5.1 Introduction
This chapter will both discuss and summarise the main aspects of the thesis, addressing the research questions and aims of the study, the results and their relation to published literature and will conclude with recommendations for practice and for future research. Before commencing the discussion chapter it is worth revisiting the aim of the study. This study aimed to gain a more accurate understanding of ME occurrence in one large Paediatric Intensive Care Unit (PICU) and to explore the paediatric intensive care (PIC) team’s perceptions of MEs and how they perceive that they learn from them. The specific research questions asked and the answers generated are presented here first, before commencing the integrated discussion with the literature and looking at them in more detail; they are
5.2.1 How do self-reported medication administrations error rates by PICU nurses compare to those observed in practice?
Underreporting of MEs was observed on the PICU. Three MEs were observed out of 59 medication administration episodes, and none of these errors were identified through either the formal reporting system or via the paper form used on PICU. This suggests that MEs remain underreported and that direct
observations of practice provide a more accurate incidence of errors and in identifying true ME rates, rather than relying on reporting alone. An additional advantage of using the observation method was the identification of areas to improve medication safety administration on the PICU. Interruptions and distractions across the whole team on PICU were frequent and observed to increase the number of violations and deviation from protocols for medication administration. The aspect of not reporting and its link to blame and fear of
punishment, was noted during the observations, focus groups and interviews and was highlighted as a contributory factor in the lack of reporting of
medication errors.
5.5.2 How do doctors and nurses who work in the PICU perceive MEs, the management of errors and how they learn from them?
Staff perceptions of the reality of practice and working on PICU gave an insight into how the culture of PICU may contribute to MEs. Nurses and doctors
perceived that internal and external distractions were commonplace on PICU, affecting the whole PICU team. Nurses articulated how consultants, doctors and families interrupted them during medication administration, and nurses talked of how they could not always control these interruptions and distractions.
However, the doctors and consultants perceived that nurses interrupted and distracted them whilst they were prescribing and they also stated that they thought this was sometimes the result of nurses’ lacking situational awareness. In contrast to the nurses, the consultants, senior doctors and ANPs stated they did have some control over these distractions. Another factor which the nurses and nurse managers perceived contributed to MEs on PICU, was the nurses noncompliance with protocols, specifically the protocol for two nurses to independently check IV medication during administration.
Communication problems around the management of MEs were highlighted, which were enhanced by shift working and inconsistencies in management. Managers did not always follow the standardised procedure and this was exacerbated by the absence of bedside nurses at the critical incident meetings. There was the perception amongst the doctors and pharmacists that better engagement of bedside nurses would lead to better understanding of the process following a ME to improve the learning process.
Whilst staff perceived that reporting of MEs is an important first step in the process of learning, they highlighted many barriers. Nurses stated that clinical workload, time, blame, punishment and prioritising other tasks inhibited
reporting. Interestingly, some doctors perceived that it was the nurses’ job to report MEs. Doctors perceived that their workload, time burden of paperwork, logistics, failure and blame would inhibit their reporting. From the scenarios introduced at the beginning of the nurse focus group and interviews, the likelihood of reporting was also dependent on the perceived harm and consequence to the patient of the error. Misconceptions and inconsistencies around reporting of MEs arose due to the use of personal definitions of what constituted an error, which was particularly evident with near misses.
The current reflective learning tool used by this unit, given to individuals following involvement in a ME, has the potential to share learning across the PICU team, but learning may be inhibited at the beginning if it is not handled effectively. Doctors reported that learning took place following a ME through informal discussions with their colleagues, with the added benefit of gaining support following an error. Nurses explained that feedback following a ME on the PICU was reliant on emails and the managers expressed frustration that staff did not always read and learn from. Both nurses and doctors highlighted the importance of feedback, which gave an incentive to report and learn from other errors. Nurses described how emails were a form of negative feedback following a ME on PICU. By striking a balance of communication through emails that introduced additional positive feedback on areas such as the success of interventions introduced on the PICU, may increase the incentive to read these emails.
5.2.3 What is the quality of the ME reflective learning tools submitted in the PICU?
The content analysis of the learning tools highlighted that the current practice of learning from MEs using these tools does not always lead to the required self- analysis and reflection on the error, nor demonstrates individual leaning.
Overall, the quality of reflection and self-analysis was poor. Frequently, the tool seems to be used by nurses to express the emotional effects of the error and this suggests that the tool is used as a coping mechanism to deal emotionally with an error. In contrast, doctors more often described the error in an
unemotional and objective manner. Staff often blamed themselves and then looked externally to find an excuse and rationalise the error. Where individual learning was identified, staff had a heightened awareness of the need to be more focused. However, the fact that these tools were given to their managers, may reflect people telling the managers what it is perceived they want to hear. The findings from the focus groups and interviews reinforced these findings that staff felt the reflective learning tool was a tick box exercise, that didn’t achieve the required learning outcomes and it was not being used effectively.
Additionally, management perceived the reflective learning tool as a form of documentation or record of a discussion having taken place with staff following involvement with a ME, rather than a learning tool which it was intended to be.
5.3 Integrated discussion and theoretical framework
This chapter now presents an integrated discussion of the key findings and their relationship with the existing published literature. The chapter is presented in five sections, organised under the following headings: observation of
medication administration on PICU; perceived culture on PICU; factors affecting ME reporting; learning from MEs and content analysis of reflective learning tools.
Chuang et al’s. (2007) theoretical framework of learning from failure will guide the interpretation of the results. A summary of this theoretical model is shown below (Diagram 6) to aid clarity to the discussion. Chuang et al. (2007) acknowledge that learning takes place at different levels amongst individuals, groups and organisations and they theorise that to improve safety,
organisations must consider how the transfer and translation of knowledge takes place between these groups. The theoretical model draws upon learning theories and group behavior learning. It looks at how learning occurs over time and diffuses across levels, how best to translate individual learning into group learning and how individuals and groups determine which practices are effective and which are ineffective. This model was therefore chosen, to help highlight how the PICU may improve learning from failure and highlight the factors that might facilitate learning from failure and others that impede it. Within the discussion, analogies will be drawn where appropriate to the different propositions within the theoretical model. The model proposes 11 different propositions, which will be incorporated into the discussion where appropriate. They are listed in Appendix 18 to aid clarity and guide the discussion.
Diagram 6 of Chuang et al. (2007) theoretical model of learning from