Wrong Time Medication Administration Errors and Its Association with Demographic Variables among Nurses in Tertiary Care Hospitals, Karachi

Raja¹, Badil², Sajid Ali³

1. Staff Nurse, Department of Plastic and Reconstructive Surgery, Dr. Ruth K.M. Pfau, Civil Hospital, Karachi, Pakistan.

2. Assistant Professor, Institute of Nursing, Dow University of Health Sciences, Karachi, Pakistan.

3. Lecturer, Liaquat National College of Nursing, Karachi.

http://doi.org/10.36570/jduhs.2019.1.637

ABSTRACT

Objective:To determine the frequency of wrong time medication administration errors and find out its association with demographic variables.

Methods: A hospital based cross sectional analytical study was accomplished at Dow University Hospital and Dr Ruth Pfau Civil Hospital, Karachi from November 2017 to June 2018. validated questionnaire was adapted for data collection. Demographic questionnaire was filled through interview and followed by direct observation of the subjects while nurses were administrating medication to the patients.

Results:Out of total 204subjects, 106 (52%) were male participants. Large number 168 (82.3%) of the study participants age was less than 35 years. Almost half 97 (47.5%) had working experience of less than 5 years. Frequency of wrong time medication administration error was found 56/204 (27.5%).Wrong time medication administration error was statistically associated with Hospital (p-value 0.019) and working area of the nurses (p-value 0.023). On the comparison of wrong time medication administration error between the hospitals, education (p-value 0.025) and time of medication administration (p-value 0.038) found statistically significant in Dow University Hospital. While, significant association was established in working Area (wards) of the nurses(p-value0.010)and time of medication administration(p-value <0.001) in Dr. Ruth K.M. Pfau Civil Hospital, Karachi.

Conclusion:High frequency of wrong time medication administration error was found among nurses. Hospital and nurses working area (wards) were found statistically significant with wrong time medication administration error.

Keywords: Wrong time medication administration errors, Associated factors, Nurses, Tertiary Care Hospitals, Karachi.

Correspondence to: Raja,E-mail: rajakhatri33@gmail.com

INTRODUCTION

Medication administration error (MAE) is theleading risk factor for the patients safety. It has severe deleterious effects including prolonged hospital stay, excessive cost, discomfort, harm, and death.^1,2 MAE may happen at any point, from prescription to administration. Nurses playvital role in medication administration because it is a prime and routine responsibility of nurses. Furthermore, nurses spent 40% of their working period on medication administration.³For patient safety, nurses are accountable to administer the right drug in the right dose at the right time to the right patient by the right route. Therefore, nurses double and triple-check the medicine, its dosage, and patient identification, to administer the medication by the right time and right route and thoroughly monitor the patient.⁴

Recent research study has revealed that at minimum one medication error occurs on the hospitalized patientsper day.⁵It has been documented by the National Patient Safety Agency that globally wrong time medication administration error (WTMAE) is the 2^ndmost common type of error, which may be life-threatening to the patients.⁶ Consequently, due to medication administration error, more than 4 million patients examine at the health care sectors, and 117,000 hospitalized yearly.⁷ In addition, thousands of admitted patients die annually in America only, ranging from 44,000 to 98,000. Besides, for this reason, around 77 million dollars as extra expenditures are wasting on such type of effects annually.^8,9 Whereas, almost half of the medication-related adverse effects are preventable.¹⁰

The rationale of this study is that varying findings results are reported in literature regarding the WTMAE both nationally and internationally.^6-11 Therefore, we conducted this study with the aim to determine the frequency of wrong time MAEs and its association with demographic variables.

METHODS

This cross-sectionalanalytical study was conducted at Dow University Hospital and Dr. Ruth Pfau Civil Hospital, Karachi. Time periodof this study was eight months of periods from November 2017 to June 2018. Nurses having one-year clinical working experience and registered with Pakistan Nursing Council were approached for the study. Subjects having less than one-year clinical experience and studentsnurses were excluded from the study. Data were gathered through non-probability purposive sampling method.

Validated proforma was used to collect data and which tool was adopted from previous published research, which was conducted in Ethiopia¹. The reliability of the tool was (r) = 0.72 computed by Cronbachs alpha test. The study protocol was approved by Institutional Review Board of Dow University of Health Sciences, Karachi(IRB-968/DUHS/Approval/2017/11). Moreover, data collection permission was granted from both respective hospitals. Informed written consent was taken from all participants prior to the data collection. Secrecy of the data collection was also guaranteed. Demographic questionnaire was filled by principle investigator (PI) through interview and followed by direct observation of the participants while nurses were administrating medication to the patients. During the observation the participants were assessed for exact time of medication administration, after that it was validated with the doctors order to identify the wrong time medication administration error. Subjects were assessed working in morning, evening and night shift during the entire week.

Statistical package for Social Sciences (SPSS) version 21.0 was utilized for data entry and data analysis. Qualitative variables such as educational status, gender, working area,duty shift were computed in frequency and percentages. Whereas, quantitative variables like working experience, age of the participants, nurse to patients ratio were presented in mean and standard deviation. Chi-square test was applied to determine the association of wrong time medication administration errors with demographic variables.Significance level was considered at a p-value ≤ 0.05.

Figure 1: Frequency of Wrong Time Medication Administration Errors (n= 204)

Table 1: Association of wrong time medication administration error with socio- demographic factors (n= 204)
	Error		No Error		Chi-Square	p-value
	n	%	n	%
Age (year)
25-30	18	20.45	70	79.55	5.8	0.053
31-35	23	28.75	57	71.25
≥36	15	41.67	21	58.33
Gender
Male	26	24.53	80	75.47	0.350	0.207
Female	30	30.62	68	69.38
Education
Diploma in Nursing	32	24.24	101	76.52	0.143	0.094
BS. Nursing	24	33.80	47	66.20
Hospital
DUH	7	14.90	40	85.10	0.039	0.019
CHK	49	31.21	108	68.79
Experience
1- 5 years	21	21.65	76	78.35	4.589	0.088
6- 10 years	13	26.54	36	73.46
> 10 years	22	38	36	62
Working Area (wards)
Surgical ward	23	39.00	36	61.00	14.395	0.013
Medical ward	23	33.80	45	66.20
ENT ward	5	18.50	22	81.50
Ortho ward	1	6.30	15	93.80
Gynae ward	3	14.30	18	85.70
Private room	1	7.70	36	61.00
Patients ratio
1 - 10	16	22.86	54	77.14	1.250	0.535
11 - 15	17	31.48	37	68.52
>15	23	28.75	57	71.25
Time of medication administered
10 am	45	41.28	64	58.72	3.317	0.190
2 pm	10	22.73	34	77.27
10 pm	1	2	98.0	98
CHK: Civil Hospital Karachi, DUH: Dow University Hospital, n: number Chi-square test applied, p-value <0.05 taken as significant

RESULTS

A total of 204 nurses were included for the study. There were 106 (52%) male and 98 (48%) female. Large number 168 (82.3%) of the subjects had age less than 35 years. Majority of133 (65.2%) of study participants had graduated in nursing diploma. With respective to experience, 97 (47.5%) of the subjects had experience up to 5 years. Most of 109 (53.4%) the subjects were working in morning shift duty. Nearly one-third 80 (39.2%) of the subjects had administered medication to more than 15 patients.

Figure 1 exhibits frequency of wrong time medication administration errors among nurses. 56 (27.45%) nurses committed WTMAE while 148 (72.55%) did not do WTMAE.

The association of wrong time medication administrated errors with socio-demographic characteristics showed thatage group ≥ 36 years age committed more 15 (41.67%) wrong time medication administration errors. However, association of variable age with wrong time medicationadministration error was not statistically significant, butvery close to significant (p-value 0.053). In gender, more wrong time medication administration errors 30(30.62%) have been reported in female nurses. Whereas, wrong time medication administration error was not found significantly associated with gender variable (p-value 0.207). As for as education concern, more wrong time medication administration error 24 (33.80%) was found in BS. Nursing graduated nurses but it was not significantly associated with education variable (p-value 0.094). (Table 1)

Regarding wrong time medication administration error in hospitals, hospital "B" experienced most of the wrong time medication administration error 49 (31.21%). Moreover, the significant association of wrong time medication administration error was observed with hospital variable (p-value 0.019).

When compared to on basis of experiences, more wrong time medication administration error 22 (38%) was found in nurses who had more than 10 years working experiences. While its significant association was not established with experience variable (p-value 0.088).

Majority of 50 (50%) wrong time medication administration error was happened in pediatric ward. Furthermore, significant association of wrong time medication administration error was determined with working area of nurses (p-value 0.013). In patients ratio, nurses who administered medication 11 to 15 patients committed many of wrong time medication administration error 17 (31.48%). Conversely, the significant association of wrong time medication administration error was not confirmed with patient ratio variable.

Most of the 45 (41.28%) wrong time medication administration error was occurred at time 10am by nurses during medication administration. On the other hand,its significant association was not proven with time of medication administered variable (p-value 0.190).

Table 2: Comparison of wrong time medication administration error between the hospitals (n= 204)
Variables	DUH						CHK
	Error	No Error			p-value		Error	No Error		p-value
	n (%)	n (%)					n (%)	n (%)
Age (year)
25-30	3 (16)	16 (84)	0.053			15 (22)		54 (78)	0.073
31-35	2 (8)	22 (92)				21 (37)		35 (63)
≥36	2 (50)	2 (50)				13 (41)		19 (59)
Gender
Male	5 (16)	26 (84)	0.741			21 (28)		54 (72)	0.406
Female	2 (13)	14 (87)				28 (34)		54 (66)
Education
Diploma	1 (4)	24 (96)	0.025*			31 (29)		77 (71)	0.314
BS. Nursing	6 (27)	16 (73)				18 (37)		31 (63)
Experience
1- 5 years	3 (9)	31 (91)	0.059			18 (29)		45 (71)	0.355
6- 10 years	4 (31)	9 (69)				9 (25)		27 (75)
> 10 years	0 (0)	0 (0)				22 (38)		36 (62)
Patients ratio
1 - 10	7 (15)	39 (85)	0.672			9 (38)		15 (62)	0.739
11 - 15	0 (0)	0 (0)				17 (31)		37 (69)
>15	0 (0)	1 (100)				23 (29)		56 (71)
Time of medication administered
10 am	2 (10)	18 (90)		0.039^*		43 (48)		46 (52)	<0.001^*
2 pm	5 (33)	10 (67)				5 (17)		24 (83)
10 pm	0 (0)	12 (100)				1 (3)		38 (97)
CHK: Civil Hospital Karachi, DUH: Dow University Hospital, n: number Chi-square test applied, *p-value significant

The comparison of wrong time medication administration error with socio-demographic factors between the hospitals showed thatage variable is also insignificant with WTMAE. Age variable represents that more errors done by younger nurses in both hospitals. Similarly, more errors found in less experienced participants. Association of WTMAE with age and experience found insignificant (p-value ≥0.05). Most of the medication errors committed by male nurses rather than female nurses in both Dow University Hospital and Dr. Ruth K.M. Pfau Civil Hospital.While, association with gender were also found statistically insignificant (p-value ≥0.05). Higher errors were noted among diploma passed nurses in either hospital. Moreover, the association of WTMAE and education was found significant (p-value 0.025) in DUH but insignificant in Dr. Ruth K.M. Pfau Civil Hospital. Higher errors recorded in the gynae ward of both hospitals. On the other hand, the significant association was established in Dr. Ruth K.M. Pfau Civil Hospital (p-value 0.010) but not in DUH with wrong time. Majority of errors were noted in those nurses who administered medication to more than fifteen patients. However, the significant association of patient ratio and wrong time medication administration error was not confirmed. Mostly wrong time medication administration errors were happened at night time by study participants during medication administration. Along with, its significant association was confirmed with WTMAE in both hospitals (p-value 0.039 and <0.001). (Table 2)

DISCUSSION

Medication error is a major risk factor for patient safety. The findings of this study showed that 27.5% of the nurses administered medication on wrong time. Somewhat similar finding was reported in a study in which dose error has been documented most common error that accounts for 34.8%.¹¹ Although, another study showed that WTMAE is a foremost type of error, which accounts 72.6%, and followed by the missed dose error and unauthorized medicine error.¹² Large number of 53.6% wrong time medication administration errors has been documented in a study accomplished in Ethiopia.¹ Causal factors which may leads to the MAEs are the shortage of nursing staffs, lack of pharmacological knowledge, unexperienced nurses and improper communication between nurses, un-understandable doctors writing and inappropriate work division.^13-15

Research study conducted in Pakistan, shown that error rate is 21%, amongst; WTMAE was reported as a major type of error.¹⁶One more updated research study determined very high frequency of MAE that is 82.1%. Among them, missed dose error was the most common and after that wrong time medication administration.¹⁷ In Karachi, Pakistan, 17% of medication doses administered on wrong time while 7.5% missed doses have been recorded in a private health care organization.⁶Another study revealed that, MAEs usually carried out by nurses because who they directly involved in medication administration process.¹⁸ This finding is not very far from the study conducted in Netherlands 25.4%.¹⁹ However, a study conducted in Iran disclosed that 41.7% and 47.7%administered medication on wrong time.^20,21 Percentage of such types of error may be reduced if nurses follow the proper protocol of medication administration.²² Hence, continue nursing education (CNE) regarding medication administration should be provided to the nurse because nurses are the last person in the medication process to rectify any error before it happening. Thus, determining the causes of wrong time MAE and their solution should be the utmost importance for every health care organization.

Result of current study showed that 80 (39.21%) of the study subjects administered medication to more than 15 patients. Working area (wards) of the nurses was found to be statistically significant with wrong time medication administration errors. In contrast, a Malaysian study revealed that nurses working in ICU committed less medication errors.²³This might be due to the patients ratio. In wards wrong time errors may happens because of high workload thats why nurses are more prone to medication errors. In this study, we havent found statistically significance between wrong time medication administration errors and nurses age, gender, work experience and education. Similarly, the research studies accomplished in different areas of the Iran also not found statistically significance with stated demographics.^24-26

In present study, most of participants age was between 25-30 years, the results are similar to a study conducted in South Korea, where age group 25-29 years were 143 (45.9%) ³.In current research study nearly half 97/204 (47.54%) participants work experience were less than 5 years. Likewise, a study conducted in Iran, where 65% of the study participants work experience was less than 5 years.²⁷

The finding of this study could be highlighted in the light of limitation that this study was conducted in urban setting; result may not be representing the nurses working in rural setting. Secondly, this study is a descriptive study;therefore, interventional study may be conducted to minimize the risk of MAEs.On the basis of result it is recommended that CNE related to medication administration should be conductedfor the nurses to update the knowledge. Organizational factors like error reporting systems and regular checks may help in tackling the problem of medication administration errors. Hire more qualified and skilled nurses.Minimize the distraction and interruptions during medication administration by using no interruptions zones and No-Talk.

CONCLUSION:Wrong time medication administration error is highly prevalent among nurses working in public sector organization and it was found statistically significant with hospital and nurses working areas (wards).

Authors contribution:Raja substantially contributed to the conception and design of the study. Badil worked in the acquisition, analysis, and interpretation of data and drafted the manuscript,PK revised it critically for important intellectual content gave the final approval of the manuscript.

Conflict of interest: None

Funding: None

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