IDENTIFICATION OF SAFETY BARRIERS IN THE PREPARATION AND ADMINISTRATION OF MEDICATIONS BY NURSING PROFESSIONALSABSTRACT
Objective: to describe the professional compliance standards regarding knowledge of safety barriers in the preparation and administration of medications.
Method: a descriptive, quantitative, retrospective study conducted between January and December 2021 in a hospital in Southern Brazil, involving nursing professionals. The Objective Structured Clinical Examination was implemented in a simulated clinical station using a checklist that included safety barriers. Descriptive analysis was performed using absolute numbers and percentages.
Results: a total of 1,682 professionals participated. The safety barriers identified were: electronic medical prescription (86.1%), patient identification wristband (80.3%), pre-filled medication labels before preparation (74.5%), and medication dilution chart (63.9%). Compliance with knowledge of safety barriers was found to be in full compliance for 73.8% of professionals, partially compliant for 19%, and non-compliant for 7.1%.
Conclusion: compliance with identified safety barriers demonstrated the professionals’ knowledge in care provision.
KEYWORDS:
Learning; Simulation Training; Nursing Education; Patient Safety; Continuing Education.
HIGHLIGHTS
Knowledge of nursing professionals about safety barriers in healthcare.
The medical prescription was the most frequently cited safety barrier.
The majority of participants demonstrated compliance in identifying the barriers.
The importance of compliance standards in medication preparation.
RESUMO:
Objetivo: descrever o padrão de conformidade profissional em relação ao conhecimento sobre as barreiras de segurança no preparo e administração dos medicamentos.
Método: estudo descritivo, quantitativo, retrospectivo, realizado entre janeiro e dezembro de 2021, em hospital do Sul do Brasil, com profissionais de enfermagem. Implementou-se o Exame Clínico Objetivo Estruturado em estação clínica simulada, por aplicação de checklist contemplando barreiras de segurança. Realizou-se análise descritiva em números absolutos e percentual.
Resultados: participaram 1.682 profissionais. As barreiras sinalizadas foram: prescrição médica eletrônica (86,1%), pulseira de identificação do paciente (80,3%), etiquetas de medicamentos preenchidas previamente ao preparo (74,5%) e tabela de diluição de medicamentos (63,9%). O padrão de conformidade em relação ao conhecimento sobre as barreiras apresentou-se em 73,8% dos profissionais como conforme; em 19% deles como parcial conforme e em 7,1% como não conforme.
Conclusão: a conformidade em relação às barreiras de segurança identificadas, demonstrou o conhecimento dos profissionais na assistência.
DESCRITORES:
Aprendizagem; Treinamento por Simulação; Educação em Enfermagem; Segurança do Paciente; Educação Continuada.
HIGHLIGHTS
Conhecimento dos profissionais de enfermagem sobre barreiras de segurança assistenciais.
A prescrição médica foi a barreira de segurança mais citada.
A maioria dos participantes apresentou conformidade na identificação das barreiras.
A importância do padrão de conformidade no preparo de medicamentos.
RESUMEN
Objetivo: describir el estándar de conformidad profesional sobre el conocimiento de las barreras de seguridad en la preparación y administración de medicamentos.
Método: estudio descriptivo, cuantitativo, retrospectivo, realizado entre enero y diciembre de 2021, en un hospital del sur de Brasil, con profesionales de enfermería. El Examen Clínico Objetivo Estructurado se implementó en una estación clínica simulada, mediante la aplicación de una checklist que incluye barreras de seguridad. Se realizó un análisis descriptivo en números absolutos y porcentajes.
Resultados: Participaron 1.682 profesionales. Las barreras mencionadas fueron: receta médica electrónica (86,1%), pulsera de identificación del paciente (80,3%), etiquetas de medicamentos completadas antes de la preparación (74,5%) y tabla de dilución de medicamentos (63,9%). El 73,8% de los profesionales obtuvo conforme en el estándar de conformidad sobre el conocimiento de las barreras; el 19% de ellos parcialmente conforme y el 7,1% no conforme.
Conclusión: la conformidad de las barreras de seguridad identificadas demostró el conocimiento de los profesionales en la atención.
DESCRIPTORES:
Aprendizaje; Entrenamiento por Simulación; Educación en Enfermería; Seguridad del Paciente; Educación Continua.
HIGHLIGHTS
Conocimiento de los profesionales de enfermería sobre barreras de seguridad en la atención.
La prescripción médica fue la barrera de seguridad más mencionada.
La mayoría de los participantes obtuvo conformidad en la identificación de las barreras.
Importancia del estándar de conformidad en la preparación de medicamentos.
INTRODUCTION
Medication errors are one of the leading causes of preventable harm in healthcare institutions. In response to this issue, the World Health Organization (WHO) launched the third Global Patient Safety Challenge in 2017, titled “Medication Without Harm,” with the goal of reducing serious and preventable medication-related harm by 50% over the next five years1
In the United Kingdom, a research identified that medication errors are common, with half of these errors related to the administration stage2. A systematic review of medication errors in Latin America, where nursing professionals were the most frequently observed, found that the most common errors were related to timing, dosage, and omission of medications3. In Brazil, at a regional hospital in Rio Grande do Norte, errors were primarily associated with prescription due to a lack of information regarding dosage, dilution, and scheduling intervals4.
Healthcare institutions, aiming for excellence in care, seek to create strategies to prevent errors, as well as permanent educational spaces aligned with protocols and best evidence, which help reduce potential adverse events. It is noteworthy that safe practices promote a secure environment. It is noteworthy that safe practices promote a secure environment5.
In a hospital setting, the nursing team plays a crucial role in preventing errors in the preparation and administration of medications6. However, it is essential to identify and utilize safety barriers, meaning being aware of the importance of using protocols, materials, equipment, and other tools that help prevent errors in daily work7.
A study conducted to analyze patients’ perceptions of nursing staff adherence to safety barriers found that out of 15 barriers analyzed, eight are never adhered to by the team. Key highlights include the non-use of the two patient identification wristband identifiers, allergy wristbands, hand hygiene, and the lack of information provided to patients about the medications to be administered8.
In this context, it is understood that healthcare institutions must foster a culture of safety, ensuring adherence to good practices and assuming responsibility for safety by the professionals themselves, colleagues, families, and patients, thereby reducing the risk of harm associated with patient care to an acceptable minimum9. To achieve this goal, it is necessary to provide educational spaces using active methodologies, such as teaching strategies centered on the participatory construction of the learning process in a flexible, interconnected, and hybrid manner10
The Objective Structured Clinical Examination (OSCE) is a simulation teaching technique that enables the assessment of competencies and is also used for evaluating prior clinical knowledge through standardized procedures and patients11,12.
The use of facilitating strategies, such as the OSCE, in the health training of workers transforms practice. Supporting teams in work processes and fostering collective exercise experiences for analysis reinforces a sense of belonging and collective co-responsibility13.
In light of the above, the objective of this study was to describe the professional compliance standards regarding knowledge of safety barriers in the preparation and administration of medications.
METHOD
This descriptive, exploratory, quantitative, and retrospective study was conducted following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines in all its stages14 and carried out in a large public university general hospital accredited by the Joint Commission International (JCI)15 in Southern Brazil.
The institution has a Nursing Education Service (SEDE) that develops, monitors, and evaluates educational activities for training, development, and updates within the scope of the nursing work process. This service is engaged in various improvement processes. Based on the analysis of adverse events and quality indicators, the need to implement a standard for the preparation and administration of medications was identified.
To implement this standard, a hybrid distance learning (EaD) activity called “Safety in Medication Preparation and Administration” was developed, along with the practical application of this knowledge in theoretical-practical stations using the OSCE methodology.
The researchers developed a form in a checklist format containing 21 safety barriers, reproduced in a simulated scenario. The barriers were defined in accordance with the institutional standard, following JCI15 recommendations, and were identified by the participant and marked by the facilitator on the checklist.
The “Safety Barriers” station was conducted in a simulated environment that replicated a nursing station, with an adjacent room featuring a hospitalized patient (mannequin). The facilitator guided the professional through the activity, during which they were to identify, point out, and verbally justify the safety barriers observed in the scenario.
For the development of the activity, the professional had four minutes, and the facilitator had one minute for educational feedback regarding the participant’s performance, addressing strengths and potential areas for improvement in the process.
Data collection was retrospective, covering the period from January to December 2021. Regarding eligibility criteria, data from the “Safety Barriers” station forms completed by nursing professionals were included. Forms related to units where professionals did not provide direct patient care, such as the Central Sterile Services Department, were excluded. Data were entered by the researchers into Microsoft ExcelⓇ. The variables were categorized as follows:
a) Safety Barriers: electronic medical prescription, patient identification wristband, allergy alert wristband, medication label standardization, pre-filled medication labels before preparation, oral dosing syringe, specific tubing for enteral nutrition, tray separator, hand sanitizer, poster with the six “rights” of medication administration, standardized institutional disinfectant, sterile 70% alcohol sachet, medication dilution chart, alcohol dispenser, high-alert medication poster, oral solution expiration date poster, filled saline label, occluders for cannulas and tubing, patient diet label, medication preparation tray, date, and shift label on tubing.
b) Compliance with the safety barriers: compliant (identified nine or more barriers), partially compliant (identified five to eight barriers), and non-compliant (up to four barriers).
The data were verified in ExcelⓇ by the lead researcher and a research assistant to avoid potential data entry errors. Participant observation was aided by facilitators who underwent prior theoretical and practical training. The SEDE team calibrated the OSCE scenario to reduce the Hawthorne effect, where professionals actively change their behavior when they know they are being observed and monitored.
The study’s power calculation was performed using the PSS Health online tool16 to test whether the proportion of compliance differed from 0.5. With a sample size of 1,682 participants, a significance level of 5%, an expected compliance rate of 80%, and using the exact method, the study achieved a power of 100%.
Data were analyzed using Microsoft Excel and SPSS (Statistical Package for the Social Sciences) version 29.0. The statistical analysis was descriptive, expressed as percentages and absolute numbers.
The study was approved by the Research Ethics Committee of the institution under opinion no. 5.516.268 (CAAE 59876222.8.0000.5327).
RESULTS
A total of 1,156 (68.7%) nursing technicians, 457 (27.2%) nurses, and 69 (4.1%) nursing assistants participated in the OSCE-based educational strategy. Table 1 describes the safety barriers related to the medication preparation and administration process identified by the professionals.
Safety barriers identified by professionals in the OSCE clinical station (n=1,682). Porto Alegre, RS, Brazil, 2021
The classification of compliance with the safety barriers identified by the professionals is described in Table 2.
Compliance with safety barriers in the medication process at the OSCE clinical station (n=1,682). Porto Alegre, RS, Brazil, 2021
DISCUSSION
The process of preparing and administering medications is a routine activity for nursing professionals. A study conducted in pediatric inpatient units identified that the medication process steps were mostly performed by nursing technicians, without full adherence to safety barriers, which compromises the quality of care provided17.
In healthcare, it is essential for the entire team to have knowledge and understanding of safety barriers in the medication process to avoid potential errors related to care and ensure patient safety8. Training professionals to standardize the actions to be performed includes creating flowcharts, checklists, standard operating procedures, and enhancing a culture of safety, thereby promoting a reduction in medication dosage errors8
The digitalization of the record-keeping system can be considered an advancement in ensuring safe care practices. Electronic medical and nursing prescriptions, automated medication distribution systems with barcodes, and adherence to the “nine rights” of medication administration are some of the safety barriers in this process8,18.
The most identified barriers were electronic medical prescriptions and patient identification wristbands, totaling 86.1% and 80.3% of participants, respectively. Considering that, in the institution under study, the two identifiers adopted at the time of data collection were the full name and the medical record number, the percentage achieved for compliance during the OSCE reflects the ongoing concern to emphasize the goal of correct patient identification. A study conducted in a hospital in the state of São Paulo, Brazil, reported that 79% of the patients interviewed stated that their names were not checked before medication administration8. This finding highlights the importance of using this safety barrier in care, as it is known that failures in this process are responsible for high rates of harm that could have been avoided8.
The standardization of labels for identifying medications after preparation also serves as a safety barrier before medication administration. In the institution where this study was conducted, there is a standard practice for checking the “six rights” during the medication process: the right patient, right medication, right dose, right route, right time, and right documentation. The literature also identifies additional “rights” that should be observed during verification, which includes providing patient guidance8,17. This topic is extensively addressed with the entire nursing team, both during the onboarding of newly admitted professionals and through a continuous education program. Medical and nursing prescriptions are used by professionals from the beginning of medication preparation. Failure to observe these safety barriers, especially not checking them, can pose risks in this process8,17.
The step of transcribing information from the medical prescription onto the label ensures that medication preparation and administration are not based solely on memory but serve as a moment for verification and the possible identification of inconsistencies, thereby preventing errors. A study on adherence to safety barriers in the medication administration process in pediatrics highlights the importance of having the following items described on the medication label: the right patient, right medication, right route, right time, and right dose17. This strategy is a low-cost measure but reorganizes the workflow, preventing patients from being subjected to potential errors that can occur at all stages of the medication preparation and administration process19.
For medication preparation, professionals have access to a dilution chart in the units, which provides information such as reconstitution, dilution, maximum concentration, and administration time. In a public hospital in the Zona da Mata region of the state of Minas Gerais, Brazil, it was found that 24.3% of errors occurred during preparation and were related to dosage19,20. This finding supports the importance of healthcare institutions adopting standardized documents with information related to safe practices.
Medication administration errors involving switching medications and/or patients can be related to the failure to observe barriers, such as drug segregation on trays when there is a need to medicate different patients at the same time19. The use of tray separators, which ensure that each compartment contains only the medications intended for a single patient, is another safety barrier to be adopted in care. This tool was implemented as a way to create a physical barrier that makes nursing work safer.
It is understood that this barrier alone does not prevent errors; it is also necessary to verify the medication before its administration. The other barriers mentioned by professionals did not have a high frequency but are part of the set of safety strategies and are relevant in clinical practice19.
The use of hand sanitizer by professionals for hand hygiene and standard disinfectants for surfaces supports safety and infection control related to care, being considered important barriers in the medication preparation process21. This study observed that there is room for improvement regarding the team’s adherence to these practices, as they are measures that promote patient safety in the use of medications21. Research conducted in Brazilian hospitals presents similar results, highlighting that nursing professionals do not comply with hand hygiene standards during medication preparation22, 23.
Regarding the use of devices that alert professionals to possible errors related to the correct route of medication administration, the institution in this study has adopted the use of oral dosing syringes because their design inhibits switching the route of administration. This barrier, although not frequently mentioned by participants, is already used in the institution as a safety measure.
The use of allergy alert wristbands on patients was not initially identified as one of the barriers by professionals; however, it remained among the top nine mentioned. It is one of the safety goals in the hospital setting and can enhance vigilance, thereby preventing harm to patients24.
Adherence to safety barriers is an expected behavior, as it prevents adverse events and contributes to safe care. However, studies show that non-adherence may be related to existing system issues and the complexity of healthcare services. Many safety barriers are strategies involving systems and human factors. However, the importance of patient, family, or caregiver participation in error prevention cannot be overlooked8, 19.
There are many strategies used to develop skills among healthcare teams to ensure patient safety. The use of simulated environments, particularly the OSCE, has demonstrated the potential for professionals to apply knowledge in scenarios very similar to those they experience in care settings in an immersive way. In skills development, the OSCE has gained prominence as an educational strategy that enhances professionals’ self-confidence25, and it enables learning from successes and mistakes in decision-making within a simulated environment26.
It is understood that the main limitation of this study may be the lack of evidence regarding the application of knowledge of barriers in direct patient care, necessitating future studies. However, the methodology used (OSCE) proved to be efficient and innovative when developed with nursing professionals. It was also an important methodology used during the COVID-19 pandemic, as it is an individual strategy that avoids gatherings.
CONCLUSION
After analyzing the results related to safety barriers, it was evident that most nursing professionals in the study are aware of important barriers for safety in the medication preparation and administration process, reinforcing safe practices. The safety barriers most frequently cited by nursing professionals were electronic medical prescriptions, patient identification wristbands, pre-filled standard medication labels before preparation, medication dilution charts, and tray separators.
The identification and use of safety barriers by nursing professionals in the steps involved in the medication preparation and administration process help prevent potential errors, improving the stages involving medications and providing greater safety and quality in care.
It is hoped that the findings of this study can support new research that evaluates the applicability of nursing professionals’ knowledge in their care practices, emphasizing safe care. Furthermore, it is highlighted that a continuous educational approach to safety barriers with the nursing team can minimize errors in the medication process, thereby mitigating harm to patients and society.
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HOW TO REFERENCE THIS ARTICLE:Cogo ALP, Perdomini FRI, Flores GE, Severo IM, Brahm MMT, Dias M de OT. Identification of safety barriers in the preparation and administration of medications by nursing professionals. Cogitare Enferm. [Internet]. 2024 [cited “insert year, month and day”]; 29. Available from: https://doi.org/10.1590/ce.v29i0.96832.
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Associate editor:
Dra. Cremilde Radovanovic
