softwaredoes not report on overdoses. Programming medicines wereexperienced as difficult and correcting incorrect documenta-tion was even more difficult. Additionally, errors in medicinesoftware were experienced as problematic. RNs described thesoftware’s inability to recognize some medicines, suggestingwrong medicine or route or not finding the right form.Furthermore, RNs experienced the software as unreliable dueto its technical errors: the software may throw a number ofmedicine strengths to the next row in the printed medicinechart, which may cause errors in dispensing and result in anerror in administering. RNs also experienced printing of thecharts as problematic and not systematically including all thedocumented medicines.

The supports RNs desired in documentingwere clarity forthe medicine charts and the opportunity to do documentingubiquitously, regardless of time and place (e.g., during themedicine rounds). RNs urge that software would include allthe important information needed (e.g., medicine software,patient records, medication history, prescribing and lastexpiration dates, and PRN medicines) in the MAP.

Medicine Software and Drug Databases in Data Transfor-mation. Medicine software was experienced as a key com-ponent in supporting a safe MAP. RNs experienced thesoftware supporting safety mostly with its controlling anddirective documenting by reporting erroneous medication

(e.g., wrong dose), verifying the right medication, and con-trolling the prescribing process. Furthermore, the softwareenhances documenting by being clear and automatic and byclarifying medicine and tray charts, leaving no possibilityfor misinterpretation. However, some inhibitory factors ofa safe MAP came up in relation to software functionality.RNs experienced the software as clunky by describing itas slow, uncertain, inflexible, and difficult for conductingdifferent tasks. For instance, making corrections or changes(e.g., changing the programmed timings of medicines) wasdifficult. RNs experienced the software lacking of technicalreliability by describing it as unreliable in data transform.RNs had a great responsibility when documenting, for thesoftware leaves room for human error. Thus, RNs have tocheck software functions in order to rest assured that allthe prescriptions exist in the printed medicine chart andthat the printout in the medicine room is up-to-date, as thesoftware does not react if the newest chart has not beenprinted and placed in the medicine room. Furthermore, RNsexperienced the software as unable to identify medicine errors,for not identifying or labeling interactions between differentmedicines or not identifying the same medicines betweendifferent brands.

With the medicine software, RNs use drug databases(Pharmaca Fennica, Duodecim) and other colleagues tosupport the MAP. Based on the quantified analysis of thequestions in the paper form, a majority of the RNs citedemploying Pharmaca Fennica daily or close to daily (12/19and 4/19, resp.) and some (3/19) weekly when dispensing.The primary source applied for finding generic medicineswas Pharmaca Fennica (11/19), followed by Duodecim (7/19),and then other colleagues (3/19). The majority of RNs (𝑛 =11/18) cited needing assistance often (close to daily or daily)for finding generic medicines from the medicine cabinet.Subsequently, assistance for this was needed occasionally(once or twice a week, 𝑛 = 3/18) and rarely (once or twicea month or less) for the RNs (𝑛 = 4/18).

4.3. Dispensing. In both units, each RN dispenses medicinesto the patients they are in charge of over their shift. Althoughdispensing was experienced as laborious, difficult, time con-suming, restless, and the most problematic stage of the MAP,RNs experienced it positively as a demanding task, requiringa lot of headwork, accuracy, concentration, and knowledgein order to evaluate if the medicines in the medicine andtray charts are valid. Moreover, dispensing was experiencedpositively as developing, educating, and maintaining skillsand also as a way of gaining more patient information.

The problems experienced in dispensing were relatedto availability of medicines, medicines, and environment.Unavailability of medicines leads to acquisition of missingmedicines, which was experienced as a burdensome andtime-consuming task, involvingmultiple stages (e.g., request-ing from another unit or pharmacy, making an order tothe pharmacy). Medicine-related problems were experiencedwhen prescribed medicines were incompatible, difficult,or impossible to dispense or to prepare the right dosage(e.g., medicine missing median line). In addition, a high


number of patients and unfamiliarity with them, substan-tial amount of generic substitutions, constantly changingmedicine brands, and generic substances were problematicfrom the RNs’ perspective. Verifying (double checking)of dispensed medicines was experienced as difficult andADEs (errors in dispensedmedicines or dispensedmedicinesmismatching with medicine chart) were problematic forcausing extra work. Additionally, unusual administrationtimes were problematic to remember alongside routine-like times. Furthermore, RNs experienced several problemsrelated to operational environment. RNs experienced thatthe medicine room was often cramped and not peacefulenough to concentrate on the demanding task, when peopleare coming and going; or the RN is interrupted for havingto conduct another task (e.g., patient alarms). In addition,impractical properties of the medicine cabinets impededfinding themedicines, by being impractical and disorganized.The printed medicine charts were experienced as equivocalfor the unclear markings of medicines on hold and especiallywhen tray charts were folded in half on the medication tray.Furthermore, RNs experienced it as problematic when othercolleagues forgot to print and take the updated medicinechart to the medicine room. Additionally, PRN medicines,only visible in the software,were experienced as laborious anddifficult for having to leave the medicine room to check thoseif needed.

RNs desired the most support in the dispensing stage.First, RNs desired assistance with finding, identifying, andverifying medicines or generic substances easier and faster asthe following citation shows:

“If it would be possible to have a device where youcould quickly, at a glance, see the appearance ofthe medicine and the medicine box.”

Support was also desired for verifying dispensed medicinesand to have certainty that the prescribed medicines aredispensed. RNs cited quicker facilitation if an electrical devicewould notify them of medicines that need to be dispensed.The bar code scanning method [38] was also mentioned asone solution in facilitating the verification of the right patientor medications. Second, RNs desired up-to-date and clearlyprinted medicine charts. Printing was problematic, for bothnot being certain if the chart in medicine room is validin accordance with the latest prescriptions or changes andthe prescriptions being unclear for the different handwrittenmarkings on them. Third, support with documenting wasdesired, especially with narcotic medicines dispensed sepa-rately and documented twice over. RNs expressed a desire todocument dispensed medicines to one place only and thatthe documented data would be updated in real time withpatients’ MARs. Fourth, RNs expressed needing assistance insecuring a safe and peaceful dispensing space to eliminatedistractions. Other elements RNs desired for support werefacilitating the availability and ordering process of medicinesand getting help from the pharmacist in general and whenproblems arise with dispensing the medicines. Finally, RNsdesired collective directions for dispensing (e.g., coloredmedicine cups indicating administering times and dispensingon collective times).

4.4. Administering. The problems RNs experienced inadministering were related to patients, medicines, medicineequipment, course of action, and environment. Patient-relatedproblems come up when a patient refuses or is unable to takemedication. For instance, a patient may refuse to take genericsubstances and desire medicines with specific brands; orthey may have swallowing problems. Additionally, a highturnover of patients was experienced as problematic andpossibly a leading cause for the medicine-related problemsexperienced, such as administration to a wrong patient.The medicine devices were dysfunctional from the RNs’perspective. For instance, medicine cups tip over easily,especially when having a high amount of medicines in them.In addition, the inability to recheck or verify medicines inpatients’ rooms was also problematic. RNs thought it wouldbe convenient to be able to check medicines regardless oftime or place, as the following:

“. . .if a patient wants to go through all themedicines in the medicine cup, and there aremedicines that I don’t identify, it would be nice toget help for that. . .that I could check the medicinesright there (in the patient’s room) by what themedicine looks like. . .I would be able to go throughthe medicine one by one with the patient. . ..”

Lack of collective instruction was experienced as prob-lematic for causing differences in practices. Unspecified orincomplete instructions caused uncertainty, for instance, onwhether medicines are administered to patients in isolation.Some RNs leave the medicine(s) on the “block,” while othersare uncertain when or if the medicines were administered atall. Furthermore, RNs experienced administering medicinesin a calm environment without any distractions to be impos-sible.

The desired support in administering was uniform: RNsdesired to be able to check and verify medicines ubiquitously(e.g., in patients’ rooms). RNs desired to identify and verifymedicines and check their purpose of use if a patient desiresto look through them and also to be able to check patients’MARs, regardless of time or place:

“. . .a device where you could check a patient’s PRNmedicines at a glance.”

Assistance in securing a peaceful environment was alsodesired in this stage.

5. Discussion

5.1. Summary of Evidence. The aim of this study was todescribe the MAP from the RNs’ perspective, by describingthe RNs experienced problems and desired support in theMAP. This study shows that RNs have various roles inthe MAP and RNs confront numerous obstacles impedingtheir work, making the MAP problematic. Yet, medicationadministration was experienced mostly as a positive task.

Problems in the MAP were experienced throughout theprocess. Problems related to RNs’ role in prescribing events,such as interpreting equivocal prescriptions, may expose risks,


as recognized in previous studies where nurses identifiedthe illegible handwriting of physicians [6, 8, 25], complexorders (unclear expression and illegible writing) [7], and poorphysician communication [26] as being conditions causingmedication errors. Furthermore, RNs experienced the dis-connection betweenmedicine software and printedmedicinecharts as problematic. Moreover, this could cause errors ifRNs forgot to print the updated chart for the medicineroom, whenmany new orders are given at unscheduled timeswithout informing the RNs, or when physicians put ordersinto the wrong data field, thus making it even harder forRNs to notice these changes as found in this study. Tirednessand exhaustion [6, 8, 25] could easily affect forgetting toprint the updated medicine chart, thus causing errors. RNsdesired the prescriptions to be up-to-date and in real time,meaning that when the physician makes an order in thesoftware, it would be updated in the medicine room as well,without having to print a new chart. As found in this study,erroneous prescriptions were also found problematic in thestudy of Mayo and Duncan [6], where RNs experienceddrug errors occurring when a physician prescribes a wrongdose. Moreover, Gill et al. [39] found that nurses identifiedprescribing errors as the second most contributing factor tomedication errors. Thus, as the results show, RNs desiredmedicine software that enables precautions (e.g., notificationsof erroneous dosing). Another desire was to have collectivedirections, for instance, considering the times when physi-cians made orders. However, this might be impossible due toconstantly changing conditions of patients. Other problemsRNs experienced in their role in prescribing (e.g., medicinechart correctness) are concurrent with how RNs experiencedtheir role of an advocate, an active attendee, and a person incharge. In this respect, RNs are patients’ gatekeepers and frontline warriors when it comes to the patients’ safety and bestinterests. Although physicians are in charge of prescribingand documenting prescriptions, the RNs’ involvement issubstantial in both actions. Occasionally, RNs have to exceedtheir duties for physicians not complying with unit policieswhen documenting prescriptions. As the results show, nurses’roles in medication management cannot be overemphasized[14].

The problems RNs experienced in documenting weremostly related to the dysfunction of the software. The resultssuggest that the current IT does not adequately supportRNs’ work in the MAP. The software is prone for humanerror and its usability is inflexible. RNs desired new ITto be applied for the MAP that would enable ubiquitousdocumenting and clarity for the printed medicine charts,where one solution could be the use of electronic chartsonly. Dispensing was found as the most problematic stagein the MAP. Unavailability of medicines was experiencedas problematic in dispensing. Similarly, Vogelsmeier et al.[27] recognized the absence of needed medications as abarrier to safe medication. Furthermore, a high volume ofgeneric substitutions was experienced as problematic andwas concurrent with the support desired: facilitating finding,identifying, and verifying medicines.This is significant whentaking into consideration the study of Jones and Treiber[25], who found that large number of medicines scheduled,

at peak times, causes medication errors frequently. It canbe assumed that a large number of generic substitutionsmay cause even more errors. Moreover, constantly chang-ing medicine brands and generic substitutions, which wereexperienced as problematic in the study, can be seen in otherstudies as well. Both Mayo and Duncan [6] and Ulanimoet al. [8] discovered that drug errors occur when there isconfusion between two drugs with similar names. In thestudy of Tang et al. [7], nurses identified unfamiliarity withmedications (e.g., new drug name, similar drug names orpackages, seldom-used drug, and unclear labeling) as acondition that results inmedication error. Additionally, Jonesand Treiber [25] found that nurses perceived look-alike orsound-alike drugs as a cause of frequent medication errors.According to health professionals, deviations may occur asa result of confusing medications due to the similar namesand packaging of medicines; therefore, avoiding confusingmedicines is a significant factor in preventing ADEs [11].Also, the desired aid of pharmacists can play a key role inpreventing the medication errors reaching patients [24]. Theproblems acknowledged in dispensing demonstrate the needfor the consideration of applying newmedication-dispensingtechnology to support RNs in dispensing, which nurses havealso perceived as a factor in reducing medication errors[25].

Finally, problems and support desired in administer-ing medicines were discovered. Patient-related problems inthis study are similar to Dilles et al. [28], who found thepatients’ right to refuse care as a barrier to safe medicationmanagement. Furthermore, the inability to verify medicineswhile administering was experienced as problematic. Hence,the chance for ubiquitous usage of medicine software wasa uniform desire on behalf of RNs. A lack of collectiveinstructions in administering, discovered in this study, isconcurrent with [28], who discovered insufficient guidelinesbeing a barrier to safe medication management.

Operational environment-related problems were experi-enced as problematic in each stage of the MAP, excludingprescribing. Previous studies [18, 19] show that interruptionsduring medication administration are common and can leadto human error. In the study of Mayo and Duncan [6], RNsranked the top perceived causes of drug errors where dis-traction of others (coworkers, patients, or events) was rankedas the second-highest cause of medication errors. Similarly,other studies [8, 25, 39] have recognized interruptions anddistractions as contributing factors ofmedication errors fromthe nurses’ perspective. Additionally, in the study of Tang etal. [7], nurses identified having to solve other problems whileadministering drugs as the leading condition that resulted inmedication error. On the strength of the study and previousstudies, it is highly important, and a crucial factor, to enableconcentration on the task in preventing deviations in theMAP, as Harkanen et al. [11] have also found in their study.Clarity for the problematic, unclear medicine charts was alsodesired, which is found to be a barrier to safe medicationfrom nurses’ perspectives [28]. Hence, forgetting to print anupdated chart should be replaced with electronic charts, thuserasing possible human error.


5.2. Study Strengths and Limitations. The two methods usedfor data collection and two persons analyzing the data(data and researcher triangulation) strengthen the validityof the results. Additionally, motivation and enthusiasm ofthe participants can be considered as strength. However, thisstudy has some limitations. The data was collected usinginterviews and questions in a paper form developed for thisstudy on the basis of previous research but not validated inearlier studies.This research is limited to one hospital and twounits only; thus, the results are not generalizable. However,they aremainly in line with results in several previous studies.The study provided new insights precisely from the RNsperspective of MAP and their actions during MAP and puttogether previous research, hence creating a comprehensivewhole of the MAP.

The study is valuable in that it describes RNs’ personalexperiences with the MAP. This study identified both anumber of problems confronted and the support desiredin the process, hence aiding the development of a moresafe and flowing process. Furthermore, this study providesa framework for nurse managers to utilize the results of thisstudy when planning the safety of the MAP in a hospital caresetting.

6. Conclusion

Recognizing RNs’ concerns and recognizing desired supportin the MAP are important first steps in improving the MAP.The problems recognized in this study are in line with boththe support RNs desire and previous studies considering thecauses of medicine errors. The results of this study showthat there are improvements required in the MAP for RNsto be able to conduct safe medication administration andmaintain patient safety. RNs have plenty of ideas of how theMAP could be developed, and their views should be takeninto account when developing the process. Further researchis needed when developing and applying new technologysolutions to assist medication management in order to be themost convenient from users’ perspectives.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

Authors’ Contribution

Hanna Pirinen, Lotta Kauhanen, Riitta Danielsson-Ojala,Johan Lilius, Ilona Tuominen, Natalia Dıaz Rodrıguez, andSanna Salantera designed the paper. Hanna Pirinen, LottaKauhanen, and Riitta Danielsson-Ojala collected the data.Hanna Pirinen and Lotta Kauhanen analyzed the data.HannaPirinen and Lotta Kauhanen helped in writing the originalpaper. Riitta Danielsson-Ojala, Johan Lilius, Ilona Tuominen,Natalia Dıaz Rodrıguez, and Sanna Salantera helped in paperreview and comments. All authors have read and approvedthe final paper.

Acknowledgments

The study was supported by Special State Grant EVO (no.13190, TurkuUniversity Hospital) funding.The authors thankall the RNs from the two units who participated in this study.

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