Competencia medicamentos de los profesionales enfermerosen la notificación de incidentes en el medio hospitalarioun estudio de intervención

Abstract

REGISTERED NURSES COMPETENCE IN REPORTING MEDICATION INCIDENTS IN THE HOSPITAL SETTING: AN INTERVENTION STUDY ABSTRACT BACKGROUND Medicine related incidents (MI) are the most common type of incident associated with hospital care. The Spanish national study on the adverse events (AE) associated with hospitalization (ENEAS) estimated that 37.4% of AE or incidents in hospitals are related to medication and that 4.1% of hospitalized patients experience AE associated with the use of medication. The spontaneous reporting systems, although necessarily complemented by other strategies, are a very efficient source of information regarding the MIs, attributable to their low cost and easy access. However, the underreporting by healthcare professionals, especially notable among Registered Nurses (RN) limits their information capacity. RN spend about 40% of their working time on the process of using medicine use, which places them in an outstanding position to detect and report MI; Frequently, it is this group of professionals who first identify the occurrence of these types of incidents, although their most common reaction is to communicate with the medical team. Nurses are the healthcare professionals that provide the least ADR notifications to spontaneous reporting systems in our context. Most of the strategies carried out, mainly for medical and pharmaceutical professionals to improve or increase the notification of MIs in the hospital environment, have proven to be effective. However, some limitations in their designs, like the need to adapt them to the target population, require studies designed for the nursing profession in the hospital setting. The objective of this study was to determine the impact of a multifaceted institutional intervention (MII) for patient safety by considering the notifying competence of nursing professionals to report medication related incidents in the hospital setting. METHOD Design: Quasi-experimental before-after intervention study without control group. Population: Clinical RN and midwives belonging to the staff of the University Hospital Puerta de Hierro Majadahonda and accessible by email. Variables Studied Independent Variables: socio-demographic and work-related characteristics of nursing professionals: sex; age; academic level in Nursing; academic level in other disciplines; overall professional experience; work area; professional experience in the current work area; work shift; employment situation; frequency medication administration; training in patient safety. Dependent Variables Main outcome: overall reporting competence, measured through the synthetic variable constructed from the tally of the 34 items of the questionnaire selected for this purpose. Each of the items were assigned a value between 1 and 5 points. Score range possible from 34 to 170 points. Other outcome Variables: Weighted scores of dimensions attitudes, knowledge and skills; Original responses to the 34 items of the questionnaire; Self-reported prevalence of MI notifications; Monthly incidence of reports of suspected ADRs to the Spanish Pharmacovigilance System; Cumulative incidence of notifications of MI (Harmless ME, harmful ME / ADR, total MIs), based on data provided by the Hospital Quality Unit. Instrument for Data Collection Self-administered electronic questionnaire NORMA version 2.0 and 2.1 , designed ad hoc for this research and subjected to a face and content validation through literature review, experts in the field, and piloting, prior to its use for baseline measurement. Process for data collection The field work was performed, from a chronological standpoint, in 3 stages: baseline or preintervention was carried out between May 6 and June 20, 2013; The multi-faceted intervention occurred between baseline and final measurement, which took place between 15 April and 1 June 2015. Data Treatment and Analysis Descriptive statistics of the variables were conducted, calculating measures of central tendency and dispersion for the continuous variables as well as absolute frequencies and percentages for the qualitative or categorical variables. To determine the before-after change in each of the variables, the McNemar test was used for paired samples in dichotomous or dichotomized categorical variables, the Wilcoxon test in ordinal variables with more than two categories, and the t-test of Student for paired samples in order to compare the means in continuous variables. The bivariate analysis of the dependent variables (mean differences in global competence and its dimensions, competence improvement and becoming reporter of MI) and all independent variables were carried out using the Chi square test (with exact Fisher correction, where needed) and the t-Student test for independent samples; when performing the bivariate analysis over the dependent variable becoming reporter of MI, mean differences in global competence an its dimension, were considered independent variables. Multiple lineal regression models were performed, taking the overall competence mean difference and skills mean difference as dependent variables, and those that showed a significant association (p≤0.20) in the bivariate analysis as explanatory variables. Multivariate logistic regression model was done, taking as dependent variable having become MI reporter after the MII, and, as explanatory variables, those that showed a significant association (p≤0.20) in the bivariate analysis. In general, work was done with a significance level ≤ 0.05. Confidence intervals were calculated at 95% accuracy. The programs used for data processing were Excel, SPSS 22.0 and Stata 14.0. RESULTS The final paired sample consisted of a total of 139 RN, mostly women, in 91.4% (n = 127). The average age was 37.3. (SD: 8.69) and 14.9 years (SD: 8.12) of professional experience in Nursing at the time of pre-intervention. The mean of the main variable, overall reporting competence, increased significantly from 112.5 points (95% IC: 110.72-114.21) before the multi-faceted institutional intervention to 120.4 points (95% IC: 118.09-121.75) after it. In the analysis by competency dimensions, attitudes of the RN increased an average of 0.24 points (95% IC -0.53, 1.01); knowledge dimension increased 0.34 points (95% IC: -0.81, 1.49), and skills experienced a statistically significant increase of 7.38 points (95% IC: 5.69-9.06). In the bivariate analysis carried out by the difference of means in overall competence and in their dimensions before and after MII, according to socio-demographic and work-related characteristics of the population, no significant differences were observed within the categories of the different variables studied. In the attitudes dimension, it was associated with having received training in patient safety (p <0.001). 73.4% (n = 102) of RN improved their overall reporting competence after MII, defined as the increase of at least one point in the final questionnaire with respect to the baseline questionnaire. In the bivariate analysis, in which the in the notifying competence and in each of its three dimensions were taken as the dependent variable and, as independent, socio-professional and academic variables, no statistically significant association was observed. The multivariant significant model showed that increasing one point in the competence mean difference, increased the odds of becoming an MI reporter in 2.9% (CI 95%; 1.000- 1.058). Improving one point in the skills dimensión, increased 6.4% ( CI 95%: 1.020- 1.110). the odds of becoming MI reporter. The trends of MI reported by hospital RNs between January-2010 and May-2016 using jointpoint regression models showed a monthly significant increase of 4.3% MI [AAPC (CI 95% 1.6;7.0)] due to the reporting of harmless MI. CONCLUSIONS The competence in reporting medication incidents among nursing professionals of a University hospital in the Community of Madrid increases after the implementation of a multi-faceted institutional intervention in terms of patient safety. The improvement in overall reporting competence can be explained by the increase in the skills dimension, which is associated with RN having received training in patient safety MII is effective in increasing the prevalence of RN which self-report being MI reporters, as well as the trend of harmless MI reporting (medication errors) within the Institution but has no effect on the reporting of harmful MI or ADR. Institutional support for ME reporting, framed within the regional patient safety policy, could help explain this fact. It is necessary to take a closer look at the reasons that explain the low implication of the RN in the reporting of ADR. Qualitative research focused on a deep analysis of conversations with RN, other health professionals and institutional leaders could help to better understand this phenomenon in order to guide the planning and implementation of future interventions. This work additionally contributes with an unpublished self-administered electronic questionnaire (NORMA questionnaire) to explore the competence among hospital RN to report medication related incidents. The instrument shows an adequate face and content validity following the review of the literature, the expert criterion, and the pilot study, although future studies to continue with the validation process are recommended. KEY WORDS: Adverse drug reaction. Medication error. Nursing. Spontaneous reporting systems. Multi-faceted intervention.