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The characteristics of medication administration incidents involving Bachelor of Science in Nursing students… Ellis, Kaitlin 2020

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The Characteristics of Medication Administration Incidents Involving Bachelor of Science in Nursing Students during Clinical Practice Education by  Kaitlin Ellis BScN, RN, Queen’s University, 2010  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES AND POSTDOCTURAL STUDIES (Nursing) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) July 2020  © Kaitlin Ellis, 2020     ii    The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, a thesis entitled:  The Characteristics of Medication Administration Incidents Involving Bachelor of Science in Nursing Students during Clinical Practice Education  submitted by Kaitlin Ellis in partial fulfillment of the requirements for the degree of Master of Science in Nursing  Examining Committee: Dr. Maura MacPhee Supervisor  Dr. Lenora Marcellus Supervisory Committee Member  Cathryn Jackson Supervisory Committee Member iii  Abstract Registered nurses (RNs) provide medications to patients when they are unable to provide these medications to themselves such as when they are unwell or incapable. RNs are responsible for ensuring that the medication administered are appropriate for the patient’s situation and also that the right medication is provided to the right patient, at the right dose, via the right route, at the right time, and for the right reason, as well as documented using the appropriate methods. This process can be disrupted and a medication administration incident (MAI) may occur. When an MAI occurs, RNs are responsible to identify, resolve and report the error. Bachelor of Science in Nursing (BSN) students learn to administer medications through clinical practice education and during this process can be involved in MAIs. The purpose of this study is to gain an understanding of MAIs involving BSN students over three academic years. Understanding the characteristics of MAIs that students are involved in will help educational and healthcare organizations develop systems to mitigate the potential for these MAIs to occur. I conducted a cross-sectional retrospective case study of reported MAIs involving BSN students over three academic years. I reviewed aspects of type of MAIs, contributing factors and documented responses of students and nurse educators. Students reported 88 MAIs during this period. Incorrect dose, administration technique and incidents of omission were the most frequently reported MAI involving student nurses. Individual factors, stressful environments and communication challenges were reported most frequently as contributing to MAI occurrence. Students document actions taken immediately following discover of MAI and to a lesser extent in the long-term. Through the MAI reports, iv  nursing educators document responses which include debriefing, evaluation of professionalism, following-up with leadership and clarifying details of the MAI reported by the student. Students involved with MAIs can identify, report and document MAI, contributing factors and responses to these incidents. Supporting a shift away from individual blame and evaluation creates a culture of safety within education. Creating multi-incident reviews that inform policy and curriculum can allow the MAI reports to have a positive impact on nursing education and healthcare in general.   v  Lay Summary The goal of my research is to understand the characteristics of medication errors involving student nurses during clinical education experiences. I completed a three-year review of incident forms submitted to the school of nursing and found that students are infrequently involved in medication administration incidents. These incidents rarely cause harm to patients. The most frequent types of incidents involving students are incorrect dose, incorrect administration technique and missing doses of medication. These incidents are complex and students documented that individual factors, stressful environments and deficits in communication contributed to the MAI. Students report the incident to the healthcare team, inform the patient, care for the patient, make corrective actions to the situation that led to the incident, report the incident to a provincial reporting system and inform their instructor. Nursing instructors provide debriefing of events, evaluation, provide follow-up with leadership and clarify event details within the report.   vi  Preface  Under the guidance of my supervisor: Dr. Maura MacPhee and in collaboration with committee members Dr. Lenora Marcellus and Cathryn Jackson, MSN, RN, I completed all aspects of this research. The study received ethics approval from the University of Victoria Human Research Ethics Board in a harmonized review with the University of British Columbia Behavioral Research Ethics Board. Certificate number: H19-00173. The study also received approval from the Camosun College Research Ethics Board. Certificate number 2020-03.       vii  Table of Contents  Abstract ................................................................................................................................... iii Lay Summary ............................................................................................................................ v Preface ...................................................................................................................................... vi Table of Contents ....................................................................................................................vii List of Tables ............................................................................................................................ xi List of Figures..........................................................................................................................xii List of Abbreviations ............................................................................................................. xiii Acknowledgements ................................................................................................................. xiv Dedication ................................................................................................................................ xv Chapter 1: Introduction ............................................................................................................ 1 1.1 Medication Administration ..........................................................................................1 1.2 Near-Misses and Medication Errors .............................................................................3 1.3 Professional Responsibility for Prevention and Reporting of Medication Incidents ......4 1.4 Systems Theory: A Theoretical Approach to Incident Analysis ....................................6 1.5 Culture of Safety ..........................................................................................................6 1.6 Problem Statement .......................................................................................................7 1.7 Research Purpose and Questions ..................................................................................7 1.8 Outline of Thesis .........................................................................................................8 Chapter 2: Literature Review ................................................................................................... 9 2.1 Search Strategy .......................................................................................................... 10 2.2 Overview of Literature Reviewed .............................................................................. 11 viii  2.3 Types of Student MAI ............................................................................................... 11 2.4 Contributing Factors of MAIs Involving BSN Students ............................................. 15 2.5 Causes of MAIs Involving BSN Students................................................................... 16 2.6 Responses of Student Nurses and Educators when an MAI Occurs ............................ 17 2.6.1 Reporting Practices and Procedures ....................................................................... 18 2.7 Limitation of Results ................................................................................................. 19 2.8 Chapter Summary ...................................................................................................... 20 Chapter 3: Methods ................................................................................................................ 21 3.1 Study Design ............................................................................................................. 21 3.2 Theoretical Foundations ............................................................................................. 22 3.3 Study Setting and Sample .......................................................................................... 22 3.4 Permission to Access Data ......................................................................................... 24 3.5 Ethical Considerations ............................................................................................... 24 3.6 Data Collection Methods ........................................................................................... 25 3.6.1 Inclusion Criteria ................................................................................................... 26 3.6.2 Missing or Incomplete Data ................................................................................... 26 3.7 Data Analysis ............................................................................................................ 26 3.8 Chapter Summary ...................................................................................................... 27 Chapter 4: Findings ................................................................................................................ 28 4.1 Types of MAIs Involving Student Nurses .................................................................. 28 4.1.1 Three-Year Frequency of Types of MAI ................................................................ 28 4.1.2 Types of MAI Reported During Three Academic Periods ...................................... 31 4.1.3 Types of MAI by Course Level .............................................................................. 33 ix  4.2 Student Discovered MAIs Not Directly Involved With .............................................. 37 4.3 Documented Contributing Factors and Causes of Reported MAIs .............................. 38 4.3.1 Three-Year Frequency of Documented Contributing Factors .................................. 38 4.3.2 Documented Contributing Factors by Academic Period ......................................... 44 4.3.3 Documented Contributing Factors by Course Level ............................................... 44 4.4 Documented Responses ............................................................................................. 45 4.4.1 Documented Immediate Actions Following MAI Occurrence ................................ 46 4.4.2 Long-Term Actions and Reducing Reoccurrence ................................................... 47 4.4.3 Documented Instructor Responses ......................................................................... 49 4.5 Chapter Summary ...................................................................................................... 51 Chapter 5: Discussion ............................................................................................................. 52 5.1 Types of MAI Involving Student MAI Key Findings ................................................. 52 5.2 Documented Contributing Factors Key Findings ........................................................ 57 5.3 Documented Responses of Students and Nursing Instructors Key Findings ................ 61 5.4 Limitations ................................................................................................................ 64 5.5 Chapter Summary ...................................................................................................... 65 Chapter 6: Implications for Nursing Practice ........................................................................ 66 6.1 Key Implications for Practice ..................................................................................... 66 6.2 Conclusion................................................................................................................. 68 References................................................................................................................................ 69 Appendices .............................................................................................................................. 75 Appendix A Blank Incident Form with Identifiers Removed ................................................. 75 Appendix B Letter and Permissions ....................................................................................... 78 x  B.1 Invitation Letter ..................................................................................................... 78 B.2 Permission Form A ................................................................................................ 81 B.3 Permission Form B ................................................................................................ 82 Appendix C Data Collected from Incident Form .................................................................... 83 Appendix D Clinical Course Descriptions Background Data Collection Sheet ....................... 84 Appendix E Types of MAI Defined ....................................................................................... 86  xi  List of Tables Table 2-1 Database Keywords Used ............................................................................................9 Table 2-2 Types of MAI Involving Student Nurses in Published Reports .................................... 14 Table 4-1 Three-Year Frequency of Type of MAI ....................................................................... 29 Table 4-2 Three-Year Frequency of MAI Shift of Occurrence .................................................... 30 Table 4-3 Three-Year Frequency of Perceived Degree of Harm ................................................ 31 Table 4-4 Type of Reported MAI by Academic Period ............................................................... 32 Table 4-5 Degree of Perceived Harm by Academic Period ........................................................ 33 Table 4-6 Type of MAI by Course Level .................................................................................... 36 Table 4-7 Perceived Degree of Harm by Course Level .............................................................. 37 Table 4-8 Three-Year Frequency of Student Discovered MAIs Not Directly Involved With ........ 38 Table 4-9 Three-Year Frequency of Documented Contributing Factors ..................................... 39 Table 4-10 Number of Documented Contributing Factors per Incident ...................................... 41 Table 4-11 Documented Contributing Factor by Type of MAI ................................................... 42 Table 4-12 Perceived Degree of Harm and Contributing Factors .............................................. 43 Table 4-13 Documented Contributing Factors by Academic Period .......................................... 44 Table 4-14 Documented Contributing Factor Proportions by Course Level over Three Years ... 45 Table 4-15 Documented Immediate Responses .......................................................................... 47 Table 4-16 Documented Long-Term Actions.............................................................................. 48 Table 4-17 Documented Prevention Measures........................................................................... 49 Table 4-18 Documented Instructor Responses Over Three-Year Period .................................... 50  xii  List of Figures Figure 2-1 PRISMA Flowchart .................................................................................................. 10 Figure 4-1 Number of Reported MAI throughout the BSN Program ........................................... 34 Figure 4-2  Number of Report MAI at Course Level for Academic Periods ................................ 37  xiii  List of Abbreviations AE- Adverse Events BCCNP- British Columbia College of Nursing Professionals BC PSLS- British Columbia Patient Safety and Learning System BSN- Bachelor of Science in Nursing CASN- Canadian Association of Schools of Nursing CIHI- Canadian Institute for Health Information  CMIRPS- Canadian Medication Incident Reporting and Prevention System  CNE- Clinical Nurse Educator CNL- Clinical Nurse Leader CPSI- Canadian Patient Safety Institute  ISMP- Institute for Safe Medication Practices Canada  MAI- Medication Administration Incident MRN- Most Responsible Nurse MRP- Most Responsible Physician NCC MERP- National Coordinating Council for Medication Error Reporting and Prevention RN- Registered Nurse  xiv  Acknowledgements  Thank you to my supervisor Dr. Maura MacPhee and to my committee members Dr. Lenora Marcellus and Cathryn Jackson, MSN, RN, for your ongoing support and expertise during this process. Your perspective, insights and guidance have taught me so much.  I would also like to thank Dwayne Pettyjohn, MSN, RN and Dr. Susan Duncan for partnership in this work. Thank you to the students and nursing educators who completed medication incident reports over the years- without you this work would not be possible. Furthermore, I would like to acknowledge the motivation and support offered to me by Dr. Darlaine Jantzen. You inspired me to pursue this research and supported me in initiating this project.  Thank you to Jo-Ann Clar and Dr. Lenora Marcellus for delivering the incident reports to my home during the COVID 19 Pandemic to ensure my research could continue.  Thank you to my Mom and Dad; you gave me every opportunity throughout my life and taught me the value of hard work. Your unwavering support of my goals has made me know anything is possible.   To Mom and Dad Ellis thank you for helping us during this time. To my husband Dave, thank you for your love, patience, guidance, and editing. I appreciate all that you do to support me.    Finally to Elizabeth, thank you for letting mommy work – I am done now, let’s go to the park!   xv  Dedication  For my past, present and future students. “Be calm, be kind and be safe” – Dr. Bonnie Henry. This is excellent advice during a pandemic, but also when you are learning to provide care to patients. 1  Chapter 1: Introduction Medications are an essential component to the treatment of illness and the promotion of comfort and well-being. Registered nurses (RNs) often provide or supervise the administration of medications to hospitalized patients. Quality nursing education in medication administration is essential to prepare future nurses to provide medications to patients safely. Student nurses are involved in medication administration incidents (MAIs) while developing competency in medication administration and these errors have the potential to harm patients and can cause trauma to the student nurse. As a nursing educator, I have witnessed the impact that making an error can have on a student’s success within a clinical rotation. Students can become fearful, anxious, stressed, lose confidence, and, as a result, under-perform after being involved in an MAI. There is no clear guideline for nursing educators to follow to address an MAI: Educators typically use individual judgement to evaluate if the MAI made by a student is a result of a lack of competence or due to other factors. The MAI system needs to be updated to meet current trends in healthcare that shifts the blame from individuals to a culture of safety promotion. The aim of this study is to investigate the characteristics of MAIs involving Bachelor of Science in Nursing (BSN) students during clinical practice. This chapter is an introduction to these concepts through a summary of medication administration practices and education. Definitions of the important aspects of MAIs and near-misses is contained within this chapter along with theoretical foundations, problem statement, and research questions for the proposed study. 1.1 Medication Administration Medication administration is the process where medications are prepared and provided for therapeutic reasons. The process of medication administration is specific to each practice setting and may include different routine practices depending on a variety of factors. Nurses 2  provide medications in a variety of settings including clinics, hospitals, and in the community. The British Columbia College of Nursing Professionals (BCCNP), formerly the College of Registered Nurses of British Columbia (CRNBC) (2010), approaches this complex aspect of the role of nurses through a practice standard outlining the nurses’ professional responsibility surrounding medication administration. According to this practice standard, it is the responsibility of the nurse to ensure that the medication provided is within their scope of practice to administer and is appropriate for the patient’s situation. Nurses are guided to adhere to the “seven rights of medication administration” through ensuring that the right medication is provided to the right patient, at the right dose, via the right route, at the right time, and for the right reason, as well as documented using the appropriate methods.   Administering medications is considered a foundational skill which is a major component of nursing care (Fothergill Bourbonnais & Caswell, 2014). BSN students learn pharmacology and pathophysiology as a foundation for medication administration practices. The procedure of how to prepare, administer, and monitor the effects of medications are typically first introduced in the laboratory setting. This controlled setting is the ideal situation to teach and practice the process of administering medications. The BSN student then consolidates this skill in the clinical setting under various levels of supervision by a nursing educator or RN (Reid-Searl et al., 2010). Each educational institution approaches the education of medication administration using their own methods with variances in foundational courses, laboratory experience, and clinical supervision requirements. Despite educational support and supervision, MAIs occur while developing competence in the medication administration domain in the clinical setting.   3  1.2 Near-Misses and Medication Errors Medication errors are one of the major adverse events (AEs) which occur in health care settings. An AE is defined by the Canadian Patient Safety Institute (CPSI) (2011) using the term “patient safety incident” and encompasses “an event or circumstance which could have resulted, or did result, in unnecessary harm to a patient (p.11, para.6).” These incidents are further categorized into incidents leading to harm, no known harm, and near-miss events where the incident does not reach the patient. Both the Institute for Safe Medication Practices Canada (ISMP Canada) (2019) and the CPSI (2011) discourages the use of the term “error” to describe these events as the word “error” may assign individual blame on the person most involved in the event. While the term “medication error” remains the common terminology used in practice and within the literature, I will replace error with incident to support current recommendations from leaders in patient safety whenever possible.  The ISMP Canada collaborated with the Canadian Institute for Health Information (CIHI) and Health Canada (2002) in the development of a nationwide Medication Incident Reporting and Prevention System for Canada (CMIRPS). The following definition is used in the work of this coalition adapted from the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)(2018) replacing the term “medication error” with “medication incident.”   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, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use (“About Medication Errors”, para. 1).  4  In a large retrospective chart review examining the number of AEs that occur in Canadian hospitals, Baker et al. (2004) found the AE rate to be 7.5 per 100 acute care hospital admissions. Physicians who reviewed these AEs determined that 36.9% of the AEs were preventable. Nearly a quarter of all AEs were fluid or drug related. Teaching hospitals were found to have higher rates of preventable AEs compared to small and larger community hospitals, which could suggest the potential for learning environments to have a greater risk for AEs to occur.  1.3 Professional Responsibility for Prevention and Reporting of Medication Incidents The role of the RN often includes a wide range of responsibility in the medication administration process, including understanding the factors that increase the potential for MAIs to occur and taking appropriate actions to prevent these situations. The BCCNP (2010) directs that when a medication error or near-miss occurs, nurses have a professional responsibility to resolve and report this incident in a timely manner. Employers have the responsibility to provide environments that allow for safe medication administration and support the reporting of medication errors and near-misses.  ISMP Canada (2018), through a multi-incident analysis of reports made to CMIRPS, determined that healthcare students from multiple disciplines including medicine, pharmacy, and nursing are associated with medication incidents. It was concluded that students can make a positive contribution to medication safety by recognizing, resolving, and reporting medication incidents made by other members of the team. Students lack experience, which may contribute to incidents, but their inexperienced perspective may allow them to question processes that allow for the incidents to occur.  The British Columbia Patient Safety and Learning System (BC PSLS) collects data on medication incidents made at healthcare organizations across British Columbia including 5  incidents involving BSN students. Through this system, the reporter anonymously reports a safety event, such as an MAI, through the intranet at an organization. This data is stored in a secure database for further analysis and to allow for collaboration and learning. Managers, leaders or experts may be notified of the incident depending on the severity of the event (British Columbia Patient Safety and Learning System, 2014). There is an absence of published reports available using the data from BC PSLS pertaining to MAIs involving BSN students. Educational institutions are absent from the reporting feedback, unless a manager or leader notifies the educational stakeholders, leading to the collection and synthesis of the MAI data remaining either not completed or unpublished. To my knowledge, no open or routine method of sharing data on MAIs involving BSN students has been made available from the BC PSLS to educational institutions.   At the educational institution level, there may or may not be procedures developed and utilized to report MAIs. Within nursing education, MAIs involving BSN students historically have been associated with a lack of competence or inappropriate adherence to the “rights of medication administration.” In recent years, a ‘culture of safety’ shift has raised awareness of other factors, such as contextual factors, that contribute to MAIs (Fothergill Bourbonnais & Caswell, 2014). The Canadian Association of Schools of Nursing (CASN) and the CPSI (2018) have developed suggested learning outcomes for undergraduate nursing curricula in patient safety. These learning outcomes include learning to appropriately recognize, respond to, and disclose MAIs and near-misses.   6  1.4 Systems Theory: A Theoretical Approach to Incident Analysis The CPSI (2012) recommends that incident analysis should use a systems-based approach. This recommended approach is solution-focused and involves an evaluation of the multiple factors that may have contributed to the incident’s occurrence. I will use a systems-based theoretical perspective to analyze MAIs involving BSN students for my thesis (See Chapter 3: Methods).  When an MAI occurs, foundational concepts from James Reason’s Swiss Cheese Model (2000) can be used to help focus on solutions to prevent future MAIs from occurring. A guiding principle of this model accepts that all humans are vulnerable to errors and perfect performance is impossible. This model removes the focus from the individual when a mistake occurs to focus on how the system allowed an incident to occur. The model uses an analogy of several slices of Swiss cheese lined up with holes in each layer. For the incident to occur, the holes need to line up allowing the unintentional event to pass through. In healthcare, although multiple layers or systems are designed to prevent incidents from occurring, ‘holes’ continue to exist, and incident prone situations occur. When an MAI or near-miss occurs, an examination of the contextual factors can allow for additional systems to be developed to block future MAIs from occurring. These systems need to accommodate the unique needs of all disciplines practicing within the environment including learners and those who are temporarily practicing within the environment.  1.5 Culture of Safety A culture of safety is also termed a no-blame or just culture. The CPSI (2012) highlights that organizations that foster a safe culture prepare for mistakes before they occur and have a plan for when unexpected events occur. In the framework “Canadian Incidence Analysis”, the CPSI (Beard et al., 2012) explains the value of updating these plans and procedures often to meet 7  an organization’s changing culture. Within nursing undergraduate education, it is a challenge to adapt to the changing culture not only within the program but also within the multiple practice environments in which BSN students practice. Fostering a culture of safety within the evaluative nature of nursing education has challenges. A shared accountability model where responsibility is shared between individuals and systems can be used when an incident occurs to facilitate the incident becoming a learning opportunity. Fairness, transparency, and trust are values that underlie this approach within nursing education (Barnsteiner & Disch, 2017). My evaluation of MAIs involving BSN students, therefore, will avoid blaming students, educators or institutions. The focus of this approach is to prevent or reduce future MAIs from occurring through gaining a greater understanding of the phenomenon and the complexities of MAIs involving BSN students.   1.6 Problem Statement Safe medication administration is a fundamental aspect of nursing education (Canadian Association of Schools of Nursing and Canadian Patient Safety Institute, 2018; Cooper, 2014; Harding & Petrick, 2008). Student nurses, as new learners, are prone to making MAIs (Cebeci et al., 2015; Cooper, 2014; Dolansky et al., 2013; Harding & Petrick, 2008; Tabassum et al., 2015; Walsh et al., 2018; Wolf et al., 2009; Zieber & Williams, 2015). There are few reports available that describe the factors associated with MAIs involving BSN students, the perceived causes, and the responses of students and educators.  1.7 Research Purpose and Questions The purpose of my thesis was to conduct a comprehensive review of MAIs involving BSN students over the last three academic years. Understanding the characteristics of MAIs involving BSN students can assist in the formation of policy and procedure that supports a safe patient culture in nursing education. Understanding the characteristics of MAIs that students are 8  involved in will help educational and healthcare organizations develop systems to mitigate the potential for these MAIs to occur. My research questions are: What are the types of MAIs involving BSN students that occur during clinical practice that are reported to the educational institution? What are the documented causes and contributing factors to MAIs involving BSN students? And what are the documented BSN student and nursing educator responses to MAIs involving BSN students?   1.8 Outline of Thesis This chapter has provided a brief background on important concepts related to characteristics of MAIs involving BSN students. Chapter 1 has highlighted the research problem, purposes and questions. Chapter 2 will provide a detailed literature review summarizing existing literature on the topic of the characteristics of BSN student MAIs. Chapter 3 contains a discussion of the methods including research design, sampling plan, access, recruitment, data collection, measures, and analytical plan related to the proposed study, as well as ethical considerations. Chapter 4 contains findings from my analysis as they relate to my research questions. Chapter 5 contains discussion related to findings. Chapter 6 contains implications for practice, recommendations and conclusions based on this research.   9  Chapter 2: Literature Review To gain an understanding of the existing literature related to the characteristics of student MAIs in clinical settings, I conducted a literature search in September 2018. A reference librarian assisted with the identification of an appropriate search strategy to address the research questions. Table 2-1 outlines the keywords for each database searched and the number of records found. My inclusion criteria were peer-reviewed empirical literature that were determined to be relevant to the research questions through key terms and published in English after 2008. My exclusion criteria were articles on student MAIs in non-clinical contexts, such as teaching strategies or simulations. My purpose was to capture documented student MAIs and exclude hypothetical student MAIs.  Table 2-1 Database Keywords Used Database Search Strategy Number of Records CINAHL (MH Students, Nursing) OR (student* N2 nurs*)  AND (MH Medication Errors) OR (medication* or drug*) N2 error*) OR ("safety event*) OR (adverse event*)  189 Medline (Ovid)  (MeSH Students, Nursing) OR (“student* adj2 nurs*) AND (MeSH Medication Errors/nu [Nursing]) OR  (medication* or drug*) adj2 error OR (safety event*) OR (adverse event*)  148 EMBASE (Ovid) EMBASE terms (nursing student/ or baccalaureate nursing student/ or male nursing student) OR (student* nurs*) OR (nurs* student*) AND EMBASE term (medication error) OR (medication* error*) OR (drug* error*) OR (safety event*) OR (adverse event*) 131 Total 468    10  2.1  Search Strategy The searches from the three databases were combined and 189 duplicated articles were removed. The remaining records were screened by title for relevance to the topic. During this screen, all titles determined to be relevant to the research questions were included. Forty-three articles remained after title screen and abstracts were reviewed for relevance to the research questions. Twenty articles were excluded as deemed irrelevant, opinion or strategy-based, or not empirical research. Figure 2-1 details this process. Full-text copies of twelve articles were accessed and reviewed in full.  Figure 2-1 PRISMA Flowchart   11  2.2 Overview of Literature Reviewed Twelve articles were included for review as they pertained to my research questions. Three articles used qualitative methods and nine articles used quantitative methods. Only three reports reviewed were from Canada and are more representative of the educational and healthcare culture of my proposed study (Harding & Petrick, 2008; Walsh et al., 2018; Zieber & Williams, 2015). Three reports examined characteristics of MAIs involving student nurses during education at schools of nursing in the United States of America (Cooper, 2014; Disch et al., 2017; Wolf et al., 2009). Two reports were from Iran (Koohestani & Baghcheghi, 2009; Vaismoradi et al., 2014), one from the Philippines (Valdez et al., 2013), one report from Turkey (Cebeci et al., 2015), and one report from school of nursing data in Pakistan (Tabassum et al., 2015). To summarize these articles according to my research questions, I used four overarching themes: the types of student MAIs; the contributing factors of student MAIs; the causes of student MAIs; and responses from students and educators to student MAIs. 2.3 Types of Student MAI To gain an understanding of the types of student MAIs that occur during clinical practice, I examined the prevalence of student MAIs, the categorized type of MAI, and the perceived level of harm to the patient.  In a Turkish cross-sectional study of 324 students placed in the hospital setting for at least one semester, 38.5% (n =124) declared they had made an MAI (Cebeci et al., 2015). Valdez, de Guzman and Escolar-Chua (2013) found the percentage of students in the Philippines who made an MAI to be lower at 18.8% (n=62) and a near-miss rate of 54.4% (n=179). Tabassum et al. (2015) found in a cohort of 324 students in Pakistan 2.3% (n=7) reporting an MAI. One American school of nursing, with 610 students per semester except for 84 students in 12  the summer semester, found that during five semesters 26 MAIs were reported (Cooper, 2014). Within a sample of three academic years, Harding and Petrick (2008) reviewed 77 MAIs reported through incident reports made during a Canadian community college baccalaureate program. Walsh et al. (2018) found 24% (n=25) of students surveyed at a Canadian school of nursing reported making one MAI and 3% (n=3) had made two MAIs.  Seven of these reports categorized MAIs by the “rights of medication administration”, and five of the reports included the categories of errors of omission/missed dose, and administration technique error. I extracted the data pertaining to the type of student MAIs from these reports and have displayed pertinent findings on Table 2-2. Two reviewed reports were excluded from this table, because different MAI categories were used (Cooper, 2014; Walsh et al., 2018). The frequency of types of MAIs varied across the reports, perhaps due to different methods of data collection and reporting.  Harding and Petrick (2008) and Valdez et al. (2013) found errors of omission to be the most frequent category of MAI with 34% (n=26) and 41.9% (n=26), respectively. Cebeci et al. (2015) found this to be one of the least common types of MAI with 1.5% (n=6) through a survey of students. It is possible this number is lower because the students were unaware of any omission errors. Tabassum et al. (2015) found no student MAIs in this category, but at this school of nursing, all medication administration was directly supervised by a nurse educator, potentially limiting omission errors along with other types of MAIs.  Wrong dosage was found to be the most frequent type of student MAI in two reports at around 22% of the errors (Cebeci et al., 2015; Wolf et al., 2009). Valdez et al. (2013) found providing medications at the wrong time led to 40.3% (n=25) MAIs where in other reports the prevalence of wrong time MAIs were not as high. Walsh et al. (2018) found that the most 13  common student MAIs were “not giving the medication within agency policy timeline” (21%) and giving medication at the wrong time (18%). Wrong documentation was also a frequent type of MAI reported by Cebeci et al. (2015) and Walsh et al. (2018) with 18% of the MAIs categorized into inaccurate documentation. Administration technique errors accounted for many MAIs made by students. Wolf et al. (2009) found 29.6% attributed to this type of student MAI. Similarly. Cebeci et al. (2015) found administration technique errors in 23.8% of MAIs. Wrong patient, medication and route types of MAIs were less common. Tabassum et al. (2015) and Wolf et al. (2009) found no MAI in the wrong patient category and in the other reports these MAI were proportionally less than other types of MAIs.14  Table 2-2 Types of MAI Involving Student Nurses in Published Reports  Cebeci et al., 2015 Harding & Petrick,  2008 Valdez et al., 2013 Tabassum et al., 2015 Wolf et al., 2009  n = 402 n =77 n = 62 n =7 n =27  Type of MAI n % n % n % n % n % Incorrect Patient 35 8.8 5 6.0 4 6.5 0 0 0 0 Incorrect Drug 22 5.5 * * 4 6.5 0 0 2 7.4 Incorrect Dosage 90 22.8 * * 10 16.1 1 14.3 6 22.2 Incorrect Route 7 1.8 5 6.0 2 3.2 1 14.3 3 11.1 Incorrect Time 5 1.5 * * 25 40.3 0 0 2 7.4 Incorrect Documentation 73 18.1 * * ** ** 0 0 ** ** Omission 6 1.5 26 34.0 26 41.9 0 0 7 25.9 Incorrect Administration Technique 96 23.8 * * 3 4 4.8 6.5 1 14.3 8 29.6 Unique Categories Not following up on effects- 35 (8.8%) Errors of commission - *  Un-supervised Admin.- 3 (42.9%) Multiple category selection permitted  Adding wrong drug to fluid- 6 (1.5%)   Misread medication record - 1 (14.3%)   Adding wrong electrolyte to fluid- 2 (0.5%)       Extra dose- 2 (0.5%)               * values not provided in published report  ** not classified  15  2.4 Contributing Factors of MAIs Involving BSN Students The complex nature of healthcare environments contributes to MAIs involving BSN students. According to the literature, important contributing factors associated with MAIs involving BSN students are: workload increase, stress, fatigue, and challenges with written and verbal communication. A root-cause analysis (RCA) of a student MAI, from an American school of nursing, found, for example, that the environment, personal factors, unit communication, unit culture, and educational factors led to the MAI (Dolansky et al., 2013). This highlights the compounding nature of contributing factors. Workload increase was associated with other systems factors, such as number of tasks to complete within time restrictions and increased patient acuity (Cebeci et al., 2015; Harding & Petrick, 2008; Tabassum et al., 2015; Vaismoradi et al., 2014; Valdez et al., 2013; Walsh et al., 2018). Increased stress was another important contributing factor that led to MAIs involving BSN students. Valdez et al. (2013) found there were many factors associated with student stress: “in-excess” (increased workload) factors and “in-experience” (lack of experience with knowledge and skills related to care) factors led to “in-tension” (increased stress). Fatigue contributed to 43% (n=140) of MAIs reported (Cebeci et al., 2015), although fatigue was not well-defined in the literature reviewed.   Challenges with both written and verbal communication can contribute to MAIs involving BSN students. Harding and Petrick (2008) found inexperience or misinterpreting the Medication Administration Record (MAR) contributed to 42% of omission MAIs reported. The MAR can have issues such as illegibility and transcription from doctor’s orders errors. A case study highlighted situations where the information in the electronic MAR can be retroactively entered which led to medications being repeated (Dolansky et al., 2013). Communication deficit was related to 38% (n=123) of MAIs involving BSN students reported (Cebeci et al., 2015). In 16  these situations, students received conflicting or confusing information, such as different directions by nurses and nurse educators (Dolansky et al., 2013). Looks-alike or sounds-alike patient names, medication names, and labels also contributed to wrong patient, wrong medication or wrong dose MAIs occurring (Cebeci et al., 2015; Harding & Petrick, 2008; Vaismoradi et al., 2014; Valdez et al., 2013; Wolf et al., 2009).  2.5 Causes of MAIs Involving BSN Students Student related causes for MAIs were violation of rights (not following proper procedure), performance deficit (doing the skill related to medication administration wrong) and knowledge deficit (not having the knowledge necessary). Some studies reported multiple causes for MAIs involving BSN students. Overall, the literature was vague about methods for determining the causes of MAIs. Vaismoradi et al. (2014) found that students most commonly attributed MAIs to knowledge or skill deficits and did not reflect on how the environments and other situations contributed to incidents. This perspective was associated with fear of reporting and under-reporting by students (Koohestani & Baghcheghi, 2009). Dolansky et al. (2013) recommended using a RCA to more accurately determine the cause of MAIs. Violation of the rights of medication administration was one documented cause of many student MAIs. Valdez et al. (2013) highlighted the central role of violation of rights, but also how these violations are influenced by stress and workload factors, written communication deficits, and inexperience.  Knowledge and skill deficits can be mediated by experienced supervision and some schools have policies that students are supervised through every medication administration (Tabassum et al., 2015). However, in another study, supervision increased stress and students reported resentment for a lack of independence when administering medications (Vaismoradi et 17  al., 2014). Cooper (2014) concluded that students are rarely independent, so the role of clinical nursing educators and clinical education are important aspects to consider when examining causes of student MAIs. Wolf et al. (2009) found performance deficits were in n= 12 cases and knowledge deficit in n=9. Cebeci et al. (2015) was the only report which statistically analyzed the difference between semesters in MAI rates and found that there was no statistical significance between semesters for when MAIs were made. Tabassum et al. (2015), however, found more MAIs in the second year, which was attributed to inexperience with pharmacology and drug calculations at that point in students’ education. Conflicting findings indicate the complexity of factors that influence/cause student MAIs.    2.6 Responses of Student Nurses and Educators when an MAI Occurs When a student MAI occurs, there are student and educator emotional, procedural and educational responses to the MAI. Students who made an MAI reported fear for the effects on the patient and also fear of punitive results (Cebeci et al., 2015; Koohestani & Baghcheghi, 2009; Walsh et al., 2018; Zieber & Williams, 2015). Anxiety was also reported by students who made an MAI (Cebeci et al., 2015). When a mistake was made the experience was traumatic to students, increasing the potential for unsafe behaviours and more MAIs (Walsh et al., 2018). Other negative emotions found by Cebeci et al. (2015) were guilt, sadness, panic, worry, loss of self confidence, and anxiety about loss of patient’s trust. This highlights the need for an awareness of negative emotions when addressing MAIs involving BSN students and an understanding that when students make an MAI report these emotions may impact their response.  18  2.6.1 Reporting Practices and Procedures Disch et al. (2017) surveyed 1667 American schools of nursing to determine whether prelicensure nursing programs had policies, tools or procedures for reporting and following up on student MAIs and near-misses. Of the 557 responding schools, half of the schools reported no written policy for actions to take with students post MAI or near-miss. Fifty-five percent of the responding schools had no tool to report MAIs or near-miss events. Only fifteen percent of the responding schools of nursing analyzed MAI trends.  Koohestani and Baghcheghi (2009) found through a questionnaire of students that 80.12% of MAIs were reported to the nursing instructor. Walsh et al. (2018) found there was a complicated relationship between a student’s willingness to report an MAI and actions taken. Professional obligation, responsibility, and accountability led to students increasing their comfort in reporting MAIs, where fear of social and academic penalties led to MAIs remaining unreported and therefore hidden from incident reports. Anonymous questionnaires and semi-structured interviews are methods used to capture information on unreported MAIs. Feedback from the nursing educator can be viewed as positive or negative from the perspective of the student nurse and has an impact on future willingness to disclose mistakes made. Receiving “no positive feedback” was found by Koohestani and Baghcheghi (2009) as the highest level of perceived barrier to reporting an MAI. “Fear of decreasing evaluation score and introducing education problems” was found to be the next highest perceived barrier. Vaismoradi et al. (2014) found many variances in how educators debriefed and provided feedback following an MAI. Zieber and Williams (2015) found that a punitive approach to MAIs involving BSN students led to the student fearing the negative effects of reporting the MAI and resulted in 19  concealing MAIs made at a Canadian school of nursing. Support offered during the phase after the MAI from nurses, family members, peers and the clinical instructor allowed the students to link the mistake to learning. The perspective and experiences of clinical nursing educators involved in MAIs involving BSN students was absent from the literature. In addition, the process or the actions of nurse educators with respect to MAIs involving BSN students was not found in the literature. Walsh et al. (2018) found that from a student perspective, feedback following an MAI varied in location, timing, and perceived focus. Students reported that the feedback they received would influence their intentions to report future MAIs. Eighteen percent of those students who reported making an MAI indicated that based on the feedback they received they would be less likely to report a future MAI. Zieber and Williams (2015) examined the importance of support through mistakes to link the MAI respond to a more positive learning experience. Students appear to have individual preferences to the feedback they receive after an MAI. Some students reported wanting subjective feedback focused on their level of competence where other students preferred objective feedback focused on the mistake (Walsh et al., 2018). There was no literature evidence with respect to how clinical nursing educators determine the types of feedback to provide or other responses to MAIs involving BSN students.  2.7 Limitation of Results Researchers in the literature reviewed used data collected through incident reporting systems and reports made to schools of nursing (Cooper, 2014; Harding & Petrick, 2008; Tabassum et al., 2015; Wolf et al., 2009). Validity and reliability of these reporting systems are not well established. Questionnaires were used in other studies, and they rely on the memory of the students who made the MAI, which may not accurately reflect the scenario and be subjected 20  to response and reporting biases (Cebeci et al., 2015; Koohestani & Baghcheghi, 2009; Valdez et al., 2013; Walsh et al., 2018). These same biases may exist within the research conducted using case study, focus groups, and interviews (Dolansky et al., 2013; Vaismoradi et al., 2014; Zieber & Williams, 2015). Another limitation of the literature evidence is variability in how data were collected and reported across schools of nursing: different categories or terms were used for student MAIs. Established and operationalized definitions of each of these categories of MAI were not found. It is unknown the process the student, nurse or nursing educator undergo to determine the category of MAI and the accuracy of this category selection when creating the incident report. Cebeci et al (2015), Harding and Petrick (2008), Valdez et al. (2013) and Wolf et al. (2009) used the rights of administration along with errors of omission to categorize MAIs where other reports used only the rights of administration or unique categories (Cooper, 2014; Tabassum et al., 2015; Walsh et al., 2018).  2.8 Chapter Summary The literature review found few reports that detailed the phenomenon of MAIs involving student nurses. There was a degree of variance in results found within the published reports. As noted above, there were limitations with respect to collecting and reporting student MAI data. The literature highlighted the importance of having clear and safe ways of reporting MAIs, and the need to organize and synthesize data in a standardized fashion. It appears that MAI reports were evaluated on an individual basis and not evaluated from a systems-based approach as recommended by experts in patient safety. Most importantly, these data need to be used to promote cultures of safety versus blame and shame. 21  Chapter 3: Methods The purpose of this study is to examine the characteristics of MAIs involving student nurses reported to one baccalaureate science of nursing program. This study aims to answer the following questions: 1) What are the types of MAIs involving BSN students during clinical practice that are reported to the educational institution? 2) What are the documented contributing factors and causes of the reported MAIs involving BSN students? 3) What are the documented student and nursing educator responses to MAIs involving BSN students?   This chapter discusses the study methods, beginning with a description of the research design, study setting, and sampling plan. This chapter also includes ethical considerations, data collection methods, measures, and analytical approach.  3.1 Study Design To answer these research questions, I conducted a cross-sectional retrospective case study of reported MAIs involving BSN students over three academic years (September 2016-August 2017, September 2017-August 2018, and September 2018-August 2019). This study design is informed by Cooper (2014), Harding and Petrick (2008), and Tabassum et al. (2015). I analyzed existing incident reports from these academic years to form a description of the type of MAIs reported, documented contributing factors and causes as well as documented responses of the students and educators.  22  3.2 Theoretical Foundations As recommended by the CPSI (2012), all incident analysis was undertaken from a systems-based approach. This recommended approach is solution-focused and involves an evaluation of the multiple factors that may have contributed to the incident’s occurrence.  3.3 Study Setting and Sample One four-year BSN nursing program participated due to availability of incident reports and availability of stakeholders to collaborate on this project. The BSN program in this study typically enrolls 160 new students a year. There is minor fluctuation in enrollment over the academic periods studied. Details of enrollment by course level and academic year can be found in Appendix D. The BSN program in Victoria, BC is offered collaboratively by Camosun College and the University of Victoria. The first five terms of the program take place at Camosun College. The Camosun College model of clinical practice education covers the first two and half years of the program and consists of group instruction under the supervision of a nursing educator or nursing instructor. Nursing students are assigned to a clinical practice setting and to specific elements of care that match the educational needs and scope of practice of the students. Nursing educators are employed by the school of nursing and act as additional educational supports for the health care team within the practice settings. The final four terms of the BSN are taught at the University of Victoria. There are two primary models for practice education: the Collaborative Learning Unit (CLU) model and the preceptorship model. Over 80% of students are in CLU placements. The model of clinical practice education is under the direct supervision of an RN, which is often referred to as the MRN (Most Responsible Nurse), who has a shared patient assignment with a student nurse working with them. The MRN is employed by a health authority. In addition to the direct supervision of the MRN, there is a 23  nursing educator who indirectly supervises their education and evaluation of learning, and coaches nurses in student teaching approaches.  Across the four-year program, new skills are first introduced in the laboratory setting before being implemented into practice. Typically, new skills are supervised closely until competency has been achieved. Clinical education takes place in different practice settings, depending on the course level or level of learning. Clinical practice courses are part of all levels of the program and the number of practice hours varies depending on the course. Clinical practice during the program occurs at various settings, including complex care, acute care, specialty areas, and within the community. In year one there are three practice courses with a total of 256 hours of practice education. In year two there are three practice courses with a total of 480 hours of practice education. In year three there are two practice courses with a total of 388 hours of practice education. In year four there are three practice courses with a total of 576 hours of practice education. Students typically change practice settings with each new clinical practice course. Student responsibility and level of supervision for medication administration varies between practice settings and may change depending on a wide range of factors. Typically, as a student moves to a new course level there is a gradual increase in number of patients within the assignment and responsibility to provide more complete care, including an increased responsibility for medication administration. Student medication administration accountability depends on many factors, such as the numbers of medications, their routes, and monitoring requirements. The educators and nurses need to negotiate best learning experiences for students.  Policy from the schools of nursing dictates that when an MAI involves a student nurse, this incident must be reported to the school of nursing through a “Student and Patient Incident Event Reporting and Learning Form.” A blank copy of the incident report is found in Appendix 24  A. This form was developed in consultation with the BC PSLS, so that student learning is similar to expectations in practice. A faculty guide is also available for background information on developing a culture of safety in relation to adverse incident reporting. These incident reports are typically completed in paper form by the student with instructor comments, and then submitted to the appropriate quality and safety committee chairperson within the school of nursing to guide learning and inform improvements. The incident reporting process is promoted in the BSN program as an important component of a culture of safety. Relevant aggregated trend information from incident analysis is shared with the practice site.   3.4 Permission to Access Data For this study, I sent a formal letter and consent to access data (see Appendix B) to the chair, or appropriate substitute, of each educational institution to request access to the incident reports pertaining to reported student MAIs. A summary of the study, including the research purpose and questions, design, sampling plan, measures, data collection, and data analysis plans, as well as a proposed timeline, was included with the request letter. I obtained approval letters and permission to access to these incident records by both institutions which offer separate components of the BSN program. I also requested background information for the clinical courses, including a brief description, enrollment data, and the number of clinical practice hours per clinical course. See Appendix D for the tool I used to collect background data on clinical practice courses.  3.5 Ethical Considerations I obtained ethics approval from the University of Victoria Human Research Ethics Board in a harmonized review with the University of British Columbia Behavioural Research Ethics Board. I also obtained ethics approval through the Camosun College Research Ethics Board. 25  According to ethics requirements, I received de-identified hard copies of the incident reports with any identifying information of educators, students, or staff involved with the MAI removed. Copies of the de-identified hard copy reports are stored in a safe and secure location, and I used an encrypted Microsoft Excel Spreadsheet to store, organize, and analyze the data from the reports. All related aggregated and analyzed data are stored on an encrypted and password protected computer in a secure location. The hard copies and computer files pertaining to this study will be retained for five years past the end of the study and, after five years, they will be destroyed per UBC ethics guidelines, the educational institutions had the right to withdraw the data from the study at any point. Copies of my completed report, with evidence-based recommendations, will be shared with the schools of nursing that participated in this study.  3.6 Data Collection Methods Data from the de-identified incident reports were organized in a Microsoft Excel 2016 spreadsheet, my data collection tool, using the same field headings as the incident report. The categories of information collected and those added to the data collection tool are found in Appendix C. Definitions used to ensure accurate categorization of MAI type and examples of defining incidents are available in Appendix E. I organized the data from the reports by academic year and clinical course level. I further categorized the MAIs involving BSN students into actual MAIs and near-misses. As I analyzed the data, I added other categories to my data collection tool (See Appendix C). For example, MAI categories on the incident report include omission, incorrect client, dose, route, time, medication, reason, and documentation and “other.” From “other” MAIs I created three additional categories, “incorrect scope for student”, “incorrect administration technique” and “nurse MAI” (versus student MAI). I also categorized all MAIs for perceived degree of harm and used four categories: no harm, harm, near-miss, and not 26  specified. The incident reports that described the incident as “harmful” were further classified into “harm to student” and “harm to client.” I calculated the frequencies of perceived degree of harm as a three-year total, by course level, and by academic year of occurrence. Finally, I noted if there was more than one type of error per student MAI.  3.6.1 Inclusion Criteria All available incident reports from academic periods for September 2016-August 2017, September 2017-August 2018, and September 2018-August 2019 that pertained to the research questions were included in the analysis.  3.6.2 Missing or Incomplete Data Data from the reports underwent screening to ensure appropriateness to the research questions. I attempted to complete missing fields of the incident report using other fields of the report whenever possible. For example, for course levels that were not recorded, I used the date of the incident report to determine course level. The majority of missing data was course level and shift of occurrence (which I completed with the assistance of other report data). Missing data that could not be completed in this fashion was recorded as undocumented, and I also noted the types of missing data (e.g., instructor notes). 3.7 Data Analysis I completed all statistical analyses using Microsoft Excel 2016. To examine the first research question (What are the types of MAI involving BSN students during clinical practice that are reported to the educational institution?), I used basic descriptive statistics to calculate the frequency of MAIs, types of MAIs, shift of occurrence, and perceived degree of harm. Descriptive statistics included frequency counts of each category of MAI as a three-year total, by course level, and by academic year of occurrence. 27  To examine the second research question (What are the documented contributing factors and causes of the reported MAIs involving BSN students?), I used deductive categories for contributing factors based on The Canadian Incident Analysis Framework (Beard et al., 2012). In addition, I inductively identified other contributing factors not in the framework.  To assess for the number of contributing factors, I examined the frequency of contributing factor per type of MAI as a three-year frequency to understand any patterns between types of MAI and contributing factors.  To examine the third research question (What are the documented student and nursing educator responses to MAIs involving BSN students?), I conducted a content analysis to inductively identify categories for these elements of the incident report form: actions taken, prevention measures and instructor comments. Each incident report was examined to determine the follow-up actions following the MAI. I created categories for types of actions and calculated the frequency of types of actions. This included whether a BC PSLS report was submitted. The final analysis to determine the nursing educator response involved content analysis of instructor comments. I identified common categories and determined the frequency of these categories by three-year frequency. I calculated frequency counts for non-student MAI incidents by type of incident, shift of occurrence, course level, and perceived degree of harm.  3.8 Chapter Summary Within this chapter, I have detailed the approach to gaining an increased understanding of the types of MAI, contributing factors to these MAI and documented responses of students and nursing educators when MAI occur.  28  Chapter 4: Findings A total of 88 MAI reports were analyzed according to the methods described in Chapter 3. A total of 81 reports were student MAIs and seven of the reports (8%) were nurse MAIs, described in Section 4.4.  4.1 Types of MAIs Involving Student Nurses To examine the first research question (What are the types of MAI involving BSN students during clinical practice that are reported to the educational institution?), the data was analyzed as a three-year frequency, by academic year, and at the course year level.  4.1.1 Three-Year Frequency of Types of MAI A three-year total of 81 MAI reports contained 92.6% (n=75) actual events and 7.4% (n=6) near-miss events. Table 4-1 presents the results from this analysis in order of frequency. The three most frequent types of incidents were incorrect dose 18.5% (n=15), incorrect administration technique 16% (n=13), and incidents of omission 16% (n=13). Definitions used and example incidents are found in Appendix E. 29  Table 4-1 Three-Year Frequency of Type of MAI  Three-Year Frequency Type of MAI n % Actual Events 75 92.6 Incorrect Dose 15 18.5 Incorrect Administration Technique 13 16.0 Omission 13 16.0 Incorrect Medication 9 11.1 Incorrect Time 8 9.9 Incorrect Client 5 6.2 Incorrect Administration Technique and Route 3 3.7 Incorrect Administration Technique and Time 2 2.5 Incorrect Documentation 1 1.2 Incorrect Dose and Documentation 1 1.2 Incorrect Dose and Time 1 1.2 Incorrect Route 1 1.2 Incorrect Scope 1 1.2 Omission and Incorrect Documentation 1 1.2 Omission and Incorrect Time 1 1.2    Near-Miss Events 6 7.4 Near-Miss Incorrect Administration Technique and Route 3 3.7 Near-Miss Incorrect Dose 2 2.5 Near-Miss Incorrect Scope 1 1.2  I analyzed the timing of MAIs according to shift of occurrence. Students were involved in MAIs during day shifts of 6, 8 and 12-hour duration and 12-hour night shifts. Table 4-2 presents the results of these analyses. A higher proportion of MAIs occurred during day shifts compared to during night shifts.  30  Table 4-2 Three-Year Frequency of MAI Shift of Occurrence  Three-year Frequency Shift of Occurrence n % 6 Hour Day Shifts 3 3.7 8 Hour Day Shifts 17 21.0 12 Hour Day Shifts 38 46.9 12 Hour Night Shifts 23 28.4  Table 4-3 summarizes three-year perceived degree of harm as indicated on the incident report. No harm events were the most common type of perceived harm level 71.6% (n=58) where there was no known harmful effect or obvious adverse outcome for patients. An example would be: A patient is given a medication later than originally ordered and has no signs or symptoms of negative outcomes.  The three-year frequency of total perceived events causing harm was 19.8% (n=16). On the incident form, harmful events are categorized as harm to client or harm to student. Harm to client events accounted for 8.9% (n=7) of the total events analyzed. This harm was not well described within the reports but appeared to result in minimal changes in patient treatment plans and outcomes. An example: A patient missed a dose of an anticoagulant at bedtime and this was discovered the morning after the missed dose and provided at that time. The patient was at increased risk of blood clots, but did not experience a blood clot. The student and instructor coded this incident as harmful. Harm to student events accounted for 11.1% (n=9) of the total events. These events were primarily needle puncture events during subcutaneous injections of medications. Protocols for these events were completed according to school of nursing requirements.  31  Table 4-3 Three-Year Frequency of Perceived Degree of Harm  Three-year Frequency Degree of Perceived Harm n % No Harm 58 71.6 Harm to Student 9 11.1 Harm to Client 7 8.6 Near Miss 6 7.4 Not Specified 1 1.2  4.1.2 Types of MAI Reported During Three Academic Periods I completed an analysis for three academic periods to see if there were differences across the three time periods with different student cohorts. Each academic period has four course levels where students’ assignments become more advanced with respect to number of patients cared. Academic period 1 was September 2016-August 2017, academic period 2 was September 2017-August 2018, and academic period 3 was September 2018-August 2019. Table 4-4 summarizes the data by frequency of MAI types. Academic period 1 contained 41.9% (n=34) of total MAIs reported, academic period 2 contained 22.2% (n=18), and academic period 3 contained 35.8% (n=29) of the MAI reports. For academic period 1, dose (26.5%) and administration technique (23.5%) errors were most frequent, accounting for approximately half of student errors. In academic period 2, 22.2% of the errors were medication-related (i.e., wrong medication), with dose (16.7%) and omission (16.7%) errors contributing to the majority of student errors. In academic period 3, omission errors were most frequent (20.7%) followed by administration technique (13.8%) and dose (10.3%).  32  Table 4-4 Type of Reported MAI by Academic Period  September 2016 to August 2017 September 2017 to August 2018 September 2018 to August 2019  n=34 n=18 n=29 Type of MAI n % n % n % Actual Events             Dose 9 26.5 3 16.7 3 10.3 Administration Technique 8 23.5 1 5.6 4 13.8 Omission 4 11.8 3 16.7 6 20.7 Medication 3 8.8 4 22.2 2 6.9 Time 4 11.8 2 11.1 2 6.9 Client 2 5.9 1 5.6 2 6.9 Admin. Technique and Route 0 0 1 5.6 2 6.9 Admin. Technique and Time 0 0 0 0 2 6.9 Documentation 1 2.9 0 0 0 0 Dose and Documentation 1 2.9 0 0 0 0 Dose and Time 0 0.0 0 0 1 3.4 Route 1 2.9 0 0 0 0 Omission and Documentation 0 0 1 5.6 0 0 Omission and Time 0 0 1 5.6 0 0 Scope 0 0 1 5.6 0 0        Near-Miss Events            Admin. Technique and Route 0 0 0 0 3 10.3 Dose 0 0 0 0 2 6.9 Scope 1 2.9 0 0 0 0  Table 4-5 summarizes the perceived degree of harm over the three academic periods. No harm incidents were most frequent across academic periods. Of note is that the first two academic periods had low or no near-miss events, while Academic period 3 had 17% near-miss events.  33  Table 4-5 Degree of Perceived Harm by Academic Period  September 2016 to August 2017 September 2017 to August 2018 September 2018 to August 2019 Three Year Total  n=34 n=18 n=29 N=81 Degree of Perceived Harm n % n % n % N % No Harm 26 76.5 15 83.3 17 58.6 58 71.6 Harm to Student 5 14.7 1 5.6 3 10.3 9 11.1 Harm to Client 1 2.9 2 11.1 4 13.8 7 8.6 Near Miss 1 2.9 0 0 5 17.2 6 7.4 Not Specified 1 2.9 0 0 0 0 1 1.2  4.1.3 Types of MAI by Course Level Each academic period contains four course levels for each year of the BSN program. Figure 4-1 displays the number of reported MAIs at each course level. Overall, there was an increase in the frequency of reported MAIs as progression through levels occurred. 3.7% (n=3) of the MAI reports were from first year clinical courses. During level 2, there were 11.1% (n=9) of the total MAIs. Level 3 had 17.3% (n=14) of the reported MAIs. The highest frequency of reported MAIs was found in level 4 with 67.9% (n=55) of all reported MAIs occurring at this level.  34  Figure 4-1 Number of Reported MAI throughout the BSN Program   3914550102030405060Year 1 Year 2 Year 3 Year 4Number of MAI ReportedCourse Level35  Table 4-6 summarizes the types of reported MAIs analyzed by course level. At level 1, the MAIs were incidents of omission. At level 2, there were more near-miss events (55.5%) incidents of dose (11.1%), medication (11.1%) and time (11.1%). At level 3, incorrect medication (21.4%) and time (21.4%) were the most frequent MAI categories. At level 4, the most frequent categories were dose (21.8%), administration technique (20%) and omissions (18.2%).    36  Table 4-6 Type of MAI by Course Level                Table 4-7 summarizes perceived harm by course level. Near-miss events were mostly reported during level 2, with a total of 83% (n=5) of all near-miss events reported during level 2, with the remaining near-miss events found in level 1. All harm to client events occurred during level 4 of the program and the majority of harm to student events were at level 4.  Level 1 Level 2 Level 3 Level 4  n=3 n=9 n=14 n=55 Type of MAI n % n % n % n % Actual Events         Dose 0 0 1 11.1 2 14.3 12 21.8 Administration Technique 0 0 0 0 2 14.3 11 20.0 Omission 2 66.7 0 0 1 7.1 10 18.2 Medication 0 0 1 11.1 3 21.4 5 9.1 Time 0 0 1 11.1 3 21.4 4 7.3 Client 0 0 0 0 1 7.1 4 7.3 Administration Technique and Route 0 0 0 0 1 7.1 2 3.6 Administration Technique and Time 0 0 0 0 1 7.1 1 1.8 Documentation 0 0 0 0 0 0 1 1.8 Dose and Documentation 0 0 0 0 0 0 1 1.8 Dose and Time 0 0 0 0 0 0 1 1.8 Route 0 0 1 11.1 0 0 0 0.0 Scope 0 0 0 0 0 0 1 1.8 Omission and Documentation 0 0 0 0 0 0 1 1.8 Omission and Time 0 0 0 0 0 0 1 1.8 Near-Miss Events         Administration Technique and Route 0 0 3 33.3 0 0 0 0 Dose 0 0 2 22.2 0 0 0 0 Scope 1 33.3 0 0 0 0 0 0 37  Table 4-7 Perceived Degree of Harm by Course Level  Level 1 Level 2 Level 3 Level 4 All Level Total   n=3 n=9 n=14 n=55 N=81 Perceived Degree of Harm n % n % n % n % N % No Harm 2 66.7 4 44.4 12 85.7 40 72.7 58 71.6 Harm to Student 0 0 0 0 1 7.1 8 14.5 9 11.1 Harm to Client 0 0 0 0 0 0 7 12.7 7 8.6 Near Miss 1 33.3 5 55.6 0 0 0 0 6 7.4 Not Specified 0 0 0 0.0 1 7.1 0 0.0 1 1.2  Figure 4-2 displays the number of reported MAI by academic period and level in the program. This graph displays the differences at the course level over the academic periods.   Figure 4-2  Number of Report MAI at Course Level for Academic Periods    4.2 Student Discovered MAIs Not Directly Involved With The MAI incident reports are designed so that students can report incidents they indirectly experience (e.g., committed by a nurse versus student). Seven nurse-related MAIs 21216635241318051015202530September 2016-August 2017 September 2017-August 2018 September 2018-August 2019Number of MAIAcademic PeriodYear 1Year 2Year 3Year 438  were discovered and reported by student nurses to the educational institution. All these MAIs were at the fourth course level on night shift and they involved documentation errors. Table 4-8 summarizes the types of MAI found by student nurses.  Table 4-8 Three-Year Frequency of Student Discovered MAIs Not Directly Involved With  Three-Year Frequency  n=7 Type of MAI n % Omission and Incorrect Documentation 2 28.6 Incorrect Dose and Documentation 2 28.6 Incorrect Dose, Medication and Documentation 1 14.3 Incorrect Documentation 1 14.3 Near-Miss Omission and Incorrect Documentation 1 14.3  4.3 Documented Contributing Factors and Causes of Reported MAIs To examine the second research question (What are the documented contributing factors and causes of the reported MAIs involving BSN students?), I examined all reports to determine documented contributing factors and causes. Although the literature does separate these concepts, I was unable to determine the cause of the reported MAIs based on the documentation available. The categories from content analysis were: individual factors, stressful environments, communication, educational factors, and safety system failure.  4.3.1 Three-Year Frequency of Documented Contributing Factors I calculated the frequency of each contributing factor on the overall three-year total, academic period and course level. Some incidents had multiple contributing factors. Table 4-9 displays the three-year frequency of contributing factors.  39  Table 4-9 Three-Year Frequency of Documented Contributing Factors Contributing Factors Three-year Total Count Percentage of Total Incidents (N=81) Individual Factors 58 71.6 Communication 34 42.0 Stressful Environments 33 40.7 Educational Factors 26 32.1 Patient Factors 21 25.9 Safety System Failure 21 25.9  Contributing factors were either individual factors or systems factors that I categorized as communication, stressful environments, educational factors, patient factors and safety systems failures. Individual factors (71.6%) were students’ descriptions of individual factors that they perceived contributing to the MAIs, such as “fatigue,” “lack of self-care,” “lack of diligence,” “stress,” “anxiety,” and “being distracted.”  Communication failure was the most frequent category (42%) of contributing systems factors in MAIs. This category included written and verbal communication contributing factors. Common written contributing factors were related to the medication administration record (MAR), such as use of symbols and variability across sites in MAR forms and pharmacy processes. Verbal contributing factors were most related to lack of clear communication with the nurses and educators around medication tasks. Some students expressed the need for opportunities to ask more questions.  Stressful environments was another category of contributing systems factors, accounting for 40.7% of MAIs. Students reported busyness, loudness, a changing environment, needing to 40  complete tasks quickly, rushing for morning report, the stress of learning new skills and pressure to take on additional tasks. Educational contributing systems factors accounted for 32.1% of MAIs. These factors included student reports of student inexperience, deficits in knowledge, and variability in supervision support from nurses, such as the MRN. Some students also reported educational challenges associated with adaptation to different practice environments, nursing routines and practices.  Patient factors, accounting for 25.9% of MAIs, included changes in acuity, orders, and care needs. In addition to changes in patient care needs, other contributing factors included interruptions and requests from other patients.  Safety system failures accounted for 25.9% of MAIs. This category included equipment malfunction (11.1%), such as auto retract needles not retracting fully or IV pumps not infusing medication, and double check failures (12.3%). There are several medications such as anticoagulants, insulin, narcotics that require a second check from a nurse prior to the medication being provided. In these double-check failure incidents, the nurse confirmed the dose of the medication yet the MAI still occurred. Safety system failures also included students breaking typical protocols or taking short-cuts (e.g., taking medications from another source due to pharmacy processing delays).  It is evident from the MAI reports that MAIs are complex and that the report allows the student an opportunity to reflect on aspects of the MAI, including multiple contributing factors that may leave the medication administration process vulnerable to an MAI occurrence. Table 4-10 summarizes the number of documented contributing factor themes per MAI report reviewed.  41  Table 4-10 Number of Documented Contributing Factors per Incident Number of Contributing Factors Documented Frequency Percentage of Total MAI (N=81) One Factor 17 21.0 Two Factors 31 38.3 Three Factors 20 24.7 Four Factors 9 11.1 Five Factors 4 4.9  Table 4-11 summarizes which contributing factors were attributed to each type of MAI. Keep in mind that multiple contributing factors could contribute to the same incident. For example, of the 15 dose incidents, 10 were individual factors, 2 were stressful events, 2 were educational factors, 3 were safety systems failures and 4 were patient factors. The purpose of this table is to identify patterns related to multiple contributing factors. The patterns are better exemplified in Table 4-12. Individual factors were documented in 85.7% of harm to client MAIs and 75.9% of no harm MAIs. Safety systems failure was documented in 66.7% of MAIs in the harm to student incidents. Educational factors were highest frequency for the near-miss category (66.7%).   42   Table 4-11 Documented Contributing Factor by Type of MAI   Individual Factors Communi-cation Stressful Environments Educational Factors Safety System Failure Patient Factors Type of MAI N n % n % n % n % n % n % Actual              Dose 15 10 66.7 10 66.7 2 13.3 2 13.3 3 20.0 4 26.7 Administration  13 8 61.5 0 0 5 38.5 1 7.7 8 61.5 5 38.5 Omission 13 10 76.9 9 69.2 5 38.5 6 46.2 0 0 1 7.7 Medication 9 8 88.9 2 22.2 5 55.6 4 44.4 4 44.4 3 33.3 Time 8 6 75.0 3 37.5 3 37.5 2 25.0 3 37.5 2 25.0 Client 5 5 100 0 0 5 100 1 20 0 0 1 20.0 Admin. and Route 3 3 100 1 33.3 2 66.7 2 66.7 0 0 3 100 Admin. and Time 2 0 0 1 50.0 0 0 1 50 1 50.0 0 0 Documentation 1 1 100 1 100 0 0 0 0 0 0 0 0 Dose and Documentation 1 1 100 1 100 1 100 0 0 0 0 0 0 Dose and Time 1 1 100 1 100 1 100 0 0 1 100 0 0 Route 1 1 100 0 0 1 100 1 100 0 0 0 0 Omission and Time 1 1 100 1 100 1 100 0 0 0 0 0 0 Omission and Documentation 1 0 0.0 1 100 0 0 1 100 0 0 1 100 Incorrect Scope 1 1 100 1 100 1 100 1 100 0 0 1 100 Near-Miss              Admin. and Route 3 1 33.3 0 0 1 33.3 3 100 0 0 0 0 Dose 2 1 50 1 50 0 0 1 50 1 50 0 0 Scope 1 0 0 1 100 0 0 0 0 0 0 0 0 43  Table 4-12 Perceived Degree of Harm and Contributing Factors  Individual Factors Communication Stressful Environment Education Safety System Patient Factors Perceived Degree of Harm n % n % n % n % n % n % No Harm  (N=58) 44 75.9 28 48.3 26 44.8 20 34.5 13 22.4 15 25.9 Harm to Student (N=9) 5 55.6 0 0 4 44.4 1 11.1 6 66.7 4 44.4 Harm to Client (N=7) 6 85.7 3 42.9 1 14.3 1 14.3 0 0 2 22.2 Near-Miss  (N=6) 2 33.3 2 33.3 1 16.7 4 66.7 1 16.7 0 0 Not Specified (N=1) 1 100 1 100 1 100 0 0 1 100 0 0  44  4.3.2 Documented Contributing Factors by Academic Period I organized contributing factor data by academic period in Table 4-13. There are slight variations over the academic periods. Across academic periods, individual factors accounted for the greatest frequency of contributing factors.  Table 4-13 Documented Contributing Factors by Academic Period  September 2016-August 2017 September 2017-August 2018 September 2018-August 2019  Total number of incidents (N=34) Total number of incidents (N=18) Total number of incidents (N=29) Contributing Factor n % n % n % Individual Factors 25 73.5 13 72.2 20 69.0 Communication 13 38.2 9 50.0 12 41.4 Stressful Environments 13 38.2 9 50.0 11 37.9 Educational Factors 5 14.7 7 38.9 14 48.3 Safety System Failure 13 38.2 4 22.2 4 13.8 Patient Factors 7 20.6 10 50.0 4 13.8   4.3.3 Documented Contributing Factors by Course Level I also analyzed the contributing factors by course level to determine if there were differences in the contributing factors by course level. The data related to this analysis are presented in Table 4-14. For example, during course level 1 there were three MAIs with multiple contributing factors including individual factors, and a variety of systems factors (i.e., communication, stressful environment, educational factors). The MAI numbers increase over course levels with individual factors, stressful environment and educational factors accounting for greater proportions of error.    45  Table 4-14 Documented Contributing Factor Proportions by Course Level over Three Years  Level 1 Level 2 Level 3 Level 4  N=3 N=9 N=14 N=55 Contributing Factor n % n % n % n % Individual Factors 1 33.3 6 66.7 11 78.6 40 72.7 Communication 3 100 3 33.3 5 35.7 23 41.8 Stressful Environment 1 33.3 4 44.4 7 50.0 21 38.2 Educational Factors 1 33.3 6 66.7 5 35.7 14 25.5 Safety System Failure 0 0 2 22.2 4 28.6 15 27.3 Patient Factors 0 0 0 0 3 21.4 18 32.7  4.4 Documented Responses To examine the third research question (What are the documented student and nursing educator responses to MAIs involving BSN students?), I analyzed completeness of records, documented actions taken, students’ recommendations for prevention, and instructor comments.  4.4.1 Completeness of MAI Reports Primary details of the incident, including date of event, discovery, practicum information and who the event impacted, was completed on most MAI reports. The student’s reflection on learning was completed on all forms. Instructor comments were not documented on eight of the MAI reports. The most frequent area of incompleteness was the final page of the report, which involves an incident analysis using a constellation diagram. A constellation diagram is used during the analysis of incidents to help visualize the incident and the factors that contributed to the incident. The person responsible for analyzing the incident is able to draw connections between the contributing factors that have an influence on other contributing factors (Beard et al., 2012). In 72.8% (n=59) of the MAIs an incident analysis constellation diagram was not 46  completed. When this component was completed, it was completed by the student reporting the incident.   4.4.1 Documented Immediate Actions Following MAI Occurrence I analyzed actions after student MAIs based on incident report sections. For immediate follow-up actions, I created response categories over a three-year period that identify the most common responses by students. These response categories and frequencies are summarized in Table 4-15. In over 70% of the incidents, the two most common responses were reporting to the care team (72.8%) and submitting to the BC PSLS (71.6%). Reporting to the care team included: reporting to the MRN, clinical nurse leader (CNL), clinical nurse educator (CNE) or manager of the care unit, informing the patient’s most responsible physician (MRP), pharmacist, or other members of the team. Completion of the BC PSLS was separate documentation that is required by healthcare authorities as part of their error tracking process. Corrective actions (30.9%) included follow-up such as providing missed medications, making adjustments to the MAR, sending medication memos to pharmacy and using pharmacy direction to reschedule future doses of medications. Instructor notification was required for all student MAIs, but only 25.9% of students immediately contacted their instructors. Assessment and care of patients (22.9%) included follow-up assessments, vital signs, monitoring of blood glucose levels, monitoring for potential adverse events and providing medications as ordered. Patient disclosure took place in 16% of incidents when the patient, including their family when appropriate, was informed of the MAI. Lower frequency responses of immediate actions were documented for patient chart documentation (9.9%); workplace health protocols (9.9%) for student injuries, such as needle sticks; and secure items (1.2%), which involved seeking out and labeling malfunctioning equipment. Five reports had no immediate response documentation (6.2%).     47  Table 4-15 Documented Immediate Responses  Three-year Frequency Documented Responses n % of Total Incidents Reported to Care Team 59 72.8 Submitted BC PSLS 58 71.6 Corrective Actions 25 30.9 Reported to Instructor 21 25.9 Assessment and Care of Patient 18 22.2 Patient Disclosure 13 16.0 Documented in patient chart 8 9.9 Workplace health protocol 8 9.9 No documentation of actions 5 6.2 Secure items 1 1.2  4.4.2 Long-Term Actions and Reducing Reoccurrence Although there is a section on the incident reports for long-term actions, it was difficult to categorize these based on available information. Some immediate actions were documented in the long-term actions field, and some long-term actions were student learning reflections about prevention of future errors. Table 4-16 summarizes long-term actions that I categorized based on completed reports. As shown in Table 4-16, almost half of the reports had no long-term actions. It is not known whether the field was left blank or if long-term actions were not anticipated.   48  Table 4-16 Documented Long-Term Actions  Three-year Frequency Long-Term Actions n % No Long-Term Actions Documented 38 46.9 Learning Related Actions 12 14.8 Workplace Health Protocol Follow-Up 9 11.1 No Long-Term Actions Needed 8 9.9 Corrective Action Taken 5 6.2 Patient Monitoring 5 6.2 Educational Follow-up 2 2.5 Follow-up Patient Care 1 1.2 Patient Treatment 1 1.2  As noted above, some student reflections on potential prevention measures were documented in other fields of the report, particularly long-term actions. I categorized student prevention measures by three-year frequency in Table 4-17. Approximately half (48.1%) of the students said that more “caution” should be taken to prevent future errors. The second most documented prevention measure was improved communications (27.2%).  49  Table 4-17 Documented Prevention Measures  Three-year Frequency Prevention Measure n % Caution 39 48.1 Communication 22 27.2 No Documented Prevention Measures 8 9.9 Self-care 6 7.4 Increase Knowledge 4 4.9 Don't Rely on Safety Mechanism 3 3.7 Supervision 2 2.5 Change in Unit Routines 2 2.5 Equipment Improvement 2 2.5 Unsure of Prevention Measures 2 2.5 Add Sharps Bin to Room 1 1.2 Change Administration Technique 1 1.2 Change Label 1 1.2 Unpreventable 1 1.2  4.4.3 Documented Instructor Responses I categorized instructor responses to student MAIs in Table 4-18 over a three-year period. In most instances I created categories based on instructors’ exact words. Similar terms were used in instructors’ documentation. Instructors often documented multiple responses per incident. One-third (33.3%) of instructors documented that they “debriefed” the incidents with students. Debriefing was not defined in their comments or methods described. Almost one-third (28.4%) provided “educational interventions or corrections” such as commenting on a need to add learning goals to learning plans. Similarly, 24.7% of instructors did an “assessment of learning” from the error, such as “the instructor assessed what the student had learned from the 50  experience.” “Timeliness of reporting” was commented on in 18.5% of MAI reports. These comments referred to error reporting to the MRN and instructor. Comments such as “the student demonstrated professionalism through reporting the incident” were found in 17.3% of MAI reports. Some instructor comments validated that they had read and approved students’ critical reflections after an incident (11.1%). “Additional information” (8.6%) included information about the event added to the student’s documentation by the instructor. These comments provided additional explanation of the situation and a description of what happened during the event. Instructors documented: “follow-up with leadership” in 6.2% of MAIs. For example, when a systems safety concern was identified by the student, instructors followed up with the student’s assigned nurse or the manager. In 11.1% of MAI reports instructor comments were not documented. In 3.7% the comments were categorized as “verification of student responses” where no further explanation was provided.   Table 4-18 Documented Instructor Responses Over Three-Year Period  Three-year Frequency Instructor Responses n % Debriefed Incident 27 33.3 Educational Interventions and Corrections 23 28.4 Assessment of Learning from Experience 20 24.7 Timely Reporting 15 18.5 Positive evaluation of Professionalism 14 17.3 Reflection of Student Documented 11 13.6 No Comments Documented 9 11.1 Additional Information 7 8.6 Follow-up with Leadership 5 6.2 Verification of Student Responses 3 3.7  51  4.5 Chapter Summary Multiple analyzes were conducted to examine the MAI reports from a three-year overview, academic period and course level perspective. I examined types of MAI, shift of occurrence, perceived degree of harm, documented contributing factors and the responses of the students and nursing educators. Key findings will be discussed further in the following chapter.   52  Chapter 5: Discussion This study examined reported MAIs involving BSN students during clinical practice education in one BSN program. Through thorough review of available MAI reports between September 2016 and August 2019, I described the types of MAIs that students are involved in, the documented contributing factors to these MAIs, and the responses of the students and the nursing educators. This approach allowed me to highlight the complexity of these incidents from a three-year academic time period and course level perspective.  In this chapter, I will discuss how this work is situated within similar current evidence and the significance of this study. I organized this chapter into the overarching themes of the study: types of MAIs; documented contributing factors; and, the documented responses of student and nursing educators.  5.1 Types of MAI Involving Student MAI Key Findings A total of 88 MAI reports were documented during the three-year timeframe of this study. It is hard to gauge whether this number of reports is comparable to published reports of student MAIs due to differences in program enrollment, practice hours and unknowns about frequency of student medication administration and degree of direct supervision.  Descriptive reports of student MAIs have been reported in the nursing education literature on other Canadian BSN programs. In a similar three-year review that occurred within a Canadian BSN program that admits 32 students a year, Harding and Petrick (2008) reviewed 77 reports during this timeframe. Walsh et al. (2018) found 24% of students surveyed at a Canadian school of nursing reported making one MAI and 3% had made two MAIs.  An American BSN program with about 610 students per semester found that over five semesters 26 MAIs were reported (Cooper, 2014). In another American study examining six 53  years of reports of MAI involving student nurses, N=27 incidents were found related to tubing and catheter incidents (Wolf et al., 2009). In a Turkish study, Cebeci et al (2015) found that 38.3% of BSN students reported making an MAI during clinical practice. Tabassum et al. (2015) found in a cohort of 324 BSN students in Pakistan, 2.3% reported an MAI. Valdez et al (2013) found through a survey of 329 student nurses in the Philippines that 18.8% reported MAIs. Across these international studies, MAI rates varied widely. This body of literature also suggests that actual student MAI rates could be higher than reported depending on a range of factors, such as students’ fear of reporting (Cooper, 2014; Dunn, 2014; Hartnell et al., 2012; Koohestani & Baghcheghi, 2009; Natan et al., 2017; Noland & Carmack, 2015). In my study there were few near-miss incidents reported (7.4%). Reasons for this are not well understood but some explanations include lack of student and faculty understanding of what a near-miss is and how to report it from a safety perspective (ISMP-Canada, 2007). In one Turkish survey by Cebeci et al. (2015), the researchers found that near-misses were reported as “no error” events and these comprised 26.9% of the total student MAIs. It is very important, therefore, to have clear operational definitions for all types of MAIs and pre-graduate and post-graduate education to support accurate student, nurse and instructor reporting. All instructors including part-time faculty need to be aware of these MAI reporting procedures including the need to document near-miss incidents. Part-time clinical educators may require additional support around learning competencies in incident reporting and procedures. Incident forms need to be introduced to all faculty and students alike (Emerson et al., 2019).  In this study, most MAIs were not associated with client harm (8.9%) or student harm (11.1%). In the studies cited above, it is notable that they did not include categories for harm to students as a potential MAI outcome. There are a variety of harm to client scales cited in the 54  literature, such as the US National Coordinating Council for Medication Error Reporting and Prevention Index (Wolf et al., 2009). This index is similar to the BC PSLS system. The incident report form used in my study uses the same harm scale as The Canadian Incident Framework (Beard et al., 2012) that focuses on individual versus systems errors and does include documentation about harm to clients and to students. At the nursing program for this study, students are expected to complete the school of nursing incident report form and the BC PSLS. It is concerning that terms are different across incident reporting forms. Although the Canadian Incident Framework (Beard et al. 2012) is considered comprehensive, in my study I needed to add extra categories to capture all the types of student MAIs. In this study, I used incident report categories in my data collection table, and I needed to add two extra categories to capture all the types of student MAIs including incorrect administration technique, and incorrect scope.  I calculated student MAI frequencies over three years by academic period and by course level. I used these different approaches to look for patterns of incident occurrences, single or multiple, to provide insights for clinical educators. Findings were consistent across the three separate academic periods, suggesting that patterns were due to actual contributing factors in the students’ clinical education experiences. Across academic periods and over course levels, the most notable trend was an increase in frequency of student MAIs over time: There was an increase in MAI frequency across course levels for all three academic periods. This increase in MAI frequency corresponds with increased student responsibilities associated with medication administration, more patients per assignment, greater patient acuity and less direct supervision. Near-miss incidents were only reported in the first and second course levels of the program, suggesting that closer supervision and educator or nurse intervention may have resulted in less actual errors and more potential errors or near 55  misses for novice student learners. In the higher course levels, students are more independent with primarily nurse supervision. Nurse supervision of nursing students can be influenced by systems factors in the practice environment, such as interruptions and workload (Reid-Searl et al., 2010). Another possibility is suggested by the research of Cowen, Hubbard and Hancock (2016) who described the fears and concerns of student nurses before their first clinical experiences. Making a mistake was a fear reported by 63.5% of students. Students in the first course levels, therefore, may be more sensitized to making MAIs, while as students progress through course levels, they may lose that level of caution that protects against carrying through on medication incidents. If this is the case, educators need to regularly reinforce the importance of MAI safeguards. In both clinical and academic settings, nursing education can address areas that lead to incident prone situations. (Cleary-Holdforth & Leufer, 2013). MAI occurrence was more frequent during day shifts compared to during night shifts. Many factors can contribute to this finding, including an increased number of student learning experiences during daytime versus nighttime hours and more medications given during patient waking hours. These shift differences in student MAI frequencies were similar in a study by  Harding and Petrick (2008). They documented that more daytime errors were due to larger numbers of medications given by students during the day shifts.  Incorrect dosage was the most frequent type of student MAI (18.5%) in my study. In addition, this type of MAI accounted for the majority of incidents causing client harm (57.1%). This type of student MAI was also the most frequent student MAI in a study by Cebeci et al (2015) that recorded 22% of wrong dosage incidents.   Incorrect administration technique was another frequent student MAI, accounting for 16% of all errors in my study. I created this category from “other” errors on the incident report 56  form because it was not an explicit category on the institutional report form. This type of incident was reported in other literature on student MAIs (Cebeci et al., 2015; Tabassum et al., 2015; Valdez et al., 2013; Wolf et al., 2009), but definitions of incorrect administration varied across these studies, making it difficult to compare other study findings to the findings in my study. Not only was this the second most frequent MAI in my study, but it also accounted for all the reports of harm to students (n=9), emphasizing the importance of providing more granular descriptions of harm categories for clients and students.   Another frequent MAI type was omission (16%). Harding and Petrick (2008) and Valdez et al. (2013) found errors of omission to be the most frequent category of MAIs, with n=26 (34%) and n=26 (41.9%), respectively. Of interest is that Cebeci et al. (2015) found this to be one of the least common types of MAI (1.5%) in their survey study with BSN students. It is possible that this number was lower because the students were unaware of any omission errors. Tabassum et al. (2015) found no student MAIs for this category, but students in their sample were required to be directly supervised for all medication administration, potentially limiting omission errors along with other types of MAIs. In my study, this type of MAI was documented for one case of harm to client (14.3%) showing the potential for omissions to lead to harm. Omission errors, therefore, should be considered as serious as commission errors by students, educators and nurses.  Students also reported seven MAIs that were due to nurses’ MAR transcription mistakes. They documented these MAIs on the incident report form as “incorrect documentation.” These incidents occurred during the fourth course level when students learn order transcription and verification. This study finding also highlights the importance of requiring students to verify all 57  information on their assigned patients’ MARs before medication administration: This is an institutional requirement for its students.  5.2 Documented Contributing Factors Key Findings The Canadian Incident Analysis Framework (Beard et al., 2012) highlights the importance of a system-based approach to examining contributing factors beyond the individual human error perspective. For my content analysis of contributing factors, I used the following categories: individual factors, stressful environments, communication, educational factors, patient factors, and safety system failure. Section 4.3 provides a description of these categories. I also recorded whether there was one contributing factor or multiple factors. Overall, 21% of the MAIs were due to a single documented factor. The majority of student MAIs had more than one contributing factor and 4.9% of MAIs were due to five contributing factors. Only 27.2% of MAI reports had completed incident analyses, and it is notable that students were the ones to complete these analyses. The use of a constellation diagram or incident analysis framework (Beard et al., 2012) is important to understand the root causes of an error. Dolansky et al (2013) described the use of root cause analysis as an effective method for investigating student MAIs.  Although a culture of safety approach emphasizes how most MAIs are systems issues (Beard et al., 2012), in my study 71.6% of student MAIs were perceived by students as being due to individual factors, such as fatigue, stress and lack of diligence. The frequency of documented individual factors may suggest a tendency of self-blame versus systems thinking. The frequency of documented individual contributing factors increased across the course levels, indicating the need for ongoing education regarding culture of safety and systems errors versus individual errors. Barnsteiner and Disch (2017) promote the use of a shared accountability model in the development of Just Culture within nursing education. In the shared accountability model, 58  individual and systems accountability needs to be considered when a student MAI occurs, and it should be treated as a learning opportunity for students, nurses and educators. Fairness, transparency, and trust are values that underlie this approach within nursing education. Vaismoradi et al. (2014) found that students most commonly attributed MAIs to knowledge or skill deficits and did not reflect on how the practice environment and other factors contributed to MAIs. Student attributions of self-blame were also associated with fear of reporting and under-reporting by students (Koohestani & Baghcheghi, 2009).  Another systems contributing factor was deficits in communication (42% of student MAIs). This systems factor was often documented by students in conjunction with individual factors. Communications deficits included both written and verbal communication errors. In one example where the student made a recording error on a patient MAR, they also cited their “lack of confidence.” Harding and Petrick (2008) found that MAR misinterpretation (i.e., the student not understanding an institution’s MAR form) contributed to 42% of omission errors by students. A case study (Dolansky et al. 2013) highlighted situations where transfer of information on an electronic MAR resulted in delays and duplication of medication administration. These researchers concluded that technology and electronic institutional records need to be included in orientation for students and educators. In another study (Cebeci et al. 2015), communication errors accounted for one third of student MAIs (Cebeci et al., 2015). These findings highlight the importance of thorough student and faculty orientation to institutions’ communication systems, policies and practice related to medication administration.   Stressful environments was another systems factor, accounting for 40.7% of all student MAIs in my study. Students reported busyness of the unit, loudness, a changing environment, needing to complete tasks quickly, rushing for morning report, and in a few instances, pressure to 59  take on additional tasks. As with documentation of other systems factors, students often documented individual factors as well, such as “stress.” Students often require additional time to complete tasks they are learning, particularly in today’s practice environments. In other studies of students MAIs, student workload (the nature of student patient assignments) was cited as an important educator consideration: considering patient acuity and types, numbers and administration routes of medications (Cebeci et al., 2015; Harding & Petrick, 2008; Tabassum et al., 2015; Vaismoradi et al., 2014; Valdez et al., 2013; Walsh et al., 2018). In my study, I included a separate category for patient systems factors, such as patient acuity. This category accounted for 25.9% of MAIs, emphasizing the importance of careful consideration of student workload when making assignments. We can learn a great deal from the nursing literature about systems factors that influence the quality and safety of nurse performance, hence student performance. Nurse researchers have identified several systems factors in the work environment that adversely affect nurse and patient outcomes, particularly workload and interruptions (MacPhee et al., 2017).  Nearly a third of MAI reports indicated educational factors as contributing to student MAIs. Educational factors included deficits in knowledge, nurse supervisor variation including the experience of the supervising nurse, and knowledge of specific practice protocols. Knowledge and skill deficits can be balanced by experienced nursing supervision, and some schools have strict policies about direct student medication administration (Tabassum et al., 2015). Another study, however, showed that such close supervision increased stress and students’ reports of resentment and unpreparedness for independent practice, given the lack of autonomy during medication administration (Vaismoradi et al., 2014). In the Tabassum et al. study (2015), more education-related MAIs happened during the second year of their four-year 60  program, which the researchers attributed to inexperience with pharmacology and drug calculations at that point in the students’ education. All types of MAIs, near-misses and actual events, should be analyzed to see where knowledge deficits may be occurring at different course levels. In my study, educational factors were documented on all near-miss MAI reports in the first and second course levels (n=7). These near-misses suggest ways for educators to strengthen medication administration education early on in the BSN program.   A quarter of MAI reports in my study were safety systems failures. This category included equipment malfunction (n=9), such as inappropriate retraction of auto-retract needles and IV pump malfunction. These types of systems failures accounted for 66.7% of harm to student incidents, reinforcing the importance of documenting these events for follow-up by occupational health officers. In my study, one student injury was due to inappropriate activation of the safety mechanism for an auto-retract needle. In this category there were also double-check failures (n=10), where an MAI occurred despite students verifying administration of a medication by a nurse (as required by policy). Hewitt, Chreim and Forster (2016), through the use of semi-structured interviews with several health care practitioners including doctors, nurses, pharmacists and other professionals, found inconsistent practices around double-checking procedures, particularly short-cuts due to time constraints. Educators, therefore, need to be aware of healthcare team workarounds or practice site short cuts that do not adhere to policy and may put students at risk.  I explored patterns in documented contributing factors related to the perceived degree of harm and found individual factors were attributed to 85.7% of harm to client MAIs compared to 75.9% of no harm MAIs. This difference may suggest that students have more self-blame in incidents of perceived harm. Some literature on attribution theory and student learning can be 61  utilized to help gain an understanding of the student’s tendency to look to themselves when trying to understanding why MAIs have occurred. According to Gaier (2015), attribution theory holds the assumption that when students first start mastering skills in a new environment, they draw causal connections or attributions between themselves and outcomes from their actions: It’s hard for them to see beyond their own attributions. To help students see beyond their own attributions, educators need to provide alternate attributions and assist students with recognizing other factors influencing outcomes. Collaboratively filling out an incident report form and completing an incident analysis are two ways to reinforce systems perspectives to errors.   5.3 Documented Responses of Students and Nursing Instructors Key Findings My review of the student MAIs revealed a number of ways to improve documentation, particularly use of standardized operational definitions of all omission and commission errors reported in the quality and safety literature. As mentioned above, a notable documentation gap was the lack of incident analysis completion by instructors, and thus, a missed opportunity to fully explore the complexities of student MAI and contributing factors. Walsh et al. (2018) found there was a complicated relationship between a student’s willingness to report an MAI and actions taken. When MAI reporting was linked to professional obligation and moral responsibility, students expressed greater comfort and acceptance of MAI reporting. Fear of social and academic penalties, however, resulted in students ‘hiding’ or not reporting MAIs. In my study, there was no evidence of students’ concerns with academic penalties for making errors. Students documented “fear” as an individual contributing factor, suggesting that students’ emotional reactions to making mistakes needs more review and discussion with their clinical instructors.    62  On the incident forms it was difficult to differentiate between immediate actions and long-term actions after an error. The quality and safety literature recommends that immediately after an incident there should be an informal debriefing followed by a formal quality and safety review of the incident after a complete incident analysis (Salas et al., 2008). One aspect of immediate follow-up is patient disclosure. Patient disclosure is an important part of an MAI response that is best initiated immediately upon discovery of the incident (Beard et al., 2012; Windwick et al., 2011). There is a dearth of literature on students’ involvement in the patient disclosure process. It is important for schools of nursing to follow organizational policy on patient disclosure, given the legal and ethical sensitivities of error, particularly error with the potential to cause harm.   Another immediate action after an MAI involves securing defective equipment. The Canadian Incident Analysis Framework (Beard et al., 2012) recommends securing items related to the event such as medications, packages, and defective devices. These items should be kept in a secure place and photographs are often helpful to follow-up investigation. Immediate and long-term actions should be determined as a collaborative effort between the practice site and the educational institution. In my study, there was little evidence of ongoing communications about a student MAI between the practice site and the school of nursing. In my findings, only 6.2% of MAIs were discussed between the instructors and practice leadership (based on instructor comments). Because of the quality and safety implications of student MAIs for both institutions, there needs to be standardized processes for collaboratively conducting immediate debriefs, incident analyses and communications about actions based on incident analyses. When looking through the literature on practice-academic collaborations, I could only locate one article by Barnsteiner and Disch (2017) that discussed the importance of incorporating 63  practice site safety errors into student clinical education. Overall, I could not locate any articles that discussed collaborative institutional processes for addressing immediate or long-term actions associated with student MAIs.    Another finding from my study raises concerns about consistent follow-through on student MAIs. On the incident report form, students filled out the long-term actions component of the form in some cases, however, this section of the form was left blank for 46.9% of student errors, suggesting a lack of educator attention to follow-through on student MAIs. Typically, students attributed the errors to individual factors and a common follow-up actions were to “use caution” or “improve my personal practice.” Due, perhaps, to lack of formalized follow-through and communications between schools of nursing and practice sites, very little specific information was provided on the report form about immediate or long-term actions by the practice site or the educational institution.  In my study I found that students sometimes discussed follow-up actions in their self-reflections, versus the specified immediate and long-term sections of the form. It is possible that they felt more confident documenting about the error in the self-reflection section. In schools of nursing students are often expected to do reflective practice (Bulman et al., 2012). Findings from my study suggest that educators should build on learning tools and practices already in place, such as reflective practice. After an MAI, for example, guided self-reflection through a quality and safety lens may provide rich learning opportunities for students and yield insights to future error prevention.   On the incident report forms, one third of instructors said they “debriefed” with students, but they did not describe what they did or how they debriefed the students. Debriefing is a another valuable learning approach for gaining insights into errors (Rivera-Chiauzzi et al., 2016). 64  Vaismoradi et al. (2014) found many variances in how educators debriefed and provided feedback following an MAI. Other instructor comments pertained to “addressing students’ learning needs.” Most comments were concrete actions, such as instructing students to complete additional online learning modules or to add more goals to their learning plans. Among these instructor comments there was no indication of using an appreciative inquiry or positive learning approach to debriefing or student learning needs assessment. Receiving “no positive feedback” was found by Koohestani and Baghcheghi (2009) to be the greatest perceived barrier to MAI reporting. “Fear of decreasing evaluation score” was found to be another perceived barrier. It is important, therefore, for educators to ensure that their responses to MAI reporting are non-punitive. In a Canadian study, Zieber and Williams (2015) found a punitive approach to MAIs involving BSN students led to the student fearing the negative effects of reporting the MAI and resulted in concealing MAIs. Approaches such as reflective practice and debriefing are important learning approaches for students after an MAI error, but the “how” is equally important. Positive support offered after the MAI from nurses, peers, and the clinical instructor can enhance student acknowledgement of the error as part of learning.  5.4 Limitations A limitation of this study is that the reliability and validity of the incident reports that I analyzed have not been determined. There is a high potential that the collected incident reports capture only a portion of MAIs that occur. Literature reveals that there is a potential for MAIs to go under-reported due to both individual student and institutional factors (Koohestani & Baghcheghi, 2009; Walsh et al., 2018; Zieber & Williams, 2015). This study is limited to the format and the information contained within the reports submitted to the schools of nursing and notes that some information was not documented on the tool. It is important to note that the 65  absence of a documented contributing factor, effect on a patient, response by a student, nurse or nurse educator does not mean that these events did not occur.   Determining contributing factors to MAIs involved an analysis of many fields of the reports and was subjected to my bias in the interpretation of the descriptions. I formed concept maps and conducted checking of the descriptions three times. I found that there was variation in vocabulary and how students described contributing factors. The results of this analysis include only students’ contributing factors, which I could not verify.   5.5 Chapter Summary This chapter discussed the key findings of the study, linking these findings to peer-reviewed literature. An important finding was the persistence of students’ attributions of error to themselves across all four course levels and in all three academic periods. The literature suggests the importance of education reinforcement of culture of safety principles with closer review and follow-up on student MAIs as a learning experience for students.   66  Chapter 6: Implications for Nursing Practice  6.1 Key Implications for Practice Incident analysis involves determining if an individual from the same professional group with similar qualifications and experience would act in the same way in a similar situation (Beard et al., 2012). Complete incident analyses, including a constellation diagram, were only completed for 27.2% of student MAIs in my study. Incident analysis, as a learning tool for practice and educational institutions, should be conducted jointly on student MAIs, to inform practice and policy and to inform student clinical education and learning. A shared accountability model, which incorporates students, faculty and organizational leaders, will ultimately create a safer environment for both patients and students and will continue a commitment for a fair and just culture within nursing education (Barnsteiner & Disch, 2017).  Student nurses learn and practice the important skill of medication administration in a dynamic and complex environment. The complexity within this environment can lead to stress and challenges in communication, both verbal and written. These factors are further compounded by patient factors and the potential for safety systems to fail, leaving the practice environment prone to MAIs. Students are particularly vulnerable as they develop nursing competencies and skills in ever-changing practice settings. In addition to environmental systems factors that may contribute to student MAIs, educational factors also contribute to MAIs. Educators may not always be able to buffer students against the busyness of practice settings, but they can orient students to site differences and ensure students’ clinical education addresses systems factors associated with student MAIs. One area where educators must pay extra attention is double-check medications and procedures. Quality and safety literature warns providers to avoid taking short cuts and straying from protocol, but short cuts and workarounds still happen in busy 67  practice environments. It is important, therefore, for educators to ensure all double-check medications and procedures are adhered to when students are involved (Debono et al., 2013) As nurse educators, we need to be aware of the impact of attribution theory (Gaier, 2015) on students’ tendency to blame themselves for errors, especially when patient harm occurs. We can always teach students technical aspects of improved time management and organizational skills, but what may matter most is our sensitivity to the self-blame attributions that put students at risk of greater stress and fear in learning contexts.  Incorrect dose, administration techniques, and incidents of omission were the most frequent types of student MAIs in my study and in the domestic and international literature on student MAIs. These types of MAIs and their contributing factors indicate that teaching medication administration extends beyond the rights of medication. When preparing students to enter practice we can create realistic scenarios that reflect the complexities of stressful environments and the communication factors present within the clinical environment. Among students’ documentation of follow-up actions, the most frequent student recommendation for preventing a similar error was “using caution.” A concern is how this recommendation may be normalized by students because they are always told to be “cautious.” As educators we need to operationalize what “using caution” is in practice.  Instructor responses to MAIs were variable, and many comment boxes were blank on the incident report forms. It was also apparent that students were primarily responsible for filling out the forms with minimal input by their MRNs or instructors. There should be standardized, collaborative approaches for documenting student MAIs that involve the practice site, the student and the institution’s educator. There is a dearth of literature on practice-academic collaboration with respect to quality and safety documentation, reporting and clinical education. The quality 68  and safety literature endorses the importance of immediate debriefing (i.e., immediate action) and incident analyses (i.e., long-term action) (Salas et al., 2008). Students learn best after an MAI when a positive, non-blaming, supportive approach is used (Walsh et al., 2018).  6.2 Conclusion The incident report form reflects many incident categories from The Canadian Incident Analysis Framework (Beard et al., 2012) and explicitly states that the information is collected to promote a non-blaming culture. Aspects of how these forms are completed in reality represents some opportunity to improve the form and the practices of completing the form. I recommend that the form be reviewed and the MAI category of incorrect administration technique be added. The classification of type of MAI should use a validated level of harm scale with clear definitions of levels of harm. It is especially important to require standardized approaches to short-term and long-term instructor actions with documentation of how these actions were carried out on behalf of student learning. The incident analysis, for example, is known to expand learning post-MAI. It was concerning that so few incident analyses were completed in my study. Reasons for this need to be explored and addressed.  Nursing education prepares BSN students for the complex world of healthcare. Unfortunately, MAIs occur during this process. Collection and analysis of the information surrounding these events has the potential to improve nursing education and better prepare BSN students to detect and respond to unsafe environments in the future.  69  References Baker, G. R., Norton, P. G., Flintoft, V., Blais, R., Brown, A., Cox, J., Etchells, E., Ghali, W. A., Hébert, P., Majumdar, S. R., O’Beirne, M., Palacios-Derflingher, L., Reid, R. J., Sheps, S., & Tamblyn, R. (2004). 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International Journal of Nursing Education Scholarship, 12(1), 1–9. https://doi.org/10.1515/ijnes-2014-0070 75  Appendices Appendix A   Blank Incident Form with Identifiers Removed  76   77   78  Appendix B   Letter and Permissions B.1 Invitation Letter July 5, 2019  To Whom It May Concern,   You are receiving this letter because you have formal accountability for records of medication administration incidents reported for students who attend Camosun College or the University of Victoria Bachelor of Science in Nursing program.   I am asking your permission to analyze these reports as a component of my thesis work at the University of British Columbia (UBC). I am a Master of Science in Nursing student at UBC and work as a nursing educator with Camosun College.   The title of my thesis study is: The Characteristics of Medication Administration Incidents Involving Bachelor of Science in Nursing Students during Clinical Practice Education. The purpose of my study is to gain an understanding of the characteristics of the medication administration incidents that BSN students are involved in during clinical practice. Through a comprehensive review of the incident reports over the past three academic years, I will gain insights into the types of incidents that occur, the documented causes and contributing factors to these incidents, and the documented student and instructor responses to these events. This knowledge gained will assist in the formation of policy and procedure that supports a safe patient culture in nursing education. Furthermore, understanding the characteristics of the medication 79  administration incidents that students are involved in will help support educational and healthcare organisations develop systems to mitigate the potential for these incidents to occur in the future.   I am requesting access to any existing documents pertaining to reported medication incidents involving student nurses for three academic years (September 2016-August 2017, September 2017-August 2018, September 2018-August 2019). I will copy and de-identify these documents: They will contain no student, instructor or location-specific references. Incidents will be coded according to types of incidents. These anonymized documents will be stored in a safe and secure location. All analyses will be conducted on an encrypted and password protected computer and stored securely on the encrypted and password-protected UBC Workspace. I will have ethics approval from the University of British Columbia, the University of Victoria, and Camosun College before commencing this study.   I am also requesting background information on each clinical course including a brief course description, enrollment data, and the number of clinical practice hours per clinical course. This information will be used to describe the program without using the name of the institution or courses involved.   I will share all findings and conclusions from my analysis along with evidence-based recommendations that could be used to guide policy and nursing education regarding safe medication administration.  80  If you choose to support this project, please complete and return the attached consent to release this information to me. I look forward to working closely in partnership in this project. If you have any questions, please contact myself or my thesis supervisor, Dr. Maura MacPhee. Our contact information is as follows:  Student Investigator Kaitlin Ellis, MSN Student, UBC School of Nursing Kaitlin.ellis@alumni.ubc.ca  Supervisor Maura MacPhee, UBC School of Nursing  maura.macphee@ubc.ca  Committee Members Cathryn Jackson, UBC School of Nursing Lenora Marcellus, The University of Victoria   Thank you,   Kaitlin Ellis, BSN, RN    81  B.2 Permission Form A Consent for the Release of Information  As the Chair of the School of Nursing at Camosun College, I consent to Kaitlin Ellis’ access to the following documents: Reported medication incidents involving student nurses at Camosun College for three academic years (September 2016-August 2017, September 2017-August 2018, September 2018-August 2019).   Name:___________________________________________   Signature:_________________________________________  Date:________________     82  B.3 Permission Form B Consent for the Release of Information  As the Director of the School of Nursing at the University of Victoria, I consent to Kaitlin Ellis’ access to the following documents: Reported medication incidents involving student nurses at the University of Victoria for three academic years (September 2016-August 2017, September 2017-August 2018, September 2018-August 2019).   Name:___________________________________________   Signature:_________________________________________  Date:________________   83  Appendix C   Data Collected from Incident Form Data Collected Added Categories not on the Incident Form Date of Incident Academic Periods (September 2016-August 2017, September 2017-August 2018, September 2018-August 2019) Type of Incident (Harmful incident/no harm/near miss) Harmful Events categorized to harm to student or harm to client Course Number Level of Course (Level 1, 2, 3, 4) Shift of Occurrence (6 hour day, 8 hour day, 12 hour day, evening, 12 hour night)  Type of Incident Omission, incorrect client, dose, route, time, medication, reason, documentation -Incorrect administration technique -Incorrect Scope  Multiple-selected category incidents:  -Incorrect Administration Technique and Route -Incorrect Administration Technique and Time -Incorrect Dose and Documentation -Incorrect Dose and Time -Omission and Incorrect Documentation -Omission and Incorrect Time Follow up Actions taken Immediate Long-term Not documented category collected BC PSLS Yes or No  Concise Description of Event  Potential Outcomes from this incident  Learning about yourself, your nursing practice, and the environment reflection  Prevention Measures  Instructor Comments  Incident Analysis Constellation Diagram Summary  84  Appendix D  Clinical Course Descriptions Background Data Collection Sheet  September 2016-August 2017 September 2017-August 2018 September 2018-August 2019  Semester Code Brief Description of Practice Course Number of Students Enrolled Practice Hours Number of Students Enrolled Practice Hours Number of Students Enrolled Practice Hours Level 1 September-December 1A No medication administration responsibly 160 42 160 42 160 42 January- April 1B Long-term or complex care settings Begin providing medications at end of rotation 160 70 160 70 160 70 May-June 1C Integrate learning from previous terms Variety of settings- chronic, rehab, supportive care 152 144 156 144 160 144 Level 2 September-December 2A Acute, sub-acute or rehab More complex medication practice, introduction to SQ and IV at the end of the term 154 168 160 168 160 168 January-April 2B Acute medical, surgical or specialty area Increased patient load and medication responsibility and independence in some cases 158  168 160 168 162 168  May-June 2C Integrate learning from previous terms 154 144 158 144 158 144 85   September 2016-August 2017 September 2017-August 2018 September 2018-August 2019  Semester Code Brief Description of Practice Course Number of Students Enrolled Practice Hours Number of Students Enrolled Practice Hours Number of Students Enrolled Practice Hours Variety of settings Level 3 September-December 3A Complex practice environments and specialty areas Direct and indirect supervision 152 196 154 196 158 144 May-Mid June 3B Integrate learning from previous terms Variety of settings 167 192 131 192 170 192 Level 4 Mid June-to end of July 4A Integrate learning from previous terms Variety of settings 163 192 128 192 169 192 January-Mid February 4B Integrate learning from previous terms Variety of settings 178 192 168 192 129 192 Mid-February to end March 4C Consolidate learning and transition to nursing profession Variety of settings 176 192 161 192 125 192 86  Appendix E   Types of MAI Defined Type of MAI Definition Examples Omission “A missed dose; failing to provide a dose of a product to a patient, unless the dose was refused or held for a reason.” (BC PSLS, 2019, p. 1) On a night shift forgot to provide a 0600 medication.   Forgot to give the patient their midnight dose of an antibiotic.   When doing the nightly chart check, the student realized they had missed a medication ordered to be given at 2100.   Took a glucose and did not initiate the orders related to the finding.   With time (see below) With documentation (see below)  Incorrect Client/Patient “Involvement of a patient other than the intended recipient.”(BC PSLS, 2019, p. 2)  Sometimes describes as “wrong patient, medication and dose” While hurrying to get to break entered the wrong room and gave the medication to the wrong patient.   There was a last minute change to the assignment and the student mixed up which patient was which and provided the wrong medication to the wrong patient.   Giving similar medication in the same room, gave the wrong medications to the wrong patient.  Incorrect Dose (known as “Wrong Quantity” and “Extra dose”) Wrong Quantity “An additional, unscheduled dose of a product administered after an original dose given.” (BC PSLS, 2019, p. 2) Extra Dose “Too high or too low a dose or amount of a product. Includes dose, strength and concentration.” (BC PSLS, 2019, p. 3) Student provided an intermittent acting formulation of a drug that was suppose to be controlled release.  Student provided double the amount of a medication because they did not break a tablet in half.   87  Type of MAI Definition Examples Student misinterpreted the MAR thinking they needed to give 1 tablet instead of 0.25 of a tablet.   Medication maximum daily amount exceeded when the previous shift did not tally totals and the student calculated total incorrectly.  With documentation (see below) Incorrect Route “Administering a product by a route other than what was intended.” (BC PSLS, 2019, p. 2) Student provided medication orally when ordered IV.   With administration technique Patient requested medication be given a different route and student provided medication via that route without following protocol.  Providing a medication to an elderly person IV direct instead of IV intermittent as the drug manual stipulates.  Incorrect Administration Technique (including “Wrong Rate or Frequency, and “wrong storage or location” “Administering a product by … an incorrect method or procedure” (BC PSLS, 2019, p. 2) “Prescribing or administering a product at an incorrect rate (too fast or too slow) or frequency (too often or not often enough), including a product prescribed at an unapproved rate or frequency and/or administered at a rate or frequency different from was prescribed.” (BC PSLS, 2019, p. 2) “Keeping a therapeutic product in the incorrect location.” (BC PSLS, 2019, p. 3) After given a subcutaneous injection did not dispose of the needle without injuring self.   When a medication was delivered to the unit did not follow storage policy.   A medication required reconstitution and injection into an IV intermittent bag. The student reconstituted the drug but didn’t complete the process.   With route (see above) With Time (see below) Incorrect Time “A dose of regularly-scheduled product not being given at the scheduled time, except when there is justifiable reason for the dose not being given, such as New admission orders processed and student thought all needed to be given. One was not an evening medication.  88  Type of MAI Definition Examples readjustment of medication administration times, diagnostic testing or passes.”(BC PSLS, 2019, p. 3)  Used the wrong time of blood work to adjust a medication.   A medication that is normally given in the morning was ordered in the evening. The student gave it in the morning.   With administration technique A medication needed to be adjusted according to a protocol and was not resulting in a faster dose than ordered.   With omission Student forgot to provide a medication until later in the day which led to the evening dose being delayed.   With incorrect dose A dose of the medication was transcribed incorrectly which led to it being given at the wrong time and dose.  Incorrect Medication (known as “Wrong Product” and “No Order) “Use of an incorrect product” (BC PSLS 2019, p. 2) “Dispensing, administering or withholding a product without authorization from a prescriber.” (BC PSLS, 2019, p. 1) One similar appearing medication in the medication storage drawer. Gave that medication instead of the one ordered.   Wrong IV medication infused.   Provided a medication that has the same indication, route and dose but not ordered.   Incorrect Reason Right reason is one of the “seven” rights of medication administration. Nurses determine if a medication is appropriate for the client before administering (BCCNP, 2010).  -No reported MAI in this category -Not described well in literature reviewed  Providing an antihypertensive medication to a patient who is hypotensive.  89  Type of MAI Definition Examples  Providing an anticoagulant to a patient who is actively bleeding.  Incorrect Documentation BCCNP (2019) defines documentation as written and or electronically generated information about a client that describes the care provided for that client. Nurses document timely and appropriate reports of assessments, decisions about client status, plans, interventions, and client outcomes.  An incorrect documentation incident is when some aspect of the medication administration process was not correctly documented. This includes transcription of orders, documentation of assessment associated with a medication or documenting on the MAR when a medication has been provided. This is differentiated from when aspects of documentation contributes to an MAI. For example, if an incorrect dose was provided because of MAR formatting this is considered an incorrect dose.   Read an order wrong for a drug level lab request and processed the lab work so the patient received the test too early.   With omission Did not process discharge prescriptions.   With dose  Did not sign administration of a drug and the next shift provided this medication.  Incorrect Scope Scope of practice is the activities that nurses are educated and authorized to perform set out in the under the Health Professions Act and complemented by standards, limits and conditions set by BCCNP. One of these conditions is that all student nurses be supervised. Regulatory supervision requires that the RN knows the student’s competence, set the conditions, and manages the risks to clients. When a student acts in contradiction to these set authorized activities or without supervision this is considered incorrect scope.   Administered a medication that required students to have a double-check without the double-check being completed.   Near-Miss  A member of the health-care asked the student to provide a cream. The student was not authorized to provide medications. The instructor informed the student of this.   

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