The Literature Review: A Few Tips On Conducting It

Running head: LITERATURE REVIEW
LITERATURE REVIEW
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1Literature Review
Introduction
Keeping records of medications and using the clinical knowledge plus reasoning to
understand the role and timing of a medication is critical and very much imperative in the
clinical scenario (Taxis, K., Kochen et al. 2017). In acute care departments such as intensive
care and intensive coronary care unit, the patients are prescribed with a lot of medications to
address the multisystem or multi-symptomatic needs of the patient (Lichtner et al. 2019).
Similarly in the critical care departments and high dependence units, the use of analgesics
along with sedatives and other medications to treat the aggravating symptoms and
complications of the patient is very crucial. It is to be noted that the right medication should
be prescribed by the doctors to treat the exact condition and address the clinical needs of the
patients is very much important and any errors in these areas can prove very costly and life
threatening for the patient (Singh et al., 2019).. Similarly, the role of the registered nurses is
to administer in the right medications in the right time and in right combination with other
drugs or medications, as exactly mentioned in the prescription (Truitt et al. 2016). The route
of medication administration and the mode of medication administration is also a very critical
clinical aspect that needs to be taken into consideration by the nurse in order to administer a
specific medication to a specific patient correctly and appropriately, thus promoting
medication safety (Rishoej et al. 2017).
Scope of the problem
In the new graduate nurses who lacks the psychological safety, the necessary skills,
experience and expertise to provide the right medication to the patient in the right way
possible creates or rather leads to issues with medication safety (Al Dweik et al. 2017). The
new graduate nurses are more prone to workplace disruption and have chances of
demonstrating a disruptive behavior in relation to self-skills, intrapersonal skills and
communication plus collaboration skills that can create a lot of barriers to the right way of

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medication administration, thus leading to decrease in the medication safety (Howlett, Cleary
& Breatnach 2018). Medication incidents refers to the various adverse drug events arising
from the lack of safe medication practice in a patient centered care scenario and these
incidents can arise from lack of evidence based medication administration practice, lack of
proper medication disposal, misuse plus disuse of drugs and prescription of a certain
medication to an different patient as well as lack of proper filling up of medicine charts and
clinical documentation (Strudwick et al. 2018)
Overdose and omission of the important medications can led to severe complications
in the patient such as central nervous system depression, shock, respiratory failure,
cardiovascular complications and these areas of medication safety disruption can also prove
fatal for the patient (Hotham et al. 2018). Communication and clinical decision making by the
doctors and the nurses especially who are actually involved with the prescription and
administration of medications – are the two most important aspects that are to be taken into
consideration to improve medication safety on a day to day basis in a clinical scenario
(Oxelmark et al. 2018).
According to the report ‘An Integrated Approach to Patient Safety Surveillance by
WA Health Service Providers, Hospitals and the Community’ (2018), there are various issues
that lead to the causation of adverse medication events or medication incidents that affects
both the quality of care being delivered by the health care staffs and the clinical outcomes of
the patient (Yung et al. 2016). According to this this report, in the year of 2017-2018, a total
of out of reported 7,797 medication incidents, about 7172 cases were confirmed cases and
about 24.4 per cent of the total clinical incidents were alone accounted by medication
incidents only. The female patients were found to be administered with the wrong
medications more than the male patients (52 percent of females versus 48 percent of the
males). In the report, there were five medical departments that were identified with the most

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confirmed cases of medication incidents and errors. The departments with highest to lowest
number of medication incidents followed as general medicine (14.2%), psychiatry (5.9%),
general surgery (5.3%), rehabilitative medicine (4.8%) and oncology (3.5%). The main types
of identified medication incidents were medication administration failure, inappropriate dose
of medication given, incorrect fluid and medication given, overdose or extra dose
administered and extravasation. Opioids that are used as narcotic analgesia were the dugs that
were mostly involved in the causation of the medication incidents (n=853) and errors while
the congestive heart failure treating drugs presented with the least number of medication
incidents (n=169). Mostly, as mentioned in this report, the psychotropic drugs, sedatives and
the pain killers were the major drugs that were involved with the adverse medication
incidents. Of all the causes that led to the causation or rather the presentation of these
medication incidents, the main reasons identified in this report was lack of safety
communication (30.2%), lack of compliance with evidence based procedures, guidelines and
practice policies (25.9%), problems in the competence, skills and knowledge (20.4 %),
problems and issues with work scheduling and disruptive work environment (10.1%) and due
to the factors related to the patients (8.1%).
In the other report ‘An Integrated Approach to Patient Safety Surveillance by WA
Health Service Providers, Hospitals and the Community’ (2017) – different sets of findings
were revealed relating to the same above mentioned areas of medication incidents. According
to this report, in the year of 2016-2017, about 6,996 medication incidents had been reported
and out of them, there were confirmed cases of 6,445 and about 23.2 per cent of the total
clinical incidents were accounted by the presentation of medication incidents only. The
female patients were found to be administered with involved in majority of the medications
incidents as compared to the male patients (50.7 percent of female patients were involves). In
the report, there were five medical departments that were identified with the most numbers of

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confirmed cases in regards to adverse medication incidents and medication errors. The
departments with highest to lowest number of medication incidents followed as general
medicine (15%), general surgery (6.3%), rehabilitative medicine (6%), psychiatry (4.6%),
and oncology (4.1%) respectively. The medication incidents types, identified on the basis of
highest to lowest number of errors were - incorrect dose of medication, omission of
medications, administration failures, incorrect fluid and medication administered and extra
medication dose administered Opioids were involved in the most number of medication
incidents (n=775) and errors while electrolyte imbalance managing drugs were involved in
least number of medication incidents (n=155). Again, as compared to the previous 2018-19
report where there were several other causes, types and drugs in relation to medication
incidents were identified but again, the sedatives, narcotics and the psychotropic drugs were
severely involved in the medication incidents, in both the cases. Of all the causes that led to
the causation or rather the presentation of these medication incidents - the cardinal reasons
identified in this report were errors with communication (29.8%), lack of compliance with
evidence based procedures, guidelines and practice policies (24%), problems in the
competence, skills and knowledge (21.1 %), problems and issues with work scheduling and
disruptive work environment (10.2%) and due to the factors related to the patients (7.3%).
Human factors responsible for disruption of medication safety
Communication problems
Härkänen, M., Saano, S., & Vehviläinen‐Julkunen, K. (2017) aims to study ‘Using
incident reports to inform the prevention of medication administration errors’ and finds out
important factors in relation to lack of safety communication that cause disruption of
medication safety in the hospitals. The researchers of the study use a descriptive, qualitative
study with an inductive content analysis to understand the underlying factors of medication
administration by the nurses in a clinical scenario and finds out communication problems

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pertaining to distribution and delegation of clinical duty among the nurses, interpersonal
cooperation and safety information flow. Lack of proper training to enhance the safety and
therapeutic communication parameters of the nurses and lack of educational workshops plus
staff development sessions were highly responsible for the lack of safe communication during
medication administration and patient handover, leading to more complex presentation of the
medication incidents. Lack of therapeutic communication between the nurses posted in the
departments and wards and lack of empathy between the patient and the nurses led to
negative attitudes and negative perceptions among the clinical nurses that led to causation of
medication administration errors and disruption of patient safety in relation to patient safety
as well. Lack of communication and support from the supervisors and senior nurses were also
implicated.
Lack of compliance with policies, guidelines and procedures
Cox et al., (2020) aims to understand ‘Implementation of an interprofessional learner
team-based medication reconciliation and review in an Internal Medicine-Pediatrics resident
continuity clinic’ and finds out important correlations between the compliance with evidence
based practice of medication documentation plus other policies with the presentation of
medication therapy problems(MTPs) in the clinical, institutional and community health
scenario. Lack of understanding about the procedures, rules and evidence based practice
guidelines by the medical resident and the community clinic nurses with the framework of a
pediatrics-internal medicine clinic led to the various complications in relation to the various
issues pertaining to patient safety, therapeutic interactions, assessment and understanding of
the clinically presented issue, the function and role of multiple medications for a single
specific clinical case (Jokanovic et al. 2016). The lack of understanding of the quality
parameters and quality control methods were deeply involved with the disruption of
medication safety in the community areas. The lack of interprofessional or interdisciplinary

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collaboration between the different members of multidisciplinary team were the major causes
that lead to more complications with knowledge and resources required for compliance with
the evidence based practice and policy framework in relation to medication prescription by a
medical resident.
Problems with skills, competence and knowledge
Kosari, S. (2018) aims to study ‘Medication errors in nursing homes: The role of
pharmacological knowledge’ and finds out important results in relation to the lack of
knowledge, skills concerning medication administration that lead to wrong medication
administration along with overdose of medication. The central problem identified in this
study was that the nursing students and the new nursing students showed a huge knowledge
gap about pharmacological properties of medication that led to confusion, negative
perception and wrong medication administration, causing a life threatening error (Lee et al.
2018). The nursing residents were found to be involved with wrong medication dose
calculations that disrupted the medication safety in the nursing homes. Lack of skills such as
clinical reasoning, problem solving, informed practice and apt clinical decision making were
also deeply involved with the presentation of adverse medical events and medication
incidences.
Workplace disruption issues
Houck & Colbert (2017) aimed to study ‘Patient safety and workplace bullying: An
integrative review’ and finds out critical factors pertaining to disruption of workplace that
affects a nurse’s medication safety practice. The researchers of the study performs an
integrative review to find out bullying, negative interactions in the workplace, lack of
psychological safety, lack of guidance by the new nurses by the senior supervisors and
experienced nurses lack with negative perception about alcohol and other drugs abuse
students, social stigmas, biases and sociocultural discrimination in the workplace were

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severely and intricately involved with the disruption of medication safety behavior of the new
graduate nurses and the nursing students (Wahr & Merry 2017). Lack of positive attitude
about the patient and the treatments along with the demonstration of deficiency to work
collaboratively with the other teams of the nursing team, medical team and allied health
teams due to intercultural conflicts and social discrimination in the workplace – attributed to
most of the medication incidences being caused by the nurses in a hospital and nursing homes
framework.
Patient factors
Oxelmark (2018) aimed to study ‘Registered Nurses’ experiences of patient
participation in hospital care: supporting and hindering factors patient participation in care’
and finds out lack of patient participation in a medication administration process to be a
hindrance factor to promotion and maintenance of medication safety by the nurses. The study
used the semi structured interviews followed by thematic analysis of the collected to find out
the most important theme – forming partnerships with the patients. Rapport building and
forming a therapeutic relationship with the student was critical to the process of safe
medication administration and the scenarios, where there was a lack of relationship building
with the patient, posed greater threats of medication errors where the patient did not provide
feedback regarding the wrong medications being administered.
Methods to improve patient safety
Hayes et al. (2019) aims to study ‘Learning to liaise: using medication administration
role-play to develop teamwork in undergraduate nurses’. The researchers of the study found
out the importance of nursing motivational interviewing and roleplaying exercise to develop
better compliance with the medication administration in strength based team framework. The
role paying exercises between the nurses improved the clinical, therapeutic communication
along with medication safety. The method mentioned in this article is useful for the new

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graduate nurses but the scientific article lacked substantial evidence support to back the
information. The role of supervisors in the role playing exercise was not mentioned.
Debono et al., (2017) aimed to study barriers and facilitators to electronic medication
management systems in two Australian hospitals and finds out nursing staff training, staff
development sessions and workshops being undertaken by the hospital authority to improve
nursing compliance of the evidence based medication administration using Electronic
Medication Management System (EMMS) is vital. The technology training and regular
clinical supervision plus guidance to the new graduate nurses with the use of the electronic
tools are critical interventions that improved the medication safety in the hospitals, in a great
manner. The barriers to the exercises were lack of interpersonal communication skills.
Although the method recommended by the study is very important for the nurses in
development of medication safety policy compliance but the method is cost ineffective. It
may not be affordable by primary care and community clinics plus nursing homes.
Conclusion
Hence it can be concluded saying that lack of safety communication in between the
clinical staffs, between the clinicians and the supportive staffs, lack of collaboration with the
other members of the multidisciplinary team (MDT) and lack of a therapeutic communication
with the patient plus family of the patient is critically implicated in the presentation of
adverse medication incidents. Health information such as electronic medical records and
electronic reminders have been incorporated and despite the incorporation of different
standardization procedure maintaining the clinical flow from right medication prescription to
right medication administration – various adverse medication incidents occurs across the
wards and the medical departments. Opioids, antibiotics and psychotropic medications,
normally are the ones that relates to the most number of medication incidents across the

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medical departments as because these medications are maximally used to control the
symptoms and the diseases of the patients.

10Literature Review
References
Al Dweik, R., Stacey, D., Kohen, D., & Yaya, S. (2017). Factors affecting patient reporting
of adverse drug reactions: a systematic review. British journal of clinical
pharmacology, 83(4), 875-883. https://doi/full/10.1111/bcp.13159
Cox, N., Christensen, S., Mayer, J., Como, N., Tracy, M., Sheffield, C., & Turner, K. (2020).
Implementation of an interprofessional learner team-based medication reconciliation
and review in an Internal Medicine-Pediatrics resident continuity clinic. Journal of
Interprofessional Education & Practice, 100316.
https://doi.org/10.1016/j.xjep.2020.100316
Debono, D., Taylor, N., Lipworth, W., Greenfield, D., Travaglia, J., Black, D., &
Braithwaite, J. (2017). Applying the theoretical domains framework to identify
barriers and targeted interventions to enhance nurses’ use of electronic medication
management systems in two Australian hospitals. Implementation Science, 12(1), 42.
Retrieved from https://link.springer.com/article/10.1186/s13012-017-0572-1
Härkänen, M., Saano, S., & Vehviläinen‐Julkunen, K. (2017). Using incident reports to
inform the prevention of medication administration errors. Journal of clinical
nursing, 26(21-22), 3486-3499. https://doi.org/10.1111/jocn.13713
Hayes, C., Power, T., Davidson, P. M., Daly, J., & Jackson, D. (2019). Learning to liaise:
using medication administration role-play to develop teamwork in undergraduate
nurses. Contemporary nurse, 55(4-5), 278-287.
https://doi/full/10.1080/10376178.2018.1505435
Hotham, E. D., Lloyd, R. A., Petito, E. S., & Suppiah, V. (2018). Medication administration
issues in residential aged care–four cases. Journal of Clinical Gerontology and

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Geriatrics, 9(4), 156-159. Retrieved from https://www.agingmedhealthc.com/wp-
content/uploads/2019/09/v9i407_jcgg-2018-0004.pdf
Houck, N. M., & Colbert, A. M. (2017). Patient safety and workplace bullying: An
integrative review. Journal of nursing care quality, 32(2), 164-171. https://doi:
10.1097/NCQ.0000000000000209
Howlett, M. M., Cleary, B. J., & Breatnach, C. V. (2018). Defining electronic-prescribing
and infusion-related medication errors in paediatric intensive care–a Delphi
study. BMC medical informatics and decision making, 18(1), 130. Retrieved from
https://link.springer.com/article/10.1186/s12911-018-0713-8
Jokanovic, N., Tan, E. C., van den Bosch, D., Kirkpatrick, C. M., Dooley, M. J., & Bell, J. S.
(2016). Clinical medication review in Australia: a systematic review. Research in
Social and Administrative Pharmacy, 12(3), 384-418.
https://doi.org/10.1016/j.sapharm.2015.06.007
Kosari, S. (2018). Medication errors in nursing homes: The role of pharmacological
knowledge. J Intensive Crit Care Nurs. 2018; 1 (1): 9-10. 11 J Intensive Crit Care
Nurs. 2018 Volume 1 Issue, 1. https://DOI:10.35841/critical-care-nursing.1.1.10-11
Lee, C. Y., Beanland, C., Goeman, D., Petrie, N., Petrie, B., Vise, F., ... & Elliott, R. A.
(2018). Improving medication safety for home nursing clients: A prospective
observational study of a novel clinical pharmacy service—The Visiting Pharmacist
(ViP) study. Journal of clinical pharmacy and therapeutics, 43(6), 813-821.
https://doi.org/10.1111/jcpt.12712
Lichtner, V., Baysari, M., Gates, P., Dalla‐Pozza, L., & Westbrook, J. I. (2019). Medication
safety incidents in paediatric oncology after electronic medication management

12Literature Review
system implementation. European journal of cancer care, 28(6), e13152.
https://doi.org/10.1111/ecc.13152
Oxelmark, L., Ulin, K., Chaboyer, W., Bucknall, T., & Ringdal, M. (2018). Registered
Nurses’ experiences of patient participation in hospital care: supporting and hindering
factors patient participation in care. Scandinavian journal of caring sciences, 32(2),
612-621. https://doi.org/10.1111/scs.12486
Rishoej, R. M., Almarsdóttir, A. B., Christesen, H. T., Hallas, J., & Kjeldsen, L. J. (2017).
Medication errors in pediatric inpatients: a study based on a national mandatory
reporting system. European journal of pediatrics, 176(12), 1697-1705. Retrieved
from https://link.springer.com/article/10.1007/s00431-017-3023-8
Singh, C., Crawford, K., Willey, S., Hall, H., Harder, K., Plummer, V., & Williams, A.
(2019). Medication adherence among people of Indian ethnicity living with chronic
disease following migration to Australia. Collegian.
https://doi.org/10.1016/j.colegn.2019.06.002
Strudwick, G., Reisdorfer, E., Warnock, C., Kalia, K., Sulkers, H., Clark, C., & Booth, R.
(2018). Factors associated with barcode medication administration technology that
contribute to patient safety: an integrative review. Journal of nursing care
quality, 33(1), 79-85. https://doi: 10.1097/NCQ.0000000000000270
Taxis, K., Kochen, S., Wouters, H., Boersma, F., Jan Gerard, M., Mulder, H., ... & Pont, L.
G. (2017). Cross-national comparison of medication use in Australian and Dutch
nursing homes. Age and ageing, 46(2), 320-323.
https://doi.org/10.1093/ageing/afw218
Truitt, E., Thompson, R., Blazey-Martin, D., Nisai, D., & Salem, D. (2016). Effect of the
implementation of barcode technology and an electronic medication administration

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record on adverse drug events. Hospital pharmacy, 51(6), 474-483.
https://doi.org/10.1310/hpj5106-474
Wahr, J. A., & Merry, A. F. (2017). Medication errors in the perioperative setting. Current
Anesthesiology Reports, 7(3), 320-329. Retrieved from
https://link.springer.com/article/10.1007/s40140-017-0227-4
Yung, H. P., Yu, S., Chu, C., Hou, I. C., & Tang, F. I. (2016). Nurses’ attitudes and perceived
barriers to the reporting of medication administration errors. Journal of nursing
management, 24(5), 580-588. https://doi.org/10.1111/jonm.12360