Critique Report on Two Articles on Medication Safety in Healthcare

This report critiques two articles on medication safety in healthcare, evaluating the research methods applied and the extent to which they are trustworthy, appropriate and relevant. The articles utilize experimental design to rule out the effectiveness of their intervention in reducing medication and non-medication related errors. The findings of both articles can be utilized in future studies and nursing practice, despite certain limitations.

Critique Report
Critique Report
Medications are the most commonly used treatment measure in the healthcare
that contributes to the significant improvement in healthcare setting when used
effectively (ACSQHC, 2013). However, the use of medication may also be linked with
certain harm and hence the nurses should adapt varied techniques to prevent
medication and non medication-related errors while caring patients in practice area
(emergencies, medical/surgical ward) (Douglas, 2017, Athanasakis, 2012). In this
report, two articles were systematically analyzed to evaluate the extent to which the
research methods applied are trustworthy, appropriate and relevant (Steen, 2011).
Article A
Blank, F. S. J., Tobin, J., Macomber, S., Jaouen, M., Dinoia, M., & Visintainer, P.
(2011). A “Back to Basics” Approach to Reduce ED Medication Errors. JEN: Journal of
Emergency Nursing, 37(2), 141-147. doi:10.1016/j.jen.2009.11.026
Article B
Westbrook, J. I., Ling, L., Hooper, T. D., Raban, M. Z., Middleton, S., & Lehnbom, E. C.
(2017). Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions
during medication administration: a cluster randomised controlled feasibility study. BMJ
Quality & Safety, 26(9), 734-742. doi:10.1136/bmjqs***********3
In a critique, assessment of the study-title gives valuable information about the
study. Moreover, a title should be concise, clear and should portray the fundamental
nature of the study; which is evident in both articles (Polit, 2016). The abstract of both
articles gives valuable insight into the study’s complexity (Iverson, 2014). Literature
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review involves critical summary of the studies related to the topic of interest which is
prepared to contextualise the study problem as evidenced in both articles that focuses
on medication-related and non medication-related error studies.
In a research-study, identifying the study problem and formulating the study
steps as per hypothesis is critical (Fink 2013). It is evident that both articles have
appropriately identified their problem based on the PICO (Problem/population,
Intervention/experimentation, Comparison/control and Outcome) framework. Both
studies have provided an appropriate, accurate and understandable purpose to assess
the effectiveness of interventions in minimizing the medication and non-MAEs as
advised by Iverson (2014). Objectives are the specific accomplishments that are framed
to achieve what the researchers have decided to enquire (Polit, 2016). Both have
presented concise, adequate and achievable objectives. Hypothesis that is a
predicted/expected relationship between study-variables were not found in these
articles (Moule, 2013).
Research methodology is defined as the techniques that are utilized to structure
a study as well as to gather and analyze data in a systematic manner (Polit, 2016). It is
evident in both articles from their structural fashion by utilizing adequate research
methods along with sequential discussion in the study-text (Panneerselvam, 2014).
Research design is considered as the integral part of methodology as it is the overall
plan for research study that addresses the research question; including specifications
for improving the study’s integrity (LoBiondo-Wood, 2014).
In both articles, quantitative design is used that enables comparison of two
treatments (Yartsev, 2017). In Article-A, non-randomized design with one-group
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comparing pre- as well as post-outcome variables was used which is a quasi-
experimental design that is used to draw causal impact of intervention on target
population without randomization (THS, 2015). While, cluster randomized control-trails
(RCT) was adopted in Article-B which is a true experimental design with manipulation;
control and randomization. They have selected cluster design to reduce contamination
during the implementation of intervention and hence Article-B’s design is better than A
(LoBiondo-Wood, 2014).
Data collection is the process by which data is gathered to address the research
problem and the device used to collect data is called as instrument (LoBiondo-Wood
2014). In Article-A, the use of pre- and post-tests, survey (Likert scale) and identifying
the no. of MAEs through chart reviewing and safety reports (voluntary) is appropriate.
Similarly, in Article-B, the use of structured survey, Likert scales and structured direct-
observations is adequate.
Target population is defined as an entire group of population; the researcher is
interested to propose study as well as generalize the study-findings (THS, 2015). The
target population of the nurses working in the ED of a tertiary-care centre, U.S in Article-
A and nurses working in 4 medical & 4 surgical wards of Adelaide hospital, Australia in
Article-B is adequate.
Fink (2013) emphasises that samples are the part of the population that
represents the entire population. Selection of 95 nurses in pretest while 84 in both tests;
81 in pre-survey while 73 in post-survey; 299 pre-charts while 295 post-charts in Article-
A indicate possible 10% attrition. They used convenience sampling that involves
selecting the volunteering participants but it may cause self-selection bias. They have
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given a educational flip-chart along with slide-show titled ‘Preventing medication &
intravenous administrational errors’ to reduce MAEs.
In Article-B, the selection of 70 nurses in control and 77 nurses in experimental
group is adequate for a RCT. They used stratified random sampling by stratifying the
wards (clusters) by area (medical/ surgical) in 1:1 ratio among which 2 wards of each
area were randomly allocated to receive the intervention as advised by Polit (2016). The
experimental group nurses were trained to wear a vest during administration of
medication with educational intervention while control group was blinded to the
intervention. .
Validity is the degree to which the inferences made in the research-study are
accurate. Internal validity is defined as the extent to which the intervention (independent
variable) has inferred, rather than confounding variables causing observer effect (Polit,
2016). In both articles, the researchers have quoted varied studies to specify the
existence of causal relationship between intervention and outcome. They have tried to
prove the internal-validity by finding statistical-difference between pre-test and post-test
group in Article-A while control and interventional group in Article-B. But, no statistical
difference was found in Article-A which underestimates the study’s validity.
External validity is the extent to which the inferences regarding the relationships
that are observed about the setting variations, subjects and study-duration and/or study-
outcomes has to be accounted (Houser, 2011). Both studies were conducted in the
same setting, while in Article-B, nurses working in varied type were analysed which may
question external validity in Article-B.
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Measurement validity is the extent to which the measurement-instrument
measures what it is subjected to measure (Fink, 2013). There are no evidence of
validity and reliability assessment of the study-instruments in both articles. In Article-A,
only face validity was taken which questions the study-validity whereas in Article-B,
structured survey was conducted but no evidence of reliability.
Blinding is the technique used to prevent the subjects participating in the study
from obtaining information about study-participants, intervention and/or
researchers/investigators in-order to reduce possible bias (LoBiondo-Wood, 2014). In
Article-B, control nurses were blinded to the study’s aim as well as to the intervention at
the baseline which suggests that Article-B findings are more trustworthy than Article-A.
The statistical analysis that involves the organization as well as analysis of
information by utilizing statistical measures as descriptive and inferential measures
were employed (NewCombe, 2012). In Article-A, Knowledge test (n=84) showing 92%
with perfect scores in post-test while 69% in the pre-test (P=0.0001, p<0.05) indicates
that the difference is statistically significant. In behavior-survey, the post-survey
response is higher than pre-survey response (P=0.98) which is statistically insignificant
and in-regard to chart review, little difference was noted between number and
percentage of MAEs in pre (n=287) with 25% vs 24% in post (n=296) at P=0.78 which is
also statistically insignificant while the number of voluntarily-reported MAEs has fallen
from 1.28 to 0.99/1000 ED-patients.
The finding of Article-B indicates that the baseline interruptions are 57/100
administrations with 87.9% of non-MAEs and the unrelated medication interruptions was
significantly reduced in interventional ward from 50/100 administrations (CI-95%:45-55)
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to 34/100 (CI-95%:30-38) as evidenced in Kliger (2012). Controlling for clustering shows
that the drug interruption was significantly-reduced to 15/100 administrations than in
control wards. Among interventional nurses, only 48% have supported to implement this
intervention as a hospital policy as using vests consumes time; cumbersome as well as
hot. The analysis in both articles suggests that the researchers have done an in-depth
scrutinizing of informations as per their study-outcomes and have also tested
hypothesis.
The aim of conducting any study is to find-out appropriate solutions for the
selected problem and also to disseminate the trustworthy findings (Polit, 2016). Article-
A’s findings indicate that the intervention implemented has enhanced the knowledge of
improved medication administration but hasn’t been translated into practice. Use of
instruments without validity assessment; single ED setting; convenience sampling
method (causing self-selection bias) with chances for 10% attrition in post-survey
(absence of 8 nurses in post-survey) questions the study’s applicability. In-spite of
disadvantages, the educational intervention can be employed in nursing practice to
enhance medication safety to some extent (with basic ideas) by minimizing MAEs.
Article-B’s findings show that the intervention has statistically reduced the
number of non-MAEs which is similar to Keers (2013). But, the study was conducted in
single setting which questions applicability in other settings. In-spite of blinding, about
30% of control nurses have informed that they were aware of the use of vest by the
interventional wards which could affect the nurse’s behavior. Further, observation of
participant-nurses could have increased consciousness of interruptions. Additionally,
the influence of interruptions on MAEs and patient harms was not assessed. Despite
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these limitations, Article-B findings can be utilized in wards as it is an RCT. However,
the intervention technique could be little modified as only 40% of nurses has accepted it
to be their hospital policy.
In conclusion, all the major findings that are related to the study aims should be
discussed by relating to the hypothesis (Polit, 2016). The conclusions of both articles
are found to relate to the findings logically. No distortions were attempted in fitting their
pre-conceived ideas. They have mentioned about the advantages as well as
disadvantages of these studies as given by Boswell (n. d.). They have given their
recommendations for future studies along with its applicability in nursing practice. Thus,
conclusions given in these studies are appropriate.
To conclude, both Articles A & B have utilized experimental design to rule out the
effectiveness of their intervention in reducing MAEs and non-MAEs. Though their
attempt to promote medication safety had equivocal results, their findings have
inculcated in-depth insight about medication process. Despite certain demerits that are
evident in these studies, their findings can be utilized in future studies.
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Reference
ACSQHC- Australian Commission on Safety and Quality in Health Care (2013),
Literature Review: Medication Safety in Australia. ACSQHC, Sydney.
Athanasakis, E. (2012). Prevention of medication errors made by nurses in clinical
practice. Health Science Journal, 6(4), 773-783.
Boswell, C. (n. d). Chapter14: The research critique process and the evidence based
appraisal process. Retrieved from
http://samples.jbpub.com/9781284079654/9781284108958_CH14_Pass03.pdf
Douglas, H. E. (2017), Improving our understanding of multi-tasking in healthcare:
drawing together the cognitive psychology and healthcare literature. App Ergon,
59, 45–55.
Fink, A. (2013). Conducting Research Literature Reviews: From the Internet to Paper.
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Houser, J. (2011). Nursing Research. Retrieved from https://books.google.co.in/books?
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Iverson, K.M. (2014). Women veterans’ preferences for intimate partner violence
screening and response procedures within the Veterans Health Administration.
Research in Nursing and Health, 37, 302-311
Keers, R. (2013). Prevalence and nature of medication administration errors in health
care settings: a systematic review of direct observational evidence. Ann
Pharmacother, 47, 237–56.
Kliger, J. (2012). Spreading a medication administration intervention organizationwide in
six hospitals. Jt Comm J Qual Pt Safety, 38, 51–60.
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LoBiondo-Wood, G & Haber, J. (2014). Nursing Research: Methods and Critical
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http://www.tropicalhealthsolutions.com/statsglossary
Yartsev, A. (2017). Advantages and disadvantages of RCT. Retrieved from
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research -methods -and-statistics/Chapter%202.0.2/advantages-and-
disadvantages-randomised-control-study-design
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