Knowledge about the administration and regulation of high alert medications among nurses in Palestine: a cross-sectional study

Medication safety during administration is a major concern at a global level, and is related to safety and quality of patient care [1‐3]. Medication errors (MEs) are unintended failures in the drug treatment process that can occur during prescription, dispensing, storing, preparation and administration of medications. MEs are one of the major concerns of nursing professionals internationally [4]. High alert medications (HAMs) are considered to be one of the most medications associated with a high risk of serious harm if administered improperly, and are responsible for the majority of harmful errors [5‐13]. [5‐13]. Nurses are responsible for administration of HAMs; incorrect administration can have a significant clinical outcome, and at times can be fatal. A considerable amount of literature has been published on the pharmacology knowledge of nurses [5‐9]. Overall, these studies highlight the need for more research to evaluate nurses’ knowledge of pharmacology for the purpose of drug administration [5‐10].

The American Pharmaceutical Association classifies HAMs according to the following list of categories: chemotherapeutic agents (oral and parenteral), cardiovascular medications (e.g., adrenergic drugs), narcotics (e.g., morphine or fentanyl), anticoagulants (e.g., warfarin and heparin), neuromuscular blocking agents (e.g., rocuronium or succinylcholine), benzodiazepines (e.g., midazolam) and electrolytes (e.g., 15% potassium chloride (KCl)) [11]. HAMs are commonly used in the emergency room (ER), intensive care unit (ICU), paediatric ward and medical ward. Because HAMs are used in emergency situations, they bear a heightened risk of causing patient harm when used incorrectly. Some HAMs have a narrow therapeutic index, e.g., warfarin, which when used improperly, rapidly causes the undesirable side effect of bleeding. Further, well-known chemotherapeutic agents, such as vincristine, require special handling, and should be administered according to the manufacturer’s recommendations, “FOR INTRAVENOUS (IV) USE ONLY”. If administered by another route of administration, e.g., intrathecal, it will cause significant patient harm, and even death. Moreover, most nurses fall into error while calculating chemotherapeutic doses. For example, they may use patient body weight (BW), when most chemotherapeutic doses are determined based on body surface area (BSA). Further, one of the most common factors contributing of patient harm is fast infusion rate of HAMs, e.g., fast IV bolus push of KCL and insulin.

The nurse has many tasks to do in Palestine, and likewise, in most countries around the world, to reach correct and safe administration. These tasks include preparing medications, administrating medications, reporting adverse drug reactions, monitoring the effectiveness of treatment, and counselling patients about their medications. Several studies have been conducted among nurses in Palestine to investigate their knowledge about many topics [12‐16], but none of these studies were about HAMs, which are the most dangerous and critical medications. Inadequate nurse education, and inadequate experience in administration, storage and dose calculation, increases the risk of MEs. To the best of our knowledge, there is no work investigating the knowledge of HAMs among nurses in Palestine. There is a lack of studies on this topic both in Palestine and in the surrounding countries, and it is considered one of the factors that make our health services and organizations poor and incompetent. In this study, we tried to determine if nurses had adequate pharmacology knowledge of HAMs administration and regulation in West Bank, Palestine. This study will try to uncover these weaknesses and gaps in our health system, and will focus on finding optimal solutions, which is considered an urgent need. Further, this study will assist in the design of new strategies for teaching, training and practice. Nurses need up to date medication education so they are able to provide optimal care to patients, and remain safe in their professional field.

In total, 301 nurses who were working in the included wards (ER, ICU, paediatric and medical) in seven governmental hospitals were approached to participate. Out of the 301 nurses, 280 nurses completed the questionnaire, with a response rate of 93%.

This is the first study of its kind in the Palestinian and Arab world. A review of the literature did not reveal any comprehensive studies of HAMs knowledge targeting nurses who practice anywhere in our country. Therefore, we need to evaluate nurses’ knowledge about HAMs in order to be able to provide appropriate education to update their knowledge, and also to prevent any improper handling of high risk medications that can put patients’ lives in danger. In addition, the knowledge gained from this study can be used for implantation of HAMs for the purpose of ensuring correct and safe administration, and to eliminate MEs that cause harm to patients [23]. The results of this study will establish the first baseline data regarding nurses’ HAMs knowledge, so that relevant educational and training programs can be initiated. Moreover, the findings of this study can help decision makers in academia to determine the proper courses to offer students in nursing schools, with respect to the use and handling of HAMs.

The response rate in our study was 93%; this is a very acceptable response rate, and is higher than a similar study in Taiwan [19], which had a response rate of 79.2%.

Several previous researchers [4, 10, 24, 25] have claimed that nurses have insufficient knowledge, and that this contributes to ME. This was the first study in Palestine to confirm this, especially with regard to HAMs; more than 60% (67.1%; 188/280) of respondents achieved HAMs knowledge scores less than 70%, with a mean score of 59.9 ± 15.1. Our results were consistent with a study in Taiwan [19], which revealed that nurses had insufficient knowledge about HAMs. Similarly, in China [26], researchers evaluated physicians’, pharmacists’, and nurses’ knowledge regarding HAMs, and found that nurses had the poorest knowledge.

Similar to previous studies, the current study found that the most common administration errors were related to lack of knowledge regarding IV drug administration, especially with regard to giving electrolytes as IV boluses (3% NaCl, 15% KCl, 10% Ca gluconate or 10% CaCl_2,), and the dangerous consequences related to this. Electrolytes are commonly use and correct administration of them is vitally important. A Brazilian study [27] found that 74.0% of paediatric prescribed HAMs were for electrolytes. Further, in Taiwan [19], 30% of nurses were found to be giving electrolytes in an improper way.

It was surprising that 50.4% of nurses did not know that 500 mL of 3% NaCl should not be given as fast infusion for patients who have low sodium levels, as this may cause local pain and venous irritation. 3% NaCl is a concentrated solution and should be infused slowly with constant observation of sodium levels and oedema; IV administration of this solution should not exceed 100 mL\hour or 400 mL/24 h [28].

Moreover, 39.2% of nurses did not know that 10% CaCl₂ should not be given as a fast IV push. CaCl₂ injection should be administered slowly into a large vein, as it may lead to a cutaneous burning sensation and peripheral vasodilation. Additionally, we found that 31.4% of nurses did not know that 10% Ca gluconate and 10% CaCl₂ are not interchangeable. These results confirmed that nurses had inadequate pharmacological knowledge about drugs they administer. The findings are consistent with those of Nadosi and Newall, who found that 74% of nurses in the north of England had insufficient pharmacology knowledge [10].

It is known that injection of KCl intravenously at excessively high speed may cause a cardiac arrest; this has been reported as a cause of death worldwide [27]. Reassuringly, 76.8% of nurses understood that 15% KCl should not be given as a fast IV push, though there was a small percentage of nurses who did not know this. Previous studies have recommended that nurses should not have free access to 15% KCl, and that this drug should not be stored in nursing units [19, 29, 30]. We recommend removing KCl from nursing units and re-educating nurses about its fatal effects and its proper administration.

Chemotherapy is considered one of the most dangerous cytotoxic drugs; errors in chemotherapy calculation can be catastrophic. Despite this, our study revealed that 53.6% of nurses did not understand that the adult chemotherapy calculation is based on BSA, whereas chemotherapy for children is based on BW. Similarly, this question had the lowest correct response rate (24.6%) in the study by Hsaio et al. [19]. A study in the USA suggested that it is important to increase nurses’ awareness about the fetal cytotoxic effect of chemotherapeutic agents, and the importance of accurate dosing of these agents [31].

Regarding Port-A route, 69.3% of nurses did not know about this route and its correct usage. As such, 45.7% of nurses reported using a Port-A route for blood withdrawal and drug injection generally, which is incorrect; this was the highest incorrect response rate among the questions assessing HAMs administration knowledge. This result contradicts the results of a Taiwanese study [19], where 64.9% of respondents answered this question correctly. Port-A route is not widely used in our hospitals, and most nurses did not know about it; this was the major cause of lack knowledge about it.

Insulin is one of the most important HAMs, as insulin overdose due to insufficient HAMs knowledge can lead to hypoglycemia. Using a dedicated syringe for the administration of insulin, and understanding that ‘unit’ is the dosage expression, not ‘cc’ or ‘mL’, are two necessary concepts for administration of insulin [19]. Despite that, 32.1% of nurses replaced an insulin syringe with a 1 mL syringe, and 52.9% replaced ‘unit’ with the abbreviation ‘U’. The use of ‘U’ instead of units might get confused with the number ‘0’, ‘11’ or with ‘cc’ [19]. These results concur with an Iranian study [32] which found that 40.5% of MEs occurred due to the use of acronyms and abbreviations. Another previous study [33] proposed that inadequate knowledge about diabetes contributes to insulin errors. In our study, 43.6% of nurses agreed with the presence of multiple drug concentrations to help them to choose. However, multiple concentrations and multiple dosing options can lead to error [34]. We suggest the use of dedicated insulin syringes, the encouragement of double checks, the separation of look-alike and sound-alike drugs, such as heparin and insulin, and the identification of the correct concepts related to insulin dosage expression, will reduce insulin-related administration errors.

Drug regulation is the control of drug use, administration, handling and storage. It is an important issue that needs attention and care from staff. In fact, drug regulation mistakes are responsible for a high percentage of risky medical errors, which is what motivated us to undertake this study. Regarding atracurium regulation, this drug should be refrigerated at 2–8 °C to preserve potency, and it should be used within 14 days, even if re-refrigerated [35]. However, 40.7% of respondents did not know that atracurium should be refrigerated, and they believed that it can be stored normally with other drugs. This drug is very dangerous as it may cause respiratory depression as a result of diaphragm muscle relaxation; the lack of knowledge on the correct handling of this drug is extremely concerning.

In our study, it was surprising that 47.9% of nurses used a spoon for paediatric dose expression. Spoons are available in various different sizes and are not sufficiently accurate to ensure a correct actual dose for children [36].

Fentanyl patch is a regular narcotic used for pain relief in patients with chronic pain; this patch is effective, well tolerated and has a long duration of action. Moreover, it has the advantage of avoiding IV administration. A previous report from the FDA described deaths and life-threatening adverse effects after health care professionals’ improperly recommended the fentanyl patch for the relief of headaches, or for after surgery, or for the treatment of pain associated with cancer and osteoarthritis, in patients who were not opioid tolerant [37]. Although there are studies describing the role of the fentanyl patch for the relief of chronic pain, only 48.6% of nurses knew about them. Whereas, in a previous study [19], this information was well known, and this question had the highest correct response rate of 91.1%. Fentanyl patch is not available in our hospitals and we suggest that it should be made available, given its advantages [38].

In order to find solutions for nurses’ insufficient knowledge about HAMs, it is important to know the most commonly encountered obstacles that lead them to make errors. Our results showed that the most common obstacle nurses encountered when administering HAMs was conflicting views between the nurse and doctor (37.9%). Moreover, 22.9% of respondents believed that confused prescription was another obstacle. Consistent with the results of another study [32], 78.5% of nurses believed that illegible prescriptions are responsible for the incidence of MEs. In order to resolve this problem, nurses, doctors and pharmacists should improve their communication skills. Further, establishment of a computerized system may reduce misunderstanding of prescriptions.

No established standard operating procedure for HAMs was the second most commonly reported obstacle (37.1% of nurses endorsed this).Several studies recommended that hospitals should develop their own list of HAMs, have a process for dealing with HAMs, and should establish this process in their hospital [39‐41]. Therefore, we suggest establishing standard operating procedures for managing and handling HAMs.

Many studies have suggested that lack of knowledge is the main cause of MEs. For example, insufficient knowledge was the main obstacle that nurses encountered in Taiwan (75.4%) [19]. Similarly, inadequate knowledge of pharmacology (administration routes, drug side-effects, drug incompatibilities and the way of preventing them) was one of the human factors associated with MEs [32, 42]. The study of Johnson and Thomas [4] found that 77.1% of nurses agreed that it is important to update their knowledge of pharmacology. Further, 23.9% of nurses in our study considered insufficient knowledge a main obstacle, and 81.8% said that they needed additional training. In order to resolve this problem, HAMs training and teaching programs should be established in each hospital and nursing school. The findings of our study are consistent with the study of Hsaio et al. [19] which found that easy access to HAMs was the least common obstacle encountered during administration of HAMs.

Regarding factors associated with HAMs knowledge, we found significant differences according to gender, whereby males were more knowledgeable than females. Conversely, in Saudi Arabia [24], males were found to have the poorest pharmacology knowledge. All respondents in the Taiwanese study [19] were females. The current study found that HAMs knowledge score increased as the educational level and nurse’s position increased; nurses with a master degree and head nurses were the most knowledgeable groups. Conversely, in Saudi Arabia [24], head nurses were the least knowledgeable group. Further, in the study by Johnson and Thomas [4], there was no significant difference in the knowledge about medication according to level of education. In our study, no significant relationship between HAMs knowledge score and years of experience was found. This is consistent with the study of Johnson and Thomas [4], but inconsistent with the Taiwanese [19], as this study found that nurses’ knowledge increased as years of experience increased.

Nurses who had HAMs training and ICU training achieved higher knowledge score, which supports the importance of training and continuing education. Moreover, we found that nurses who were working in the ICU achieved higher knowledge scores. However, in a Jordanian study [43],there was no significant difference between ICU and other wards with regard to the rate of MEs. It is expected that nurses in the ICU are more knowledgeable about medications than nurses in other wards because they deal with more critical and acute cases; this was confirmed in our study.

As a strong point, the current study is, to our knowledge, the first study in the Palestine and Arab world assessing nurses’ knowledge of HAMs administration and regulation. In addition, the large sample size is strength of this study, which enabled good statistical power.

However, our study had some limitations. First, this study was of a comparative cross sectional design, whereby nurses were assessed only once at a specific period of time. Moreover, the generalizability of the results is limited as the sample was taken from government West Bank hospitals; private hospitals were not studied. Nonetheless, in Palestine, the government sector is considered the major provider of health care services.

Our results provide evidence suggesting that nurses have insufficient knowledge of HAMs administration and regulation, especially with regard to the administration of IV boluses. Lack of knowledge was one of the obstacles nurses encountered during administration of HAMs; this can result in MEs. Nurses reported that they would like to have additional training to update their pharmacology knowledge. They also reported that conflicting views between nurses and doctors, and the lack of established standard operating procedures for HAMs, were the most commonly encountered obstacles during administration of HAMs; these contribute to the possibility of MEs. Males and nurses who were working in the ICU ward were the most knowledgeable. Moreover, nurses who had ICU and HAMs training achieved higher knowledge scores, which confirms the importance of HAMs training in improving nurses’ knowledge, and therefore, reducing MEs. We also found that as nurses’ educational level and position increased, so too did knowledge levels.

The findings of this study have a number of important implications for future practice including: