Intravenous Administration (IV) of drugs is a common practice nowadays that involves several different stages, amongst which the phases of medication preparation and administration are frequently delegated to nurses. This procedure is potentially hazardous and carries with it a multitude of risks if any lapse in the proper administration of medications occurs. The following paper discusses the article “Errors in the administration of intravenous medication in Brazilian hospitals” by Anselmi, Peduzzi, & Santos (2007) and critically reviews it. The paper is divided in to several sections, each of which critically review the different sections covered in the article.
This article is entitled “Errors in the administration of intravenous medication in Brazilian hospitals (Anselmi, Peduzzi, & Santos, 2007).” This title adequately describes the study being conducted and its purpose and throws light on the settings in which this study is being carried out i.e. Brazilian hospitals. Moreover, it has the advantage of being precise and to the point, so that the attention of the readers is grasped and they want to read on (Parahoo, 2006). Furthermore, it is simple and unambiguous and thus easily understandable for all groups of readers ranging from professionals to students. However, one limitation of this title is that it does not indicate the type of study being conducted, for example, qualitative versus quantitative, prospective versus retrospective, etc. Thus, it becomes difficult for the readers to gauge from the title whether the article is relevant for them.
The abstract of an article is one of the most important parts of an article as it determines whether a reader would continue reading an article or not (Parahoo, 2006). The abstract of this article is concise yet comprehensive and adequately summarizes all the sections of the article adequately except for the methodology section, which in my opinion, should more explicitly describe the study design, data collection and analysis method, etc. Moreover, the results should have included some statistics about the important findings as figures have a greater impact and are more effective than words in the effective communication of the significant outcomes of the study conducted. In totality, the article provides a reasonable overview of the article but lacks in that it does not elaborate on the methodology and does not emphasize the important results using statistics.
The introduction section of an article is aimed at identifying the research problem, to determine the magnitude of the problem in the society and to provide the rationale behind carrying out the study (Parahoo, 2006). The introduction of this article starts with providing an overview of the structure and functioning of the nursing workforce in Brazil and then moves on to discuss the different professional policies regarding nursing practice which exist. The problem of the increasing recruitment of lesser skilled workers in the place of professional nurses is then pointed out and its potential hazards outlined (Sorio, 2002 cited in Anselmi, Peduzzi, & Santos, 2007). The introduction then provides a background on IV drug administration, its potential risks and the possibility of errors at different phases of this process which can have implications for the patient and also to the society as a result of the costs associated with these errors. All these facts give the reader a clear idea of the rationale and purpose of the study. Moreover, the introduction also highlights the magnitude of the problem in various regions of the world and presents findings of the different studies conducted in this regard till date (O’Hare et al., 1995; Cousins et al., 2005 cited in Anselmi, Peduzzi, & Santos, 2007). Furthermore, the introduction also points out the lapses and limitations of previously conducted studies in the region viz. the use of questionnaires/interviews or error notification reports as a measure of the burden of this problem (Bueno et al., 1998; Carvalho et al., 1999 cited in Anselmi, Peduzzi, & Santos, 2007) and the lack of studies involving direct observation of worker’s performance (Anselmi, Peduzzi, & Santos, 2007). Thus, the authors effectively justify the basis of carrying out this study. An additional strength of the introduction of this article is the explicit operational definition of the variables involved such as medication preparation and medication administration (Anselmi, Peduzzi, & Santos, 2007). Thus, the introduction provides an adequate background and rationale for the study and clearly states the problem and its magnitude.
The literature review provided in an article provides an in-depth view of the research done on the topic. It should be based on an extensive review of literature and discuss all aspects of the topic in question (Parahoo, 2006). The literature on errors related to IV drug administration is adequately reviewed by the authors, and in addition to the region concerned, i.e. Brazil, studies from other regions of the world have also been quoted (Taxis & Barber, 2003b; Wirtz et al., 2003 cited in Anselmi, Peduzzi, & Santos, 2007). A fair number of primary sources have been used. Most of the studies quoted support the author’s claims that there is a high incidence of medication administration errors throughout this world and no literature to contradict this claim has been quoted. Most of the literature qouted is fairly recent, however, the studies qouted for Brazil are a bit outdated and more recent studies should have been included, if they exist. Overall, the literature review is pertinant to the study being conducted, is logically organised and provides an insight to the reader of the research which has already being conducted on this subject.
Hypothesis and research question
The authors of this study hypothesized that, as previously identified, the two most important factors which determined the proficiency of nursing personnel were knowledge and technical skills, and thus those who had acquired these characteristics were less likely to perform erratically (Anselmi, Peduzzi, & Santos, 2007). This study had the aim of determining the frequency of errors in the admininstration of intravenous medication preparation and administration by direct observation, in the setting of three hospitals in Brazil, focusing on workers who had taken the PROFAE professionalization course, which is recommended by the Ministry of Health in Brazil (Brasil, 2001; Baraldi, 2005 cited in Anselmi, Peduzzi, & Santos, 2007). The study objectives are explicit, goal-directed and concise. They are researchable and complement the introduction and literature review provided. Moreover, they are designed in such a way that they tend to serve the purpose of overcoming the shortcomings in the existing literature.
The study conducted was a cross-sectional study undertaken in three hospitals of Brazil over a period of approximately eight weeks (Anselmi, Peduzzi, & Santos, 2007). The study design chosen was appropriate according to the study aims. The use of any other study design such as case-control, in which a comparison of the knowledge and skills of the nurses amongst those who encountered problems due to errors in IV medication administration and those who didn’t would have been required, and cohort, which would have meant comparing the error rates amongst nurses who had received training under the PROFAE professionalization course and those who hadn’t, would have been ethically, statistically and functionally incorrect.
In this article, the operational definitions of the variables being used are clearly stated. The most important variable in this study is the IV medication error which was defined as “a dose prepared and/or administered by nursing personnel different than that prescribed by the physician and on the patient’s records (Allan & Barker, 1990; Wirtz et al., 2003; Cousins et al, 2005 cited in Anselmi, Peduzzi, & Santos, 2007).” The four types of errors which can be committed were identified by the authors viz. wrong patient, wrong drug, wrong dose and dose omission (Allan & Barker, 1990; Barker et al., 2002; Han et al., 2005 cited in Anselmi, Peduzzi, & Santos, 2007). For the purpose of simplifying data organization and analysis, the errors were grouped in to those which can occur in the medication preparation phase and those which can occur during administration phase (Allan & Barker, 1990 cited in Anselmi, Peduzzi, & Santos, 2007). The statement and defining of the variables involved in the study removes ambiguities and eliminates any possibility of doubts arising in the readers mind, thus contributing towards the strength of the study.
Sample and Sampling procedure
In this study, convenience sampling was undertaken which was appropriate, given the operational, logistic and financial limitations of the study (Anselmi, Peduzzi, & Santos, 2007). Using appropriate statistical tests, the sample size was calculated to be 21 subjects per professional category, for each hospital (Anselmi, Peduzzi, & Santos, 2007). However, the actual sample size for each hospital was less than this calculated sample size due to the limitations of the hospital having less than the required number of workers and sample losses due to various reasons (Anselmi, Peduzzi, & Santos, 2007). There were no specific inclusion and exclusion criteria specified for the selection of subjects. However, inclusion and exclusion criteria for hospital selection were explicitly mentioned (Anselmi, Peduzzi, & Santos, 2007). The sampling procedure and the sample size used in this study are appropriate and modulated according to the study design and limitations.
The sample used in this study can be used as a representative sample since it is comprised of subjects recruited from three different hospitals in Brazil which diminishes selection bias. The use of such a representative sample improves the strength of the study as it contributes towards the generalizability of the results.
Instrument or Data collection tools and Data collection procedure
As mentioned before, this study is unique in that it used the direct observation of the health care provider while medication administration as the data collection method. This data collection tool was prevalidated via a study previously conducted in the outpatient settings two years prior to this study (Anselmi, Peduzzi, & Santos, 2007).
The data collection procedure was carried out once a week whereby an observer accompanied the nursing personnel on their allocated activities. The role of the observer was to verify the medications and dosages for each patient using the hospital records and recording them, to observe the nursing worker in the performance of medication preparation and administration and monitor whether the nurses checked the patient’s name, medication, dosage and route of administration before administration of the drug (Anselmi, Peduzzi, & Santos, 2007). Moreover, in case an error was identified, the role of the observer was to intervene and prevent the occurrence of an error. Although in such a case, the error was recorded despite the fact that it had not actually occurred (Anselmi, Peduzzi, & Santos, 2007). The prevention of actual occurrence of the errors once they were identified was crucial from the ethical perspective.
The observers were required to document the data in to two separate checklists for the preparation and the administration phases (Anselmi, Peduzzi, & Santos, 2007). This was essential since in a vast majority of cases, different individuals performed the tasks of medication preparation and administration for the same patient. The process of data collection took place on weekdays and on the time of the day when most frequent administration of medications took place (Anselmi, Peduzzi, & Santos, 2007).
An important factor which contributes towards the strength of this study is the multitude of steps taken to prevent information bias. These include pre-testing the data collection tool and carrying out a pilot study to ensure the validity of the results (Anselmi, Peduzzi, & Santos, 2007). In order to reduce variability amongst the different observers, training of the observers and supervisors was undertaken whereby the data collection procedure was demonstrated and taught to the observers and was standardized (Anselmi, Peduzzi, & Santos, 2007). Moreover, elaborate instruction on how to fill the checklists were provided to the observers to aid in the data collection and registration process (Anselmi, Peduzzi, & Santos, 2007).
This article clearly outlines the data collection procedure and highlights the steps taken to reduce bias and thus ensure the validity of the finding. Such a comprehensive description of the data collection procedure helps in replication of the study methodology by other studies conducted in the future.
The data which was collected was entered and stored into a FOX-PRO databank and analyzed using Statistical Package for the Social Sciences (SPSS) version 10.0. The error rate was calculated as percentages which were obtained by dividing the number of instances of drug administrations during which errors were recorded by the total number of drug administration instances (Allan & Barker, 1990; Flynn et al., 2002 cited in Anselmi, Peduzzi, & Santos, 2007). The confidence intervals were calculated for these error rates and the p-value or alpha was set at 0.5 or 5%. The minimum and maximum values for error rates were also calculated (Anselmi, Peduzzi, & Santos, 2007).
The results revealed that the overall error rates in all three hospitals were low (Anselmi, Peduzzi, & Santos, 2007). The most frequent type of errors during medication preparation phase were omission dose errors followed by wrong dose errors. There were no instances of wrong patient errors recorded in the all three hospitals (Anselmi, Peduzzi, & Santos, 2007). On the other hand, for the drug administration phase, wrong dose were the most common followed by dose omission errors (Anselmi, Peduzzi, & Santos, 2007). The results of the study are clearly stated and the pertinant findings are emphasized. Moreover, the authors have made appropriate use of tables for the organised and effective presentation of results.
Relaibility and Validity
The authors of this study took several steps to ensure the reliability of findings of this study and improve the validity of the results. One of themost important facotrs which led to improved validity was the use of the direct observation method. Moreover, several steps were taken to reduce information bias such as prevalidation of the data collection tool, conducting a pilot study, training of the observers and supervisors and provision of guidelines on how to record data in the checklists (Anselmi, Peduzzi, & Santos, 2007). All these steps helped in reducing the variability of the data cllected and contributed towards tge validity of the results.
From the perspective of research ethics, this study was conducted after obtaining ethical approval from the Research Ethics Committee of the University of Sa˜o Paulo Nursing School (Anselmi, Peduzzi, & Santos, 2007). Moreover, on an individual basis, each study participant was given a clear description of the study objectives and its protocol and informed consent was obtained. The confidentiality and anonymity of the study participants was also ensured (Anselmi, Peduzzi, & Santos, 2007).
Another important aspect of this study which can lead to an ethical dilemma was the question of what to do in case an error was identified by the observer. It would have been ethically incorrect to turn a blind eye to and ignore the error and letting the nursing personell to carry out their tasks without interference. This problem was overcome by intervention on the part of the observers when any error was identified and subsequent rectification of the error in order to eliminate anny possibility of harm to the patient (Anselmi, Peduzzi, & Santos, 2007).
This study is has important implications for clinical practice. This study is relevant to the everyday practice of nurses since the IV drug administration is one of the most common tasks performed by nurses and thus it is a potential area where errors can be committed (Anselmi, Peduzzi, & Santos, 2007).
This study makes an important contribution towards nursing practice since it identifies the areas in which errors most commonly occur and the causes of such errors. This helps in determining areas where intervention strategies can be implemented in order to reduce the occurrence of errors. Moreover, it also identifies that education and skills training of nurses can help in reduction of such errors. Thus, programs such as the PROFAE professionalization course should be devised and implemented on a wide scale.
Discussion and Conclusions
The authors effectively discuss their results and compare them with previously quoted literature in the discussion section of their paper. The discussion is well organized and provides explanations to account for the differences in the results of this study and previously conducted studies. The authors also correctly identify the limitations of their study viz. the variability in the number of doses observed in each hospital and the short time duration over which the study was conducted. Moreover, they also identify potential areas for future research on this subject and emphasize the pressing need for similar large scale observational studies conducted on a nationwide scale. In the end, the authors conclude that the error rates observed in their study are ,ower than those observed in other national and international studies. They identify the most common types of errors in the preparation and administration phases viz. ommission dose and wrong dose, respectively.
Anselmi, M. L., Peduzzi, M., & Santos, C. B. (2007). Errors in the administration of intravenous medication in Brazilian hospitals. Journal of Clinical Nursing , 16: 1839–1847.
Allan EL & Barker KN (1990) Fundamentals of medication error research. American Journal of Hospital Pharmacy 47, 555–571.
Baraldi S (2005) Supervisa˜o, Flexibilizac¸a˜o e desregulamentac¸a˜o no mercado de trabalho: antigos modos de controle, novas incertezas nos vı´nculos de trabalho da enfermagem. Tese, Escola de Enfermagem/ USP, Sa˜o Paulo, SP.
Barker KN, Flynn EA, Pepper GA, Bates DW & Mikeal RL (2002) Medication errors observed in 36 health care facilities. Archives Internal Medicine 48, 1931–1937.
Brasil (2001) Secretaria de Gesta˜o de Investimento em Sau´ de. Projeto de Profissionalizac¸a˜o de Trabalhadores da A ´ rea de Enfermagem (PROFAE). Revista Formac¸a˜o 1, 7–12.
Bueno E, Cassiani SHB & Miquelin JL (1998) Erros na administrac ¸a˜o de medicamentos: fatores de risco e medidas empregadas. Revista Baiana de Enfermagem 11, 101–119.
Carvalho VT, Cassiani SHB, Chiericato C & Miasso AI (1999) Erros mais comuns e fatores de risco na administrac¸a˜o de medicamentos em unidades ba´ sicas de sau´ de. Revista Latino-am Enfermagem 7, 67–75.
Cousins DH, Sabatier B, Begue D, Schmitt C & Hoppe-Tichy T (2005) Medication errors in intravenous drug preparation and administration; a multicentre audit in the UK, Germany and France. Quality and Safety in Health Care 14, 190–195.
Flynn EA, Barker KN, Pepper GA, Bates DW & Mikeal RL (2002) Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. American Journal of Health System Pharmacy 59, 436–446.
Han PY, Coombes ID & Green B (2005) Factors predictive of intravenous fluid administration errors in Australian surgical care wards. Quality and Safety in Health Care 14, 179–184.
O’Hare WCB, Bradley AM, Gallagher T & Shields MD (1995) Errors in administration of intravenous drugs. British Medicine Journal 10, 1536–1537.
Parahoo, K. (2006). Nursing Research: Principles, Process and Issties. London: Palgrave Macmillan. Houndmills Basingstoke.
Polit, D.F. & Beck, C. (2004). Essentials of nursing research: Methods, appraisal, and utilization. (7th ed.) Philadelphia: Lippincott.
SPSS 10.0 (1999) Statistical Program for Social Sciences, versa˜o 10.0 Base 10.0. User’s Guide Copyright by SPSS Inc., Chicago, IL.
Streubert, H. (1998). Evaluating the qualitative research report. In J. Haber & LoBiondo Wood (Eds). Nursing research: Methods, critical appraisal, and utilization (4th ed., pp. 445 465). St Louis: C.V.Mosby.
Taxis K & Barber N (2003b) Ethnographic Study of Incidence and Severity of Intravenous Drug Errors. Web.
Wirtz V, Taxis K & Barber ND (2003) An observational study of intravenous medication errors in the United Kingdom and in Germany. Pharmacy World and Science 25, 104–111.