Knowledge and Practices related to High-alert Medications

(HAMs) among Nurses working in the Emergency Department

of a Private Tertiary Care Hospital in Karachi, Pakistan
Principle Investigator: Abdul Kabir
Thesis Supervisor: Dr. Khairulnissa Ajani
Committee member: Ms. Shireen Shehzad Bhamani
Committee member: Ms. Shirin Rahim
Committee member: Ms. Alizah Alaman
Presentation Outline
• Background
• Rationale of the study
• Research Questions
• Research Methodology
• Ethical Considerations
• Data Collection
• Data Analysis
• Results/Discussion
• Strengths & Limitations
• Recommendations
• Conclusion
 Background
• Medication administration is the most common nursing intervention that is associated with risks
and adverse events for inpatients. (Anderson & Townsend, 2015)

• Medication errors (MEs) can cause serious health injuries or even death to patients, therefore
ISMP termed these medications as high-alert medications (Belknap, 2001)

• The 14th leading cause of patient harm and death is MEs. (Bekele et al., 2020)

• Nurses are responsible for harm to patients resulting from medication administration errors
(WHO,2019)

• HAMs are drugs when used inappropriately can cause significantly serious and life-threatening
harm to patients as compared to general medicines. Chances of fatality increase if MEs occur
while dealing with HAMs, which is a subclass of medication.
(Labib et al., 2018)
 Background
• Discrepancies in handling HAMs are reflected across the globe, which increases the disease
burden, health expenses, and lead to lengthy hospitalization
(Farag et al., 2017)

• HAMs have a narrow therapeutic index and are frequently used in the emergency room, Intensive
Care Units (ICU), pediatric wards, and medical wards. (Zyoud et al., 2019)

• Mortalities and morbidities due to medications error are common in Pakistan but there is no
proper reporting system to update and address these issues. (DAWN News,
2017)

• A recent incident was highlighted on April 22nd, 2019, when the wrong medication administration
of 15% KCL to a 9-month baby, at a private tertiary care hospital, in Karachi, took the life of the
patient, which drew the attention of stakeholders towards this serious issue.
(Salman et al., 2020a)
 Rationale
• Researcher’s personal interest and clinical experience

• The low knowledge level regarding the safe handling of HAMs adds to the
nationwide mortalities in Pakistan and there is no proper reporting system
to monitor these preventable deaths

• Knowledge regarding HAMs is vital as it causes severe consequences in

comparatively general medicines (Shen, Yan, Xin, & Sun, 2018)

• The availability of literature related to this specific issue is very limited in

the South Asian region, especially in Pakistan
 Research Questions

• What is the mean score of nurses’ knowledge regarding high-

alert medications?

• What is the level of nurses’ practices in dealing with high-alert

medications?
 Research Methodology

Study Design Descriptive Cross-sectional

Study Setting ED of a Private Tertiary Care Hospital

Study Population Registered nurses working in the ED

Sample Size 100 nurses

Total population sampling

Sampling Strategy
Consecutive sampling technique
 Ethical Considerations

Privacy,
confidentiality
Written , and
informed anonymity of
Permission consent from the
from the the study participants
Permission departmental participants were
from the Chief chair of the (nurses) maintained
Ethical Medical ED
Approval from Officer of the
the Ethical hospital
Review
Committee
(ERC) of the
setting
 Data Collection

Demographic 1. Knowledge Tool 2. Practice Tool

08 Questions 62 items 44 items

Narcotics Insulin Concentrated NMBA

Electrolytes

Anticoagulants
Thrombolytic LASA
VALIDITY AND RELIABILITY OF THE TOOLS:
PILOT TESTING
CVI > 0.90 excellent content validity (Polit and Beck, 2012)
Content Validity Index (Knowledge tool)
• Clarity: 0.83
• Relevance: 0.95

Content Validity Index (Practice tool)

• Clarity: 0.82
• Relevance: 0.88

Reliability
• Cronbach Alpha (Knowledge tool): 0.88
• Cronbach Alpha (Practice tool): 0.71
Acceptable value > 0.70 (Tavakol & Dennick, 2011)
 Eligibility Criteria

• Nurses registered with the Pakistan Nursing Council.

Inclusion • At least six months of working experience in direct
Criteria patient care in the ED.
• At least a nursing diploma or baccalaureate degree.

• Nurses having less than six months of working

experience.
Exclusion • Nurses not involved in direct patient care, like, Nurse
Criteria Managers.
• Nurses on leave during the study period.
 Recruitment Plan

Total nurses (N=100)

Not willing = 04

n= 96
Annual leave = 01

n=95

Not eligible = 03

n= 92
 Statistical Analysis

Statistical Package for Social Sciences (SPSS) version 26

Categorical Continuous
Variables Variables

Frequencies Means

Standard
Percentages Deviation
 Demographic Characteristics of the Study
Participants (n=92)
Variables Frequency Percentage
Age in years (Mean ± SD) 29 ± 6
<25 years 25 27.1%
25-30 years 33 35.9%
>30 years 34 37%
Gender
Male 37 40.2%
Female 55 59.8%
Professional qualification
RN Diploma 14 15.2%
BScN 43 46.7%
Post-RN 33 35.9%
MSN/MPH/MBA 2 2.2%
 Demographic Characteristics of the Study
Participants (n=92)
Variables Frequency Percentage
Designation
95.7%
Registered Nurse 88
4.3%
Assistant head nurse 4
Professional graduating school
41.3%
AKU-SON 38
58.7%
Non-AKU-SON 54
Experience in years (Mean ± SD) 6±4
10.9%
<1 year 10
42.4%
1 to 3 years 39
13.0%
>3 to 5 years 12
33.7%
>5 years 31
 Overall knowledge and practices of nurses
regarding HAMs (n=92)
Nurses’ overall knowledge score (total Nurses’ overall practice score in
score = 62) percentage (total score = 88)

Mean Score (SD) Mean Percent (SD) Mean Percent (SD)

53 (5) 85.83% (8.75) 62.54% (18.03)

Nurses’ knowledge level Nurses’ practices level

Frequency Percentage Frequency Percentage

Satisfactory 80 87% Satisfactory 27 29.3%

Unsatisfactory 12 13% Unsatisfactory 65 70.7%

 Nurses’ knowledge related to the main eight
categories (n=92)
Max. score Mean ± SD Percent Mean ± SD
A: HAMs 6 5.58 ± 0.82 92.93±13.59
B: Narcotics 13 11.40 ± 1.72 87.71±13.25
C: Electrolytes 11 10.02 ± 1.23 91.11±11.19
D: Anticoagulants 8 6.09 ± 1.53 76.09±19.14
E: Thrombolytics 5 4.47 ± 0.75 89.35±14.96
F: LASA 6 5.09 ± 1.02 84.78±17.06
G: Insulin 8 5.58 ± 0.82 77.72±17.27
H: NMBA 5 4.36 ± 1.72 87.17±14.70
 Nurses’ practices related to the main seven
categories (n=92)

N Max. score Mean ± SD Percent Mean ± SD

A: HAMs 92 20 13.08±3.88 65.38±19.41

B: Insulin 21 16 10.71±3.10 66.96±19.37
C: Anticoagulant 18 12 06.55±1.97 54.62±16.47
D: Narcotic 04 14 06.00±4.54 42.85±32.47
E: LASA 22 10 05.68±2.53 56.81±25.33
F: Electrolyte 36 10 05.86±1.79 58.61±17.91
G: Thrombolytic 05 06 02.60±1.81 43.33±30.27
 Barriers while administering HAMs
Yes No
Barriers N (%) N (%)
1: I have insufficient knowledge. 37 (40.2%) 55 (59.8%)
2: I have to accept oral orders. 13 (14.1%) 79 (85.9%)
3: Confusing prescription. 36 (39.1%) 56 (60.9%)
4: Inconsistent opinions between nurses. 35 (38%) 57 (62%)
5: Inconsistent opinions between doctor and nurse. 43 (46.7%) 49 (53.3%)
6: There is no reference for drug use. 26 (28.3%) 66 (71.7%)
7: I receive uncertain answers from colleagues. 38 (41.3%) 54 (58.7%)
8: Unclear dose calculation. 25 (27.2%) 67 (72.8%)
9: I mix high-alert medications with other drugs. 15 (16.3%) 77 (83.7%)
10: Easy access to high-alert medications. 30 (32.6%) 62 (67.4%)
11: There is no suitable person to consult. 19 (20.7%) 73 (79.3%)
Strengths Limitations
• To the best of the researcher’s knowledge, • Limited in generalizability
first of its kind to be found in Pakistan
• Varied number of years of experience of
• Easily Replicable
nurses might influence the results
• The CVI of the knowledge and practice tools
were 0.95 and 0.88, respectively.

• Tools were reviewed by six experts and pilot-

tested in the study context

• Practices were observed daily for eight

weeks, in all three shifts
 Recommendations

Educational Level
 The concept of HAMs should continue to be thoroughly covered in the undergraduate nursing
curriculum
 Evidence-based practice guidelines regarding HAMs should be shared with registered nurses
and students
 Orientation sessions for new nurses should be provided to help them become acquainted with
set policies and their application.
 Seminars should be organized to concentrate on the knowledge regarding HAMs.
 Nursing Instructors responsible for teaching should be closely engaged in the supervision of
the students at the bedside.
 Practice Level
 HAMs practices should be observed and monitored by nurse instructors, or team leaders
specifically during weekend days and night shifts.
 Compliance with the established guidelines and policies.
 The nursing education services should reinforce institutional policies during the
probation and hiring process.
 Simulation in the skill lab.
 Nursing educators should spend time on the clinical floor to enhance practice.
 Nurse educators can initiate curriculum modification with an emphasis on reshaping and
improving clinical practice.
 Combining classroom teaching with clinical supervision as well as ongoing feedback and
reflection that is specifically customized to each student's requirements based on their
self-motivated identification.
 Research Level
• Future research on:
• Nurses' attitudes toward HAMs to determine why there is a mismatch between their
knowledge and their practices
• The factors that contribute to medication errors in the emergency setting in Pakistan must
be investigated further
• It is recommended that a study of this kind be conducted in different units, hospitals, and
provinces of the country with a larger sample size for further research to gain a better
understanding of the safe use of HAMs in various backgrounds and clinical expertise
• Observational and interventional studies should be planned to assess the impact of
educational programs on the knowledge and practices of nurses regarding HAMs
• Qualitative research may be conducted on the same subject to examine nurses'
perspectives on the knowledge-practice gaps and to learn more about the causes and
potential solutions
 Conclusion
• There is a difference in the nurses’ knowledge and their actual practices
regarding HAMs in the emergency department.

• The participants had good knowledge about HAMs, yet their knowledge was
not reflected in their actual clinical practices

• Based on the findings of the current study, the medication administration

process can be revised, which will help shape best practices for the safe use
of HAMs

• Furthermore, this may make management more conscious of the

importance of arranging ongoing educational sessions and training for
nurses, thereby improving the safe use of HAMs
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 Acknowledgments

Thesis Committee Special Thanks to

• Parents, Siblings, and Family
• Dr. Khairulnissa Ajani • Ms. Fatima Shahabuddin
• Ms. Shireen Shehzad Bhamani • MScN Faculty
• Ms. Shirin Rahim • Study Participants
• Ms. Alizah Alaman • MScN Colleagues
• Ms. Zunaira
• Ms. Madiha
• Shahid Khan
• Sajid Iqbal, Saddam Hussain
Thank You