Patient safety in nursing care during medication administration.
Júlian Katrin Albuquerque de Oliveira, Eliana Ofélia Llapa-Rodriguez, Iza Maria Fraga Lobo and 3 others
PMID 30110095WHAT IT FOUND
In 378 observed ICU medication administrations via central lines, no nurse or technician followed every safety step.
Hand hygiene before preparation occurred in 1 of 378 cases, and vial disinfection in 6 of 378. Gloves and sharps disposal were adhered to, but patient protection steps were frequently skipped.
Key findings
01The overall conformity rate for the medication administration procedure was 0%, meaning no professional complied with all standardized steps.
02Hand hygiene after preparing medication was performed in only 0.2% of cases (1 of 378), and disinfection of multidose vials or ampoules occurred in 1.5% of cases (6 of 378).
03Actions protecting the patient, such as hand hygiene and device disinfection, had significantly lower adherence than actions protecting the professional, such as using gloves (87.5%) and discarding sharps correctly (97%).
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The study was conducted in a single ICU in Brazil, so the results may not generalize to other healthcare systems or settings with different staffing ratios. Observation bias is possible; although researchers tried to mitigate this by not showing the checklist to staff, the presence of observers may have altered behavior (Hawthorne effect), potentially inflating adherence rates compared to unobserved practice. The study did not measure clinical outcomes such as actual infection rates, so it reports on process failures rather than patient harm.
Declared interests
No specific funding sources or conflicts of interest are explicitly declared in the provided text.
The easy way to misread this
Do not interpret the high adherence to glove use and sharps disposal as evidence that the team is practicing safe medication administration. The study found that 0% of procedures were fully compliant with all safety steps, and the most critical infection-prevention actions (hand hygiene and disinfection) were almost entirely omitted.