Protocol Violations during Medication Administration in Pediatrics
Abstract
The paper uses a new measure of protocol violations to explore the extent of violations in the medication administration process. 203 nurses in three units of a free-standing pediatric hospital were provided with a survey assessing violations in the medication administration process; 120 nurses responded for a response rate of 59%. Violation data were collected for three stages of the medication administration process: matching medications to the medication administration record, checking patient identification, and documenting administration. The percentage of nurses who reported violating protocol in the medication administration process ranged from 8.4% to 30.2% in routine situations, and from 32.2% to 53.0% in emergency situations. Violations in the medication administration process may lead to medication errors. To improve medication safety, efforts should be taken to discover the system deficiencies that produce such frequent violations. System redesign should then address these deficiencies.
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Reiterating existing rules or enacting more rules may not reduce workarounds.
“Therefore, reiterating existing rules or enacting more rules may not reduce workarounds. 38-44”
From Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety (2008) · cites this paper as [44]
Reiterating existing rules or enacting more rules may not reduce workarounds.
“Therefore, reiterating existing rules or enacting more rules may not reduce workarounds. 38-44”
From Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety (2008) · cites this paper as [43]
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- Authors
- Alper, S. J., Karsh, B.-T., Holden, R. J., Scanlon, M. C., Patel, N., & Kaushal, R.
- Affiliations
- University of Wisconsin–Madison (US)
- Medical College of Wisconsin (US)
- Monroe Carell Jr. Children's Hospital (US)
- Cornell University (US)
- Venue
- Proceedings of the Human Factors and Ergonomics Society Annual Meeting
- Publisher
- SAGE Publications
- Published
- 2006-10
- Volume
- 50
- Issue
- 10
- Pages
- 1019-1023
- ISSN
- 0163-5182 (ISSN-L)
- 1071-1813
- 2169-5067
- OpenAlex
- W1978073738
- Cited by
- 10
- References
- 18
- Citations by year
- 2023: 1 · 2018: 1 · 2012: 1
- FWCI
- 1.87
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Proceedings of the Human Factors and Ergonomics Society Annual Meeting (publishedVersion)
- Funders
- Agency for Healthcare Research and Quality
- Topics
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Health Sciences › Medicine › Infectious Diseases › Infection Control in Healthcare
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Keywords
- protocol violations, medication administration, pediatric nursing, medication errors, drug safety, patient identification verification, medication administration records, documentation errors, emergency situations, system redesign
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