Evidence Digest

Evidence to Guide Medication and PatientSafety Practices in Hospitals

Section Editor: Bernadette Mazurek Melnyk, RN, PhD, CPNP/NPP, FAAN, FNAP

The purpose of Evidence Digest, a recurring column inWorldviews, is to provide concise summaries of well-

designed and/or clinically important recent studies alongwith implications for practice, research, administration,and/or health policy. Articles highlighted in this columnmay include quantitative and qualitative studies, system-atic and integrative reviews as well as consensus statementsby expert panels. Along with relevant implications, thelevel of evidence generated by the studies or reportshighlighted in this column (see Figure 1) is included atthe end of each summary so that readers can integratethe strength of evidence into their health-care decisions.

• Level I: Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs), or evidence-based clinical practice guidelines based on systematic reviews of RCTs

• Level II: Evidence obtained from at least one well-designed RCT • Level III: Evidence obtained from well-designed controlled trials without randomization • Level IV: Evidence from well-designed case-control and cohort studies • Level V: Evidence from systematic reviews of descriptive and qualitative

studies • Level VI: Evidence from a single descriptive or qualitative study • Level VII: Evidence from the opinion of authorities and/or reports of expert committees

Modified from Guyatt & Rennie, 2002; Harris et al., 2001

Figure 1. Rating system for the Hierarchy of Evidence(from Melynk & Fineout-Overholt 2005).

Harne-Britner S., Kreamer C., Frownfelter P., HelmuthA., Lutter S., Schafer D.J. & Wilson C. (2006). Improvingmedication skills of practicing nurses and senior nursingstudents. Journal for Nurses in Staff Development, 22(4),190–195.

Purpose. The purposes of this study were to: (1) assessmedication calculation skills of nurses and baccalaureatenursing students, and (2) determine the effects of teachingstrategies to improve these skills.

Copyright ©2007 Sigma Theta Tau International1545-102X1/07

Sample. A convenience sample of 22 practicing nurses,who had 4–34 years of experience, and 31 senior baccalau-reate students at one college in the Northeast United States.

Design. Quasi-experimental pilot study.Measures. An investigator developed instrument, the

Medication Calculation Survey, was used to assess: comfortlevel with medication calculation; frequency of performingmedication calculations; patient care workload; availabilityand accessibility of resources for medication calculations;patient care workload; availability and accessibility of re-sources for medication calculations; and preferences forobtaining assistance with medication calculations. Medica-tion calculation tests that focused on IV calculation skillswere developed.

Methods/Procedure. All subjects viewed a 10-minutepresentation that provided general information about med-ical errors, a brief literature review and medication errordata. Following the presentation, subjects completed theMedication Calculation Survey and received a calculatorto complete the Medication Calculation Pretest. Then, sub-jects were allowed to choose one of four interventions toimprove their computational skills, including: (1) a 30-minute classroom tutorial session, (2) a self-study work-book, (3) a self-study using their own references, and (4)no intervention. Four weeks later, participants completedthe Medication Calculation Post-test.

Findings. Forty-one percent of the students and 55% ofthe nurses could not calculate IV medication or flow rateswith 90% accuracy. Students’ pre-test scores ranged from 6to 20, with an average of 15.9; post-test scores ranged from11 to 20, with an average of 17.4 (average increase of 1.5).The nurses’ pre-test scores ranged from 15 to 20, with anaverage of 15.5; post-test scores ranged from 15 to 20, withan average of 18.6 (average increase of 3.1 points). Bothgroups demonstrated a significant increase in pre- to post-test scores. All intervention groups showed improvementfrom pre- to post-test, regardless of the educational strat-egy used. A statistically significant positive relationshipwas found between the nurses’ self-ratings of frequencyof performing medication calculations and higher medica-tion calculation pre-test scores. In addition, students whorated themselves as more comfortable with IV medicationcalculation had higher test scores.

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Commentary with Implications for Clinical Practice andAdministration. Despite the fact that this study was weakin internal validity (i.e., the ability to say that the in-terventions were related to a change in outcomes) andexternal validity (i.e., the ability to generalize the find-ings from the sample to the greater population) due tothe small convenience sample, important findings fromthis study indicate that a large percentage of nurses andnursing students have not mastered IV medication ad-ministration skills and that the act of taking a pre-test onIV medication calculation led to improvements on post-testing. Regardless of what interventions the nurses re-ceived, their post-test scores improved. This has impor-tant implications for clinical practice and administrationin that it appears that the simple act of having nurses andstudents complete a periodic test on medication calcula-tion should lead them to assess their own knowledge andskill set which, in turn, could prompt them to take actionto improve their skills. In essence, the medication testitself may act as a simple intervention to improve themedication administration knowledge and skills set ofnurses and students. Because participants were providedwith calculators, errors were related to lack of knowledgeand skills to solve math problems versus math errors.

Comfort level in performing the calculations as well asfrequency of performing them were related to test scores,which also has important practice implications. In unitswhere nurses are only required to periodically performthese skills, more frequent testing may be necessary tokeep these skills updated. For those nurses who need re-mediation, educational classes or online skills buildingmodules can be developed. Future full-scale randomizedcontrolled trials to determine the best strategy for ensur-ing competency of nurses and nursing students in theirmedication calculation skills are needed.

Level of Evidence: III.

Burke K.B. (2005). Executive summary: The state ofthe science on safe medication administration sympo-sium. American Journal of Nursing, March(Suppl.), 4–9.[For the full report of this symposium, see www.nursi-ngcenter.com/ajnmedsafety]

Purpose. The purposes of this invitational symposiumwere to: (1) describe the state of the science on safe medica-tion administration; (2) delineate barriers to safe adminis-tration of medication; 3) develop approaches to overcomebarriers to safe medication administration, (4) identify gapsin research to facilitate and improve the safety of medi-cation administration by nurses, (5) recommend clinical,educational, research, and policy procedures for safe med-

ication administration across a variety of settings, and (6)create strategies for disseminating the symposium’s find-ings and recommendations.

Participants. The participants were 40 nursing and pro-fessional experts in clinical practice, administration, edu-cation and research, including leaders in regulatory andconsumer sectors as well as representatives from industry.

Design. Invited symposium.Methods. On day one, the symposium began with two

presentations on research and practice issues regarding safemedication administration as well as tragedies caused byerrors in health care delivery. On day two, speakers sum-marized the state of the science on safe medication ad-ministration. An industry panel also addressed the role oftechnology in overcoming systems issues. Participants thenformed small groups to identify barriers to safe medicationadministration and discuss new approaches to overcomethem.

Findings. The seven most significant barriers to safemedication administration identified by this group of ex-perts with several strategies to address them included: (1)lack of a “just culture of safety” [two solutions: partnerwith professional and educational groups as well as or-ganizations to ensure that both undergraduate and con-tinuing education curricula promote safety at all levelsof nursing; give patients “smart” cards containing exten-sive data, including their medications and history, (2)lack of interdisciplinary collaboration and communication(two solutions: educate nurses, physicians, and pharma-cists together; have multidisciplinary panels create stan-dardized practice guidelines); (3) nurses’ working envi-ronment does not support safety (two solutions: createstaffing patterns that allow flexibility in responding tounanticipated changes in patient acuity and volume; re-design nurses’ jobs in ways that make it harder to makeerrors); (4) voices of front-line nurses missing in deci-sion making and systems design (two solutions: providea means for direct caregivers’ input in reporting errors andidentifying areas for change; put nurses on product designteams); (5) difficulties in translating research into prac-tice (involve front-line nurses in well-funded, high-quality,multidisciplinary, multi-site studies; test research and pi-lot projects to see how well new approaches work beforeputting them into practice); (6) policy not driven by ev-idence (two solutions: disseminate research in ways thatmake it accessible to both clinicians and policy-makers;require that evidence drive policy); and (7) insufficientfunding for research (two solutions: develop consumerleadership within the community to convince legislatorsof the need for research; obtain third-party reimburse-ment for projects identified in the literature as effectiveprotocols).

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Commentary with Implications for Administration andFuture Research. Given that medical errors account fora substantial number of hospital deaths each year andthat these errors are the most common types of sucherrors, more initiatives must be devoted to developingevidence-based practices to reduce them. Convening aninterdisciplinary panel of experts was a significant firststep to identifying the major barriers to safe administra-tion and suggesting creative solutions to overcome eachof these barriers. Dissemination of these solutions glob-ally is important so that hospital administrators will takeaction on the suggested solutions in their own institu-tion by implementing key solutions. Further research isgreatly needed to gather solid evidence behind the beststrategies for reducing medical errors for administratorsas well as policy-makers.

Level of Evidence: VII.

Kellog, V.A. & Havens, D.S. (2006). The shift coupon.An innovative method to monitor adverse events. Journalof Nursing Care Quality, 21(1), 49–55.

Purpose. To test the ability of registered nurse (RN) com-pleted Shift Coupons to collect adverse events data in thehospital setting, which included determining: (1) the ex-tent to which adverse events occur, (2) the cause(s) of theadverse events reported, and (3) whether there was a dif-ference between the number of advance events reported onShift Coupons versus on incident reports.

Sample. A random sample of 1,000 RNs were selectedto participate in the study from all RNs living in the stateof Pennsylvania in the United States. A total of 231 RNscontacted the investigators to state that they could or wouldnot participate in the study due to a variety of reasons (e.g.,no direct patient care, retired). Of the 769 remaining RNs,355 returned at least 1 Shift Coupon for a response rate of46.2%.

Design. Descriptive Survey.Measures. The Shift Coupon was used to provide a quick

and easy method to report adverse events. This instrumentconsists of 12 items, most of which asked the RN to checkhis or her answer to the item from the choices provided. Theitems revealed information about: (1) the location wherethe shift was worked; (2) type of unit; (3) hours worked; (4)number and acuity of the patients assigned to the RN; (5)whether an adverse event occurred during the shift and,if so, the type of adverse event; (6) the perceived causeof the adverse event; (7) the consequence to the patient;(8) whether the adverse event could have been prevented;and (9) whether an incident report was completed for theadverse event.

Methods/Procedure. A survey was mailed to the partici-pants along with an instructional sheet on how to completethe Shift Coupon and a Coupon Booklet that contained11 Shift Coupons. Participants were asked to complete acoupon within 1 hour of completing a shift for a total of fiveshifts. After completing five coupons, the RNs were askedto return the completed coupons in the provided postedenvelope.

Findings. A total of 1,937 Shift Coupons were returned,with 1,369 (70.7%) coupons reporting on shifts workedin hospital settings. The highest number of couponswere returned by RNs who worked on medical/surgicalunits (33.4%) and intensive care units (17.8%). On themajority of Shift Coupons (70.9%), nurses reported noadverse events, which left 397 coupons reporting ad-verse consequences. The most common adverse eventswere: (1) patient complaints (e.g., blood pressure cuff ap-plied too tightly), delay in procedures, (2) medication er-rors (18.9%), family complaints (17.6%) and patient falls(12.1%). The most commonly reported reasons for theseadverse events included: lack of staff (36.8%); lack of com-munication (30.5%); and work overload (28.5%). For mostadverse events reported on Shift Coupons (70.5%), the RNsreported that no incident reports were completed. Most of-ten, incident reports were not completed for family com-plaints and medication errors. The majority of unexpectedpatient deaths and falls reported on Shift Coupons werealso reported on incident reports.

Commentary with Implications for Clinical Practiceand Future Research. The major limitation of this studywas that RNs self-reported adverse events on ShiftCoupons as well as information about the completionof incident reports in their clinical settings. A strongerdesign would have been to collect incident report datadirectly from the hospitals and compare it to RNs reportsin order to determine accuracy and reliability of the self-report data. Overall, there were a substantial number ofadverse events reported, with the most frequent occur-rences being patient and family complaints as well asmedical errors. Furthermore, the reasons reported forthese adverse events are very disconcerting, given thatthe nursing shortage is expected to escalate into the nextdecade and most adverse events were linked to a lack ofstaff and communication along with work overload. Thisstudy supported that Shift Coupons may be an excellentmethod for collecting data on adverse events in compar-ison to routinely used incident reports. Further study isneeded to establish construct validity and reliability ofthe Shift Coupon. Randomized controlled trials to de-termine the most effective strategies for improving staffcommunication and diminishing staff overload with newmodels of care are urgently needed.

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Level of Evidence: VI.

Wolosin R.J., Vercler L. & Matthews J.L. (2006). AmI safe here? Improving patients’ perceptions of safetyin hospitals. Journal of Nursing Care Quality, 21(1), 30–38.

Purpose. The purposes of this study were to: (1) de-scribe the current status of patients’ perceptions of theirpersonal safety in hospitals, (2) determine how char-acteristics of patients and hospitals influence perceivedsafety, (3) determine how perceived safety relates toother patient satisfaction issues, and (4) identify howhospitals can maximize patients’ perceptions of safety/security.

Sample. The final sample was comprised of surveys from637,894 adult patients who had been discharged from 495hospitals from all regions of the US (a response rate ofapproximately 25%). The hospitals ranged from 15 to 1,338beds, with a median size of 239 beds. Sixty-two percent ofthe patients were women, with a modal age of 18–34 years.The modal length of hospital stay was 2–3 days.

Design. Descriptive survey.Measures. All data came from the Press Ganey Inpatient

Surveys, which have established construct validity and highinternal consistency reliabilities. Twenty-nine survey items(e.g., degree of safety/security felt in hospital) were rated ona five-point Likert scale from very poor (1) to very good (5).Responses were then transformed into a 100-point scale forthe purposes of reporting the data.

Methods/Procedure. The questionnaires were mailed toadult patients shortly after discharge from the hospital.

Findings. Most of the patients (approximately 93%)rated their perceived safety as good to very good. The av-erage safety rating was 87.8. In terms of age and safety,older men, 50–79 years of age, felt safer than younger ones,but younger women (i.e., up to age 34 years) felt saferthan older ones. Patients who were given more informa-tion about patient rights and related topics at registrationfelt safer than those given less information. Perceptions ofsafety declined with an increased length of stay. Patientswithout roommates felt significantly safer than patientswho shared a room. Ratings of safety correlated positivelywith ratings of personal dimensions of care. Findings alsoindicated that hospitals can maximize patients’ perceptionsof safety/security through using private rooms when possi-ble, keeping length of stay low, responding to concerns andcomplaints, and tending to patients’ emotional and spiri-tual needs.

Commentary with Implications for Clinical Practice,Administration and Future Research. Although this re-search was a descriptive study that cannot support causeand effect relationships, its generalizability is tremen-dous based upon the large numbers of hospitals in-cluded across the US. However, it must be acknowledgedthat hospitals participating were those interested in pa-tient safety and, therefore, may be instituting more mea-sures to ensure it. In addition, although the responserate was typical for mailed surveys (i.e., 25%), the non-responding individuals could have had lower percep-tions of patient safety and chose not to respond, whichcould have skewed the findings more positively. Patientswho perceived greater safety were those who receivedmore detailed information about the hospital practices.Therefore, hospital administrators and nurses should en-sure that all patients entering acute care hospitals receivean informational session on these issues. In addition,keeping open lines of communication and handling pa-tient complaints sensitively should lead to higher per-ceptions of patient safety along with tending to patients’emotional and spiritual needs. Future research is neededto determine whether ratings of perceived safety are re-lated to actual numbers of adverse events in hospitals.Randomized controlled trials also are needed to deter-mine the most effective strategies for enhancing patients’perceptions of safety. In addition, it would be interestingto conduct a study to determine if perceptions of patientsafety are related to their health outcomes (e.g., lengthof stay).

Level of Evidence: VI.

ReferencesGuyatt G. & Rennie D. (2002). Users’ guides to the medical

literature. Washington, DC: American Medical Associa-tion Press.

Harris R.P., Hefland M., Woolf S.H., Lohr K.N., MulrowC.D., Teutsch S.M. et al. (2001). Current methods ofthe U.S. Preventive Services Task Force: A review of theprocess. American Journal of Preventive Medicine, 20(3,Suppl.), 21–35.

Melnyk B.M. & Fineout-Overholt E. (2005). Evidence-based practice in nursing & healthcare. A guide tobest practice. Philadelphia: Lippincott, Williams &Wilkins.

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