Project Title: Factors Affecting The Medication Administration Delivery Times

of Nurses: Basis For An Intervention Plan

Authors: Dominne Grizette R. Calegan, MAN, RN

Nurse II, Project Team Leader
OB-Gynecology Ward
Dr. Paulino J. Garcia Memorial Research and Medical Center

Danna Victoria D. Padilla, MAN, RN

Nurse II
Women and Child Protection Unit
Dr. Paulino J. Garcia Memorial Research and Medical Center

Research Assistants:

Mc Daryl B. Valiente, MAN, RN

Nurse II, Emergency Room

Ma. Theresa Garcia, MAN, RN

Nurse II, Emergency Room- OB

Victor C. Pagtalunan, MAN, RN

Nurse II, Pediatric Ward

Leonard SD. Feria, RN

Nurse II, Neonatal Intensive Care Unit

Marian Kristine DJ. Ayroso, RN

Nurse II, Hemodialysis Unit

Kristine Arlene Mae P. Buluran, RN

Nurse II, Female Medical Ward

Implementing Agency: Dr. Paulino J. Garcia Memorial Research and Medical Center
Mabini St., Brgy, Quezon District,
Cabanatuan City, Nueva Ecija
(044) 463- 8888

Cooperating Agency: Department of Health

Regional Office 3, Maimpis, City of San Fernando
Pampanga

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 Table of Contents
Pages
1. Title Page . . . . . . . . . 1
2. Significance of the Study . . . . . . . 3
3. Review of related Literature and Studies . . . . 3
4. General Objective . . . . . . . . 7
5. Methodology . . . . . . . . 8
6. Inclusion and Exclusion Criteria . . . . . . 8
7. Enrolment of the Participants . . . . . . 8
8. Dummy Tables . . . . . . . . 9
9. Work Plan Schedule . . . . . . . 11
10. Data Gathering Procedure . . . . . . . 12
11. Sample Questionnaire . . . . . . . 13
12. Estimated Budgetary Requirements . . . . .. . 16
13. References . . . . . . . . . 17

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Significance of the Study

The study will determine the factors affecting the medication administration delivery times
of the nurses. The goal of this study is to improve patient safety by reducing delays in
administration among patient. Thus, will be a basis for an intervention plan that will benefit
the nurses, the institution, and most importantly the patients receiving the medications in a
timely manner.

Review of Related Literature and Studies

This presents the review of related literature and studies made by foreign and local
researchers and local setting which are relevant to the present study.

Introduction

Numerous studies involved in the medication administration process that focuses on

medication errors including the factors contributing to it. But there is still a gap between the
standard time and definition of delay of administration to medicines to patients. And
strategies must be considered in order to lessen the harm and provide safety and quality care
to patients. An intervention plan must be established to prevent occurrence or eradicate such
circumstances of medication error in the hospital setting.

Nurses are the ones directly involved in the patient care, and this includes administering
medications to provide comfort and relief from their diseases. Medication error is defined as
‘a failure in the treatment process that leads to, or has the potential to lead to, harm to the
patient’. (Aronson, 2009)

The United States National Coordinating Council for Medication Error Reporting and
Prevention defines a medication error as: “any preventable event that may cause or lead to
inappropriate medication use or patient harm while the medication is in the control of the
health care professional, patient, or consumer. Such events may be related to professional
practice, health care products, procedures, and systems, including prescribing, other
communication, product labelling, packaging, and nomenclature, compounding, dispensing,
distribution, administration, education, monitoring, and use” (World Health Organization).

Medication errors specifically the delay in the administration process have occurred in all
health care facilities at least once. Prompt addressing on this issue must be provided through
education and procedural safeguards so these incidents can be avoided.

Meanwhile, Hospital Nursing Service Administration manual of the Department of Health,

defines medication error as dose of medication that deviates from the physician’s order as
written in the patient’s chart or from standard hospital policy and procedures, except for
errors of omission. The nine (9) categories of medication errors include, omission error, wrong
dose error, wrong-route error, wrong-rate error, wrong dosage form error, wrong-time error,
wrong-preparation of a dose, and incorrect administration technique. As to wrong-time error
defined as, administration of dose of a drug greater than X hours from its scheduled
administration time, X being as set by hospital policy.

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Incidence

Medication Error (ME) is a worldwide issue, but most studies on ME have been undertaken in
developed countries and very little is known about ME in Southeast Asian countries.
According to Salmasi, Khan, and Wong (2015) the most frequently reported types of
administration error were incorrect time, omission error, and incorrect dose among the 11
Southeast Asian countries being included: Brunei, Cambodia, Indonesia, Laos, Malaysia,
Myanmar, Philippines, Singapore, Thailand, Timor, and Vietnam.

According to the National Patient Safety Agency (NPSA) in 2011, the largest identified
categories of incident reports for medication errors accounts to omitted and delayed
medicine (82,028; 16%) and wrong dose (80,170; 15%).

Medication administration is primarily a part of nurses’ everyday lives in the hospital and
factors that hinders to a patient safety concerning this cannot be denied. After gaining
support from a group of nursing staff in this institution which aims to provide actions in
determining the factors and providing an intervention plan to reduce and furthermore
eradicate the delays in the administration times of medications to patient, this study was
promoted as a basis for this action.

The Prevalence and Impact of Medication Errors

Drug administration is one of the highest risk areas of nursing practice and a matter of
considerable concern for both managers and practitioners. This poses a high potential of
medication error that leads to drug adverse reactions and more seriously to mortality.

The Nursing Times in 2010 published that medications are given late or omitted owing to the
following reasons: the drug is not prescribed, is not available (particularly out of hours), the
route of administration is not available or the patient is off the ward.

One-third among of all medication errors causing harm to hospitalized patients occur in the
medication preparation and administration phase, which is predominantly a nursing activity.
(M. Smeulers, et al, 2015).

A need for standardized medication administration times solve pharmacy and nursing
problems as it was due to an increased workload dealing with conflicting medication
administration time schedules and numerous demands. (Fishman, 1992)

In medication administration there is a term “stat”, which means immediately. This is

designed to give priority to orders that are needed most quickly. A stat medication should be
administered within 30 minutes of the time it is ordered (turnaround time). (S. Gigimol, et al,
2017). But the problem is there is a struggle with delivering stat medications consistently
under 30 minutes due to some factors that may include the availability of the drug and the
access of the nurses to the pharmacy section where the drug must be delivered.

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Timely delivery of stat medications is of important for high-quality care. Where, the more
delay to a drug administration it causes an increase in mortality in patients specifically those
with sepsis every hour that antibiotics are delayed.

Factors and Issues Concerning Medication Administration

Nurses primarily administer medication in healthcare setting. Factors that could distract and
hinder in the safe delivery of this medication must be eliminated to provide safe environment
and will reduce the risk for mortality among the patients.

In a study where nurses relate the contributing factors involved in medication errors (Tang,
Sheu, Chen, 2007), of the 72 female registered nurses who responded, the personal neglect
(86.1%), heavy workload (37.5%), and new staff (37.5%) were the highest among the factors
cited. Medical wards (36.1%) and Intensive Care Units (33.3%) were the two most error-prone
places mentioned.

In a study published in HERDIN, conducted in University of Cebu Hospital, where Level IV

Nursing students were their participants (J. Tuang, et al, 2017), where the purpose of the
study was to determine factors contributing to medication errors; “increase in workload”,
gathered the highest mean with equivalent to often; followed by the other factors such as,
distraction/interruptions, information of the drug, negligence, failure to check the patient’s
identity, and quality of prescription and emergency situation were noted as sometimes.

The World Health Organization cited factors that influence medication errors among health
care professionals and these are: lack of therapeutic training, inadequate drug knowledge and
experience and knowledge of the patient, inadequate perception of risk, overworked or
fatigue health care professionals, physical and emotional issues, poor communication
between health care professional and with patients.

Factors associated with the work environment was also included such as workload and time
pressures; distractions and interruptions (by both primary care staff and patients); lack of
standardized protocols and procedures; insufficient resources; and issues with the physical
work environment (e.g. lighting, temperature, and ventilation).

While factors associated with patients include patient characteristics (e.g. personality,
literacy, and language barriers), and complexity of clinical case, including multiple health
conditions, polypharmacy, and high risk medications).

Patient factors concerning in the delay of medication administration includes the capability
of the patient to swallow (Dysphagia). In a study made by Cohen and Smetzer in 2015, for the
delayed administration and contraindicated drugs among Parkinson’s Disease patients, it is
recommended that when taking medications, patients should be asked to sit upright with
their hips flexed at 900 and to remain sitting if possible for 45 minutes. And they should also
be encouraged to swallow twice after taking pills or drinking liquid. This is an ideal action in
giving oral medications to provide safety among clients. Hence, in an actual setting where
there are bulk of patients needing this nursing care, how is it possible to provide a 30 to 45
minutes of assistance with these patients having only an 8 to 9 hours working shift.

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Nurses are not the only ones to administer medications, physicians, patients and family
members also administer medications. Among many reasons for the prevalence of nurse
involvement in medication errors spend as much as 40 percent of their time in medication
administration (Hughes, Blegen, 2008).

The Use of Technology

Medication administration is a complex process, and wrong-time medication administration

error (WTMAE) is a high risk to patient safety (S. Taufiq, 2015). In a study made in Pakistan,
the use of electronic administration recording system (eMAR) was used in all patient locations
to provide an opportunity to decrease patient care risk and assist in development of different
strategies for system improvement to ensure safe practices.

Facilities may find existing medication use technology (eg, barcoding, electronic medication
administration records, automated dispensing cabinets), Stokowski (2012), and nurses should
provide feedback to manufacturers of medication technology on how the technology should
be improve to enhance patient safety.

In Dr. PJGMRMC, we are using the Hospital Information System to access patients’ profile, to
access and request for laboratory procedures, to request for supplies, and charge application
of procedures and use of hospital supply to clients. Yet, there is still no direct access to easy
requisition to medicines for faster communication and delivering of medicines. The process
of medication distribution, starts from the physician’s order in the charts, transcription of
nurses, pharmacist doing their ward rounds to consolidate medicines to be delivered per
patients manually in the morning shift, and then they will deliver it in the afternoon including
the IV fluids where the 24-hour shift medications must be completed.

Timely Medication Administration

According to the Institute for Safe Medication Practices (ISMP) cited by Stokowski (2012), the
guidelines must be adopted to represent the hospital’s medication administration policies.
Hospitals must create their own lists of time-critical scheduled medications, because these
priorities can vary from hospital to hospital even unit to unit. And these include: (1)
medications with a dosing schedule more frequently than every 4 hours; (2) scheduled (not
PRN) opioids used for chronic pain or palliative care (fluctuations in the dosing interval may
result in unnecessary breakthrough pain); (3) immunosuppressive agents used for the
prevention of solid-organ transplant rejection or to treat myasthenia gravis; (4) medications
that must be administered apart from other medications (eg, antacids and fluoroquinolones);
and (5) medications that require administration within specified interval before, after, or with
meals – for example, rapid, short, or ultra-short acting insulins, certain oral antidiabetic
agents (eg, acarbose, nateglinide, repaglinide, and glimepiride) alendronate, and
pancrelipase.

Additional guidelines noted as follows: (1) one hour for time-critical scheduled medications
(30 minutes before/after); (2) two hours for medications prescribed more frequently than

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daily, but no more frequently than every 4 hours (1 hour before/after); and (3) four hours for
medications prescribed for daily or longer administration intervals (2 hours before/after).

According to standards, nurses should be required to document on the electronic or paper

medication administration record the exact time a medication was given rather than just
initializing or entering given. If the medications are given on early or late, this allows
subsequent nurses to maintain the correct dosing interval for scheduled medications. When
doses are delayed or omitted, the reason should also be documented.

In the institution, there is still no existing policy cited among the work instructions, infection
control, nursing and quality procedure manuals that indicates standard delivery of medication
as to where we will classify delayed administration of drugs.

With inadequate nursing education about patient safety and quality, excessive workloads,
staffing inadequacies, fatigue, illegible provider handwriting, flawed dispensing systems, and
problems with the labeling of drugs, nurses are continually challenged to ensure that their
patients receive the right medication at the right time. And this is one of the characteristics
of our safety and quality patient care.

General Objective: Determine the factors affecting the nurses’ medication administration
delivery times

Specific Objectives:

1. Determine the Socio-demographic profile of the nurses

1.1 age;
1.2 gender
1.3 civil status
1.4 length of service;
1.5 area of assignment;
1.6 length of exposure to the assigned area

2. Determine the factors affecting the medication administration delivery times

3. Develop an intervention plan that may address the issues affecting the administration
delivery times

Expected Output
This proposal aims to provide an intervention(s) that can significantly address the issues that
may cause concerning medication administration.

Beneficiaries
The intended beneficiaries of the study are the Staff Nurses who are directly involved in the
medication administration and ultimately the patients who will be receiving these
medications.

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Project Duration
The study will be conducted from September 2019 to September 2020 that will cover 6 (six)
to 12 months.

Site of the Study

The study will be conducted in Dr. Paulino J. Garcia Memorial Research and Medical Center.

Methodology
Study Design
This study will utilize Descriptive Analytic Study in accomplishing this proposal. According to
Polit (2011), the purpose of descriptive study is to observe, describe, and document the
aspects of a situation as it naturally occurs and sometimes serve as a starting point for
hypothesis generation or theory development.

For the intervention plan, a comparative method will be utilized to determine its
implementation and its efficacy will be reported.

Study Population
The study population will be the nurses in different areas of assignment in Dr. Paulino J. Garcia
Memorial Research and Medical Center starting October 2019 to October 2020.

Inclusion Criteria
The sample for this study are the nurses assigned in the different areas in the hospital who
are directly administering medication, with more than 6 (six) months exposure in the assigned
area, and who are occupying a permanent position of nurse I and II in the hospital.

Exclusion Criteria
The study will exclude the nurses who are not directly administering medication to patients,
those who assigned to an area with less than 6(six) months of exposure, who are not
occupying a permanent position, and those who are in nurse supervisory position in the
hospital.

Enrolment of the Participants

The research assistants will first identify the participants who were assigned in the clinical
area. The research assistants will ask for the consent of these prospective respondents. The
consent is written in English and Filipino and will be read to them to ensure full understanding
of this study. Once the written consent is acquired, the participants will be enrolled in the
study.

1. Socio-demographic Data of the Respondents

The following tables present the socio-demographic profile of the staff nurses as to age,
gender, civil status, length of service, area of assignment, and length of exposure to the
assigned area.

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Table 1. The Profile of the Respondents as to Age

Age F %
20-25
26-30
31-35
36-40
41-45
46-50
41-55
56-above
Total 100

Table 2. The Profile of the Respondents as to Gender

Gender F %
Male
Female
Total 100

Table 3. The Profile of the Respondents as to Civil Status

Civil Status F %
Single
Married
Widow/Widower
Separated
Total 100

Table 4. The Profile of the Respondents as to Length of Service

Length of Service F %
(in years)
6mos-1 year
1-3
4-6
7-9
10-12
13-15
16-above
Total 100

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 Table 5. The Profile of the Respondents as to Area of Assignment

Area of Assignment F %
Ob Gyne
Pedia
Medical
Surgical
Opd/ER
OR
Total 100

Table 6. The Profile of the Respondents as to Length of Exposure to the Assigned

Area

Length of Exposure F %
(in years)
6mos-1 year
1-3
4-6
7-9
10-12
13-15
16-above
Total 100

2. Factors Affecting the Medication Administration Delivery Times

The following tables present the factors affecting the medication administration delivery
times

Table 7. Factors Affecting the Delay of Medication Administration

Factors F %
Physical Well-being of Nurses
Work Environment
Patients
Medicines
Tasks
Technology
Primary- secondary interface
Total 100

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 Work Plan Schedule
The study will be conducted from August 2019 to March 2020.

(Gantt Chart)

Activity August September October November December January February March

2019 2019 2019 2019 2019 2020 2020 2020
Drafting of the proposal study 2 weeks
Submission to the ERB for clearance 1 month
Data Gathering procedure 1 month
Data Analysis 1 month
Drafting of Conclusion 1 month
Drafting of Intervention Plan 1 month
Recommendation 1 month
Publication 1 month

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ERB Clearance
The ERB clearance will be secured from an accredited Research Ethics Review Board and
institution once clearance is obtained, the study will be commenced.

Research Utilization

Data Gathering Procedure

Research Instrument

The main tool to be used is a questionnaire, a self-scored tool to determine the factors affecting
the medication administration delivery times.

The questionnaire has the following parts:

1. The socio-demographic profile of the staff nurses. Under this will include age, gender, civil
status, length of service, length of exposure to the area of assignment.
2. Factors affecting the medication administration of nurses as to: factors associated with
the physical well-being of nurses, the work environment, the patients, the medicines, the
tasks, the technology, and the primary-secondary interface.

The drafted questionnaire will be referred to experts in the field of nursing and to ensure the
content and face validity of the tool. The questionnaire will be tried out to the selected clinical
areas in the hospital will find out if the questionnaire will be clear and easy to answer.

The reliability of the questionnaire will be established through the Chronbach’s Alpha test of
reliability that will show if the questionnaire is highly reliable and show its coefficient.

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 Appendix A
Sample Questionnaire

Direction: Please answer/check opposite the item of your correct response.

Name (Optional):_____________________________________

Part I: Socio- Demographic Profile of Staff Nurses

1.1 Age________
1.2 Gender: ___ Male ____ Female
1.3 Civil Status: ____ Single ____ Married ____ Widow/Widower ____ Separated
1.4 Length of Service: _________
1.5 Area of Assignment: ____________
1.6 Length of exposure to the area: _____

Part II: Factors Affecting the Delay in Medication Administration

Directions: Describe the factors affecting your medication administration by placing a check mark
( ) opposite each item under the appropriate column. Using the scale below:

4- Strongly agree
3- Agree
2- Disagree
1-Strongly disagree

Strongly Agree Disagree Strongly

Agree Disagree
1 2 3 4
Factors Associated with the Physical Well-
being of Nurses
1. I am physically, emotionally and mentally
fit to work as a Nurse in our Institution.
2. Problems in our unit such as delayed in
medication administration properly
addressed to the rightful channels.
3. Interpersonal and intrapersonal
relationship issues and conflict with my co
personnel affects my performance in work.
4. My drive to go to work and provide quality
service is affected due to increase

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 workload that resulted to overworked and
fatigue.
5. I am knowledgeable with regards to
medication’s risk, methods and side effect
that is usually administered in my unit.
6. When there is a drug that I have never
been heard of or administered before, I do
my own research prior in administering it.
7. I am aware of my patient’s drug and health
history and I also establish a good nurse-
patient interaction with the client.
8. I am always updated with the recent
revisions and amendments of the work
instruction in my institution especially on
medication administration.
Factors associated with Patients 4 3 2 1
1. I spend more time in giving medication on
clients who have special needs. (age,
personality, literacy, language barriers,
complexity of clinical case)
Factors associated with the work 4 3 2 1
environment
1. Our environment in the unit is conducive
for medication preparation. (lighting,
ventilation, temperature)
2. Medicine containers and cabinets are
sufficient with the number of patients in
the unit.
3. There is a sufficient resource in our unit for
medication preparation. (syringes, trolley,
hypotray)
4. Distractions and interruptions by patients,
primary care staff, other medical team and
non-medical personnel during medication
time leads to medication delay.
5. Increase workload due to increase number
of patients and documents to be
accomplished and The time pressure to
finish my duty hours contributes delay in
medication of my clients.
6. The Hospital Pharmacy is located too far
from my unit that contributes medication
delay.

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 Factors associated with medicines 4 3 2 1

1. Medicines are properly named, labelled

and packaged
2. The arrival of the medication supplies is on
the right time.
3. Medications are readily available in the
area
4. STAT medications are easily accessible
Factors associated with tasks 4 3 2 1

1. I do believe that the medication-use

process in our institution needs
improvement.
2. The frequent change in the client’s
treatment and management predisposes
delay.
3. Unpredictable and late orders in the
client’s chart predisposes delay especially
if the pharmacist did not manage to take
down the recent order due to the
unavailability of the patient’s chart during
the time that the pharmacy is in the unit.
4. The Increased number of patients and
decrease manpower results to inadequate
Nurse-patient ratio.
Factors associated with technology 4 3 2 1
1. I believe that our hospital information
system (bizbox) needs improvement with
regards to its design to lessen commission
of error.
2. The Hospital information system provides
correct information of patient.
Factors affecting primary-secondary care 4 3 2 1
interface
1. I believe that there is a limitation in the
quality of communication between and
primary and secondary care personnel.
2. There is a little justification of secondary
care recommendations.

Other factors associated to delay in giving medications: __________________________

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Estimated Budgetary Requirements

Line Item Budget (LIB)

Particulars
QUANTITY AMOUNT TOTAL
1. Personal Services
1.1 Project Team Leader 1 5000 per month 10,000 (2 months)
1.2 Project Staff 7 3500 per month 49,000 (2 months)
2. MOOE
2.1 Stipend for Statistician 1 2500 2,500
2.2 Stipend for Encoder 1 1500 1,500
2.3 Transportation Expenses 4 500 per month 4,000 (2 months)
2.4 Communication
4 300 1,200
Expenses
2.5 Project Meeting 6 500 3,000
2.6 Publication Expenses
2.6.1 Printing
5000 5,000
2.6.2 Binding
2.6.3 Supplies
TOTAL 76,200.00

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