The Creation and Maintenance of Safety in Nursing Medication Administration Practice

Medication errors are a significant challenge to patient safety. Over half of
medication errors occur during administration, largely a nursing role. A focus on
what works well rather than what goes wrong, called ‘safety II’ views necessary
adaptations in the work environment as resilient mechanisms to achieve safety.
This PhD study aimed to explore how resilience is created and maintained in
nursing medication administration. A systematic review supported iterative
development of three study objectives: to review ‘work as planned’ in local and
national guidelines; to explore how it differs to ‘work as done’ and any
consequences of changing practice; and to examine nurse perceptions of risk,
resilience and factors that drive changes in practice.
A nine-month qualitative interpretive ethnographic study on two wards of an
NHS hospital collected data through observation, interview, and document
review. The analytical framework was reflexive thematic analysis with an
abductive approach.
Main findings included establishing wider contextual pressures and local
dynamic factors influencing medication administration practice. Key safety
concepts, labelling and relatedness are explored using a safety II lens,
progressing understanding in this specific study area. Development of a model
of relatedness summarising safety practices, and a typology of variations, have
potential to strengthen future error terminology and explorative research.
There is sparse literature linking triggers and pressures to adaptive safety
mechanisms in this arena. Linking these to identified or inferred safety
outcomes progresses understanding of adaptations as individual or team
expressions of resilience. Categorisation of resilient characteristics theorybuilds from existing models of resilience in healthcare to include reactive and
proactive strategies which more accurately represent compensatory adaptions
during drug rounds. Finally, a model of resilience and a framework of
necessary factors for achieving resilience successfully address this study’s aim
by generating new understanding of the creation and maintenance of safety
resilience in medication administration.