medication errors complete
TRANSCRIPT
Novice Nurses versus Experienced Nurses: Barriers to Medication Administration
By:
Jennifer Allred
Amanda Bufkin
Andrea Davis
Earika Flemings
Rachel Hicks
Christina Mortenson
Kristen Pippin
Mary Sears
Stephany Vance
Under the Direction of:
Dr. Tammie McCoy
Bachelor of Science in Nursing ProgramMississippi University for Women
March 7, 2014
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Abstract
The research problem statement asked, “Do novice nurses or experienced nurses
have more barriers to safe medication administration in the healthcare setting?” The
research hypothesis stated that experienced nurses have more barriers to safe medication
administration than novice nurses in the healthcare setting. The null hypothesis was there
is no significant difference in the number of barriers to safe medication administration
between novice nurses and experienced nurses in the healthcare setting. A non-
experimental comparative research design was utilized to collect data from previously
registered nurses who were also students at a small, rural university in the southeast USA.
Through an online convenience sample, 44 participants completed The Barriers to Safe
Medication Administration Questionnaire. The questionnaire contained 19 questions, four
of which were demographics, and 15 of which used the semantic differential scale to
determine the prevalence of barriers during medication administration. The data collected
was coded and interpreted by the Spearman Rank Order Correlation with a preset
confidence level of 0.05. With a 0.131 correlation and p-value of p = 0.198, the student
researchers failed to reject the null hypothesis. There was no statistical data available to
support that nurses with more years of practice, experience more barriers to medication
administration than did new nurses. On the other hand, with a 0.355 correlation and p-
value of p = 0.009, the student researchers found a moderate correlation between the
number of perceived barriers reported and unit of employment. The abundant presence of
barriers during medication administration prompted the student researchers to study
which barriers licensed nurses perceived to be predominant. This study found that the
most prevalent barriers reported most frequently were understaffing, interruptions, lack of
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time, and errors in communication. This study implicates nursing because nurses were
able to identify barriers to safe medication administration. By identifying these barriers
that could potentially cause errors, this study will then allow for measures to be put in
place to minimize the occurrence of barriers that nurses face during the process of
medication administration. In future studies, researchers should expand the sample size,
allow more time for participants to access the questionnaire, and focus a new
questionnaire on the barriers which were more prevalent. Future studies should expand
on the research to determine ways to reduce the occurrence of the more prevalent
barriers.
Table of Contents
PageAbstract ……………………………………………………………………….. i-ii
CHAPTER
I. INTRODUCTION ………………….………………………………... 1-6
a. Brief Background …………………………..……..…….….… 1
b. Clinical Observation ………………………………………….. 2
c. Significance of the Research …………………………………. 3
d. Problem Statement ………………………………………….... 4
e. Purpose Statement …….…………….…………...................... 4
f. Null Hypothesis ……….………………………....................... 4
g. Research Hypothesis …..…..…………….………………….... 5
h. Definitions …………….…………………………………….... 5
i. Assumptions …………………………….……………………. 5
II. LITERATURE REVIEW ……………………….………………….... 7-22
a. Introduction ……………………………………………….….. 7
b. Importance of Safe Medication Administration ……..………. 7
c. Barriers to Safe Medication Administration ……………….… 12
d. Prevention of Medication Errors ……………………….…….. 17
e. Conclusion ……………………………………………….….... 20
III. RESEARCH DESIGN AND METHODOLOGY ……………….…… 23-26
a. Research Design …………………………………………...…. 23
b. Variables ……………………………………….………......…. 23
c. Subjects and Setting ……………………………..…………… 23
d. Data Collection Instruments …………………………….…… 24
e. Data Collection Procedures .….………….…………………… 24
f. Analysis Method …………………………………….….….… 25
g. Limitations ………………………………………….…….….. 25
IV. RESULTS ………………………………………………………….… 27-33
a. Summary ……………………………………………………... 27
b. Statistical Analysis …………………………………………... 28
c. Serendipitous Findings …………………………………….… 30
d. Alterations …………………………………………………… 31
e. Limitations ……………………………………………….…... 32
f. Similar Findings …………………………….……………….. 32
g. Contradictory Findings ……………………………………… 32
h. Conclusion ………………………………………………...… 33
V. CONCLUSIONS ……………………………………………………. 34-36
a. Summary of the Study ………………………………………. 34
b. Conclusions of the Study …………………………………… 34
c. Implications for Nursing ……………………………………. 35
d. Recommendations …………………………………………... 35
VI. Appendices ………………………………………………………….. 37
a. Appendix A …………………………………………………. 37
b. Appendix B …………………………………………………. 38
VII. References ………………………….…………..…………………… 41
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Chapter I
Introduction
Brief Background
Nurses administer medications on a daily basis. A leading cause of medical harm
in hospitalized patients stems from medication errors (DeYoung, VanderKooi, &
Barletta, 2009). A medication error can be described as an omitted dose; administering
the incorrect dose; administering a dose that is not ordered; administration of medication
to the wrong patient; improper technique with administration of medication;
administration of an expired medication or the wrong medication (Taylor, Lillis,
LeMone, & Lynn, 2011). An error could lead to an adverse event, causing harm to the
patient and costing the hospital extra expenses. According to the National Coordinating
Council for Medication Error Reporting and Prevention (2012), 98,000 deaths occur
annually in United States hospitals because of healthcare errors with a substantial number
of deaths due to medication errors. Therefore, nurses are encouraged to pay close
attention while administering medication in order to enhance patient safety.
A barrier has been defined as any realistic or perceived deterrent which could
impede safe nursing practice during medication administration. Nursing related barriers
can include lack of knowledge or understanding of pharmacology, time and work
pressures, nursing shortages, and multiple patients’ medications scheduled at the same
time (Dilles, Elselviers, Van Rompaey, & Vander, 2011). Medication management is
complex; errors can occur in all stages of the process and different professionals can be
involved (physicians, pharmacists, and nurses) (Dilles et al., 2011). The nursing staff is a
critical line of defense in order to prevent medication errors. A clinical environment can
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become a focal point for medication errors because of the multiple barriers in place.
Considering these observations, nurses need to be aware of barriers to safe medication
administration so as to ultimately reduce the amount of medication error occurrences.
Clinical Observation
Medication administration is a foundation of nursing care. As an essential
element of optimal nursing care, medication administration should enhance the
health of the patient (Taylor et al., 2011). Unfortunately, the health and safety of
the patient comes in to question when medication errors are made in the clinical
environment (Aspden, Wolcott, Bootman, & Cronenwett, 2006). On a routine
basis, the student researchers observed medication administration and identified
the barriers to medication administration that arise with clinical practice.
Throughout various clinical settings, the student researchers witnessed lenient
standards of medication administration contradicting the fundamentally safe
clinical practice of the five rights of medication administration. With these
relaxed practices, the student researchers noticed increased opportunities for
medication error in addition to an increased number of reported medication errors.
For example, while observing a registered nurse, the student researchers viewed
the nurse bypassing patient identification. The nurse did not confirm the patient’s
name or the date of birth in order to avoid arousing the patient and using excess
time in the patient’s room. She continued to hang the intravenous medication
without performing the final safety checks. In this incident, a medication error
was not made, but the nurse showed a willful disregard for proper safety protocol,
thus endangering the patient.
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Furthermore, the student researchers witnessed the improper medication
dose being administered to a patient. While preparing multiple patients’
medications, the nurse extracted the wrong dose of a patient’s medication. The
vial of medication was 0.25 mg, the dose was 0.125 mg, and the nurse withdrew
the full 0.25 mg. In this example, the number of patients that the nurse was
required to care for created a barrier to the nurse’s clinical judgment. Regardless
of the nurse’s experiences and level of comfort, a medication error was still made.
Patient safety, through medication administration, is a priority and should
be an objective of every nurse (Taylor et al., 2011). Clinical practice can generate
barriers that can cause even the most experienced of nurses to make errors. The
observations of these barriers to medication administration fostered further
examination and analysis of this portion of healthcare.
Significance of the Problem
Medication administration is important in clinical practice because medications
are used with a majority of patients in the hospital setting. Errors account for 40% of
adverse events that occur in a hospital setting (Cortelyou-Ward, Swain, & Yeung, 2012).
According to Fowler, Sohler, and Zarillo (2009), administration of medication takes up to
40% of a nurses’ time in providing patient care. If 40% of a nurses shift time is spent on
administering medications and nurses account for 40% of medication errors, then it could
be assumed that not enough time is spent on preventing medication errors. Most cases of
medication errors occur because a nurse would have bypassed at least one of the five
rights of medication administration.
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Nurses have been taught that patient safety is priority from the first day of
nursing school. Yet, in the clinical setting, nurses use alternative practices that
place the patient at risk for preventable accidents. In 2005, the overall combined
reporting of sentinel events, unexpected occurrence involving death or serious
physical or psychological injury, or risk thereof, revealed that almost 10% of
sentinel events were due to medication errors (Maiden, Georges, & Connelly,
2011). According to the Institute of Medicine, medication errors injure 1.5 million
Americans each year and cost 3.5 billion dollars in lost productivity, wages, and
additional medical expenses (Aspden et al., 2006). The high cost of adverse
events should encourage a reduction in medication errors through development of
new standards produced by evidence based practice for safe medication
administration. The data gathered from various sources suggest that although new
research is available, the number of medication errors continue to thrive in the
clinical setting. The student researchers believe that although it may take the
nurse longer to administer medications following the five rights of medication
administration, it is of utmost importance that these precautions be taken to
protect the patient from unnecessary harm, therefore improving overall care.
Problem Statement
Do novice nurses or experienced nurses have more barriers to safe
medication administration in the healthcare setting?
Purpose of the Study
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The purpose of this study is to determine whether there is a difference in
the number of barriers to safe medication administration between novice nurses
and experienced nurses in the healthcare setting.
Null Hypothesis
There is no significant difference between the number of barriers to safe
medication administration between novice nurses and experienced nurses in the
healthcare setting.
Research Hypothesis
Experienced nurses have more barriers to safe medication administration
than novice nurses in the healthcare setting.
Definitions
For the purpose of the research study, the following terms are defined:
Novice nurse. A registered nurse who has less than two years of
experience.
Experienced nurse. A registered nurse who has two or more years of
experience.
Barrier. Any condition or occurrence, which impedes the ability to
achieve an objective (Venes, 2009).
Safe medication administration. Administering medications ensuring the
right medication is given to the right patient in the right dosage via the right route
at the right time (Taylor et al., 2011).
Assumptions
For the purpose of this study, the following assumptions were made:
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1. The participants have had experience with medication administration and the barriers
to medication administration.
2. The participants are taught the importance of safe medication administration.
3. Medications are administered to patients.
4. The questionnaire accurately measures barriers to medication administration.
5. The participants answered the questionnaire truthfully and without any resources other
than their knowledge and previous experience.
6. The participants’ answers in this study were not manipulated.
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Chapter II
Literature Review
Introduction
Medication errors have been studied for many years. The importance of safe
medication administration has been clarified; barriers to safe medication administration
have been identified, and methods to prevent medication errors have been determined.
The literature supports the assumption that nurses have barriers to safe medication
administration. The following nine research studies were reviewed and indicated the need
for further research on medication administration. This study aims to expand the body of
knowledge on medication administration barriers by comparing the number of barriers
presented in novice nurses versus experienced nurses.
Importance of Safe Medication Administration
Sakowski, Newman, and Dozier (2008) determined the severity of
medication administration errors detected by bar-code medication administration
(BCMA) system. The purpose of the study was to evaluate the potential severity
of medication administration errors detected by a BCMA system. In addition,
Sakowski et al. (2008) studied the potential severity of medication errors
occurring from various types of medication administration events, including
different classes of drugs, and whether these errors were prevented or observed.
Sakowski et al. (2008) implemented a method of scenarios to guide the
research. Six hospitals within the same healthcare system in Northern California
were studied. A panel of multidisciplinary clinicians reviewed a series of error
scenarios and evaluated their potential severity on a scale of zero (no effect) to ten
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(death), using a previously validated method. The review panel consisted of three
pharmacists, two registered nurses, and one physician. Information on potential
medication errors was gathered from logs automatically created by the BCMA
system. Nurses familiar with the system were used to identify events that were
actually a prevented administration error or a confirmed discrepancy between the
written order and the administration. The information was then used to create
generic “error scenario” case studies. The case studies included the drug involved,
the ordered dose, administration schedule, and any discrepancy from the written
order identified by a BCMA caution. The mean of the single ratings from the
reviewers was then calculated to determine the severity index for each of the
administration events. Chi-square and logistic regression testing were performed
to form statistical conclusions (Sakowski et al., 2008).
A total of 945 errors containing 212 drugs were included in the review. A
total of 564 scenarios were studied for severity rating. Less than 10% of detected
errors were evaluated as moderate or severe. The majority of the errors reviewed,
91%, were evaluated as having minor severity potential. The remaining 9% were
evaluated as moderate to severe. Scenarios in which the operator continued with
the administration after receiving a cautionary sign were less probable to be
evaluated as moderate or severe than scenarios in which operators stopped in
response to a system caution, but this result was not statistically significant. For
the scenarios being evaluated as moderate or severe in which operators proceeded
with administration after a BCMA system caution, the odds ratio (OR) was 0.69.
The study found that “no order” errors, events that had no corresponding order
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entered into the computer system connected to the administration, were
significantly more probable to be evaluated as moderate or severe than other error
types. The OR of a “no order” error being evaluated moderate or severe was 5.8
(Sakowski et al., 2008).
Even though the study did not clearly state the hypothesis or problem
statement, the results directly reflected the purpose of the study. Some limitations
to this study were: the only medication administration errors assessed during this
review were those identified by the BCMA system; if the system did not identify
the error, it was not involved in the study; and the comparison of error importance
between prevented errors and discrepancies that did happen despite a system-
generated caution. The majority of medication administration errors identified by
the BCMA system were evaluated to be nonthreatening and posed minimal safety
risks. Conversely, the numbers and severity of medication administration errors
which happened despite the use of a BCMA system proposed that there were
chances to advance BCMA systems and how the information they produced
would be used (Sakowski et al., 2008).
Sakowski et al. (2008) was important because it represented potential
harm for medication errors. All types of errors were not researched due to the use
of BCMA but expressed a need for further study of medication errors and the
possibility of advancing BCMA systems in order to provide more information and
prevent future errors. Sakowski et al. (2008) showed the importance of safe
medication administration by studying the effects of bypassing the system alerts
in order to hasten the medication administration process.
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DeYoung, VanderKooi, and Barletta (2009) also conducted a research
study based on the application of BCMA, but the research evaluated the
effectiveness of BCMA rather than the severity of errors. The purpose of the
study clearly stated the need to determine the effect of BCMA on the rate of
medication errors in adult patients in a medical intensive care unit (ICU). Adverse
drug events, also known as medication errors, were noted as a growing concern
within healthcare institutions, with the incidence of these events highest in the
ICU.
DeYoung et al. (2009) research method consisted of correlational, direct
observation and convenience sampling in order to study medication error rates using
BCMA in an adult medical ICU. Certified nurses in the ICU served as the population for
the study. The type of medication error (i.e. wrong dose, wrong time, wrong route, and
wrong drug) was studied as well. A total of 1465 medication administrations to ninety-
two patients were observed in a 744-bed community teaching hospital in Grand Rapids,
Michigan.
Observation occurred 24 hours a day, during four consecutive days, one month
before, and four months after the implementation of BCMA. The observers consisted of a
small group of pharmacy residents, pharmacy specialists, and a nurse specialist. The data
collectors randomly approached nurses and asked if they could observe the nurses
administer medications. Nurses were informed that the purpose of this study was to
determine the effect of BCMA on medication safety (DeYoung et al., 2009).
The medication administration error rate was reduced 56% after the
implementation of BCMA (DeYoung et al., 2009). The reduction was seen most with
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medications being administered at the wrong time. Patient safety was improved with the
use of BCMA by lowering rates of medication errors. DeYoung et al.’s (2009) research is
relevant because it expanded the knowledge and understanding of medication errors. The
research provided information on the importance of following correct medication
administration techniques to ensure patient safety. Also, proof of proper use of assistive
technology was identified as a method to reduce medication errors as a whole.
Similar to the research studies above, Chang and Mark (2009) looked at
medication errors and what factors influenced the occurrence of medication
errors. Chang and Mark (2009) analyzed contributing factors to medication errors
occurring in acute-care hospitals and comprehend if different severities of errors
had different antecedents. Chang and Mark studied both severe errors that were
harmful to the patient’s health status which needed immediate interventions, and
nonsevere errors which did not require much intervention. Healthcare work
environments, staffing for adequacy, healthcare work conditions, and outcomes of
both the patients and organization was also analyzed. Data was collected from a
random sample of 246 nursing units in 146 hospitals in the United States,
focusing on registered nurses employed on their unit for more than three months.
A trained study coordinator was in charge of distributing questionnaires to
staff nurses and obtaining administrative data over six months. Each nursing unit
had the staff nurses complete three questionnaires. The researchers used a
generalized estimating equation with a negative binomial distribution to analyze
the data. Both nursing expertise, the way the registered nurses rated the expertise
of their nursing workgroup in terms of recognizing critical patient problems, and
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nursing experience, the average of each nurse’s experience as a registered nurse in
months, had an impact on the occurrence of medication errors. The results showed
the greater the level of nursing expertise, the fewer the nonsevere errors. In
contrast, as nursing units had more experienced nurses on the unit, more
nonsevere medication errors were made (Chang and Mark, 2009).
Chang and Mark identified barriers to safe medication administration and
showed the association between those barriers and the severity of medication
errors (2009). The researchers found nursing units with more experienced nurses
had reported more nonsevere medication errors, therefore supporting the current
research hypothesis of the students. The student’s current study further expands
on the research already conducted by examining the amount of barriers to
medication administration between novice nurses and experienced nurses.
Barriers to Safe Medication Administration
While Chang and Mark’s study presented barriers to medication
administration and determined whether or not the barriers were truly impeding,
the nursing study conducted by Maiden, Georges, and Connelly focused on the
effects that moral distress and compassion fatigue have on medication errors in a
critical care setting. The study had three specific focuses: to describe, to observe,
and to comprehend the levels of moral distress, compassion fatigue, perceptions
about medication errors, and nursing characteristics. The population included a
national sample of 205 certified critical care nurses. These nurses were members
of the American Association of Critical-Care Nurses and were required to have
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been involved with patient care delivery in the preceding year (Maiden, Georges,
& Connelly, 2011).
Researchers used quantitative surveys which were mailed to the certified
critical care nurses, as well as a qualitative survey which was sent to a subgroup
of the critical care nurses. All 205 subjects provided written, informed consents to
participate in the study. There were several quantitative surveys sent to the
subjects. One was a demographic questionnaire which asked for age, sex,
employment status, marital status, religious affiliation, unit tenure, nursing tenure,
and intent to leave current position. A moral distress scale, which contained a 38-
item, seven-response Likert-type scale, was distributed. A professional quality of
life scale containing a 30-item, five-response Likert-type scale was also sent out.
Furthermore, there was a medication administration error survey which asked
questions about reasons medication errors occurred, reasons errors are not
reported, and an estimated percentage of errors that are reported (Maiden et al.,
2011).
Maiden et al. (2011) found that the demographics of the subjects were
mostly married female, who worked full time and practiced nursing an average of
13.61 years. The average age of the individuals was 47.49 years old. There was an
elevated level of moral distress and a low level of compassion fatigue reported.
Researchers also found medication packaging was the highest reported reason for
medication errors occurring, and fear was the most reported reason for not
reporting medication errors (Maiden et al., 2011).
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Poor communication between the physician and the nurse, nurse staffing
levels, medication packaging, moral distress, and compassion fatigue were the
barriers to safe medication administration identified. The research identified
several barriers that can be included in a questionnaire to expand the knowledge.
Since fear was the most common reason for not reporting medication errors, there
was a possibility subjects in the current study will be nervous about answering the
questionnaire related to barriers of safe medication administration (Maiden et al.,
2011).
Dilles, Elseviers, Van Rompaey, and Vander (2011) focused on nurses in
nursing homes to identify different barriers to safe medication administration and
compare the importance of those barriers. Expert meetings were conducted, and
nurses from 25 institutions met to discuss the different barriers they experienced
during medication administration. A cross-sectional survey was created based on
the information collected from the expert meeting. Not all barriers stated during
the meeting were used. Instead, the survey focused on barriers related to preparing
medications, medication administration, and monitoring medication effects. A
total of 246 nurses and 270 nursing assistants from nursing homes with more than
60 beds participated in the survey.
Several barriers to safe medication administration were identified when
the data was analyzed. The main barriers identified included being interrupted
during preparation, inadequate knowledge of drug and food interactions, lack of
time for double-checking, insufficient information from the physician, and
inadequate knowledge of side effects of medications. Other barriers that the
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nurses identified were insufficient knowledge on crushing pills, inability to
correctly calculate dosage, inadequate knowledge of correct administration time,
insufficient resources for information on the topic, and limited accessibility to
pharmacists (Dilles et al., 2011).
Nurses must know which barriers are the most prominent in safe
medication administration. These barriers were considered in development of the
current studies questionnaire to expand the Dilles et al. (2011) research. Dilles et
al. (2011) identified three main barriers which included: interruption, inefficient
knowledge, and lacking of interdisciplinary cooperation (Dilles et al., 2011).
Mark and Belyea (2009) studied acute care facility staffing and changes in
medication errors. The purpose of the study was to observe the connection
between alteration in acute care unit staffing and changes in medication errors.
Additionally, Mark and Belyea (2009) focused on the implications of the study,
such as quality and patient safety which would be affected by the changes in
staffing and the changes in medication errors.
The longitudinal study utilized data that was acquired from the Outcomes
Research in Nursing Administration Project (ORNA-II). The ORNA-II was a
multisite organization study which was conducted to examine staffing, working
environment, outcomes, as well as internal and external environments. The design
for the ORNA-II was a prospective, non-experimental, longitudinal, causal
modeling design. Therefore, the research study conducted a secondary analysis
and review of the data already obtained through the ORNA-II. A sample of 284
nursing units consisting of medical surgical units or medical surgical specialty
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units in 145 JCAHO accredited hospitals consisting of 99 licensed beds were
selected. Federal, for- profit, and psychiatric facilities were excluded from the
study. Additionally, sources for the data were the American Heart Association
(AHA) Annual Survey of Hospitals and registered nurses that had been employed
for three months and working 20 hours per week. After the data was gathered, a
statistical analysis was conducted by utilizing the Mplus statistical program and
an autoregressive latent trajectory (Mark & Belyea, 2009).
Mark and Belyea (2009) reported the units evaluated averaged 13-80 beds
per unit. Additionally, slightly over half the nursing staff studied was registered
nurses. Also, half of the total hours worked during the study were performed by
registered nurses. Per 1,000 inpatient days, medication errors differed from 5.36
to 6.22 over from the identical period of time. The study produced a limited
support for the relationship between external and internal environment and nurse
staffing affecting the initial level of medication errors. Also, Mark and Belyea
(2009) found limited support for the rate of change in staffing over a six-month
period of time being affective in the change in medication errors. The study found
hospitals with a higher case mix had minor increases in errors. Hospitals involved
in teaching had an increase in errors seen over time. Larger nursing units reported
more medication errors per 1,000 patients. Overall, the study supplied little
support for a correlation between the number of nurse staffed and medication
errors (Mark & Belyea, 2009).
Mark and Belyea (2009) displayed a limited correlation between staffing
and medication errors. Thus, the study encouraged further research to look at this
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problem more in-depth and reevaluate. The study did help develop a means to
guarantee theoretical models can be used to reflect organizational reality and be
tested statistically. Therefore, the study provided information on how to improve
the patient safety and optimal care in acute facilities, and it showed the
significance in the size of a facility in relation to the number of medication errors
committed. Additionally, the study exhibited the significance of the size of the
unit in relation to the number of medication errors made in correlation with the
current research study (Mark & Belyea, 2009).
Prevention of Medication Errors
Barriers to medication administration are daunting, but can be reduced by
several prevention methods. Aspden, Wolcott, Bootman, and Cronenwett (2006)
aimed to decrease medication errors by providing prevention strategies and
creating a standard to uphold. The focus was on “safe, effective, and appropriate”
(Aspden et al., 2006, p 1), medication administration in several healthcare
environments. The report had multiple purposes, such as evaluating approaches
created to reduce medication errors, providing guidance to individuals involved
with medication, and establishing a method to evaluate healthcare costs in relation
to medication errors.
The report was an evidence-based review of literature, government reports
and data, case studies, empirical evidence, and additional materials provided by
government officials and others. The reviewed population consisted of patients,
physicians, nurses, and pharmacists in healthcare settings, who participated in the
medication process. The review considered “the nature and causes of medication
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errors; their impact on patients; and the differences in causation, impact and
prevention across multiple dimensions of healthcare delivery” (Aspden et al.,
2006, p 3). The settings included were populations of patients, healthcare settings,
clinics, and institutional cultures. Data was compiled by three committees who
then turned the information over the final 17-member committee. The 17-member
committee, composed of individuals with expertise related to the report,
conducted the review. The committee’s knowledge and expertise were enhanced
on the issue by providing a workshop (Aspden et al., 2006).
The report provided information on the steps needed to enhance patient
safety. Also, action agendas were offered to improve safety of medication
administration. The report focused on the collection of accurate medication errors
which occur in order to improve patient safety. The discussion of electronic
sources to prevent errors was supported by the Aspden et al. (2006) report.
Support was also offered to adequate division of labor, proper training, and
effective communication.
In review of the literature and research, the Aspden et al. (2006) report
compiled data on the amount of errors occurring in a year and the amount of
hospital expenses to cover the errors. Futhermore, the report explained errors of
such caliber are preventable. While doing so, the review explained that improving
provider-patient communication, effectively using technology, removing barriers
to safe medication administration, and establishing a safe environment to deliver
care were essential steps to reducing medication errors.
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Aspden et al. (2006) conducted a literature review in order to set guidelines to
prevent future medication errors. The report provided information on the occurrence and
prevention of medication errors. The report highlighted methods to prevent medication
errors, which could be beneficial when a barrier to medication administration is
presented. The methods to prevent barriers include: implementing BCMA technology at
the bedside, using automated dispensing devices, including a pharmacist during rounds of
care, eliminating abbreviations, limiting the number of different types of common
equipment, improving communication practices, implementing methods to reduce
workplace fatigue, creating a culture of safety, improving the workspace for preparing
medications, and improving patient’s knowledge of treatment. The report encouraged
further study to be conducted on the incidence, costs, and prevention of medication
errors, therefore indicating necessity of the current study (Aspden et al., 2006).
Crimlisk, Johnstone, and Sanchez (2009) also evaluated methods to move
toward safer practice. The purpose of the research study was to “develop a clinical
program that offered evidence-based practice, simulations, and best practice for
intravenous continuous infusion (IVCI) medications, and evaluate the participant
responses and the clinical outcomes” (Crimlisk et al., 2009, p 155). Educational
workshops were provided to medical/surgical nurses in a 626 bed, level one
trauma center. The research method was descriptive, quantitative, and
longitudinal. Researchers collected demographics, evaluations of the educational
workshops, nurse comments, and clinical data on medication errors for three
years.
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The Crimlisk et al. (2009) study found that nurses requested more
educational workshops to enhance knowledge of IVCI medication administration.
In 2005, five medication errors were reported, and in 2006 and 2007, only three
were reported. Medication errors that did not cause patient harm were reduced
from one error per 280 orders in 2005 to one error per 660 orders in 2007. The
research was limited to medication errors during IVCI. The research explained
that staffing representation was skewed because 72% of staff from campus
number one was full time, whereas campus number two only had 3% full time
staff (Crimlisk, Johnstone, & Sanchez, 2009).
Crimlisk et al. (2009) found that nurses believed that they needed more
education to prevent medication errors, and the researchers provided statistics to
support the nurses’ belief as correct. The study focused on IVCI medication
administration because of the seriousness in which IVCI adverse events can harm
patients. The study suggested proper education on medication administration
would reduce medication errors. The study highlighted using the five rights of
medication administration, including two extra rights: the right documentation
and the right fluid, to reduce barriers to medication administration, thereby
reducing medication errors.
Lucero, Lake, and Aiken (2010) provided a different aspect to prevention
methods. The research study examined the relationship between unmet nursing
care needs and the reporting of adverse events. A medication administration error
was considered an adverse event in the study. The data was collected from a
sample of 10,184 registered nurses in 168 acute care hospitals in Pennsylvania.
21
The design of the study was a secondary analysis of data collected in a 1999
study. The method used was a multivariate linear regression model which related
the effect of inadequate nursing care to the occurrence of adverse events, such as
medication administration errors (Lucero et al., 2010).
Surveys were collected from registered nurses from a variety of units. The
data was analyzed to determine the relationship between the quality of nursing
care and the occurrence of adverse events, including medication administration
errors. The results of the study suggested inadequate nursing care was
significantly related to the reporting of adverse events. The study concluded that
the time a nurse spends with a patient directly correlates with the outcome in
prevention of adverse events—the more time spent, the better the outcome
(Lucero et al., 2010).
The study was pertinent to prevention of medication errors by allowing
nurses to be aware of the correlation between inadequate care and the occurrence
of adverse events, such as medication administration errors. We as nurses should
spend enough time with patients to effectively provide adequate care. The extra
time spent could potentially prevent medication administration errors (Lucero et
al., 2010).
Conclusion
The Sakowski et al. (2008) and DeYoung et al. (2009) studies both researched the
use of BCMA. DeYoung et al. (2009) looked at the occurrence of medication errors,
while Sakowski et al. (2008) focused on the severity of the medication errors that
occurred. The DeYoung et al. (2009) study showed the use of the BCMA system reduced
22
the rate of errors, and Sakowski et al. (2008) research further showed the use of the
BCMA system reduced the severity of the medication errors made. Like DeYoung et al.
(2009) and Sakowski et al. (2008), Chang and Mark (2009) also researched the
occurrence of medication errors and their severity. Chang and Mark (2009) focused on
identifying antecedents to medication errors, and the ways antecedents affected the
occurrence and the severity of the errors made. All three of these research studies
analyzed different aspects of medication errors, but each had a different focus and found
results that could be tied together for further research.
According to Maiden et al. (2011), medication packaging, moral distress,
and compassion fatigue were three of the main barriers identified in safe
medication administration. However, Dilles et al. (2011) found that interruption
during preparing medications, lack of drug knowledge, and lack of time while
double-checking medication orders were significant barriers found. Both research
studies identified poor communication between nurses and physicians as a barrier.
In accordance with Dilles et al. (2011), Crimlisk et al. (2009) identified
interruption barriers to safe medication administration as telephone calls and
environmental noise. Also, Mark and Balyea (2009) found that increased unit size
was a barrier to safe medication administration.
The Aspden et al. (2006), Crimlisk et al. (2009), Lucero et al. (2010), and
DeYoung et al. (2009) research studies all incorporated prevention methods of
medication administration. Each of the research studies touched on the five rights
of medication administration. The articles recommended nurses check the
medication, route, dose, patient, and administer the medication in a timely manner
23
in order to prevent errors. All four of the research studies also supported the
prevention method of documentation before and after medication administration
in order to prevent errors such as omission, over dosing, and toxicity.
Aspden et al. (2006) and Lucero et al. (2010) suggested medication errors
are more prone to occur when there are inadequacies in staffing. In contrast, Mark
and Belyea (2009) presented conflicting information by reporting no significant
correlation between staffing and medication errors. Aspden et al. (2006) and
Lucerno et al. (2010) also discussed the prevention method of proper
communication between nurses and patients. Both studies encouraged nurses to
spend more time communicating and educating the patients in order to provide
acceptable patient care. Lucerno et al. (2010) specifically stated that the more
unmet care of patients leads to an overall decline of patient care. Finally, Aspden
et al. (2006), Crimlisk et al. (2009), and DeYoung et al. (2009) advocated for the
use of electronic devices in order to prevent medication errors. Use of IV pumps,
computerized order entry, and BCMA systems were electronic sources to aid in
safe medication administration.
24
Chapter III
Research Design
A non- experimental comparative research design was utilized in this
study. The non- experimental design used variables that already existed in the
target population. The non- experimental comparative design was appropriate for
the study due to the accumulation of quantitative data which compared novice
nurses to experienced nurses and the prevalence of barriers to medication
administration.
Variables
The independent variable under investigation was years of experience. The
years of experience were further divided into two groups, novice nurses and
experienced nurses. The dependent variable, which was predicted to fluctuate
contingent upon the amount of experience that a nurse had, was the amount of
medication administration barriers identified by each nurse. The variables
controlled in the study were a questionnaire with a specified number of questions
provided through a course management system, a set time frame in which the
subjects had to take the survey, and the previous experience of registered nursing
with all subjects. Some extraneous variables were identified by the student
researchers, which included the environment in which the questionnaire was
completed, the mood or affect of the subjects during completion of the
questionnaire, and interpretation of the questionnaire by the subjects.
Subjects and Setting
25
The student researchers gathered data from the RN to BSN students, Master of
Science in Nursing (MSN) students, and Doctor of Nursing Practice (DNP) students at a
small, rural university in the southeast United States of America. The target population
was identified as registered nurses. The accessible population consisted of the RN to
BSN, MSN, and DNP students at the small university. The student researchers utilized a
non-random convenience sampling. Data was gathered from about 30 novice nurses and
30 experienced nurses. The target population was not representative of the accessible
population due to the use of convenience sampling and the time constraints.
Data Collection Instruments
“The Barriers to Safe Medication Administration,” an online questionnaire which
was given through a course management system was used for the purpose of this study.
By non-random convenience sampling, a semantic differential scale was used within the
questionnaire. The questionnaire contained nineteen questions. Demographic questions
were asked on the questionnaire to determine if the registered nurses were experienced or
novice nurses and in what healthcare setting they practiced. Other questions that were
asked throughout the questionnaire determined the prevalence of barriers that were
present during the medication administration process. The student researchers found the
use of an online questionnaire with a semantic differential scale most appropriate to
gather the data.
The level of reliability of the research study was questionable because of the short
time span to gather the data. The limited amount of subjects used in the study also
contributed to the questionable level of reliability. The type of subjects the student
researchers questioned were not representative of the target population because the study
26
only used a limited amount of registered nurses within the field, and the subjects were
only from one school. The questionnaire was reviewed by a panel of experts resulting in
face validity.
Data Collection Procedures
The student researchers obtained advisor, International Review Board (IRB),
dean, and department chair approval. After approval, the questionnaire was entered into
the course management system (CMS). Then the researchers sent out an e-mail
containing directions for taking the online questionnaire. The questionnaire was available
through a course management system which protected confidentiality of the participants.
No identifiable data was collected. The students were not coerced into participating and
academic standing was not affected. Also, the participants were informed that the
questionnaire did not have a time limit, but it could take up to twenty minutes to
complete. The questionnaire remained open for two weeks. All participants were given
the same questionnaire to complete. Consent was given upon submission of the
questionnaire by the nurses. Participants could withdraw from the study until the
submission of the questionnaire. Before the survey closed, the researchers sent an email
to remind the participants to take the questionnaire.
Analysis Method
The Spearman rho correlational test and descriptive statistics were used to
analyze the data collected. The test was chosen because it allowed appropriate
measurement of the variables in the study. The correlational test was also reliable
for rejecting the null hypothesis. A correlational statistical test is a data analysis
method that tells if two variables are related. The variables being measured in this
27
particular study are nursing experience and barriers to safe medication
administration. Therefore, the correlational statistical test was used to analyze the
relationship between the variables given. The study was performed with a
confidence level of 0.05.
Limitations
The research study has several limitations to address. Due to time
constraints, the small sample size of students, who have previously been nurses, at
a small university in the Southeast region of the United States limited the study.
Also, the use of non-random convenience sampling affected the study. The small
sample and use of the non-random method of sampling may not have represented
the target population of the study. Having a larger sample and a random sample
may have decreased the probability of statistical error. Finally, the tool, which had
face validity only, was created by the student researchers and therefore could have
been biased. Use of a previously created tool may have made the study more
reliable. The participants were not in a controlled environment; therefore, the use
of outside resources to answer the questionnaire could have influenced the results.
28
Chapter IV
Summary of the Study
The purpose of the study was to determine whether there was a difference
in the number of barriers to safe medication administration between novice nurses
and experienced nurses in the healthcare setting. The stated research hypothesis
was that experienced nurses have more barriers to safe medication administration
than novice nurses in the healthcare setting. The null hypothesis was there is no
significant difference in the number of barriers to safe medication administration
between novice nurses and experienced nurses in the healthcare setting. The
student researchers used the Barriers to Safe Medication Administration
questionnaire which was compiled by a panel of experts. The questionnaire
(Appendix B) consisted of 19 questions, four of which were demographic
questions and 15 of which were semantic differential scale questions based on
barriers in the healthcare setting.
The student researchers collected data from 44 participants total; 34
participants had greater than two years’ experience as a nurse and 10 participants
had less than two years’ experience (Figure 1). There were a total of three males
and 41 females. Of the participants, 25 had the majority of their experience in the
hospital, five in the clinic, six in long term care, four in home health, four in other
areas of healthcare. Of the participants, 26 were medical-surgical nurses, seven
were intensive care nurses, four were emergency room nurses, three were post
critical care nurses, one was a pediatric nurse, and three were labor and delivery
nurses (Figure 2).
29
Experienced* Novice**05
10152025303540
34
10
Figure 1. Breakdown of participants by experience. This figure shows the number of participants who
worked either *two years or longer, or **less than two years.
Med/Surg ICU ER PCU Peds L&D0
5
10
15
20
25
30
26
7
43
13
Figure 2. Breakdown of participants by unit. This figure shows a breakdown of total participants by unit of
experience. Med/Surg = medical-surgical unit. ICU = intensive care unit. ER = emergency room. PCU =
post critical care unit. Peds = pediatric unit. L&D = labor & deliver unit.
Statistical Analysis
Data was coded and entered into SPSS for Spearman Rank Order Correlation
analysis. The Spearman Rho is designed to statistically rank information gathered about
two variables of interest. Then the correlation between those two variables is calculated.
30
The significance level or probability value (p value) used for this research study was
95%, or p = 0.05. The p value designates that the researcher was willing to accept that 5%
of the results were based on chance. If the calculated p value is greater than 0.05, the
correlation between the variables is insignificant. If the p value is less than 0.05, the
correlation between the variables is significant.
After data analysis, the student researchers found that there was no statistical
significant difference between novice nurses and experienced nurses in regards to the
occurrence of barriers to safe medication administration. The correlation coefficient of
0.131 with a p-value of p = 0.198 showed a very low correlation between the amount of
experience versus barrier occurrence (Table 1). The p-value being above 0.05 indicated
that the correlation was not statistically significant.
Table 1Experience versus Barriers
Categories compared rs pYears of experience &Number of barriers 0.131 0.198
Note. p<0.05, one-tailed.
Other findings included which barriers were most often and least often
perceived. Of the 15 barriers to safe medication administration listed on the
questionnaire, the four barriers reported most frequently were understaffing,
interruptions, lack of time, and errors in communication. In contrast, lack of
motivation, lack of access to a pharmacist, and compassion fatigue were
determined to be non-barriers.
31
Overall, the analysis shows that there is no statistical difference between
the amount of nursing experience and the occurrence of barriers during
medication administration. Therefore, the student researchers failed to reject the
null hypothesis. The null hypothesis stated that there is no significant difference
between the number of barriers to safe medication administration between novice
nurses and experienced nurses in the healthcare setting.
Serendipitous Findings
Based on the Spearman Rank Order correlation, there were two
serendipitous findings. An increase in compassion fatigue was reported with an
increase in years of experience. The correlation coefficient was 0.286 and the p-
value was 0.03, although there was a low correlation, it was statistically
significant (Table 2). There was also a correlation between the number of
perceived barriers reported and unit of employment. The correlation coefficient
was 0.355 with a p-value of p = 0.009 (Table 2). The moderate correlation was
statistically significant. Medical-surgical nurses reported the most perceived
barriers, while the pediatric nurse reported the least perceived barriers (Table 3).
Table 2Significant serendipitous findings
Categories compared rs pYears of experience &Compassion fatigue 0.286 0.355Unit &Number of perceived barriers 0.03 0.009
Note. p<0.05, one-tailed.
Table 3
32
Perceived Number of Barriers by Unit
UnitAvg # of Barriers* %
Medical Surgical 13.6 of 15 90.6Intensive Care 13.3 of 15 88.7Emergency Room 12.5 of 15 83.3Labor & Delivery 12.3 of 15 82.0Post Critical Care 11.7 of 15 78.0Pediatric 6 of 15 40.0*Note. Average number of barriers was determined by using survey answers reporting that a barrier was
perceived rarely, sometimes, often, or always.
Alterations from Proposal
There were no alterations to the research proposal.
Limitations of the Study
Limitations in this research study involved sample size, convenience
sampling, location of the study, time, and validity. Conducting the study at a
small university in the Southeast region of the United States limited the
accessibility to the target population. The small sample size of 43 nurses at the
small university, limited the study. The student researchers estimated gathering
results from 30 novice nurses and 30 experienced nurses. Unfortunately, data was
collected from 10 novice nurses instead of 30. Conversely, 34 experienced nurses
participated in the questionnaire. Also, the use of non-random convenience
sampling affected the study. The utilization of the small sample size and use of
the non-random sampling may not exemplify the target population. Increasing the
sample size while using a larger university may have reduced the possibility of
error. Additionally, a random sample may have decreased the probability of
statistical error. In attempt to acquire more participants, the student researchers
left the questionnaire up for three weeks rather than the original two week
33
deadline. The Barriers to Safe Medication Administration questionnaire had face
validity only. Furthermore, the questionnaire was made by the student
researchers, which could have allowed for bias. Employment of a tool already
available may have made the study more dependable. The uncontrolled
environment the participants were in may have influenced their answers and
allowed for the use of outside resources to assist with the questionnaire.
Similar Findings
Based on the literature reviewed, two studies were identified that had similar
findings. Maiden et al. (2011) found that poor communication between the physician and
the nurse, nurse staffing levels, medication packaging, moral distress, and compassion
fatigue were barriers to safe medication administration. The student researchers also
found these to be barriers of safe medication administration of nurses from a small, rural
university in the southeastern United States of America. Dilles et al. (2011) found that
being interrupted during preparation, inadequate knowledge of drug and food
interactions, lack of time for double checking, insufficient information from the
physician, and inadequate knowledge of side effects of medication were barriers to safe
medication administration. Other barriers included: insufficient knowledge on crushing
pills, inability to correctly calculate doses, inadequate knowledge of correct
administration time, insufficient resources for information on the topic, unlimited access
ability to pharmacists. They identified that the three main barriers were interruption,
inefficient knowledge, and lack of interdisciplinary cooperation. The student researchers
also found that interruptions during the medication administration process, time and work
pressure, lack of knowledge or understanding of pharmacology, poor communication
34
between the physician and nurse, and limited accessibility to pharmacists were barriers to
safe medication administration of nurses from a small, rural university in the southeastern
United States of America.
Contradictory Findings
Based on the analysis of the data gathered from the student researchers study, no
contradictory findings were found from the review of literature.
Conclusion
After analysis of the data, the student researchers found that there was no
statistically significant difference between novice nurses and experienced nurses in
regards to the occurrence of barriers to safe medication administration. Although the
student researchers failed to reject the null hypothesis, the study found that compassions
fatigue was more common in the experienced nurses. The study also found that there was
also a correlation between the number of perceived barriers reported and unit of
employment.
35
Chapter V
Summary of the Study
The purpose of the research study was to determine whether novice nurses
or experienced nurses have more barriers to safe medication administration in the
healthcare setting. The research hypothesis stated that experienced nurses have
more barriers to safe medication administration than novice nurses in the
healthcare setting. The student researchers gathered data from the RN to BSN
students, Master of Science in Nursing (MSN) students, and Doctor of Nursing
Practice (DNP) students at a small, rural university in the southeast United States
of America. A non-experimental comparative research design was utilized to
collect data from previously registered nurses. Participants completed an online
questionnaire. The data collected was coded and interpreted by the Spearman
Rank Order Correlation through the use of the SPSS system, with a preset
confidence level of 0.05. With a 0.131 correlation and p-value of 0.198, the
student researchers failed to reject the null hypothesis.
Conclusions of the Study
From the research study, the student researchers failed to reject the null
hypothesis. The null hypothesis stated there is no significant difference between
the number of barriers to safe medication administration between novice nurses
and experienced nurses in the healthcare setting. The student researchers
predicted that nurses with more years of nursing practice would experience more
barriers to medication administration than would new nurses. There was no
statistical data available to support that nurses with more years of practice,
36
experience more barriers to medication administration than did new nurses. The
results of this research study included many uncontrolled variables, which could
have affected the outcome including the limitations of the location the sample was
disclosed to, small sample size, and time.
Implications for Nursing
Current evidence based practice is very important for nurses because
medicine and technology are constantly changing and evolving to improve the
treatments that patients are provided and the outcome or prognosis of patients.
Nurses must stay up to date and practice the most recent evidenced based practice
in order to provide the highest quality of care to their patients. This study
implicates nursing because nurses were able to identify barriers to safe medication
administration. Nurses administer numerous medications to numerous patients on
a daily basis. By identifying these barriers that could potentially cause errors, this
study will then allow for measures to be put in place to minimize the occurrence
of barriers that nurses face during the process of medication administration. The
health care profession can use these findings to further increase patient safety by
preventing future medication errors.
Recommendations
The student researchers believed the research study could have been enhanced in
various ways. One major change to improve the study would have been to survey a
larger sample size of both novice and experienced nurses. This would have given more
credibility to the results obtained by having a more representative sample of the target
population. Additionally, only one institution was utilized in the study. Therefore, if the
37
student researchers expanded the study to several healthcare facilities, the results may
have been more applicable to the nursing profession. Also, the time constraints of the
study possibly could have limited the amount of participation. Thus, allowing more time
to complete the questionnaire possibly could have allowed for a greater number of
applicants. Finally, the student researchers felt that the questionnaire was too broad in
nature. As a result, a more specific questionnaire would have permitted more thorough
findings.
Further research should be conducted to determine the most significant
barrier to safe medication administration affecting both novice and experienced
nurses. Each group of participants cited several barriers impacting safe
medication administration. Thus, additional research concentrating on the single
most influential barrier may lead to more meaningful data. Furthermore,
supplementary research could possibly lead to ways to conduct safer medication
administration. Also, extra research could lead to the elimination of some barriers
to safe medication administration.
38
Appendix A
Consent Form to Dean of MUW College of Nursing & Speech-Language Pathology
Mrs. Shelia V. AdamsMUW College of Nursing & Speech-Language Pathology1100 College Street Columbus, MS 39701
January --, 2013
Dear Dr. Adams,
As baccalaureate senior nursing students, one of our requirements for graduation is to complete a research project. We are requesting your permission to send a questionnaire to the registered nurses enrolled in your graduate and RN to BSN nursing programs. We are researching the comparison of the amount of barriers to safe medication administration between novice and experienced nurses.
This process will take approximately 20 minutes of each participant’s time to complete via blackboard online. Confidentiality will be maintained throughout the study. Consent will also be obtained from each individual participant of the study. The consent form will be at the beginning of the questionnaire. The participants’ names will not be included in the study, therefore maintaining anonymity. We would appreciate your assistance in this matter. We appreciate your cooperation.
Please sign and return to the consent form by January --, 2013 to:Attn: Tammie McCoyFax: 662-___-____
____Yes, permission is granted to conduct the following research study on registered nurses enrolled in these graduate programs. ____No, permission is not granted to conduct the following research study on registered nurses enrolled in these graduate programs.
_____________________________ _________________Signature of Dean Date
Thank you,
Jennifer Allred Rachel Hicks
Amanda Bufkin Kristen Pippin
Andrea Davis Mary Sears
Earika Evans Stephany Vance
39
Appendix B
The Barriers to Safe Medication AdministrationParticipants in this study include registered nurses currently enrolled in RN to BSN, MSN, DNP programs at a university in the southeast region of the United States of America. No incentive or consequence is offered for participation in this study. By submitting this questionnaire, you are consenting to the use of the information provided by you for the purpose of this research study. All submissions will remain anonymous.
Directions: This questionnaire will be available for two weeks. It is estimated to take no more than 20 minutes to complete; however, there will not be a time limit. This questionnaire will maintain confidentiality. Participants can withdraw any time before submission.
1. Gender. o Maleo Female
2. How many years have you practiced as a Registered Nurse?o Less than two yearso Greater than two years
3. Which type of clinical place do you practice as a Registered Nurse?o Hospitalo Clinico Home Healtho Long-term Care Facilityo Other
4. Which area of practice do you have the most experience?o Drop down box: Med-Surg, ICU, NICU, ER, PCU, L&D, Peds
Please rate how each of these barriers have impacted your experiences during safe medication administration on a daily basis throughout your career as a Registered Nurse.
1. Time and work pressure (i.e., get in hurry):o Never a barriero Rarely a barriero Sometimes a barriero Often a barriero Always a barrier
2. Interruptions during the med process:o Never a barriero Rarely a barriero Sometimes a barriero Often a barriero Always a barrier
3. Multiple medications due at the same time:
40
o Never a barriero Rarely a barriero Sometimes a barriero Often a barriero Always a barrier
4. Problems in readability, clarity, and completeness of prescriptions:o Never a barriero Rarely a barriero Sometimes a barriero Often a barriero Always a barrier
5. Lack of knowledge or understanding of pharmacology:o Never a barriero Rarely a barriero Sometimes a barriero Often a barriero Always a barrier
6. Poor communication between physician and nurse:o Never a barriero Rarely a barriero Sometimes a barriero Often a barriero Always a barrier
7. Mental status of patient:o Never a barriero Rarely a barriero Sometimes a barriero Often a barriero Always a barrier
8. Compassion fatigue:o Never a barriero Rarely a barriero Sometimes a barriero Often a barriero Always a barrier
9. Lack of motivation/attitude:o Never a barriero Rarely a barriero Sometimes a barriero Often a barriero Always a barrier
10. Nurse staffing shortage:o Never a barriero Rarely a barrier
41
o Sometimes a barriero Often a barriero Always a barrier
11. Medication packaging o Never a barriero Rarely a barriero Sometimes a barriero Often a barriero Always a barrier
12. Limited accessibility to pharmacists:o Never a barriero Rarely a barriero Sometimes a barriero Often a barriero Always a barrier
13. RN work hours: o Never a barriero Rarely a barriero Sometimes a barriero Often a barriero Always a barrier
14. Work dynamics (i.e., frequent order changes):o Never a barriero Rarely a barriero Sometimes a barriero Often a barriero Always a barrier
15. Medication not being readily available on the floor: o Never a barriero Rarely a barriero Sometimes a barriero Often a barriero Always a barrier
42
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