الفهرس 
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Abstract
High alert medications are medications that are most likely to cause significant harm to the patient, even when used as intended. The ISMP reports that incident rates with this group of medicines may not necessarily be higher than with other medicines, but when incidents occur the impact on the patient can be significant (serious). The highalert medications included insulin, opioids, sedatives, and anticoagulants.
Medication errors were fatal in patients greater than 60 years of age; the three most common causes of death were improper dose, wrong drug, and wrong route of administration.The most common cause of medication error (22%) was lack of knowledge of the medication, as lack of awareness of medication interactions, incorrect dosages, incorrect mixing and overly rapid infusions. The second most frequent cause was the lack of information about the patient (14%), as inappropriate medication for that patient. The most common causes being the inappropriate or unclear dose, missing dose, or the directions for use were unclear or absent.
Mistakes involving medications are among the most common healthcare errors. Medication errors lengthen hospital stays, increase inpatient expenses, and lead to more than 7,000 deaths annually in the U.S.A. Each error costs an estimated $2,000 to $8,750. An error can happen in the home or a healthcare facility; the present research is focuses on errors in hospitals. Due to limited resources in developing countries such as Egypt, there are more risk areas that may result in higher rates of Medication Errors (MEs).
Although such problems are not present in all health organizations, some have already overcome them, and others are still in the process of addressing them. Nurses have significant opportunities to promote, maintain, identifyemerging problems and advice patients of their risk status and positively influence appropriate at self-care practices and self-care behaviors, the ideal nurse should be knowledgeable person and should have a practical skill to maintain safety of the patients.
AIM OF THE STUDY
The aim of the study is
1- Assess nurse’s knowledge in dealing with high alert medications.
2- Assess nurse’s practices in dealing with high alert medications.
Research design:
Descriptive research design was utilized for conduction this study.
Materials and method
The study was conducted at Alexandria Main University Hospital in the following settings:
3. General medical units including the nephrology, endocrine, chest diseases, cardiovascular, gastrointestinal and diabetes units. These units include a bed capacity of 574 beds.
4. General surgical units including heart and chest surgery, oncology, vascular interventional and diabetic foot surgery, neurosurgery, and urology reproductive surgery units. These units include a bed capacity of 246 beds.
5. The subject of the study consisted of all staff nurses available (167) nurses who were involved in direct patient care and responsible for administering medications at above mentioned setting and there Experience years not less than two years categories. In addition, they were distributed as (77) nurses in medical units and (90) nurses in surgical units.
Two tools were used for data collection.
Tool one: Nurse’s practices in dealing with high alert medications observational check list.It was divided to five parts:
The nurses practices when dealing with medications as general.
Assess nurse’s practices in dealing with insulin.
Assess nurse’s practices in dealing with opioids.
Assess nurse’s practices in dealing with sedations.
Assess nurse’s practices in dealing with anticoagulants.
Practice was scored on three points:
Incorrect practice=0
Correct and incomplete=1
Done correct and complete=2
Tool two: Nurse’s knowledge in dealing with high alert medications questionnaire
This tool was consists of two parts.
Part I
It was compromise items related to socio-demographic data of assigned nurses as sex, age, qualifications, years of experience, and specialty department.
Part II
Nurse’s knowledge related to high alert medications the sources of their knowledge , the definition of high alert medications, contraindications, side effect, special precautions, the availability of the drug in the unit and its dispensing , storage and labeling of the drugs for each category, the way of endorsement between each shifts and their actions in special situations.
Knowledge was scored on 3 points
Wrong answer or don’t know =0
Correct and incomplete answer =1
Correct and complete answer = 2
All scores were added for each nurse in the subject of study, total score for knowledge and practices were classified as the following:
Scoring 75% for total related to each medications, was considered satisfactory.
The scoring less than 70% was considered unsatisfactory.
The two tools were adapted according to recent review of literature, these tools were tested for content and construct validity by 5 experts in the field of medical surgical nursing, also a pilot study carried out on 10% of sample size in order to assess the clarity and applicability of the tools. According to the findings of the content validity of the jury members and pilot study, the necessary modifications were introduced.
Data collection from nurses was conducted over period of two months from (February 2017 to April 2017). Each nurse observed individually during preparation of medications and its administration throughout morning and afternoon shift, to assess their practices in dealing with high alert medications. The structured questionnaire was distributed to nurses in the medical and surgical units to assess nurse’s knowledge after explaining the aim of the study, the researcher stayed with the nurses to explain any misconceptions and the time required for filling the questionnaire by the nurse was approximately 20 minutes.
Results:
• In this study it is observed that all of the nurses were female, (20.4%) of the nurses were less than age of 30 year, while (29.9 %) of the nurses were of age between 30-40 years old, while (31.7%) of the nurses between the age of 41-50 years old and these is the highest percentage regarding to nurses age, and (18%) of the nurse’s age more than 50 years old.
• (60.5%) are technical diploma nursing and this is the highest score related to the nurses qualifications, while (39.5%) is secondary nursing diploma, (56.9%) is the most highest percentage observed for the experience years more than 18 years of experience, all of nurses are not attended any courses related to medications.
• the mean scores and the mean percentage for nurses’ practices related to medications as general, insulin, opioids, sedatives and anticoagulants it is observed that regarding the mean score and mean percentage for practices related to high alert medications as general they have (23.02 ± 2.50) (39.70 ± 4.30).
• Practices related to insulin it was observed that the nurses have mean scores and mean percentage (21.52 ± 2.31) (44.84 ± 4.81).
• Practices related to opioids it is observed that nurses mean score and mean percentage (10.29 ± 1.96) (4.31 ± 6.53).
• Practices related to sedatives it is noticed that the nurses have mean scores and mean percentage (3.08 ± 0.98) (22.03 ± 7.03).
• Practices related to anticoagulants it is observed that the nurses havemean score and mean percentage (17.71 ± 2.28) (38.51 ± 4.95).
• Total mean scores and mean percentage for the 5 items (75.63 ± 6.94) (38.59 ± 3.54).
• percentage and level of the nurses’ practices satisfactory ≥75% or unsatisfactory ≥70% regarding to the 5 main items it was observed that for practices related to high alert medications as general the nurses have (100.0 %) unsatisfactory .
• Practices related to insulin the nurses have (100.0%) unsatisfactory practices. Also for practices related to opioids the nurses have (100.0%) unsatisfactory. practices related to sedations and practices related to anticoagulants they had (100.0%) unsatisfactory practices. The total percentage related to the nurse’s practices to show(100.0%) unsatisfactory practices.
• Nurse’s knowledge related to medication as general, insulin, opioids, sedatives and anticoagulants. Knowledge related to high alert medications as general the mean score and mean percentage (10.47 ± 1.57) (74.81 ± 11.22).
• Knowledge related to insulin the mean score and mean percentage (21.30 ± 4.02) (51.95±9.82).
• Knowledge related to opioids the mean scores and mean percentage (7.78 ± 2.29) (48.65 ± 14.31).
• Knowledge related to sedatives the mean score and mean percentage (7.82 ± 3.05) (55.86 ± 21.82).
• Knowledge related to anticoagulant medications the mean score and mean percentage (13.32 ± 4.37) (45.94 ± 15.07).
• Total score of the mean and mean percentage for the 5 items (60.70 ± 11.65) (53.25 ± 10.22).
• The nurse’s knowledge related to medication as general, insulin, opioids, sedatives and anticoagulants with the percentage and level of nurses knowledge was satisfactory <75% or unsatisfactory > 70% regarding to the 5 main items .
• Knowledge related to high alert medications as general was (53.3%) of nurses have satisfactory knowledge while (46.7%) have unsatisfactory knowledge. Even for the nurses knowledge related to insulin is detected that (99.4%) of the nurses have unsatisfactory knowledge while only (0.6%) have satisfactory knowledge.
• Knowledge related to opioids most of the nurses have unsatisfactory knowledge (95.8%) only (4.2%) of the nurses have satisfactory knowledge. Knowledge related to sedatives (72.5%) of the nurses have unsatisfactory knowledge (27.5%) have satisfactory knowledge.
• Knowledge related to anticoagulant medications (98.2%) of nurses has unsatisfactory knowledge only (1.8%) have satisfactory knowledge.
• The total scores of percentage (99.4%) had unsatisfactory knowledge only (0.6%) of the nurses had satisfactory knowledge.
• The relation between overall practices with socio demographic data,there is statistically significant related to the department of work is (0.015) there is significant relationship between the department and the nurse practices.
• Statistically significant is (<0.001) there is a significant relation between number of patient assigned for each nurse and her practices.
• Statistically significant is (0.001) there is significance relationship between the time of observation and the nurse’s practices.
• Statistically significant is (0.122) no significant relationship between the age of the nurses and their practices.
• statistically significant is (0.698) no significance relationship between the qualifications and the nurses practices
• Statistically significant is (0.241) no significant relation between the years of experience and the nurse’s practices.
• The statistically significant is (0.375) no significant relation between the working hours and nurses practices.
• The relation between overall knowledge with socio demographic data, statistically significant is (<0.001) there is significant relationship between the department and the nurses knowledge.
• Statistically significant is (<0.001)there is significance relationship between the time of observation and the nurses knowledge.
• Statistically significant is (0.886) no significant relationship between the age of the nurses and their knowledge.
• . Statistically significant is (0.125) no significance relationship between the qualifications and the nurse’s knowledge.
• Statistically significant is (0.130) no significant relation between the years of experience and the nurse’s knowledge.
• The statistically significant is (0.793) no significant relation between numbers of patient assigned for each nurse and her knowledge.
• The statistically significant is (0.236) no significant relation between the working hours and nurses knowledge.
Conclusion and recommendations
Based on the findings of the present study, it could be concluded that:
• The current study concluded that, there is a gap between nurses’ knowledge and practices as compared to the standard guidelines about high alert medications administration.
• Knowledge level for all nurses participate in this study as regards dealing with high alert medication was unsatisfactory in total and subtotal areas with a lot of wrong information which lead to hazardous in practices and dangerous complications. As well, the practices level is unsatisfactory in total score.
• The current study concluded that provide continuous education and training courses about high alert medications must to be done.
Recommendations
Based on the results of the present study the following recommendations are suggested:
• Recommendations for the hospital and the administration for improving nurses knowledge and practices:
Create a list of HAMS that are in use ineach department; a list of highalert medications.
Develop medication safety policies and procedures that enhance the ability of nurses to use these medications safely.
Regularly review the safety literature about medication safety strategies forHAMS.
Orientation program for all newly enrolled nurses.
Provide nursing staff with adequate supervision and guidance regarding dealing with medications.
Pre-services and in-service training programs should be developed and provided to nurses by expert personal to improve their knowledge.
Schedule evaluation for the nurses and notify them for the points of weakness in the practices to be improved in the future.
Discussing the nurses’ point of view that may affect their practices.
Collaborative interaction between pharmacist, physician and nurses will improve nurses and assure safe administration of high alert medications.
Regular meeting between nurses, and supervisors should hold to evaluate practice and investigate ways for its continuous improvement.
Each unit should be supplied with medications handbooks, pamphlets for medications especially high alert medications to improve the nurses’ knowledge.
Encourage the usage of automated system for medications that improve the connection between each unit and department in the hospital.
Supplies the department with a scale that to use for monitoring pain level, sedation level for examples.
Supplied each unit and department with a list of international abbreviation.
Supplies medical and surgical departments with a different color code bands as yellow for allergies and red for risk of fall.
Improve the working conditions, benefits and rewards to provide for the nurses to motivate them.
• Recommendations for educational programs:
High alert medication courses for nurses on how to deal with this type, the way of separation, dispensing, administration, the nurses’ action if errors occur.
Pharmacological courses as general and emphasized on the drug action, and their interaction, the nutrition in relation to drug, as well as the clinical manifestation, drug to drug interaction, adverse reaction of some drugs.
Different investigations and blood tests program for different diseases and the normal results of its investigation.
Any new machine arrived to hospital to given orientation training.
• Recommendations for nurses:
Encourage the usage of double check of medications by two qualified nurses for, patient full name, hospital number, the name of medication, dosage, time, route, expiry date of medication.
Encourage reading back of the medication prescriptions by the nurse after written by the physician.
All nurses should always be encouraged to attend medical lectures or courses to keep pace with the rapidly growing wealth of knowledge and practice that necessary for proper nursing services.
Nurses should add to their routine obligations the regular reading of up-to-date references (periodicals, textbooks).
Encourage nurses to always preparing medication in a medications room away from any distraction.
• Suggestion for further studies:
Conduct further study in another hospital. To compare between the nurses needs in different settings.
Study some other medications group from the list ofHAMS.