Assignment: Quality and Safety Improvement
QSEN Discussion Board #1 Rubric
As a nurse leader, you are responsible for improving the quality and safety of health care systems. Describe a nursing or patient care concern or issue that needs to be addressed in your clinical practice. If your clinical practice is limited, you may be able to draw on experiences gained during clinical rotations in nursing school. Analyze the significance of the nursing practice concern in relation to the Quality and Safety Education for Nurses (QSEN) competencies described in the Cronenwatt article (Cronenwatt website – http://qsen.org/competencies/pre-licensure-ksas/).
I have decided to complete my BSN for a few different reasons. One reason is to further my knowledge in the most recent evidence based practice of nursing in order to provide better patient care. Academic nursing research is crucial to providing quality nursing care because it gives the foundation for evidence-based practice (EBP) that is often the catalyst for changes that impact patient outcomes (Falkner 2018). The next reason is my place of work requires that all ADN nurses obtain a BSN or higher within 3 years of hire, and lastly the more education I achieve the higher I get paid. All three of these reasons point back to an overarching idea that I am here getting my BSN to further myself along in my career and become a better nurse. I don’t have many concerns with getting started in my bachelorette program except the sole fact that I’d rather be outside enjoying playing sports or doing activities outside rather than being on the computer. I have never been one to like sitting on a computer for any period of time really. A few strategies that I can implement is time management, using evidence based practice sources of information, and remembering to ask for help when I don’t understand or am feeling overwhelmed. Enlist your family to keep a master calendar so everyone knows when you’re working, going to class and studying. And be sure to schedule some free time for the things you like to do, whether it’s working out, reading, listening to music or spending time with your family. That balance will help you get through the rigors of nursing school (Murphy 2015).
This assignment is restricted to the competencies of Evidence-based Practice (EBP) or Quality Improvement (QI).
Why is it critical to investigate this concern or issue?
What is the best or preferred method for dealing with this issue?
How will you, as a nurse manager or leader, improve workplace practices related to this issue?
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Quality and Safety Improvement Discussion
Describes a nursing or patient care concern that needs improvement
20
Describes the Evidence-based Practice and/or Quality Improvement QSEN competencies and relates significance of issue to QSEN competencies. Why is it important to explore this concern?
20
Describes best or preferred practices for this concern. Supports with at least one current nursing RESEARCH article.
25
Describes strategies to improve practices in the health care system. Support with at least one reference. Textbooks or current nursing literature are appropriate.
25
Grammar and APA
10
Textbook:
Sullivan, E. J. (2012). Effective leadership and management in nursing. Boston: Pearson. ISBN-13: 978-0132814546
Quality and Safety Improvement Discussion
Nursing education on quality and safety Dr. Linda Cronenwett, RN, FAAN PhD, RN, FAAN Gwen Sherwood PhD, RN, FAAN Jane Barnsteiner PhD, RN, FAAN Joanne Disch PhD, RN-C, FAAN Jean Johnson Dr. Pamela Mitchell, CNRN, FAAN Dori Taylor Sullivan is a PhD, RN, CNA, and CPHQ. On whether the KSAs for pre-licensure education are appropriate goals for students preparing for basic practice as a registered nurse, Judith Warren, PhD, RN, BC, FAAN, FACMI. Quality and Safety Education for Nurses (QSEN) addresses the challenge of equipping nurses with the knowledge and skills needed to continuously improve the quality and safety of the health care systems in which they work. The QSEN faculty members adapted the Institute of Medicine1 competencies for nursing (patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics), proposing definitions of what it means to be a competent and respected nurse.
The authors propose statements of knowledge, skills, and attitudes (KSAs) for each competency that should be developed during pre-licensure nursing education based on the competency definitions. Faculty and advisory board members of Quality and Safety Education for Nurses (QSEN) invite the profession to comment on the competencies and their definitions. A number of national commissions have identified significant issues with safety and quality in the US health-care system. 1–5 In light of these issues, multiple national committee reports concluded that if health care is to improve, providers must be prepared with a different set of competencies than are currently taught in educational programs. 1,6 Health professionals must be able to describe what constitutes good care using scientific evidence, identify gaps between good care and the local care provided in their practices, and know what activities they could initiate, if necessary, to close any gaps.
7 The 2003 Institute of Medicine (IOM) Health Professions Education report1 challenges faculties of medicine, nursing, and other health professions to mindfully alter learning experiences that form the basis for professional identity formation so that graduates are educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics. 1 To incorporate the development of the aforementioned competencies in nursing education, will, ideas, and execution are required. In contrast to medicine, where a commitment to an adapted version of the IOM competencies is now in place for the continuum from medical school to residency program to certification,8,9 nursing lacks agreement on the competencies that could apply to all nurses—that would define what it means to be a respected and qualified nurse.
At the core of nursing, however, lies incredible historical will to ensure quality and safety for patients. Evidence of valuing quality and safety competencies in nursing is evident in nursing publications,10 –12 standards of practice,13 and accreditation guidelines.14,15
The American Association of Colleges of Nursing Task Force on the Essential Patient Safety Competencies for Professional Nurs- Linda Cronenwett is a Professor and Dean at the School of Nursing, University of North Carolina at Chapel Hill. Gwen Sherwood is a Professor and Associate Dean for Academic Affairs at the School of Nursing, University of North Carolina at Chapel Hill. Jane Barnsteiner is a Professor and Director of Translational Research at the School of Nursing and Hospital of the University of Pennysylvania, Philadelphia, PA. Joanne Disch is Kathyrn R. and C. Walton Lillehei Professor and Director of the Densford International Center for Nursing Leadership at the School of Nursing, University of Minnesota, Minneapolis, MN. Jean Johnson is a Professor and Senior Associate Dean for Health Sciences at The George Washington University, Washington, DC. Pamela Mitchell is Elizabeth S. Soule Professor and Associate Dean for Research at the School of Nursing, University of Washington, Seattle, WA. Dori Taylor Sullivan is an Associate Professor and Chair, Department of Nursing at Sacred Heart University, Fairfield, CT. Judith Warren is an Associate Professor at the University of Kansas School of Nursing and Director of Nursing Informatics at Kansas University Center for Healthcare Informatics, Kansas City, KS. Reprint requests: Linda Cronenwett, PhD, RN, FAAN, Dean and Professor, School of Nursing, University of North Carolina at Chapel Hill, Carrington Hall, CB #7460, Chapel Hill, NC 27599-7460. E-mail: lcronenwett@unc.edu Nurs Outlook 2007;55:122-131. 0029-6554/07/$–see front matter Copyright © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.outlook.2007.02.006 122 V O L U M E 5 5 ● N U M B E R 3 N U R S I N G O U T L O O K Quality and safety education for nurses Cronenwett et al Table 1. Patient-centered Care Definition: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs. Knowledge Integrate understanding of multiple dimensions of patient-centered care: ● patient/family/community preferences, values ● coordination and integration of care ● information, communication, and education ● physical comfort and emotional support ● involvement of family and friends ● transition and continuity Skills Attitudes Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care Communicate patient values, preferences and expressed needs to other members of health care team Provide patient-centered care with sensitivity and respect for the diversity of human experience Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values Value seeing health care situations “through patients’ eyes” Respect and encourage individual expression of patient values, preferences and expressed needs Value the patient’s expertise with own health and symptoms Seek learning opportunities with patients who represent all aspects of human diversity Recognize personally held attitudes about working with patients from different ethnic, cultural and social backgrounds Willingly support patientcentered care for individuals and groups whose values differ from own Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort Assess presence and extent of pain and suffering Recognize personally held values and beliefs about the management of pain or suffering Assess levels of physical and emotional comfort Appreciate the role of the nurse in relief of all types and sources of pain or suffering Elicit expectations of patient & family for relief of pain, discomfort, or suffering Recognize that patient expectations influence outcomes in management of pain or suffering Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs Examine how the safety, quality, and cost-effectiveness of health care can be improved through the active involvement of patients and families Examine common barriers to active involvement of patients in their own health care processes Describe strategies to empower patients or families in all aspects of the health care process Remove barriers to presence of families and other designated surrogates based on patient preferences Assess level of patient’s decisional conflict and provide access to resources Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management M A Y / J U N E Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care Respect patient preferences for degree of active engagement in care process Respect patient’s right to access to personal health records N U R S I N G O U T L O O K 123 Quality and safety education for nurses Cronenwett et al Table 1. Continued Definition: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.
Knowledge Skills Explore ethical and legal implications of patient-centered care Recognize the boundaries of therapeutic relationships Describe the limits and boundaries of therapeutic patient-centered care Facilitate informed patient consent for care Attitudes Acknowledge the tension that may exist between patient rights and the organizational responsibility for professional, ethical care Appreciate shared decisionmaking with empowered patients and families, even when conflicts occur Discuss principles of effective communication Assess own level of communication skill in encounters with patients and families Describe basic principles of consensus building and conflict resolution Participate in building consensus or resolving conflict in the context of patient care Examine nursing roles in assuring coordination, integration, and continuity of care Communicate care provided and needed at each transition in care ing Care recently completed an enhancement to the Essentials of Baccalaureate Education for Professional Nursing Practice to include exemplars of quality and safety competencies.16 But the ideas for what to teach, how to teach, and how to assess learning of the competencies are sorely lacking, and there are few, if any, examples of schools claiming to execute a comprehensive quality and safety curriculum. continuing education programs. In addition, the definitions can provide a framework for regulatory bodies that set standards for licensure, certification, and accreditation of nursing education programs. PRE-LICENSURE NURSING EDUCATION . Quality and Safety Improvement Discussion. The competency definitions provided a broad framework for QSEN’s work to define pedagogical strategies for quality and safety education; however, as is evident in the accompanying article in this issue, when the competency names and definitions were used alone, the vast majority of pre-licensure program leaders stated that they already included content related to the competencies in their curricula.17 Relying on the respondent to interpret the general definitions of the QSEN competencies, levels of satisfaction with the extent to which students developed these competencies were high, and program leaders believed that faculty possessed the necessary expertise to teach these competencies. The QSEN faculty and advisory board members did not share the view that pre-licensure nursing students were graduating with these competencies. We knew that many students graduated without ever communicating a recommendation for a change in patient care to a physician. Many of us knew that students learned the “five rights” of medication administration but lacked the language of common concepts related to safety sciences or quality improvement methods. With the DEFINING THE COMPETENCIES Quality and Safety Education for Nurses (QSEN), funded by the Robert Wood Johnson Foundation, was designed to address these gaps—to build on the will, to develop the ideas, and to facilitate execution of changes in nursing education. Before teaching strategies could be developed, however, the QSEN faculty needed to identify specifically what was to be achieved. Working with an Advisory Board of thought leaders in nursing and medicine (see acknowledgments), the authors reviewed the relevant literatures and adapted the IOM1 competencies for nursing. The goal was to describe competencies that would apply to all registered nurses. In Tables 1– 6, the definitions are shared with the profession with the hope that nursing, through its professional organizations, can benefit from the work. If nursing constituencies find these competency definitions clear and compelling, over time the competencies can serve as guides to curricular development for formal academic programs, transition to practice, and 124 V O L U M E 5 5 ● N U M B E R Value continuous improvement of own communication and conflict resolution skills 3 N U R S I N G O U T L O O K Quality and safety education for nurses Cronenwett et al Table 2. Quality and Safety Improvement Discussion. Teamwork and Collaboration Definition: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care. Knowledge Describe own strengths, limitations, and values in functioning as a member of a team Skills Attitudes Demonstrate awareness of own strengths Acknowledge own potential to and limitations as a team member contribute to effective team functioning Initiate plan for self-development as a team member Appreciate importance of intra- and inter-professional Act with integrity, consistency and collaboration respect for differing views Describe scopes of practice and Function competently within own scope Value the perspectives and roles of health care team of practice as a member of the health expertise of all health team members care team members Describe strategies for identifying Assume role of team member or leader and managing overlaps in based on the situation team member roles and Initiate requests for help when accountabilities appropriate to situation Recognize contributions of other Clarify roles and accountabilities under individuals and groups in conditions of potential overlap in helping patient/family achieve team-member functioning health goals Integrate the contributions of others who play a role in helping patient/family achieve health goals Respect the centrality of the patient/family as core members of any health care team Analyze differences in communication style preferences among patients and families, nurses, and other members of the health team Value teamwork and the relationships upon which it is based Communicate with team members, adapting own style of communicating to needs of the team and situation Respect the unique attributes that members bring to a team, including variations in professional orientations and accountabilities Demonstrate commitment to team goals Value different styles of communication used by Solicit input from other team members to Describe impact of own patients, families, and health improve individual, as well as team, communication style on others care providers performance Discuss effective strategies for Contribute to resolution of communicating and resolving Initiate actions to resolve conflict conflict and disagreement conflict Describe examples of the Follow communication practices that Appreciate the risks associated impact of team functioning on minimize risks associated with handoffs with handoffs among safety and quality of care among providers and across transitions providers and across in care transitions in care Explain how authority gradients influence teamwork and Assert own position/perspective in patient safety discussions about patient care Choose communication styles that diminish the risks associated with authority gradients among team members Identify system barriers and facilitators of effective team functioning Participate in designing systems that support effective teamwork Value the influence of system solutions in achieving effective team functioning Examine strategies for improving systems to support team functioning M A Y / J U N E N U R S I N G O U T L O O K 125 Quality and safety education for nurses Cronenwett et al Table 3. Evidence-based Practice (EBP) Definition: Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care. Knowledge Skills Demonstrate knowledge of basic scientific methods and processes Describe EBP to include the components of research evidence, clinical expertise and patient/family values Participate effectively in appropriate data collection and other research activities Appreciate strengths and weaknesses of scientific bases for practice Adhere to Institutional Review Board (IRB) guidelines Value the need for ethical conduct of research and quality improvement Base individualized care plan on patient values, clinical expertise and evidence Differentiate clinical opinion from research and evidence summaries Read original research and evidence reports related to area of practice Describe reliable sources for locating evidence reports and clinical practice guidelines Locate evidence reports related to clinical practice topics and guidelines Explain the role of evidence in determining best clinical practice Participate in structuring the work environment to facilitate integration of new evidence into standards of practice Describe how the strength and relevance of available evidence influences the choice of interventions in provision of patient-centered care Question rationale for routine approaches to care that result in less-than-desired outcomes or adverse events Discriminate between valid and invalid reasons for modifying evidence-based clinical practice based on clinical expertise or patient/family preferences Consult with clinical experts before deciding to deviate from evidence-based protocols goal of clarifying rather than prescribing current meanings of the competency definitions, we outlined the knowledge, skills, and attitudes (KSAs) appropriate for pre-licensure education. During 2 workshops and multiple email communications, the authors led the process of KSA development. We focused on all of pre-licensure education (associate, diploma, baccalaureate, and master’s entry), because the ultimate goal is to assure that all patients will be cared for by nurses who have developed the KSAs for each competency. Quality and Safety Improvement Discussion. We tried to answer the question, “What should nursing promise with regards to its pre-licensure graduates’ quality and safety education?” At each step, we sought feedback from nursing faculty. In contrast to the results of the survey, when nursing 126 V O L U M E 5 5 ● N U M B E R 3 Attitudes N U R S I N G Value the concept of EBP as integral to determining best clinical practice Appreciate the importance of regularly reading relevant professional journals Value the need for continuous improvement in clinical practice based on new knowledge Acknowledge own limitations in knowledge and clinical expertise before determining when to deviate from evidence-based best practices school faculty from 16 universities in the Institute for Healthcare Improvement Health Professions Education Collaborative reviewed the KSA draft, they uniformly reported that nursing students were not developing these KSAs. Additional focus groups were held with faculty who taught pre-licensure students in QSEN faculty members’ schools, and the responses were the same. Although the faculty agreed that they should be teaching these competencies and, in fact, had thought they were, focus group participants did not understand fundamental concepts related to the competencies and could not identify pedagogical strategies in use for teaching the KSAs. A chief nurse executive serving on the QSEN advisory board led a focus group of new graduates. Not only did these nurses report that they lacked learning expeO U T L O O K Quality and safety education for nurses Cronenwett et al Table 4. Quality Improvement (QI) Definition: Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems. Knowledge Skills Attitudes Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clini ..Quality and Safety Improvement Discussion
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Medication administration is one of a nurse’s most crucial duties because any errors can have unintended, grave consequences for the patient. Medication errors contribute to adverse outcomes like increased duration of hospital stay, mortality rates, and high care costs. Physicians and pharmacists can cause medication errors, but those caused by nurses are the most common (Schroers et al., 2021). The purpose of this paper is to discuss factors associated with patient-safety risks in medication administration. In addition, the paper will discuss solutions to improve patient safety and coordination of care by nurses to improve patient safety and stakeholders.
Factors Leading to a Specific Patient-Safety Risk Focusing on Medication Administration
When working in a medical-surgical unit, a novice nurse administered a diabetic patient 60 IU of insulin instead of the indicated 20 IU. This led to the patient’s blood glucose levels fluctuating more abruptly than expected and becoming hypoglycemic. The attending physician noticed that the patient, who was previously active and alert, had suddenly developed confusion and was sweating and shaking. An RBS test was immediately taken and revealed the patient had sugar levels of 3.2 mmol/L. It was later established that the patient had been administered an overdose of insulin.
Wrong dosage is a common medication administration error (MAE) that risks patient safety. Factors attributed to this MAE include nurses’ clinical practices and techniques, errors in prescription, miscommunication, and errors in labeling, packaging, and nomenclature of medications. Nkurunziza et al. (2019) classify the causes of MAEs as Nurse-related, Physician-related, nurse-physician-related, and Organizational factors. Nurse-related factors include age, being a new nurse, work experience, fatigue, knowledge and skills about a medication, and dosage calculation skills. Physicians contribute to MAEs by changing medication orders to unclear orders leading to confusion among nurses. Besides, ineffective communication between nurses and physicians and nurses lacking the initiative to clarify prescription doubts contribute to MAEs (Mohammed et al., 2022). Organizational factors include a high workload for nurses, a high nurse-to-patient ratio, and interruptions during medication administration,
Evidence-Based and Best-Practice Solutions to Improve Patient Safety
Evidence-based solutions are crucial to reduce the incidence of MAEs and lower associated costs. Manias et al. (2020) identified the following solutions: Pharmacist-led medication reconciliation, pharmacist partnership, computerized medication reconciliation, prescriber education, and computerized physician order entry (CPOE). These interventions significantly reduced medication errors. Pharmacist-led medication reconciliation is time-consuming and expensive. Thus, computerized medication reconciliation is proposed as an appropriate alternative (Manias et al., 2020). However, the computerized system cannot replace pharmacists since they have the skills to take comprehensive medication history.
According to Tsegaye et al. (2020), MAEs can be prevented by adopting technology like bar-coding for medications and patients and smart infusion pumps for IV administration. The article also proposes using single-use drug packages and reducing interruptions during drug administration. In addition, nurse-physician-related factors can be addressed by creating effective communication and collaboration channels between healthcare providers. This includes facilitating open communications and team accountability among providers, which decreased MAEs. MAEs can also be reduced by developing and availing medication administration guidelines which help to enhance the quality of nursing care.
Self-reporting has also been proposed to reduce MAEs in patient care settings. Mutair et al. (2021) explain that efforts are required to promote reporting of medication errors. Reporting engages health providers in improvement opportunities and helps determine the MAE incidence’s root cause. Mutair et al. (2021) propose establishing a medication error reporting program. A successful reporting program should be safe for the provider who reports and should bring about constructive and useful recommendations and useful changes. It should also include all providers and be supported with relevant resources. Furthermore, barriers to self-reporting of MAEs among providers should be identified and addressed, significantly enhancing patient care.
How Nurses Can Help Coordinate Care to Increase Patient Safety with Medication Administration and Reduce Costs
Care coordination entails the management of a patient’s care between two or more care providers and the patients themselves. Nurses can assist in coordinating care in medication administration through structured medication monitoring, including early identification of drug-related problems (DRPs) and monitoring of ADRs to improve patient safety (De Baetselier et al., 2022). Nurses can also conduct assessments and follow up with patients on their medication regimen through phone calls to prevent DRPs.
In addition, nurses can manage patient medication self-management to prevent self-administration errors. De Baetselier et al. (2022) explain that nurses can evaluate patients’ drug self-administration competencies and caregiver-assisted self-administration and empower individuals to self-manage their medications. Regular visits by nurses and e-health interventions improve self-care and self-management of medications among patients, thus increasing their safety. Nurses can assess patients’ needs, educate patients and their caregivers before discharge, and follow up with patients after discharge. During the transition of care, nurses can identify medication discrepancies and communicate with the prescribing physician.
Stakeholders with Whom Nurses Would Coordinate To Drive Safety Enhancements
Collaboration with other healthcare professionals is indispensable. Nurses will need to coordinate with physicians, pharmacists, and patients to promote safety in medication administration. Thus, interprofessional communication is vital during discharge planning and follow-up (De Baetselier et al., 2022). For example, they will have to coordinate with physicians and inform them of the observed patients’ clinical status and needs to guide them in prescribing the appropriate medication and dosages. Besides, the nurse communicates with the physician and pharmacist on the identified side effects of medication and collaboratively plans the best therapeutic plan (De Baetselier et al., 2022). The nurse also collaborates with the patient and caregiver when educating them on the prescribed medications and during follow-up after discharge.
Conclusion
MAEs like incorrect dosage are attributed to nurse-related, physician-related, nurse-physician, and organizational factors. Pharmacist-led and computerized medication reconciliation, pharmacist partnership, prescriber education, use of technology, and self-reporting are some of the evidence-based solutions to addressing MAEs. Thus, it is possible to lower costs, and prolonged hospitalizations caused by MAEs and improve the quality of patient outcomes.
References
De Baetselier, E., Dilles, T., Feyen, H., Haegdorens, F., Mortelmans, L., & Van Rompaey, B. (2022). Nurses’ responsibilities and tasks in pharmaceutical care: A scoping review. Nursing Open, 9(6), 2562-2571. https://doi.org/10.1002/nop2.984
Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: a systematic review. Therapeutic advances in drug safety, 11, 2042098620968309. https://doi.org/10.1177/2042098620968309
Mohammed, T., Mahmud, S., Gintamo, B., Mekuria, Z. N., & Gizaw, Z. (2022). Medication administration errors and associated factors among nurses in Addis Ababa federal hospitals, Ethiopia: a hospital-based cross-sectional study. BMJ open, 12(12), e066531. http://dx.doi.org/10.1136/bmjopen-2022-066531
Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., Rabaan, A. A., Awad, M., & Al-Omari, A. (2021). The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems. Medicines (Basel, Switzerland), 8(9), 46. https://doi.org/10.3390/medicines8090046
Nkurunziza, A., Chironda, G., Mukeshimana, M., Uwamahoro, M. C., Umwangange, M. L., & Ngendahayo, F. (2019). Factors contributing to medication administration errors and barriers to self-reporting among nurses: a review of literature. Rwanda Journal of Medicine and Health Sciences, 2(3), 294-303. https://doi.org/10.4314/rjmhs.v2i3.14
Schroers, G., Ross, J. G., & Moriarty, H. (2021). Nurses’ perceived causes of medication administration errors: a qualitative systematic review. The Joint Commission Journal on Quality and Patient Safety, 47(1), 38-53. https://doi.org/10.1016/j.jcjq.2020.09.010
Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication Administration Errors and Associated Factors Among Nurses. International Journal of general medicine, 13, 1621–1632. https://doi.org/10.2147/IJGM.S289452