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Nurses’ Performance Regarding
Administration of High Alert Medication
in Coronary Care Unit
Thesis Submitted for Partial Fulfillment of the Requirement
of Master Degree (Medical Surgical Nursing)
Presented by
Gehan Karawan Sayed Sallam BSN
Faculty of Nursing - Ain Shams University
Faculty of Nursing
Ain Shams University
2016
Nurses’ Performance Regarding
Administration of High Alert Medication
in Coronary Care Unit
Thesis Submitted for Partial Fulfillment of the Requirement
of Master Degree (Medical Surgical Nursing)
Under Supervision of
Prof. Dr. Manal Houssien Nasr Professor of Medical Surgical Nursing
Faculty of Nursing – Ain Shams University
Dr. Mona Nadr Ebraheim Lecturer of Medical Surgical Nursing
Faculty of Nursing – Ain Shams University
Faculty of Nursing
Ain Shams University
2016
Acknowledgments
First and forever, thanks to Allah, Almighty for giving
me the strength and faith to complete my thesis and for
everything else.
Kindest and the most merciful for the all blessings and for
giving me the will and strength for completion of this work. I would
like to express my deeply thanks and profound gratitude to Prof.
Dr. Manal Houssien Nasr, Professor of Medical Surgical
Nursing Ain Shams University for scientific guidance and kind
supervision. It was a great privilege to work under the supervision.
She gave me much of her precious time, experience and
valuable advices to complete this work in the best way. I would
like to express my deeply appreciation and profound respect to.
Prof. Dr. Mona Nadr Ebraheim, Lecturer of Medical -
Surgical Nursing, Faculty of Nursing -Ain Shams University for
valuable instructions, cooperation, guidance, unlimited help and
support throughout this work. Last but not least, my deep
appreciation and thanks to my parent and my family for support
throughout this work.
Gehan Karawan Sayed Sallam
Dedication
I wish to dedicate this work to
My sacrificing parents, my Husband,
family, and my friends who dedicated
their efforts to let this work
come to this final
Contents
List of Contents
Subject Page No.
List of Abbreviations ............................................................... i
List of Tables ......................................................................... iii
Abstract ................................................................................. vi
Introduction ..............................................................................
Aim of the Study .................................................................... 5
Review of literature ............................................................... 8
Subject and Methods ............................................................ 70
Results .................................................................................. 81
Discussion .......................................................................... 106
Conclusion .......................................................................... 131
Recommendations .............................................................. 132
Summary ............................................................................ 134
References .......................................................................... 142
Appendices .............................................................................. I
Arabic Summary ...................................................................ـ ـــ
List of Abbreviations
i
List of Abbreviations
Abbr. Title
Bp : Blood pressure
Bs : Blood sugar
HAM : High alert medication
IV : Intravenous
ISMP : The Institute for Safe Medication Practices
LASA : Look alike sound alike
MAP : Medication administration process
MAR : Medication administration record
ME : Medication error
Mg :Milligram
Mic : Milligram
MRN : Medical Record Number
NANDA : North American Nursing Diagnosis Association
PRN : As needed, as required
SI unit : System international of units
List of Abbreviations
ii
Glossary of selected statistical symbols:
% : Percentage
< : Less than
> : Greater than
No. : Number
p : Probability that observed data is consistent
with null hypothesis.
r : Multiple correlation coefficients
SD : Standard deviation
SPSS : Statistical package for social science
2 : Greek chi squared test, to test the difference in
proportions in two or more independent groups
List of Tables
iii
List of Tables
Table No. Title Page No.
Tables in Review:
Table (1): List of high alert medication classes/
categories .......................................................... 19
Table (2): Systems of measurement and approximate
equivalents ........................................................ 26
Table (3): High Alert Medications and safety
strategies: Adult Patients .................................. 43
Table (4): Types of Medication Errors .............................. 48
Table (5): Categories of Medication Error Classification .... 50
List of Tables
iv
List of Tables
Table No. Title Page No.
Tables in Results:
Table (1): Percentage distribution of demographic
characteristics among nurses included in the
study (n=32) ........................................................... 82
Table (2): Percentage distribution of total nurse’s level of
knowledge regarding high alert medication
administration Study (n=32) .................................. 85
Table (3): Percentage distribution of nurses’ level of
knowledge regarding general pharmacology (n=32) .. 86
Table (4): Percentage distribution of nurse’s level of
knowledge regarding prescription and
calculation of high alert medications (n=32) ......... 87
Table (5): Percentage distribution of nurse’s level of
knowledge regarding routes, preparation and
administration of high alert medication (n=32) ..... 88
Table (6): Percentage distribution of nurses level of
knowledge regarding documentation and
monitoring of high alert medication (n=32) ............. 90
Table (7): Percentage distribution of nurses’ level of
knowledge regarding dispensing and storage of
high alert medication (n=32) ................................. 91
Table (8): Percentage distribution of nurses level of
knowledge regarding patient education of high
alert medication (n=32) ......................................... 92
Table (9): Percentage distribution of total nurses’ level of
practice regarding high alert medications
(n=32) .................................................................... 93
List of Tables
v
Table No. Title Page No.
Table (10): Percentage distribution of nurses’ level of practice regarding preparation of high alert medication alert medication (n=32) ....................... 94
Table (11): Percentage distribution of nurses’ level of practice regarding administration of high alert medication(n=32) ................................................... 95
Table (12): Percentage distribution for neglected practice among all nurses under study regarding administration of high alert medication (n=32) ..... 96
Table (13): Percentage distribution for nurses regarding common high alert medication administration error among nurses (n=32) .................................... 98
Table (14): Nurses attitude regarding high alert medication administration(n=32) ............................................. 99
Table (15): Relation between nurses’ total level of knowledge regarding high alert medication and their demographic characteristics (no=32) .......... 100
Table (16): Relation between nurses total practice level regarding high alert medication administration and their demographic characteristics (n=32) ..... 101
Table (17): Relation between nurses’ total attitude regarding high alert medication administration and their demographic characteristics (n=32) ..... 102
Table (18): Correlation between total nurses’ level of knowledge and attitude regarding high alert medication administration (n=32) ....................... 103
Table (19): Correlation between total nurses’ level of knowledge and practice regarding high alert medication administration (n=32) ....................... 104
Table (20): Correlation between total nurses practice and attitude regarding high alert medication administration (n=32)............................................ 105
List of Tables
vi
Table No. Title Page No
List of Tables in Pilot Study
Table (1): Expertise’s judgment regarding general
evaluation of content validity of nursing
interview questionnaire sheet regarding
knowledge with ….. ......................................... XXVIII
Table (2): Expertise’s judgment regarding general
evaluation of content validity of nursing
interview questionnaire sheet regarding practice
for high alert medication administration ............ XXIX
Table (3): Expertise’s judgment regarding general
evaluation of content validity of nursing
interview questionnaire sheet regarding attitude
for high alert medication administration. ............. XXX
Table (4): Face validity of developed data collection tools
based on agreement. ........................................... XXXI
Table (5): Cronbach’s Alpha reliability analysis. .............. XXXII
Table (6): Reliability coefficient of pilot study No. of
nursing (10) ....................................................... XXXII
List of Figures in Pilot Study
Fig. (1): Job characteristics of expertise group member
(N = 9). .............................................................. XXVII
Abstract
vii
Abstract
High alert medications are drugs that have an increased risk of
causing significant patient harm when they are used erroneously. Nurses
should have adequate knowledge and practices to be able to manage high alert
medications administration process in critical care unit and post
cardiothoracic intensive care unit. Aim: the current study aimed to assess
nurse's performance regarding high alert medication administration in
coronary care unit. Design: a descriptive explanatory study. Setting: the study
was carried out at coronary care units and post cardiothoracic intensive care
unit at Ain shams university hospitals Study subjects: A convenience sample
of 32 nursing staff worked in the previous mentioned setting. Data collection
tools: Nurses self-administered questionnaire, observational checklists and
nurse’s attitude scale toward administration of high alert medication. Results:
the total nurse's level knowledge was unsatisfactory regarding high alert
medication calculation measurement 100.0%, medication preparation 93.8%
and patient education 71.9%, the majority of nurses had unsatisfactory level
of practices regarding, and documentation error of high alert medication,
patient education 100% and monitoring of high alert medication was 65.6 %
respectively. There were significant statistical relation between nurse's
attitude and total score of knowledge, practices age and years of experiences.
There were in significant relation between knowledge, practice and academic
qualification. Conclusion: concluded that about two thirds of nurses under
this study had total unsatisfactory level of knowledge regarding
administration of HAM. While more than two thirds of nurses under study got
unsatisfactory level of practice. While half of them had positive attitude
toward administration of HAM. Recommendation: the study recommended.
The importance of designing education programs related to high alert
medication administration and it should be mandatory for nurses especially
medication calculation course .And it must be linked to all nurses curriculum
in different (diploma, technical, bachelor)
Key words: High alert medication administration, calculation, patient education
Introduction
1
Introduction
rug is a substance used in the diagnosis, treatment, or
prevention of a disease or as a component of a medication.
Medication administration process (MAP) plays a central 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 stage of the MAP, including prescribing,
documenting (transcribing), dispensing, administering, and
monitoring. Medication administration process is a time-
consuming task, taking an estimated up to 40% of nurses‟ work
time (Pirinen, 2015).
Medications are very diverse and have a wide range of
risk profiles. Those with a heightened risk of causing patient
harm are known as high-alert medications; they have serious
consequences for patients when misused (Lehne, 2010).
Attention for high-alert medications is stressed by several
leading organizations. A list of high alert medications for the
general patient population has been developed by the
institute for safe medication practices(ISMP), based on error
reports and expert opinions .The high-alert classification is
also dependent on dosage, the familiarity of the health care
professionals with the medication and the possibility of
careful monitoring (Joint Commission International
Accreditation, 2015).
D
Introduction
2
High-alert medications are medications that are most
likely to cause significant harm to the patient when misused.
Mistakes with these medications may not be more common
but may be more devastating to the patient if an error occurs.
Additionally, the consequence of an error with these
medications is far more devastating for patients in critical
care units. The harm leads not only to patient suffering but
also to additional costs associated with the care of these
patients (Ali, 2016).
Many high-alert medications have a high volume of
use. Examples of high-usage medications include insulin
amongst diabetics, anticoagulants, narcotics, and sodium
chloride for injection, opioids, antiarrhythmics, intrathecal or
epidural medications, radio-contrast agents, anesthetic agents
and neuromuscular blocking agents. Using any of these drugs
increases the likelihood that a patient might suffer adverse
events. Adverse events from these medications represent
areas of greatest harm and greatest opportunity improving
patient safety (Rashidee, 2009).
The major strategies for the safety of the medication
system, focusing specifically on HAM, there are procedures
that can be adopted to prevent medication error(ME) with
these drugs, such as: having a list of HAM, which should be
broadly disseminated; implementing guidelines to the