Nurses’ Performance Regarding

Administration of High Alert Medication

in Coronary Care Unit

Thesis Submitted for Partial Fulfillment of the Requirement

of Master Degree (Medical Surgical Nursing)

Presented by

Gehan Karawan Sayed Sallam BSN

Faculty of Nursing - Ain Shams University

Faculty of Nursing

Ain Shams University

2016

Nurses’ Performance Regarding

Administration of High Alert Medication

in Coronary Care Unit

Thesis Submitted for Partial Fulfillment of the Requirement

of Master Degree (Medical Surgical Nursing)

Under Supervision of

Prof. Dr. Manal Houssien Nasr Professor of Medical Surgical Nursing

Faculty of Nursing – Ain Shams University

Dr. Mona Nadr Ebraheim Lecturer of Medical Surgical Nursing

Faculty of Nursing – Ain Shams University

Faculty of Nursing

Ain Shams University

2016

Acknowledgments

First and forever, thanks to Allah, Almighty for giving

me the strength and faith to complete my thesis and for

everything else.

Kindest and the most merciful for the all blessings and for

giving me the will and strength for completion of this work. I would

like to express my deeply thanks and profound gratitude to Prof.

Dr. Manal Houssien Nasr, Professor of Medical Surgical

Nursing Ain Shams University for scientific guidance and kind

supervision. It was a great privilege to work under the supervision.

She gave me much of her precious time, experience and

valuable advices to complete this work in the best way. I would

like to express my deeply appreciation and profound respect to.

Prof. Dr. Mona Nadr Ebraheim, Lecturer of Medical -

Surgical Nursing, Faculty of Nursing -Ain Shams University for

valuable instructions, cooperation, guidance, unlimited help and

support throughout this work. Last but not least, my deep

appreciation and thanks to my parent and my family for support

throughout this work.

Gehan Karawan Sayed Sallam

Dedication

I wish to dedicate this work to

My sacrificing parents, my Husband,

family, and my friends who dedicated

their efforts to let this work

come to this final

Contents

List of Contents

Subject Page No.

List of Abbreviations ............................................................... i

List of Tables ......................................................................... iii

Abstract ................................................................................. vi

Introduction ..............................................................................

Aim of the Study .................................................................... 5

Review of literature ............................................................... 8

Subject and Methods ............................................................ 70

Results .................................................................................. 81

Discussion .......................................................................... 106

Conclusion .......................................................................... 131

Recommendations .............................................................. 132

Summary ............................................................................ 134

References .......................................................................... 142

Appendices .............................................................................. I

Arabic Summary ...................................................................ـ ـــ

List of Abbreviations

i

List of Abbreviations

Abbr. Title

Bp : Blood pressure

Bs : Blood sugar

HAM : High alert medication

IV : Intravenous

ISMP : The Institute for Safe Medication Practices

LASA : Look alike sound alike

MAP : Medication administration process

MAR : Medication administration record

ME : Medication error

Mg :Milligram

Mic : Milligram

MRN : Medical Record Number

NANDA : North American Nursing Diagnosis Association

PRN : As needed, as required

SI unit : System international of units

List of Abbreviations

ii

Glossary of selected statistical symbols:

% : Percentage

< : Less than

> : Greater than

No. : Number

p : Probability that observed data is consistent

with null hypothesis.

r : Multiple correlation coefficients

SD : Standard deviation

SPSS : Statistical package for social science

2 : Greek chi squared test, to test the difference in

proportions in two or more independent groups

List of Tables

iii

List of Tables

Table No. Title Page No.

Tables in Review:

Table (1): List of high alert medication classes/

categories .......................................................... 19

Table (2): Systems of measurement and approximate

equivalents ........................................................ 26

Table (3): High Alert Medications and safety

strategies: Adult Patients .................................. 43

Table (4): Types of Medication Errors .............................. 48

Table (5): Categories of Medication Error Classification .... 50

List of Tables

iv

List of Tables

Table No. Title Page No.

Tables in Results:

Table (1): Percentage distribution of demographic

characteristics among nurses included in the

study (n=32) ........................................................... 82

Table (2): Percentage distribution of total nurse’s level of

knowledge regarding high alert medication

administration Study (n=32) .................................. 85

Table (3): Percentage distribution of nurses’ level of

knowledge regarding general pharmacology (n=32) .. 86

Table (4): Percentage distribution of nurse’s level of

knowledge regarding prescription and

calculation of high alert medications (n=32) ......... 87

Table (5): Percentage distribution of nurse’s level of

knowledge regarding routes, preparation and

administration of high alert medication (n=32) ..... 88

Table (6): Percentage distribution of nurses level of

knowledge regarding documentation and

monitoring of high alert medication (n=32) ............. 90

Table (7): Percentage distribution of nurses’ level of

knowledge regarding dispensing and storage of

high alert medication (n=32) ................................. 91

Table (8): Percentage distribution of nurses level of

knowledge regarding patient education of high

alert medication (n=32) ......................................... 92

Table (9): Percentage distribution of total nurses’ level of

practice regarding high alert medications

(n=32) .................................................................... 93

List of Tables

v

Table No. Title Page No.

Table (10): Percentage distribution of nurses’ level of practice regarding preparation of high alert medication alert medication (n=32) ....................... 94

Table (11): Percentage distribution of nurses’ level of practice regarding administration of high alert medication(n=32) ................................................... 95

Table (12): Percentage distribution for neglected practice among all nurses under study regarding administration of high alert medication (n=32) ..... 96

Table (13): Percentage distribution for nurses regarding common high alert medication administration error among nurses (n=32) .................................... 98

Table (14): Nurses attitude regarding high alert medication administration(n=32) ............................................. 99

Table (15): Relation between nurses’ total level of knowledge regarding high alert medication and their demographic characteristics (no=32) .......... 100

Table (16): Relation between nurses total practice level regarding high alert medication administration and their demographic characteristics (n=32) ..... 101

Table (17): Relation between nurses’ total attitude regarding high alert medication administration and their demographic characteristics (n=32) ..... 102

Table (18): Correlation between total nurses’ level of knowledge and attitude regarding high alert medication administration (n=32) ....................... 103

Table (19): Correlation between total nurses’ level of knowledge and practice regarding high alert medication administration (n=32) ....................... 104

Table (20): Correlation between total nurses practice and attitude regarding high alert medication administration (n=32)............................................ 105

List of Tables

vi

Table No. Title Page No

List of Tables in Pilot Study

Table (1): Expertise’s judgment regarding general

evaluation of content validity of nursing

interview questionnaire sheet regarding

knowledge with ….. ......................................... XXVIII

Table (2): Expertise’s judgment regarding general

evaluation of content validity of nursing

interview questionnaire sheet regarding practice

for high alert medication administration ............ XXIX

Table (3): Expertise’s judgment regarding general

evaluation of content validity of nursing

interview questionnaire sheet regarding attitude

for high alert medication administration. ............. XXX

Table (4): Face validity of developed data collection tools

based on agreement. ........................................... XXXI

Table (5): Cronbach’s Alpha reliability analysis. .............. XXXII

Table (6): Reliability coefficient of pilot study No. of

nursing (10) ....................................................... XXXII

List of Figures in Pilot Study

Fig. (1): Job characteristics of expertise group member

(N = 9). .............................................................. XXVII

Abstract

vii

Abstract

High alert medications are drugs that have an increased risk of

causing significant patient harm when they are used erroneously. Nurses

should have adequate knowledge and practices to be able to manage high alert

medications administration process in critical care unit and post

cardiothoracic intensive care unit. Aim: the current study aimed to assess

nurse's performance regarding high alert medication administration in

coronary care unit. Design: a descriptive explanatory study. Setting: the study

was carried out at coronary care units and post cardiothoracic intensive care

unit at Ain shams university hospitals Study subjects: A convenience sample

of 32 nursing staff worked in the previous mentioned setting. Data collection

tools: Nurses self-administered questionnaire, observational checklists and

nurse’s attitude scale toward administration of high alert medication. Results:

the total nurse's level knowledge was unsatisfactory regarding high alert

medication calculation measurement 100.0%, medication preparation 93.8%

and patient education 71.9%, the majority of nurses had unsatisfactory level

of practices regarding, and documentation error of high alert medication,

patient education 100% and monitoring of high alert medication was 65.6 %

respectively. There were significant statistical relation between nurse's

attitude and total score of knowledge, practices age and years of experiences.

There were in significant relation between knowledge, practice and academic

qualification. Conclusion: concluded that about two thirds of nurses under

this study had total unsatisfactory level of knowledge regarding

administration of HAM. While more than two thirds of nurses under study got

unsatisfactory level of practice. While half of them had positive attitude

toward administration of HAM. Recommendation: the study recommended.

The importance of designing education programs related to high alert

medication administration and it should be mandatory for nurses especially

medication calculation course .And it must be linked to all nurses curriculum

in different (diploma, technical, bachelor)

Key words: High alert medication administration, calculation, patient education

Introduction

1

Introduction

rug is a substance used in the diagnosis, treatment, or

prevention of a disease or as a component of a medication.

Medication administration process (MAP) plays a central role in

nursing and is mostly managed by nurses, except prescribing

that is conducted by the physicians. However, nurses are in some

way involved in each stage of the MAP, including prescribing,

documenting (transcribing), dispensing, administering, and

monitoring. Medication administration process is a time-

consuming task, taking an estimated up to 40% of nurses‟ work

time (Pirinen, 2015).

Medications are very diverse and have a wide range of

risk profiles. Those with a heightened risk of causing patient

harm are known as high-alert medications; they have serious

consequences for patients when misused (Lehne, 2010).

Attention for high-alert medications is stressed by several

leading organizations. A list of high alert medications for the

general patient population has been developed by the

institute for safe medication practices(ISMP), based on error

reports and expert opinions .The high-alert classification is

also dependent on dosage, the familiarity of the health care

professionals with the medication and the possibility of

careful monitoring (Joint Commission International

Accreditation, 2015).

D

Introduction

2

High-alert medications are medications that are most

likely to cause significant harm to the patient when misused.

Mistakes with these medications may not be more common

but may be more devastating to the patient if an error occurs.

Additionally, the consequence of an error with these

medications is far more devastating for patients in critical

care units. The harm leads not only to patient suffering but

also to additional costs associated with the care of these

patients (Ali, 2016).

Many high-alert medications have a high volume of

use. Examples of high-usage medications include insulin

amongst diabetics, anticoagulants, narcotics, and sodium

chloride for injection, opioids, antiarrhythmics, intrathecal or

epidural medications, radio-contrast agents, anesthetic agents

and neuromuscular blocking agents. Using any of these drugs

increases the likelihood that a patient might suffer adverse

events. Adverse events from these medications represent

areas of greatest harm and greatest opportunity improving

patient safety (Rashidee, 2009).

The major strategies for the safety of the medication

system, focusing specifically on HAM, there are procedures

that can be adopted to prevent medication error(ME) with

these drugs, such as: having a list of HAM, which should be

broadly disseminated; implementing guidelines to the