Nurses’ knowledge and understanding of obstacles encountered them when administering resuscitation medications: a cross-sectional study from Palestine

One of the most important reasons for patient morbidity and mortality is medication errors (ME) [1]; furthermore, it is thought to be the most important cause of preventable harm to patients [2]. ME are a dangerous problem during treatment, especially for patients in intensive care units (ICUs) who can suffer very serious complications due to their severe illnesses and the complex pharmacotherapy programs they receive [3].

Any errors in dose, administration rate, drug concentration, type of drug, route of administration, method of administration or delay in administration, fall under the definition of ‘ME’ [4]. Research has found that there can be important errors during the preparation and administration of medications [4‐6]. There are many causes of EM, and many research studies have focused on these reasons; their findings include stressful and complex systems, workload, poor skill, distracting nurses during their work, lack of concentration, and insufficient knowledge of drug and calculation tasks, confusion between similar and sound-alike medications, use of medications with a narrow therapeutic index (NTI), and insufficient experience in nurses’ work [4, 5, 7‐10]. Furthermore, other research has found that serious incidents occur due to problems related to teamwork and knowledge related to cardiac arrest in special cases [11].

In general, the prevalence of ME was 32.1% [12] to 94% [13]. Importantly, approximately 38% of ME are caused by nurses [14]. The prevalence of ME among hospital nurses was 17% [15], while it was 39.68% among nursing students [16], and both percentages are considered high. Furthermore, a systematic review found a prevalence between 16–27% [17]. In countries in the Middle East, studies related to ME are few and do not contain sufficient information [18]. A Jordanian analysis demonstrated that the size of the hospital may play a role in the nursing rate of reporting ME and their views on this regard [19]. In the same country, lack of experience and knowledge, along with workload, was documented as the main factors behind medication error [20]. Furthermore, a retrospective study in a teaching hospital showed that 14.3% of incidents are related to ME [21]. In another Middle East country, Saudi Arabia, medication errors were found to be high in a hospital during the COVID-19 crisis as 19% [22]. Researchers explain that due to work overload among healthcare providers [22].

Unfortunately, many hospitals do not have a special form or internal system for reporting errors [23], and sometimes, health care professionals tend to report errors voluntarily and using verbal methods instead of a written or documented report [23, 24]. This led to underreporting of ME, which are estimated to be 50–60% each year [23]. Different ways of reporting errors were identified, including verbal and written on a paper [25], and the most recent one is web-based forms [26]. The consequences of ME on healthcare professionals include providing further training, improving communication, and informing the personnel who committed the error [27].

Resuscitation is a multipart process executed in a short time, frequently occurring in uncontrolled situations; a stressful situation that requires nurses with high knowledge, and where, with limited information and time nurses, should respond as fast as possible. In such conditions, nurses' performance may not be satisfactory enough, particularly when nurses are not qualified or experienced enough to respond to stressful conditions [11, 28]. Confidentiality in the resuscitation environment can generate errors in the critical stages of medication administration [29].

Nurses lacking knowledge of drugs and their appropriate doses can cause medication errors [3, 30], especially with increased stress and interruptions during medication administration among nurses [31]. The resuscitation procedure requires a rapid response of nurses to the doctor’s oral orders without enough time to get reference information on administering a resuscitation medication [32].

In addition, previous research worldwide has produced few studies on nurses' knowledge of resuscitation medications and their obstacles during medication administration. This study is considered to be the first in Palestine. To reduce morbidity and mortality among patients with ME [33], it is necessary to assess the pharmacological knowledge and to understand the obstacles they face when administering resuscitation medications. Nursing associations can then argue for mandatory training courses on administering resuscitation medications and decreasing the obstacles they encounter to minimise resuscitation ME as much as possible. This research will help university academics design multidisciplinary courses in clinical pharmacology focusing on resuscitation medication as part of ongoing nurse education that meets the needs of Palestinian nursing practice situations.

The administration of medication during resuscitation must be performed correctly, as incorrect or delayed drug administration can result in serious harm or death to patients. Therefore, the study objectives were: 1) to assess nurses’ knowledge about resuscitation medications, 2) to determine the obstacles that nurses face when giving resuscitation medications, 3) to evaluate resuscitation medication administration errors in reporting and the reason that prevent nurses to not report the errors, and 4) to determine factors that affect sufficient knowledge among nurses.

This study is one of the first in Palestine that has been performed to determine factors that affect nurses' knowledge about resuscitation medication, discuss the obstacles they encountered during medication administration, explain the causes behind not reporting ME and suggest solutions to decrease ME.

Insufficient knowledge among nurses is considered one of the most important reasons for medication administration errors [3, 4, 42].

In our study, the correct answer rate regarding high-alert medications was only 58.6%, which was quite low compared to a similar study done in Taiwan 70.5% [32], and 60.9%, 56.5%, 75.8% in studies done in Palestine and Taiwan, respectively [38, 39, 42], also proves that nurses are lacking information about resuscitation medications and high-alert medications. The question about giving 15% KCl as an IV push in emergency cases such as ventricular fibrillation achieved the correct answer rate of 87.5%, which showed good knowledge of how to avoid ME which can cause cardiac arrest and death; It was a higher rate compared to a study done in Palestine on high alert medications which was 76.8% [42], but lower than a similar study conducted in Taiwan (95.2%) [32], and the same result as Lu et al. [38]. 68.5% of nurses gave a correct answer to not giving amiodarone by the trachea to increase the effects, which is considered high compared to the same study done in Taiwan, which only achieved 42.0% [32], but still low, because there is no absorption for amiodarone through the trachea [43]. On the contrary, 63.5% of nurses still thought that atropine could be used in pulseless electrical activity treatment, which was the lowest correct answer rate, while only 29.8% of nurses answered incorrectly / do not know about this question [32] which indicates low knowledge. The next lowest correct answer rate was 44.5%, representing that more than half of the nurses who did not know that body weight is used in an epinephrine dose calculation for resuscitation of a child, which is a comparable result with a study conducted in Taiwan [32]. Calcium chloride (CaCl₂)injection should be administered gradually in a large vein, but 53.5% of nurses did not recognize this error; the same result was found by Zyoud et al. [42], while only 39.2%, 49% of nurses incorrectly answered in studies done in Taiwan [32, 38]. 32% of nurses incorrectly answered about the inability to switch between 10% Ca gluconate and 10% CaCl2, which is the same result in a study conducted in Palestine [42], but a lower correct rate than studies in Taiwan [32, 38].

To increase nurses’ pharmacological knowledge of resuscitation medication and increase patient safety, the common obstacles that nurses face and the ones that lead them to make errors should be known. In our study, we found that the major obstacle nurses faced when administering resuscitation medication was a chaotic environment during CPR, for example, with many people handling a single drug (62%). This was the third of 12 obstacles that nurses faced in a study completed by Chen et al. [32], and Ornato et al. also mentioned that too many individuals present in the resuscitation room, as well as poor teamwork and leadership, could result in errors in the resuscitation system [44]. Furthermore, the inaccessibility of pharmacists for the whole day (61%) and the similarity of different medications packaging (61%) were further obstacles.

Several studies found that a deficiency in pharmacological knowledge is the major reason for ME. For example, inadequate knowledge was the main obstacle that nurses faced in Taiwan (75.4%) [39], and 28.2% of nurses considered it an obstacle [32]. Furthermore, in our research, 48.5% of nurses considered having inadequate knowledge as a major obstacle, while another study considered interruptions during drug administration as the main obstacle 62.8% [32], while 48.5% of nurses in our study agreed with that, another studied poor communication between nurses and physicians was an important obstacle [11, 42]. In our study, 39% of nurses considered it essential to establish more trained and cooperative CPR teams for professional resuscitation action.

38% of nurses believed they had sufficient knowledge levels about resuscitation medications, while only 8% of nurses in Taiwan thought that [32], and only 3.6% and 23.6% of nurses believed themselves to have adequate knowledge on high-alert medications in Taiwan and Palestine, respectively [39, 42]. Most nurses acknowledged that they needed training on resuscitation medications as well as other studies [32, 39, 42].

In our study, we found that there was no compatibility in the definition of ME between nurses and hospitals (43.5%), which was the main reason for not reporting medication administration. The other most important causes were the negative attitudes that patients and their families towards the nurse or that they may litigate against the nurse if an EM is reported (42.5%). If something happens to the patient, nurses thought that they would be blamed as a consequence of ME (42%), and that nursing management focused on the person (rather than the system) when ME occurs (42%) [45, 46]. The study by Mansouri et al. mentioned that the ME were not documented for three reasons: fear of consequences after reporting an error, procedural obstacles and management problems [47], and in our study, fear of adverse consequences was an important barrier to reporting incidents.

To improve ME reporting, we have to create an encouraging and supportive environment with no blame and dishonor when genuine mistakes are made. Teaching nurses how and what to report incidents and giving rewards to encourage incident reporting would help. Increasing the provision of corrective actions regarding incident reports, such as training health providers to recognise medical incidents, and the existence of a reporting system, would be beneficial [45].

We suggested solutions to increase patient safety, and the nurses agreed with them. These were; an improved arrangement of drug names, labels, and packages can increase proper use of medications by healthcare providers and improve patient safety; create a continuous learning and training program for nurses and staff [6, 42, 48], prepare more trained and cooperative CPR teams to increase the efficiency of resuscitation actions [44]; provide a more effective source of reference for information about drugs, such as clinical pharmacy service, as it positively impacts the quality of care [49].

The nurses were found to lack sufficient information about the drugs they are giving. A positive direct effect was shown between the knowledge score and the male participants (p = 0.001). These findings are comparable with a study conducted by Zyoud et al. on high-alert drugs [42] and nurses working in CCU, ICU, and general wards (p < 0.001). In Taiwan, the same result was found that nurses who worked in the ER or ICU departments had more knowledge than those who worked in the EMS and obstetric-paediatric wards [32]. In addition, on the medical and surgical wards, medical errors occurred more frequently, according to Sheu et al. [50].

Our study observed that there was a significant difference according to the position of the nurses, with supervisor nurses having a higher score compared to staff and principal nurses (p = 0.035); Zyoud et al. also considered the position as a factor affecting the knowledge score and found head nurses had the highest score [42].

There was no significant relationship between the knowledge score and age, marital status, hospital, residency, years of work, education level, and CPR training. However, a positive relationship between years of work and the knowledge score had been found in several studies [32, 38, 39], educational level and the knowledge score [42], and also between the CPR training and the knowledge score [32].

In conclusion, in our study, the correct answer rate was only 58.6%, which indicates poor knowledge among nurses, which is an obstacle that causes ME. Furthermore, this study has shown that a higher knowledge score was found in male nurses and nurses working in the CCU, ICU, and general departments, but no differences were observed between nurses with regard to age, marital status, hospital, residency, years of work, educational status, and CPR training.

This study identifies the causes of drug administration-related errors by nurses during cardiac resuscitation and offers solutions. It can be helpful when others perform similar studies in their own health care systems and geographical localities. According to our results, a chaotic condition in CPR conditions were the most common obstacle that nurses faced in administering resuscitation medication at a rate of 62%. Furthermore, there is no common agreement; also would like to have extra training to improve and update their pharmacology information. According to the results and conclusions of this study, pharmacists must better organize medications so that names, labels, and packages are clearer to find and use. Continuous learning and training for nurses staff, better preparation and organized training for CPR teams to carry out resuscitation actions in a coordinated and professional way as a code blue team; providing a more effective source of reference material for information about drugs for nurses, and providing a clinical pharmacist in all departments as reference help nurses.

This study gives a great deal of insight into the clinical context, especially for nurses’ practice. Therefore, comprehensive actions that can reduce nurses’ make fewer errors should be made following the study findings. First, hospitals should increase the number of nursing staff to reduce their workload on them. Second, establishing an electronic medical library within reach of nursing hands could give nurses valuable tools to execute orders. Lastly, organising a calm and disciplined CPR environment can improve communication between nurses and physicians to reduce ME.