Patient safety in nursing care during medication administration

ABSTRACT Objective: to evaluate the conformity of care practices of the nursing team during the administration of drugs through central vascular catheter. Method: a descriptive, prospective, observational study conducted in an Intensive Care Unit. The non-probabilistic intentional sample consisted of 3402 observations of drug administrations in patients with central vascular catheters. The previously validated collection instrument was constructed based on the Guideline for Prevention of Intravascular catheter-related infections. Data was collected through direct observations of nursing practices performed by the nursing team. The analysis used analytical, descriptive and inferential statistics (Chi-square test and Fisher’s exact test). Results: a total of 3402 procedures of drug administrations were observed. Female nursing technicians performed the highest number of actions. In none of the procedures did the professional perform all necessary actions. 0.2% of drug administrations were preceded by hand hygiene and 1.3% by disinfection of the multidose vial, ampoule or injectors. Conclusion: the practice evaluated was classified as undesirable. Failure to achieve the desired conformity was probably due to the low adherence of professionals to the practice of hand hygiene and disinfection of materials, injectors and connectors.

The protocols and recommendations regarding best evidence are not able to solely modify behaviors and influence good practices for the control of infections.
Therefore, interventions and evaluations of care practices are necessary to verify if preventive actions are being carried out effectively (10) .
To evaluate the conformity of the care process, Carter's Positivity Index (PI) can be used to classify care into quality categories, such as desirable, adequate, safe, borderline, undesirable or poor (11)(12) .
Given the above and the importance of quality In order to calculate the sample size, a previous survey was carried out during seven days to determine the daily mean of the procedure observed (13)(14) . A significance level of 95% was considered, with a margin of error of 5%.
The non-probabilistic intentional sample consisted of 378 drug administrations performed by nursing professionals. The inclusion criteria were intravenous administration of drugs in patients with central vascular catheters, performed by nursing professionals who had been working at the ICU for at least six months.
An instrument was elaborated based on the recommendations of the Guideline for Prevention of Intravascular catheter-related infections (15) . The form was divided in two parts. The first one addressed the characteristics of the vascular catheter (location, composition and duration of device use) and of the nursing professionals (professional category, gender and work shift). The second part contained the nine actions to be observed during the administration of drugs and items to record the availability of equipment and supplies needed to carry out each practice.
The registration of the actions was done according to four response options (yes, no, does not apply (NA) and no record (NR)). The assistance was considered in conformity when the recorded situation was "yes" or NA and not in conformity when the answer was "no" or NR.
A pilot test was conducted to validate the instrument, verifying if it answered to the research objectives (13)(14) . The results of the pilot test were not part of the final findings of the present study. The association between variables (professional category, work shift and gender) and the procedure was also carried out. As inferential tools, the Chi-square test and the Fisher's exact test were used, adopting a significance level of 5%, in which the relation is significant when p-value <0.05. Statistical analyzes were performed using the free R software, version 3.2.3.
Nursing professionals who accepted to participate in the study signed the Informed Consent Form (TCLE).
It should be noted that for the reduction of bias in the observations, such as behavior alteration and acting, the form with the specific actions evaluated was not presented to the participants.

Results
A total of 3402 actions were observed during the administration of medications in patients using a central vascular catheter. The observations corresponded to 378 procedures performed by nursing professionals ( Table 1).

Most of the observations were of double lumen
catheters, with up to 7 days of duration and located in the right subclavian vein.
Actions involving hand hygiene (A1, A5 and A9) during drug administration and disinfection of ampoules, vials and injectors with 70% alcohol (A4 and A7) were characterized as undesirable or poor, with specific conformity rates of less than 70%.
In table 3, the action A5 (p=0.0370) stands out because it is significant. In addition, the category Nursing Technician presented a higher number of actions in conformity when compared to Nurses.
The association between the variable work shift and the medication administration procedure showed action A4 (p=0.0210) as significant, with the highest conformity rate during the night shift (40.8%). On the other hand, the action A7 (p=0.0166) showed better conformity during the morning (34.5%) and afternoon (37.7%).
The actions A2 (p=0.0142) and A8 (p=0.0013) were significant in the association between gender and the procedure observed. The highest conformity rate in action A2 was of males, with 66.6%. In action A8, the female nursing professionals showed greater adherence to the practice, of 88%.
The results showed shortcomings in the medication administration procedure. In addition, there was no professional that complied with all the standardized steps for the medication administration procedure. Thus, the overall conformity rate for the procedure was 0%, rated by Carter's PI as a poor practice.

Discussion
Nursing professionals are the category with greater involvement in the manipulation of vascular accesses and, consequently, have a greater chance of acting in the prevention of complications (10) .  (20) . However, an Australian study designed to monitor conformity with disinfection of injectors found a 60% conformity (21) .
Given these results, it is evident that the disinfection However, despite the fact that these actions have high adherence, all practices that involve the safety of the professional must be associated with the care related to patient protection. Thus, to ensure a safe care and reduce risks, all the steps of a care process, and not just some, must be carried out.

Conclusion
The evaluation of the nursing practices involving drug administration led to the identification of potentialities and vulnerabilities in the process evaluated. Regarding general conformity, in none of the procedures observed did the professional perform all actions necessary to ensure patient safety, so the practices were classified as undesirable or poor.
The actions that presented the best positivity index were the use of procedure gloves and sterile materials, in addition to the proper disposal of sharp materials.
Among the actions with negative indexes, hand hygiene and disinfection of ampoules and vials were considered as undesirable or poor practices. On the other hand, a greater concern of the professionals with their own security was observed.
The association between the variables (professional category, work shift and gender) and the procedures observed showed no significant differences. Even though some isolated actions were classified as safe, failure or absence of one of the steps of the procedure compromised the whole care practice.
Given the above, the results can be considered extremely relevant. From this perspective, the qualification of the team considering local and regional specificities and needs is an important factor for preventing errors and adverse events. Hand hygiene and disinfection of ampoules and injectors with alcohol gel are simple measures to control infections associated with the use of the central vascular catheter, and should be inserted in the care practices.
By implementing these measures, it is possible to develop and implement a safety culture in multiprofessional activities, especially nursing care activities.
In addition, these results are expected to contribute to the development of studies that can produce scientific evidence to enable better nursing care practices and construct a safety culture, favoring policies and programs in the area of patient safety.