NURS 6052 Module 4 Assignment Evidence-Based Project

Full APA-formatted citation of selected article.

Article #1

Article #2

Article #3

Article #4

Afaya, A., Konlan, K. D., & Kim Do, H. (2021). Improving patient safety through identifying barriers to reporting medication administration errors among nurses: An integrative review. BMC Health Services Research, 21(1), 1–10. https://doi.org/10.1186/s12913-021-07187-5 

  Bell, T., Sprajcer, M., Flenady, T., & Sahay, A. (2023). Fatigue in nurses and medication administration errors: A scoping review. Journal of Clinical Nursing, 32(17-18), 5445–5460. Wiley Online Library. https://doi.org/10.1111/jocn.16620 

Alrabadi, N., Shawagfeh, S., Haddad, R., Mukattash, T., Abuhammad, S., Al-rabadi, D., Abu Farha, R., AlRabadi, S., & Al-Faouri, I. (2021). Medication errors: a focus on nursing practice. Journal of Pharmaceutical Health Services Research, 12(1), 78–86. https://doi.org/10.1093/jphsr/rmaa025 

D’Errico, S. (2022). Medication Errors in Pediatrics: Proposals to improve the quality and safety of care through clinical risk management. Frontiers in Medicine, 8(814100). https://doi.org/10.3389/fmed.2021.814100 

Evidence Level *

(I, II, or III)

Level III

This is an integrative review that combines both qualitative and quantitative non-experimental studies, which falls under Level III per the Johns Hopkins model.

Level III

This is a scoping review, which involves synthesizing non-experimental studies. According to the Johns Hopkins Evidence-Based Practice Model, this qualifies as Level III evidence.

Level V

This article is a narrative literature review, primarily based on existing publications found via PubMed and Google Scholar. It does not involve primary research or a systematic methodology, and therefore falls under Level V in the Johns Hopkins Evidence-Based Practice Model.

Level V

The article is a narrative literature review, based on existing studies retrieved via PubMed and manual searching. It does not present original research or use a systematic/meta-analytic methodology, which places it in Level V according to the Johns Hopkins Nursing Evidence-Based Practice model.

Conceptual Framework 

Describe the theoretical basis for the study (If there is not one mentioned in the article, say that here).**

None stated

The abstract does not specify a theoretical or conceptual framework guiding the review. It focuses on identifying barriers without grounding them in a specific theory.

None explicitly mentioned

The study does not describe a theoretical framework. It is guided by Arksey and O’Malley’s scoping review framework and uses the PAGER framework for data analysis, but no theoretical model for fatigue or errors is applied.

None stated

The article does not present a theoretical or conceptual framework. It is a general review aimed at increasing awareness of medication errors, particularly by nurses.

None stated

The review does not explicitly state a theoretical or conceptual framework. It is focused on risk profiling and clinical strategies rather than being guided by a specific model.

Design/Method 

Describe the design and how the study was carried out (In detail, including inclusion/exclusion criteria).

Integrative Review

• Databases searched: PubMed, Web of Science, EMBASE, CINAHL, Google Scholar
• Time frame: January 2016 – December 2020
• Inclusion: Studies focusing on barriers to medication administration error reporting by nurses in hospitals
• Exclusion: Studies not focusing on nurses or not conducted in a hospital setting
• Quality appraisal: Mixed Methods Appraisal Tool (MMAT) 2018, performed independently by two reviewers (AA and KDK)
• Integration of qualitative and quantitative findings

Scoping Review

• Guided by: Arksey & O’Malley’s framework
• Data extraction/analysis: PAGER framework
• Reporting standard: PRISMA checklist completed
• Databases searched: CINAHL, PubMed, Scopus, PsycINFO
• Inclusion criteria:

• Peer-reviewed primary studies
• Written in English
• Included registered nurses in hospital settings
• Studied medication administration errors (MAEs)
• Examined fatigue, sleep, or work hours

• Time limit: No date/time restrictions
• Search completed: August 2021

Narrative Literature Review

• Databases used: PubMed and Google Scholar
• No time limit or detailed inclusion/exclusion criteria are mentioned
• The review appears non-systematic, and the number of articles included or the quality appraisal methods are not described
• Aim: To summarize types, classifications, outcomes, and strategies to reduce medication errors (MEs), especially among nurses

Narrative Literature Review

• Database searched: PubMed
• Search date: August 17, 2021
• Filters applied: Full-text, English language
• No time limits set
• Search strategy guided by the PICO framework:

P (Patient): Pediatric patients

I (Intervention): Drug therapy

O (Outcome): Adverse events/medication errors

• Screening process:
  • Phase 1: Title and abstract review
  • Phase 2: Full-text review
• Articles included focused on:

Epidemiology

Care setting (hospital/outpatient)

Risk factors

Adverse events

Personalization of therapy

Sample/Setting 

The number and characteristics of

patients, attrition rate, etc.

 Total articles retrieved: 10,929

 Final studies included: 14

 Characteristics: All studies focused on nurses in the hospital setting

 Attrition rate: Not applicable (literature review, not a primary study on patients)

 Number of studies included: 38

 Population studied: Registered nurses in hospital settings

 No specific patient or attrition details provided (since it’s a review)

 Not applicable (This is not a primary research study)

 No sample of participants or settings is included

 The general focus is on clinical practice involving nurses

• No participant sample. This is a review of existing literature
• Setting focus: Primarily pediatric inpatient care, concerning outpatient care as well
• The article references external studies that discuss data involving millions of medication errors annually

Major Variables Studied

List and define dependent and independent variables

• Independent variables: Barriers to reporting (organizational, professional, individual factors)

• Dependent variable: Reporting of medication administration errors (MAEs) by nurses

 Independent variables:

• Fatigue, measured by sleep quality, hours of work, night shifts, overtime, and circadian rhythm disruption

 Dependent variables:

• Medication Administration Errors (MAEs)
• Near Misses (NMs)

  No specific variables are defined or measured

  However, the review discusses:

• Medication Errors: classification, types, outcomes
• Prevention strategies: reporting processes, system-level fixes, education

  No statistical variables were measured in this paper

  The main themes discussed include:

• Medication errors (prescription, administration, dosage, etc.)
• Risk factors (infusions, off-label use, circadian rhythm, etc.)
• Outcomes (harm, hospitalization, death)
• Preventive strategies

Measurement

Identify primary statistics used to answer clinical questions (You need to list the actual tests done).

 Primary evaluation method: Qualitative synthesis and thematic analysis

 Quality assessment tool: MMAT 2018

 Specific statistical tests are not mentioned, as it is an integrative review that synthesizes data from various designs

 No uniform method of measurement due to heterogeneity across studies

 Tools and metrics used in included studies varied (fatigue measures were inconsistent)

 Not a meta-analysis; no specific statistical tests reported

 No statistical measurements or tools were used

 The article does not perform quantitative or qualitative analysis

 It functions as a broad overview based on available literature

• No statistical instruments or tools were applied
• The article summarizes previously published statistics, such as:

7.5 million preventable medication errors annually in U.S. pediatric patients

14–31% of pediatric medication errors result in harm or death

Pediatric patients account for 31% of all reported medication errors versus 13% in adults (USP report)

Data Analysis, Statistical or

Qualitative findings 

(You need to enter the actual numbers determined by the statistical tests or qualitative data.)

• Qualitative themes identified:

Organizational barriers:

• Inadequate reporting systems
• Management behavior
• Unclear definition of MAEs

Professional/individual barriers:

• Fear (of management, colleagues, lawsuits)
• Lack of knowledge or awareness
• Personal reasons

• No specific statistical values were reported due to the nature of the review.

 Key finding:

• 82% of studies found fatigue to be a contributing factor to MAEs and NMs

 Fatigue outcomes:

• Decreased attention, cognitive performance, and vigilance
• Linked to poor nursing performance and reduced patient safety

 Contributing factors:

• Night work, overtime, and circadian rhythm disruption

 Inconsistency noted in measurement methods and findings among studies

 No numerical data or statistical tests were reported

 Key qualitative insights include:

• Classifications of MEs
• Consequences of errors: physical, psychological, economic
• Error prevention strategies, such as:
  • The “five rights”
  • Double-checks
  • Improved labeling and communication
  • Reducing distractions and workload
  • Creating a blame-free culture

 No original statistical analysis performed

 Key statistics cited from other sources:

• Medication error rate in pediatrics: 5–27% of all orders
• Preventable medication errors were observed in 22% of pediatric inpatient cases (Takata et al.)
• Pediatric medication error reporting rate is more than double that of adults (31% vs. 13%)

 The article integrates epidemiological data and thematic risk profiles to present a high-level analysis

Findings and Recommendations

General findings and recommendations of the research

Findings:

• A combination of organizational and individual-level factors significantly hinders nurses from reporting errors.
• A punitive culture and lack of clear definitions are recurring themes.

Recommendations:

• Create non-punitive environments
• Establish clear definitions of medication errors
• Promote education and support systems to encourage reporting

Findings:

• Fatigue can negatively affect a nurse’s performance during medication administration
• Fatigue is complex and influenced by scheduling and job demands
• There is inconsistent evidence due to variation in study methods and definitions

Recommendations:

• Larger, standardized studies are needed
• Policies on safe working hours should be re-evaluated
• Implement fatigue management systems in clinical settings

Findings:

• Medication errors are multifactorial and need to be addressed systematically
• Nurses are pivotal in preventing and managing these errors
• The reporting process is key to early detection and prevention

Recommendations:

• Implement systemized guidelines for error prevention
• Increase nurse education and training
• Promote open communication
• Reduce workload and distractions
• Enhance job security and foster a non-punitive reporting culture

Findings:

• Pediatric patients are highly vulnerable to medication errors due to:

Dosage adjustment needs

Off-label drug use

Formulation and measurement complexity

Communication and documentation issues

Recommendations:

• Implement risk profiling in pediatric therapy

• Standardize dose recommendations
• Encourage electronic prescribing systems
• Enhance training for healthcare professionals
• Create and reinforce error reporting systems
• Adopt governance strategies including:

Protocol adherence

Documentation accuracy

Communication improvement

Staff education and strategic planning

Appraisal and Study Quality

Describe the general worth of this research to practice. 

What are the strengths and limitations of the study? 

What are the risks associated with the implementation of the suggested practices or processes detailed in the research? 

What is the feasibility of use in your practice? 

Strengths:

• Comprehensive review of global literature
• Use of multiple databases
• Clear categorization of barriers
• Quality assessment with MMAT adds rigor

Limitations:

• Possible publication bias
• Studies vary in design and context (heterogeneity)
• No unified statistical analysis due to study types

Risks of Implementation:

• Resistance to cultural change in hospital systems
• Legal or administrative concerns around transparency

Feasibility:

• Highly feasible with administrative support
• May require training, system updates, and policy reform

Strengths:

• Comprehensive review with no time restrictions
• Utilized structured frameworks for review and analysis
• Identified a clear relationship between fatigue and MAEs in a majority of studies

Limitations:

• Marked heterogeneity in how fatigue was measured
• No statistical synthesis (not a meta-analysis)
• Some studies included may have limited generalizability

Risks of Implementation:

• Re-evaluating nurse shifts may require policy change and incur financial/logistical costs
• Some institutions may lack infrastructure for fatigue monitoring

Feasibility:

• Feasible with leadership support and system-level changes
• May involve collaboration between nursing staff, human resources, and hospital administration

Strengths:

• Provides a broad overview of MEs and emphasizes nurses’ roles
• Highlights practical strategies for preventing errors
• Promotes a proactive, system-based approach

Limitations:

• No methodology description (e.g., inclusion criteria, article count, quality appraisal)
• Not a systematic review; lacks rigorous structure
• No data analysis, making it harder to evaluate the evidence’s strength

Risks of Implementation:

• Suggestions may be overgeneralized
• Lack of specific, evidence-backed data limits confidence in implementation outcomes

Feasibility:

• Many strategies are feasible (e.g., nurse education, communication improvements)
• Broader system reforms (e.g., workload reduction, job security improvements) may require policy and resource investments.

Strengths:

• Addresses an urgent and under-researched population: pediatric medication safety
• Summarizes a broad set of risk factors and evidence-based strategies
• Brings attention to clinical governance and systems-based prevention

Limitations:

• No quality appraisal of the included studies
• Narrative, not systematic—no transparency about article selection criteria
• No direct data synthesis (e.g., meta-analysis or statistical validation)

Risks of Implementation:

• Implementation of electronic prescribing or system-wide training may require funding and institutional change
• Resistance to change or a lack of resources in low-income settings could limit uptake

Feasibility:

• Feasible in moderate-to-high resource settings with leadership support
• Partially feasible in limited-resource environments by prioritizing training, protocol standardization, and low-cost reporting tools

Key findings

The main barriers to reporting medication administration errors are:

• Fear (of punishment, colleagues, legal action)
• Lack of knowledge
• Inadequate systems and unclear definitions

Fatigue is a major contributor to medication errors due to:

• Night shifts
• Overtime
• Sleep deprivation

 82% of studies confirmed this relationship

 There is no standardized approach to measuring fatigue in healthcare literature

Nurses are essential to error prevention

 MEs have severe physical, psychological, and economic consequences

 Reporting and preventive strategies (standardized processes, training, communication) are crucial

 Emphasis on creating blame-free and supportive environments in hospitals

Pediatric medication errors are more frequent and more harmful than in adults

 Primary risks: dose miscalculations, off-label use, formulation changes

 High-risk settings: Emergency Departments, NICUs, and ICUs

 Preventive strategies must include:

• Standardization
• Education
• Technology (electronic prescribing)
• Stronger reporting systems

Outcomes

Emphasizes the need for:

• Safe reporting environments
• Organizational culture change
• Education for nurses on medication error definitions and reporting protocols

Fatigue negatively impacts patient safety via impaired nursing performance

• Need for:
  • Standardized research methods
  • Policy changes for safe work hours
  • Fatigue mitigation strategies (e.g., scheduling changes, breaks, staff rotation)

• Increased awareness of error causes and solutions
• Suggests integrating preventive strategies into routine practice
• Supports a cultural and systemic shift toward safety, reporting, and nurse empowerment

 Improved safety through understanding and targeting pediatric-specific risks

 Better governance and error management through structured protocols and training

 Support for international alignment on pediatric medication safety practices

 Encouragement of further research and data transparency

General Notes/Comments