Nurse Education Today 33 (2013) 214–221

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Nurse Education Today journal homepage: www.elsevier.com/nedt

Faculties' and nurses' perspectives regarding knowledge of high-alert medications☆ Tsai-Feng Lo a, Shu Yu b, I.-Ju Chen b, Kai-Wei K. Wang b, Fu-In Tang b,⁎ a b

Veterans General Hospital, Taipei, Taiwan School of Nursing, National Yang-Ming University, Taipei, Taiwan

a r t i c l e

i n f o

Article history: Accepted 14 January 2012 Keywords: Knowledge High-alert medications Faculty Nurses Medication errors

a b s t r a c t The incorrect administration of high-alert medications can have serious consequences. A previous study by the authors of this study developed and validated 20 true-false questions concerning high-alert medications and suggested that the topic be taught to nurses. The perspectives of faculty and nurses, however, needed to be assessed before such teaching could be implemented. The aim of this study was to understand the views of faculty and nurses about training in high-alert medications: its importance, the frequency with which it is provided, and the ideal stage at which it should be provided. A cross-sectional study was conducted in 2008 in Taiwan. A questionnaire was used to determine whether the 20 questions are important, whether its content was being taught, and the ideal time for teaching it. Snowball sampling and descriptive statistics were used. A total of 136 faculty and 199 nurses participated. From the perspectives of faculty and nurses, all 20 questions regarding high-alert medications were important (faculty vs. nurses: 4.65 ± 0.35 vs. 4.45 ± 0.67) but the issues to which they related were insufficiently taught (faculty vs. nurses: 3.88 ± 0.87 vs. 3.06 ± 0.94). Faculty believed that the ideal stage at which to provide training on high-alert medications was during formal, in-school nursing education (94.3%) while nurses believed that the ideal stage was during in-hospital continuing education (48.9%). For training in high-alert medications, the researchers recommended the inclusion of classes on the subject as part of formal, in-school nursing education, as well as of hospital-based continuing education. The instrument's questions highlight the important concepts concerning high-alert medications which should be taught to nurses and nursing students. © 2012 Elsevier Ltd. All rights reserved.

Introduction The definition of medication error is “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health professional, patient or consumer (UK/DOH, 2004).” Although medication errors occur in hospitals in nearly one in every five doses (Barker et al., 2002), most errors do no harm to patients: the harm rate is between 1% and 2% (Leape et al., 2000). Harmful events, however, are due mainly to the injection of high-alert medications and these remain the most problematic drugs associated with medication errors. Research has demonstrated that the top five drugs cited in records of medication errors, with or without errors, are high-alert medications such as potassium chloride (KCl), insulin, morphine, heparin and warfarin (Hicks et al., 2004). According to the Institute for Safe Medication Practices (ISMP/US, 2003), high-alert medications are drugs that

☆ This research was supported by the National Science Council (NSC 96-2314-B-010044 MY2). ⁎ Corresponding author at: School of Nursing, National Yang-Ming University, 155, Section 2, Li-Nong Street, Shih-Pai, Taipei 112 Taiwan. Tel.: + 886 2 28267297; fax: + 886 2 28229973. E-mail address: fi[email protected] (F.-I. Tang). 0260-6917/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2012.01.004

bear a heightened risk of causing significant patient harm when used in error. Error does occur in an emergency situation like CPR or in routine use like KCl or insulin injection. Too rapid injection of high-alert medications (e.g. fast IV bolus push), however, is one of the most significant factors contributing to patient harm (Taxis and Barber, 2003b). The American Pharmaceutical Association lists the following eight categories of high-alert medications: cardiovascular drugs (e.g. adrenergic agonists, antagonists), chemotherapeutic agents (parenteral and oral), narcotics (e.g. phentanyl), opiates (e.g. morphine), anticoagulants (e.g. heparin, warfarin), benzodiazepines (e.g. midazolam), neuromuscular blocking agents (e.g. succinylcholine) and electrolytes (e.g. 15% KCl) (Cohen, 2007). From an educational point of view, lack of knowledge has been shown to be the most significant factor contributing to medication errors (Phillips et al., 2001; Winterstein et al., 2004; Tang et al., 2007). The nursing errors reported to the state boards of nursing are typically serious. Files were analyzed in a 21-case study of nursing errors from nine state boards of nursing. Medication errors were among the eight categories of nursing errors and lack of knowledge about high-alert medications was one of the primary causes of medication errors (Benner et al., 2002). Inadequate knowledge could be due to a failing of the individual, but could also be due to a systemic failure of school or hospital authorities to prepare staff to perform

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their roles adequately (Jordan et al., 1999; Morrison-Griffiths et al., 2002). There is an urgent need for all health professionals to be aware of the risks of high-alert medications and for the development of comprehensive strategies to improve safety in drug administration. It is imperative that this include the strengthening of formal, in-school nursing education and hospital training about high-alert medications (Page and McKinney, 2007). Before educational training programs are implemented, assessment is required. We needed faculty and nurses' perspectives about the importance, teaching frequency and ideal stage of provision of training in high-alert medications. Literature Review The Issue of Medication Errors The issue of medication errors has been openly discussed by government agencies and health professionals in an attempt to improve the quality and safety of patient care. In Taiwan, medication errors were the leading cause among 13 types of medical negligence. For these reasons, from 2010 to 2011, the first priority of hospital safety in Taiwan was to avoid medication errors and improve medication safety (Taiwan Joint Commission on Hospital Accreditation; TJCHA, 2011). There are similar situations in other countries. The US Institute of Medicine (IOM), for example, published a book (To Err is Human: Building a Safer Health System) claiming that the number of US deaths caused by medical errors was even greater than the number of US deaths caused by motor vehicle accidents, breast cancer and acquired immune deficiency syndrome (AIDS) (Kohn et al., 1999). The number of deaths specifically due to medication errors was estimated to be 7000 each year (Phillips et al., 1998). Medication safety is therefore the third of the Joint Commission's National Patient Goals (2009). In the UK, the Department of Health (DOH) raised the same issue and published a book (An Organization with a Memory) which claimed that 400 people in the UK die or are seriously injured every year in hurtful events involving medical devices (UK/DOH, 2000). The book also indicated that improvements can be achieved by avoiding repeated errors when prior lessons are learned. Medication safety is a major concern and a global issue related to the quality and safety of patient care, but, because of underreporting, the actual frequency of medication errors and the actual extent of their consequences are likely to be even greater than is yet appreciated (Lassetter and Warnick, 2003) and continuing studies are needed to explore the full scenario.

215

2009) showed that besides KCl and insulin, oxytocin was another high-alert medication which has seldom been mentioned. Table 1 (below) provides a digest of high-alert medications and sources mentioned above. Among these high-alert medications KCl is the most cited. Drug Administration Incorrect administration technique accounts for a disproportionate number of harmful errors. An analysis of 192,447 errors, for example, showed that 1.67% resulted in harm; giving medication at the wrong time had a harm rate of 1%, the wrong dose 1.9%, and the wrong route 2.6%, but the rate of harm rose to 6.2% when the wrong administration technique, such as the giving of medication too fast, was considered (Hicks et al., 2004). The administration of an intravenous (IV) bolus push of a high-alert medication is one of the most significant factors contributing to patient harm. A study on 10 wards in two UK hospitals indicated that an error rate of 73% (172/235) occurred in the administration of bolus doses, that 95% (163/172) of these errors were due to the dose being administered too quickly, and that a little more than half (52%, 85/163) of the errors were of potentially moderate severity (Taxis and Barber, 2003a). A similar study reported that among 265 IV medication errors, 97% were due to the bolus dose being injected faster than the recommended speed of three to 5 min per dose. The reasons offered by the researchers were lack of perceived risk, appropriate training and role models and the unavailability of technology (Taxis and Barber, 2003b). It is important for all nurses to understand that almost all high-alert medications that have the potential to cause harm are administered by the IV route (Paparella, 2004a; Parshuram et al., 2008). Our previous study listed 20 true-false questions with satisfactory validity and reliability concerning high-alert medications (Hsaio et al., 2010). It included some basic but important concepts about the use of these drugs. The first part (part A) was about drug administration and focused on drug delivery route and dosage. An IV bolus push, for example, is dangerous for 15% KCl, 10% calcium chloride (10% CaCl2) and 3% sodium chloride (3% NaCl). Another example is 1:1000 epinephrine; if mistakenly given by IV bolus push, it can result in a sudden increase in blood pressure, and even cause fatal ventricular fibrillation or cerebral hemorrhage. Thirty-eight percent of nurses, however, showed a lack of knowledge about this concept (Hsaio et al., 2010). Drug Regulation

High-alert Medications Medication errors are common, accounting for nearly one in every five doses (Barker et al., 2002), which result in a harm rate of between 1% and 2% (Leape et al., 2000) and 9.7% (Sheu et al., 2009). Besides the eight categories of high-alert medication listed by the American Pharmaceutical Association, different research findings have identified different high-alert medications for which special precautions should be taken. A review of medical event reports from the US national database showed that potassium chloride (KCl), heparin, xylocaine, and epinephrine (adrenaline) were the drugs most commonly involved in critical incidents (Edgar et al., 1994). In an investigation of error events, it was noted that KCl, anticoagulants and cardiovascular system (CVS) drugs are the drugs most frequently associated with potential adverse drug events (ADEs) (Bates et al., 1995). An examination of 496 fatal medication error reports indicated that 54.9% of the deaths were related to central nervous system (CNS) drugs, CVS drugs and antineoplastic (Phillips et al., 2001). A systematic review of 10 studies listed CNS drugs, CVS drugs, analgesics, anticoagulants and anti-infectives as the top five drug classes involved in preventable ADEs (Kanjanarat et al., 2003). Our published report (Sheu et al.,

Many practices have been recommended as regards the storage and regulation of high-alert medication. These include the avoidance of mistakes by storing high-alert medications in specific ways, such as not placing 15% KCl in the ward for free access by nurses. Whenever neuromuscular blocking agents are stored, they should be segregated and sequestered from other routine stock (Paparella, 2004b). To avoid mistakes, heparin and insulin should be stored separately. An audit of 370 prescriptions found that, in15%, the dosage was not

Table 1 High-alert medications and principal sources identifying them as such. High-alert medications

Source

KCl, heparin, xylocaine, epinephrine KCl, anticoagulants, CVS drugs CNS drugs, CVS drugs, antineoplastic CNS drugs, CVS drugs, analgesics, anticoagulants, anti-infectives KCl, insulin, morphine, heparin, warfarin KCl, insulin, oxytocin

Edgar et al. (1994) Bates et al. (1995) Phillips et al. (2001) Kanjanarat et al. (2003) Hicks et al. (2004) Sheu et al. (2009)

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clear (Howell, 1996). Illegible handwriting and improper abbreviations are major sources of errors. The Joint Commission (2009) suggested that in order to avoid misreading, certain abbreviations (such as “U” for “unit”) should not be used (because it may be misinterpreted as “0” or “11”). “Vials” and “teaspoons” are not appropriate dosage expressions. Dosages should be written as “mg,” “g”, and “unit” (Cohen, 2007). All health professionals should be aware of and strictly follow these drug regulations. Methods Aim The aim of this study was to understand the views of faculty and nurses about training in high-alert medications: its importance, the frequency with which it is provided, and the ideal stage at which it should be provided. Methodology A cross-sectional study was conducted in 2008 and was approved by the Institutional Review Board (IRB) of a university in Taiwan (IRB No. 960033R). We developed a questionnaire containing three questions. The first question was designed to establish whether the 20 questions asked in the questionnaire were important (importance). The second was designed to establish how often they were being taught (teaching frequency). The third was designed to establish what the ideal stage was for teaching them (ideal teaching stage). Random and snowball sampling were utilized to recruit participants. Content and face validity were determined. Descriptive statistics were used to analyze responses. Instrument Development We had previously validated an instrument containing 20 questions to evaluate nurses' knowledge of high-alert medications. These 20 questions were developed on the basis of a literature review and clinical expert consultation. It is suggested that such knowledge should be taught to nurses (Hsaio et al., 2010). On the basis of these 20 true-false questions we developed a questionnaire containing two sections. Section one of the questionnaire contained 20 statements with “reasons” to explain why they might be true or false. The statement, “10% Cal Gluconate and 10% CaCl2 are the same drug and interchangeable” for example, is a false question, because the two substances have different calcium concentrations (Cal Gluconate: 4.5 meq/g; CaCl2: 13.6 meq/g).The instruction, “When an emergency such as ventricular fibrillation happens, fast push 15% KCl 10 ml into IV” is false, because under no circumstances should 15% KCl be administered by IV bolus. The participants were asked to answer the following three questions in relation to each of the 20 statements. 1. Importance: does the statement represent concepts important to nurses? (5 = very important; 4 = important; 3 = slightly important; 2 = unimportant; 1 = very unimportant) 2. Teaching frequency: during the course of your formal, in-school nursing education, how often was the question taught? (5= always; 4 = frequently; 3 = occasionally; 2 = rarely; 1 = never) 3. Ideal teaching stage: when is the ideal stage for teaching this question? (1.During formal, in-school nursing education: A = nursing lecture; B = clinical practice; C = pharmacology class. 2. During hospital-based continuing education. 3. Other)

Section two elicited social/demographic and professional/educational characteristics. Sampling Mailing questionnaires regarding medication errors has resulted in low response rates of 6.8% (Schulmeister, 1999) and 26% (Wolf et al., 2000). Snowball sampling has been more effective in recruiting participants, with almost double the response rates (Etter and Perneger, 2000) or nearly 90% response rates (Thompson et al., 2002). By using snowball sampling with a highly anonymous research design we had previously had three successful experiences, recruiting participants with 80.0%, 100% and 79.2% response rates regarding the issue of medication errors (Tang et al., 2007; Sheu et al., 2009; Hsaio et al., 2010), but sampling bias seems unavoidable. For the reasons given above, this study was tested by means of both random and snowball sampling and the results were compared in order to determine the sampling method most appropriate to this study. We randomly selected ten nursing schools from a total of 38 in Taiwan and submitted a formal proposal to each of these ten nursing schools to ask for their permission and cooperation. Among these ten schools, after we had submitted merely a formal proposal, three agreed to participate. We then telephoned the nursing directors and invited them again and finally another two schools agreed to participate, which made it five schools. At first the response rate was only 29.8% (48/161), but, in a bid to raise the response rate, we submitted the questionnaires a second time to the consenting schools and collected another 16 questionnaires on this second occasion. In this process each step was undertaken twice. During the process, however, we also learnt some tactics to increase the response rates, such as telephone calls to faculty, which made them more inclined to participate in research, and the response rate was 39.8% (64/161). The whole process took 5 months. The snowball sampling method was used at the same time to recruit faculty to participate (Babbie, 2004). In this pilot study three of the researchers who are also members of nursing faculty contacted their colleagues and faculty friends and invited them to participate in this study. Also, when we asked them to introduce other members of faculty to join in this study we achieved an 80.9% (72/89) response rate. This process took 1.5 months. The results from random and snowball sampling were compared. Background characteristics showed that differences existed only in education and position (Table 2). The answers to the 20 questions on importance (t = 0.64; p = 0.43), teaching frequency (t = 0.42; p = 0.52) and ideal teaching stage (x = 1.60, p = 0.81) showed no significant difference. Because of the similarity of the results, the high response rates and time-saving, snowball sampling was used to recruit hospital nurses on this topic (Fig. 1). Some nurses who work in areas such as nursing homes, OPD or psychiatric wards may not need to be familiar with these high-alert medications as they are rarely used in these areas. When we designed our study, however, we aimed to understand the nurses who work in general hospitals and in such areas as medical, surgical, pediatric, obstetric, ER, and ICU wards. The sampling of nurses, therefore, was mostly focused on the above wards in which knowledge of highalert medications is important. In this study two of the researchers were also RN nurses. By using the same method, these two researchers began to invite their RN friends to join this study and to introduce other RN nurses who might be interested and willing to participate in it. We found this to be a powerful strategy for recruiting RN participants. Within 2 months a total of 199 RN nurses were participating in this study, which achieved a response rate of 80.2% (199/248). By convention, the value of estimated effect size in a two-group test of mean difference (e.g., between faculty and nurses) is in the

T.-F. Lo et al. / Nurse Education Today 33 (2013) 214–221 Table 2 Background and characteristics of faculty from random and snowball sampling methods (N = 136; random sampling: n = 64, snowball sampling: n = 72). Variable Age (years) 25–30 31–35 >35 Education Bachelor Master PhD Position Clinical instructor Lecturer Professor Teaching experience (years) b2 2–5 6–10 >10 ICU training No Yes

Random sampling n (%)

Snowball sampling n (%)

0 (0.0) 9 (14.1) 55 (85.9)

2 (2.8) 16 (22.2) 54 (75.0)

4 (6.3) 45 (70.3) 15 (23.4)

27 (37.5) 42 (58.3) 3 (4.2)

6 (9.4) 40 (62.5) 18 (28.1)

35 (48.6) 34 (47.2) 3 (4.2)

3 (4.7) 18 (28.1) 21 (32.8) 22 (34.4)

7 (9.7) 22 (30.6) 24 (33.3) 19 (26.4)

39 (60.9) 25 (39.1)

55 (76.4) 17 (23.6)

Including assistant, associate and full professor;

+

χ2

p value

3.51

0.173

217

(Polit and Beck, 2008). Considering that the average response rate for snowball sampling was about 70% (Tang et al., 2007; Sheu et al., 2009; Hsaio et al., 2010), the estimated number of questionnaires required was at least 333. In fact, 335 questionnaires were collected in this study. Ethical Considerations

24.78

b 0.001

31.35

b 0.001

1.96

0.582

3.10+

0.078

Yate's correction χ2.

range of .20 to .40 (Polit and Beck, 2008). In this study, therefore, the number of questionnaires needed was calculated using power analysis with an α level of 0.05, a power (1-β) of 0.9 and effect size of 0.3. The estimated minimal number of questionnaires was 233

Sampling (faculty)

Each questionnaire included a cover letter which explained the purpose of the study, the voluntary nature of the study and the anonymity of the responses. The seven experts who examined the content validity of the questionnaire were also consulted about ethical considerations. More importantly, the research design provided autonomy, giving faculty and nurses the freedom to decide whether or not to participate and release information. There was no identifying information on the questionnaire. A stamped envelope was provided. It was impossible to trace any questionnaire back to the respondent. Return of the questionnaire implied consent to participate in the study. (IRB No. 960033R). Data Analysis SPSS statistical software 16.0 (SPSS Ins., Chicago, IL) was used for the descriptive analysis of the questionnaire. Mean and standard deviation were used to describe the importance and teaching frequency. Percentage was used to describe the ideal teaching stage. Using the Kolmogorov–Smirnov test and the Shapiro–Wilk test we examined the normality of distribution of the data, which indicated that it was not normally distributed. The nonparametric statistical test (Wilcoxon–Mann–Whitney test) was therefore used to examine the discrepancies in the findings between faculty and hospital nurses. Results

snowball 80.9% 1.5 months

response rate process

random 39.8% 5 months

result

Importance, p = 0.43 Teaching frequency, p = 0.52 Ideal teaching time, p = 0.81

No difference

Results of Instrument Validation To examine whether the statements were appropriate and the reasons given correct, content validity was applied. Seven experts (three clinical senior pharmacists, two nurse practitioners specializing in critical care, and two senior nursing faculty members specializing in clinical teaching on medical–surgical wards) examined the entire questionnaire and offered their expert opinions about its content. They all agreed that the questions were important and the “reasons” appropriate and precise (CVI = 0.91). Cronbach α was used to examine the internal consistency of the questionnaire. The first pilot study from the 30 faculty members collected from snowball sampling was used to examine the reliability. For importance α was 0.88, teaching frequency 0.94 and the ideal teaching time 0.95. In addition, the participants in the pilot study were used to examine face validity. They were asked to comment on every question. All their comments were supportive and encouraging and no corrections were suggested. Background Characteristics

Sampling (nurse)

Snowball response rate: 80.2% process: 2 months. Fig. 1. Flowchart showing the sampling processes for faculty and nurses.

All the participants in this study were female faculty (n = 136) and nurses (n = 199). For faculty, the response rate was 54.4% (136/ 250) (random sampling: 39.8%, 64/161; snowball sampling: 80.9%, 72/89). For nurses, snowball sampling generated a response rate of 80.2% (199/248). The details are shown in Table 3. Importance In relation to both faculty and nurses, all 20 questions scored above four points, indicating that the questions were considered important.

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questions to be more important than did those who had undergone such training (4.59 ± 0.35 vs. 4.41 ± 0.79; t = 2.27, p = 0.025).

Table 3 Background and characteristics of faculty and nurses (N = 335). Faculty n = 136 Variable Age (years) b25 25–30 31–35 >35 Education Associate degree Bachelor Master PhD Position Clinical instructor Lecturer Professor Registered nurse Nurse practitioner Head nurse Teaching/nursing experience (years) b2 2–5 6–10 >10 ICU training No Yes

Nurses n = 199

n

%

n

%

0 2 25 109

0 1.5 18.4 80.1

20 61 51 67

10.1 30.7 25.6 33.7

0 31 87 18

0 22.8 64.0 13.2

40 146 13 0

20.1 73.4 6.5 0

41 74 21

30.1 54.4 15.4 143 18 38

71.9 9.0 19.1

11 73 37 15

8.1 53.7 27.2 11.0

18 52 51 78

9.0 26.1 25.6 39.2

94 42

69.1 30.9

76 123

38.2 61.8

Including assistant, associate and full professor.

Among faculty, however, they were considered more important than among nurses (4.65 ± 0.35 vs. 4.48± 0.67; U = 11678.50, p b 0.05) (Table 4). Faculty backgrounds showed no significant influence on importance. Nurses without ICU training, however, considered the 20

Teaching Frequency From the faculty perspective, in relation to teaching frequency, five questions scored over four points, indicating that they were taught frequently. The other 15 questions scored over three points, indicating occasional teaching. From the nurses' perspective, however, only seven questions were taught occasionally and scored over three points; the remaining 13 questions all scored below three points, indicating that they were rarely taught. When faculty and nurse perspectives were compared, it was found that faculty thought that the 20 questions were taught more often than the nurses did (3.88 ± 0.87 vs. 3.06 ± 0.94; U = 7055.50, p b 0.001) (Table 5). Faculty and nurse backgrounds showed no significant differences with regard to the teaching frequency, except that faculty with ICU training taught these 20 questions more often than faculty who did not have that training (4.19 ± 0.64 vs. 3.73 ± 0.93; t = 3.32, p = 0.001).

Ideal Stage of Teaching Faculty believed that these 20 questions should be taught during formal, in-school nursing education (94.3%) including nursing lectures (35.8%), clinical practice (29.7%) and pharmacology classes (28.8%) and only a small amount should be allocated to hospitalbased continuing education (3.7%) and other classes (2.1%). Unlike faculty, nurses thought that most of these 20 questions should be taught as part of hospital-based continuing education (48.9%). On this question, faculty and nurse perspectives were significantly different (x = 56.31, p b 0.001) (Fig. 2).

Table 4 Faculty and nurse perspectives on the importance of the 20 questions (N = 355; faculty: n = 136, nurse: n = 199). Part A Answer

Faculty

Item

Question

(T/F)

M (SD)

R

M (SD)

R

6

When an emergency such as ventricular fibrillation happens, push fast 15% KCl 10 ml into IV “cc” or “ml” is the dosage expression for insulin injection Insulin syringe can be replaced by 1 ml syringe When an emergency happens, fast IV push 10% CaCl2 10 ml in 1 to 2 min Port-A route can be used for blood withdrawal and drug injection generally Fast IV push 1:1000 Epi 1 amp for a patient who has mild allergic reaction Fast IV infusion of 3% NaCl 500 ml for a patient who has a low sodium level 15% KCl is better added to Ringer's solution for rapid infusion 10% Cal Gluconate and 10% CaCl2 are the same drug and interchangeable For chemotherapy dose calculation, adult based on BW, children BSA Mean

F

4.82 (0.43)

1

4.79 (0.73)

1

F F F F F F F F F

4.82 4.76 4.75 4.72 4.71 4.71 4.68 4.61 4.59 4.72

(0.43) (0.48) (0.48) (0.50) (0.52) (0.50) (0.53) (0.57) (0.56) (0.35)

1 3 4 5 6 6 8 9 10

4.61 4.59 4.59 4.57 4.51 4.68 4.63 4.58 4.46 4.60

(0.78) (0.77) (0.77) (0.79) (0.85) (0.73) (0.75) (0.77) (0.80) (0.68)

4 5 5 8 9 2 3 7 10 U = 12415.50

Use “Amp” or “Vial” for dose expression instead of “mg” or “g” 15% KCl is frequently used, so it should be easily and freely accessed by nurses For pediatric dose, use teaspoon for dose expression If a ward stores Atracurium for tracheal intubation, the drug should be stored with other drugs and easily accessed by nurses Treat Fentanyl skin patch as regulated narcotic If patient can tolerate, potassium can be administered orally instead of by IV route For convenience, heparin and insulin should be stored together in the refrigerator Use “U” instead of “unit” for dose expression Use distinctive labeling on look-alike drugs Each drug should have multiple concentrations for nurses to choose Mean Mean

F F F F

4.89 4.67 4.65 4.65

(0.31) (0.58) (0.54) (0.54)

1 2 3 3

4.44 4.53 4.38 4.64

(1.06) (0.89) (0.94) (0.79)

3 2 5 1

T T F F T F

4.60 4.53 4.49 4.44 4.40 4.37 4.57 4.65

(0.60) (0.63) (0.73) (0.76) (0.80) (0.90) (0.41) (0.35)

5 6 7 8 9 10

4.43 4.31 4.23 4.04 4.23 4.33 4.36 4.48

(0.92) (0.95) (0.98) (1.12) (1.07) (0.91) (0.72) (0.67)

4 7 8 10 8 6 U = 11372.00⁎ U = 11678.50⁎

4 8 2 10 1 9 7 3 5

Nurse

Part B 1 7 8 10 9 6 4 3 2 5 Total

T/F, true/false; R, rank; KCl, potassium chloride; NaCl, sodium chloride; Epi, epinephrine; CaCl2, calcium chloride; IV, intravenous; BW, body weight; BSA, body surface area. ⁎ p b 0.05 (U: Wilcoxon–Mann–Whitney test).

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Table 5 Faculty and nurse perspectives on the teaching frequency of the 20 questions (N = 355; faculty: n = 136, nurse: n = 199). Part A Answer

Faculty

Nurse

Item

Question

(T/F)

M (SD)

R

M (SD)

R

6 8 4 10 9 1 7 2 5 3

When an emergency such as ventricular fibrillation happens, push fast 15% KCl 10 ml into IV Insulin syringe can be replaced by 1 ml syringe “cc” or “ml” is the dosage expression for insulin injection Port-A route can be used for blood withdrawal and drug injection generally Fast IV infusion of 3% NaCl 500 ml for patient who has low sodium level Fast IV push 1:1000 Epi 1 amp for a patient who has mild allergic reaction 15% KCl is better added to Ringer's solution for rapid infusion When an emergency happens, fast IV push 10% CaCl2 10 ml in 1 to 2 min For chemotherapy dose calculation, adult based on BW, children BSA 10% Cal Gluconate and 10% CaCl2 are the same drug and interchangeable Mean

F F F F F F F F F F

4.31 4.23 4.14 3.88 3.84 3.69 3.66 3.57 3.49 3.30 3.81

(1.13) (1.16) (1.15) (1.26) (1.30) (1.30) (1.34) (1.32) (1.27) (1.44) (1.00)

1 2 3 4 5 6 7 8 9 10

3.89 2.93 3.16 3.40 3.38 2.98 2.75 2.98 2.64 2.72 3.08

(1.34) (1.31) (1.36) (1.22) (1.30) (1.19) (1.31) (1.21) (1.28) (1.26) (1.00)

1 7 4 2 3 5 8 5 10 9 U = 8099.50⁎

Use “Amp” or “Vial” for dose expression instead of “mg” or “gm” 15% KCl is frequently used, so it should be easily and freely accessed by nurses Treat Fentanyl skin patch as regulated narcotic If patient can tolerate, potassium can be administered orally instead of IV route Use “U” instead of “unit” for dose expression Use distinctive labeling on look-alike drugs For pediatric dose, use teaspoon for dose expression For convenience, heparin and insulin should be stored together in the refrigerator Each drug should have multiple concentrations for nurse to choose If a ward stores Atracurium for tracheal intubation, the drug should be stored with other drugs and easily accessed by nurses Mean Mean

F F T T F T F F F F

4.53 4.07 3.97 3.96 3.93 3.91 3.88 3.77 3.76 3.62

(0.68) (1.21) (1.17) (1.12) (1.17) (1.20) (1.33) (1.23) (1.18) (1.31)

1 2 3 4 5 6 7 8 9 10

2.98 3.62 3.52 2.92 2.64 2.79 2.88 2.90 2.89 3.24

(1.25) (1.25) (1.36) (1.18) (1.22) (1.23) (1.27) (1.18) (1.27) (1.34)

4 1 2 5 10 9 8 6 7 3

Part B 1 7 9 6 3 2 8 4 5 10

Total

3.94 (0.83) 3.88 (0.87)

3.04 (0.97) 3.06 (0.94)

U = 6453.00⁎ U = 7055.50⁎

T/F, true/false; R, rank; KCl, potassium chloride; NaCl, sodium chloride; Epi, epinephrine; CaCl2, calcium chloride; IV, intravenous; BW, body weight; BSA, body surface area. ⁎ p b 0.001 (U: Wilcoxon–Mann–Whitney test).

Discussion Importance of the 20 Questions Our results indicated that from faculty and nurse perspectives all 20 questions regarding high-alert medications were important,

60

Faculty Nurse

50

40

% 30

20

10

Teaching Frequency of the 20 Questions

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scoring 4.65 (faculty) and 4.48 (nurse). Pharmacology knowledge is important for nurses in drug administration, patient assessment, nurse prescribing and patient medication education. A national study was conducted in 33 university nursing departments in England in order to understand pharmacology education. The results supported the notion that all pharmacology-related topics are important. Among the 16 topics, however, “record keeping” and “administration of medicines” were ranked highest (Morrison-Griffiths et al., 2002). Pharmacology is also important in the training of psychiatric and pediatric nurses. In an investigation of students' knowledge of mental health nursing, 192 students reported that, among 22 self-reported questionnaire items, “I understand the therapeutic actions of psychoactive drugs,” and, “I am able to detect side-effects of psychoactive drugs,” were the two items about which students felt the least confidence (Henderson et al., 2007). The results of a study of 75 students in pediatric clinical practice showed that the most stressful aspect of clinical practice was the administration of medication to children. This lack of drug knowledge was identified as the underlying cause of stress which further resulted in fear and disappointment in clinical practice (Oermann and Lukomski, 2001). All the above studies demonstrated that pharmacology is vital to nursing education, and we further emphasize that knowledge about high-alert medications is essential to nurses.

Fig. 2. Faculty and nurse perspectives on the ideal stage for teaching about high-alert medications. (N = 355; faculty: n = 136, nurse: n = 199).

Several studies have indicated that the teaching of pharmacology is insufficient. Like previous studies and research-based evidence, our study demonstrated that, for these 20 questions regarding highalert medications, faculty considered the teaching frequency to be 3.88 and nurses 3.06 (4: frequently; 3: occasionally). The differences may be due to the possibility that the working nurses forget certain aspects of the rarely-used pharmacokinetics that they learned years previously, and to the inadequacy of teaching regarding high-alert medications.

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One study indicated that 98% of nurses and students expressed a wish that more biological science had been included in curricula in order to prepare them for practice (Clancy et al., 2000). Bullock and Manias (2002) received 23 questionnaires from faculty at 12 universities and reported that most respondents (88%) agreed that pharmacology was an important priority in the curriculum and that there was not enough time dedicated to it (55%). When ten qualified nurses from an emergency admissions unit were interviewed, a study reported a limited understanding of the subject and dissatisfaction with the teaching of pharmacology (King, 2004). By using a qualitative approach, others highlighted the need for more pharmacology, and the respondents specifically mentioned that more time should be allocated for the teaching of pharmacological concepts (Latter et al., 2000; Morrison-Griffiths et al., 2002). Nurses' perceptions of their pharmacology education focused mainly on the lack of time spent on the subject, the lack of structure, and the over-emphasis of other subjects, such as communication skills and behavioral sciences (Clancy et al., 2000). Inadequate teaching of pharmacology resulted in insufficient knowledge. In one investigation of pharmacological skill, of a possible 24 points, nurses reached a mean score of 18.6 and students 16.3 (Grandell-Niemi et al., 2005). Our previous study of 305 nurses' knowledge of high-alert medications showed a correct answer rate of 56.5%, with only 3.6% of nurses deemed to have sufficient knowledge (90% correct answer rate), and 84.6% hoping to receive more teaching and training (Hsaio et al., 2010). These results indicated that there were deficiencies in nurses' pharmacological skills. This further caused nurses stress and anxiety in performing their roles, and, more seriously, put patients at risk as they received drug therapy. Ideal Teaching Stage for the 20 Questions about High-Alert Medications It is interesting to note that faculty and nurses had different perspectives concerning the ideal stage for teaching about high-alert medications. From the perspective of faculty members, students should be fully prepared before they graduate from nursing school, so 94.3% of knowledge about high-alert medications should be taught during formal, in-school nursing education, such as nursing lectures, or as part of courses in clinical practice and pharmacology courses, and only 3.7% in hospital-based continuing education. Nurses, however, believed that nearly half (48.9%) of the knowledge should be taught to qualified nurses in hospital-based continuing education programs. The causes for such discrepancies may stem from different roles and different expectations. To arm students fully with knowledge is the role and perceived responsibility of the faculty. For them, the ideal teaching time is during formal, in-school nursing education. For a practicing nurse, knowledge of pharmacology is partly acquired in daily practice (Morrison-Griffiths et al., 2002), so the ideal teaching time is during hospital-based continuing education. Hospital-based continuing education plays a vital role in making nurses more mature and competent, especially in pharmacology. A study to determine the continuing education needs of 164 nurses indicated that “drug therapy/interactions” was the most important learning need (4.29), whereas “sexuality” was ranked last among the 58 items (2.77) (Glass and Todd-Atkinson, 1999). Most faculty (65%) also agreed that the majority of pharmacology teaching should take place in the hospital setting, such as in clinical practice, where it can be made more relevant to a particular clinical situation (Bullock and Manias, 2002). Our results conclude that both school education and hospital training play a vital role in nurses' knowledge regarding high-alert medications. Limitations Our study demonstrated that snowball sampling could achieve a higher response rate but could cause some bias in background

characteristics. The results are, however, consistent with random sampling and compatible with the findings of other studies. Snowball sampling may therefore be a cost-effective method, but it is not a substitute for a sound and rigorous data collection method. In this study, random sampling and snowball sampling showed no significantly different conclusions regarding high-alert medicationrelated factors. The study may, however, have been affected by low response rates from random sampling and some degree of bias from snowball sampling, so the findings' capacity for generalization is somewhat limited. Conclusion The results of our surveys of faculty and nurses demonstrate consistent opinions regarding importance (all important) and teaching frequency (insufficient) in relation to high-alert medications. Background characteristics played a minor role in these perspectives. The biggest discrepancy was in the ideal teaching stage, as faculty considered that the material should be taught mostly in school classes, while nurses in hospitals favored training as part of continuing education. We conclude that knowledge about high-alert medication is a vital part of nursing education but that there is some dissatisfaction concerning the amount of teaching performed on the subject. Knowledge about high-alert medications should be taught both in nursing school classes and hospital training courses. School classes and hospital-based continuing education are essential to nurses' preparation for their role in drug administration. The 20 questions demonstrate important concepts which could be used as tools to evaluate nurses' knowledge as well as to construct nursing curricula in schools and to develop the teaching materials for continuing education in hospitals. Contributions Study design: F-IT, T-FL, SY; data analysis: I-JC, T-FL, and manuscript preparation: F-IT, SY, K-WW Acknowledgment We would like to thank the members of nursing faculties and RN staff nurses for participating in this research. We would also like to thank Mr. Mark Rawson for editing our English. References Babbie, E., 2004. The logic of sampling, In: Howard, E. (Ed.), The Practice of Social Research, 10th ed. Wadsworth/Thomson, Belmont, CA, p. 184. Chap 7. Barker, K.N., Flynn, E.A., Pepper, G.A., Bates, D.W., Mikeal, R.L., 2002. Medication errors observed in 36 health care facilities. Archives of Internal Medicine 162 (16), 1897–1903. Bates, D.W., Cullen, D.J., Laird, N., Petersen, L.A., Small, S.D., Servi, D., Laffel, G., Sweitzer, B.J., Shea, B.F., Hallisey, R., Vander Vliet, M., Nemeskal, R., Leape, L.L., 1995. Incidence of adverse drug events and potential adverse drug events: implications for prevention. The Journal of the American Medical Association 274, 29–34. Benner, P., Sheets, V., Uris, P., Malloch, K., Schwed, K., Jamison, D., 2002. Individual, practice, and system causes of errors in nursing: a taxonomy. Journal of Nursing Administration 32, 509–523. Bullock, S., Manias, E., 2002. The educational preparation of undergraduate nursing students in pharmacology: a survey of lecturers' perceptions and experiences. Journal of Advanced Nursing 40, 7–16. Clancy, J., McVicar, A., Bird, D., 2000. Getting it right? An exploration of issues relating to the biological sciences in nurse education and nursing practice. Journal of Advanced Nursing 32, 1522–1532. Cohen, M.R. (Ed.), 2007. Medication Errors, 2nd ed. American Pharmaceutical Association, Washington, DC. Department of Health, 2000. An Organization with a Memory. The Stationery Office, London. Department of Health, 2004. Building a Safer NHS for Patients: Improving Medication Safety. The Stationery Office, London. Edgar, T.A., Lee, D.S., Cousins, D.D., 1994. Experience with a national medication error reporting program. American Journal of Hospital Pharmacy 51, 1335–1338.

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