Adherence to safety barriers in medication administration: patients’ perception

Objective: to analyze the perception of patients about health professionals’ adherence to safety barriers in medication administration. Method: cross-sectional and correlational study carried out in a hospital in the countryside of São Paulo, with a total of 249 adult patients admitted to the medical clinic. An electronic form developed by the researcher was used. Quantitative variables were analyzed in mean, median and standard deviation. Likert-type variables were calculated according to the perception score and the Bayesian Information criterion was used. The cutoff point for positive assessment of the patients’ perception was 0.75. Results: the average perception score was 0.29 and, of the 15 barriers analyzed, eight are never adhered by professionals, in the opinion of most patients. Also, age was the only variable with statistical significance. Conclusion: the younger the patient, the better their perception of health professionals’ adherence to safety barriers in medication administration.


Introduction
Medication errors are a major cause of care-related harm and death (1) . Worldwide, the costs for the treatment of these events correspond to approximately 1% of total health expenses (2) . Although they can occur at any stage of the medication use process (2)(3) , administration errors are the most common (2) and stand out as a challenge for professionals, patients and health institutions (4) .
Systematic reviews of the literature showed that one in five drug doses is administered incorrectly in inpatient units (5) and that the most common errors were timing errors, dose errors, dilution errors, errors in infusion rate and omission (6) . The errors usually result in moderate or severe harm and affect mainly people with complex health or social needs, in addition to extremes of age (1) .
Extensive efforts were made to prevent administration errors, including changes in care processes and the implementation of new technologies (4) . Safety barriers are defined as a set of measures used by the health team to manage potential risks related to care (7) ; therefore, they are important to ensure patient safety. However, researches revealed low adherence of health professionals to these barriers (8)(9)(10)(11) , contributing to the increased risk of harm (9) and poor health outcomes.
Safety barriers in medication administration include computerized provider order entry, automated drug delivery systems, barcodes for drugs and patients, smart infusion pumps for administering intravenous drugs, compliance with the nine rights in drug administration, protocols focused on the management of high-alert medications and hand hygiene practices (4,(12)(13)(14) . These barriers can also be classified into three major groups: optimization of medication systems; supporting professionals in managing interruptions and distractions and encouraging patient engagement in managing their own care (15) . It is clear that the nursing team plays a major role in preventing errors in medication administration. Therefore, reducing potential risks at this stage of the medication process is essential to improve the quality of care (17) . Furthermore, the inclusion of patients in the process will allow their engagement in decision-making and in the search for information about care options (18)(19) . For these reasons, patient participation in the prevention of administration errors should be encouraged.
Despite the exponential increase in attention to the participation of patients in care processes, and the various barriers implemented by health managers to reduce administration errors, the lack of research aimed at analyzing the patients' perception of professional adherence is irrefutable to safety barriers (20) .
Considering the above, the aim of this study was to analyze the patients' perception of health professionals' adherence to safety barriers in medication administration.
In this study, perception was defined as the relationship established between one person and another, including an object and/or an event during the interrelationship. Thus, each individual presents their own perception of the relationship, of what is seen or identified by the other subject (21) .

Type of study
This is a quantitative, cross-sectional and correlational study (22) . For its description, the STROBE guidelines (Strengthening the Reporting Observational Studies in Epidemiology) were used, which provide a formal and systematized structure for the criteria and methods for the selection of participants (23) .

Study setting
The study was carried out in the medical clinic of a philanthropic hospital in the city of Franca, São Paulo, Brazil. The hospital has 206 beds and is a regional reference for urgency and emergency services in medium and high complexity. It has four Gold Quality certifications, including the hospital quality certification (HQC). The medical clinic was selected because it has a greater number of admissions/month and patients, in general, remain hospitalized for a longer period of time.

Period of study
May 2019 to June 2020.

Population
Adult patients admitted to the medical clinic unit of a philanthropic hospital in the city of Franca, São Paulo, Brazil. www

Selection criteria
Patients hospitalized for at least 2 days, capable of verbal communication and oriented in time, space and about the person. Patients in isolation during the period of data collection were not included in the study.

Sample
The convenience sample consisted of a total of 249 patients hospitalized from June 2019 to September of the same year.

Data analysis
In data analysis, quantitative variables (gender, education and history of previous hospitalizations) were presented as absolute and relative frequencies, while continuous variables (patient age, how long was hospitalized and time since last hospitalization) were analyzed in terms of mean, median and standard deviation.
In the analysis of the Likert scale responses, the following scores were used for the alternatives: 1 (Always), 0.5 (Sometimes) and 0 (Never, I do not know and Does not apply -NA). The mean of the patients' perception score was calculated, whose resulting value was in the range between zero and one [0-1]. Values greater than or equal to 0.75 were considered a positive perception of health professionals' adherence to safety barriers in medication administration.
For the analysis of the standardized score, the Beta distribution (BE) or the inflated Beta distribution of Zeros and/or Ones (BEINF) was adopted, which belongs to the class of generalized additive models for position, scale and shape. As independent variables for the model, the following were analyzed: age (in years old), sex (male/ female), education (no education/1 to 4 years/5 to 8 years/9 to 11 years/over 11 years), history of previous hospitalization (yes/no) and time between the last hospitalization and the current one (in years). The last one was only present for participants who answered "yes" to the item that dealt with a previous history of hospitalization.
Regarding the total score of patient perception, the selection of the distribution of the response variable was performed using the Bayesian Information (BIC) criterion.
The model with the lowest BIC value was selected.
To assess the adequacy of the response variable, the Shapiro-Wilk Normality test was applied on the adjustment residuals. Analyzes were performed using the R software version 3.6.1 and a significance level of 5% (α = 0.05) was considered.

Ethical aspects
The study was approved by the Research Ethics

Results
Of the 249 (100%) patients, most were men (127; 51.0%), with 5 to 8 years of education (90; 36 Table 1 shows the perception of patients about the adherence of health professionals to safety barriers in medication administration, indicating that, of the 15 barriers analyzed, eight (61.5%) are never adhered to by the professionals, in the perception of most of the patients. Also, more than 80% of patients said that professionals never report on the importance of drug allergy.
Regarding the identification bracelet, 83.8% (n = 207) of the patients stated that professionals never use at least two identifiers to confirm the right patient before administering the medication. Regarding hand hygiene, 65 (26.1%) patients stated that nursing professionals "never" perform the procedure before administering the medications.   As noted in Table 2 In the second model, the explanatory variables were used: age, gender, education and time elapsed between the last hospitalization and the current one. Table 3 presents the result of the adjustment. www  well as for the promotion of a safer and more productive care environment for both parties (29) .
Of the 249 patients, 91% said they had not received information on error prevention strategies in medication administration. This is an alarming result, as patients are considered the last barrier to the prevention of administration errors (15) . Furthermore, researchers have shown that patients are often unaware of the medications prescribed during hospitalization, a fact that prevents them from becoming more actively involved in care planning (30) .

Honest, transparent and effective communication
is an important barrier to the prevention of errors (31) , The results showed that the younger the patient, the better their perception of the professionals' adherence to safety barriers in medication administration.

Discussion
The results showed a negative perception of patients about health professionals' adherence to safety barriers in medication administration (mean score = 0.29). Still, patients with more than 11 years of education had a higher mean of perception in relation to the others.
However, the total score was below 0.75.
Health literacy is a variable that is related to the patients' knowledge and attitude in relation to the management of their own care (25-26) . Studies carried out in Japan (27) and Germany (28)  to the researchers, these actions contributed to patient satisfaction and were recommended for the promotion of safe care (32) .
Non-adherence to safety barriers can be understood as a risky behavior by the professional, which contributes to the occurrence of adverse events. However, these behaviors are often related to existing problems in the system and the complexity of health services (33) . In addition, the safety strategies published in the literature focus mainly on preventing errors based on human and system factors (34) . Although these approaches are important to reduce the impact of adverse events on health outcomes, research has shown the value of including the patient as an integral member of the team in error prevention strategies (34)(35) .
In this study, 26.1% of patients reported that nursing professionals do not clean their hands and, for 11.2%, the team does not use gloves for administering injectable drugs. These results point to weaknesses in the processes that can negatively impact patients and workers.
A research carried out in a hemodialysis service in the country side of Sao Paulo (36) showed that adherence to hand hygiene practices and the use of gloves are ideal. These practices are important barriers to reducing the transmission of infections in the context of health services, especially in times of pandemic, such as COVID- 19. Furthermore, these measures are considered simple, of low cost and that have been proven to improve patient safety (37) . Continuing education programs are recommended to increase professionals' awareness of the importance of these barriers and improve adherence to institutional protocols (38) .  (40) .
Complex, dynamic, busy and under-resourced health systems are a fertile ground for serious problems and the incorrect identification of patients is one of these problems (41) . Identification failures are responsible for high rates of avoidable harm (32) ; therefore, nurses need to know to the use of medication (42) . Therefore, patients and family members must be informed about the benefits and risks related to the use of medications to improve treatment adherence and reduce potential errors (2) .
The results also showed that only age was statistically significant in the inflated beta regression analysis. Research carried out with the aim of evaluating this relationship is scarce. A better understanding of how and why age is associated with how the patient perceives interactions with health professionals can be useful for designing interventions and developing national policies that improve care delivery (43) , at all levels of care.
The patients' involvement in their own safety is a strategy recommended by the WHO to improve health care (44) . Therefore, the education and teaching of the patient and family should be the nurses' priority in care planning to favor the safe administration of medication.
Limitations of the study include the fact that data collection was performed using an electronic form developed specifically for the study. Therefore, comparisons between

Conclusion
Age was the only variable with statistical significance, that is, the younger the patient, the better their perception of health professionals' adherence to safety barriers in drug administration. The results may help health professionals and managers to improve the safety culture in hospitals, by determining patient and family engagement strategies in risk detection and planning actions aimed at preventing errors in medication administration.