ORIGINAL RESEARCH published: 14 July 2020 doi: 10.3389/fphar.2020.01026 Serious Inadequacies in High Alert Medication-Related Knowledge Among Pakistani Nurses: Findings of a Large, Multicenter, Cross-sectional Survey Muhammad Salman 1*, Zia Ul Mustafa 2, Alina Zeeshan Rao 3, Qurat-ul-Ain Khan 4, Noman Asif 3, Khalid Hussain 3, Naureen Shehzadi 3, Muhammad Farhan Ali Khan 5 and Amir Rashid 6 1 Department of Pharmacy Practice, Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan, 2 Department of Pharmacy, District Headquarter Hospital, Pakpattan, Pakistan, 3 Punjab University College of Pharmacy, University of the Punjab, Lahore, Pakistan, 4 Department of Pharmacy, Punjab Institute of Cardiology, Lahore, Pakistan, 5 Department of Edited by: Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan, 6 Department of Pharmacology, Faculty of Pharmacy, The Joseph O. Fadare, University of Lahore, Islamabad, Pakistan Ekiti State University, Nigeria Reviewed by: Introduction: Deaths-related to medications errors are common in Pakistan but these Tanveer Ahmed Khan, National Institute of Health, Pakistan are not accurately reported. Recently, the death of a 9 months old baby due to abrupt Brian Godman, administration of 15% potassium chloride injection sparked the issue of high alert Karolinska Institutet (KI), Sweden medications (HAMs) related errors in the country. Since drug administration is the prime *Correspondence: Muhammad Salman responsibility of the nurses, it is pivotal that they possess good knowledge of HAMs. Since muhammad.salman@ there is no published data regarding the knowledge of HAMs among Pakistani nurses, we pharm.uol.edu.pk; aimed to assess knowledge of HAMs among registered nurses of Pakistan. [email protected] Methods: A cross-sectional study was conducted among registered nurses, recruited using a convenient sampling technique, from 29 hospitals all over the Punjab Province. Specialty section: This article was submitted to Data were collected using a validated self-administered instrument. All data were entered Pharmaceutical Medicine and analyzed using SPSS version 22. and Outcomes Research, a section of the journal Results: The study sample was comprised of 2,363 registered nurses (staff nurses = Frontiers in Pharmacology 94.8%, head nurses = 5.2%). Around 63% were working in tertiary hospitals whereas Received: 12 December 2019 almost 25 and 12% were from district headquarter hospitals and tehsil headquarter Accepted: 24 June 2020 Published: 14 July 2020 hospitals, respectively. Around 84% of the study participants achieved scores <70%, Citation: indicating majority of Pakistani nurses having poor knowledge of HAMs administration as Salman M, Mustafa ZU, Rao AZ, well as regulation. There was no significant difference of overall knowledge among age, Khan Q-u-A, Asif N, Hussain K, hospitals, departments, training, designations, qualification, and experience categories. Shehzadi N, Khan MFA and Rashid A (2020) Serious Inadequacies in High Major obstacles encountered during HAMs administration were “getting uncertain Alert Medication-Related Knowledge answers from colleagues” (72.9%), “unavailability of suitable person to consult” (61.1%) Among Pakistani Nurses: “ ” Findings of a Large, Multicenter, and receiving verbal orders (55.6%). Cross-sectional Survey. Conclusion: Our study revealed the serious inadequacies in HAMs knowledge among Front. Pharmacol. 11:1026. doi: 10.3389/fphar.2020.01026 Pakistani nurses which may lead to adverse patient outcomes. Nurses should receive Frontiers in Pharmacology | www.frontiersin.org 1 July 2020 | Volume 11 | Article 1026 Salman et al. Knowledge of High-Alert Medications Among Nurses comprehensive pharmacology knowledge not only during in-school nursing education but also as hospital-based continuing education. Moreover, it is of immense importance to bridge the gaps between physicians, clinical pharmacists, and nurses through effective communication as this will help reduce medication errors and improve patient care. Keywords: barriers, high alert medications, knowledge, nurses, Pakistan INTRODUCTION patient care. Administration of drug to the particular patient according to the prescriber’s order is one of the most crucial tasks Medication error is defined as “any preventable event that may performed by nursing staff. Unlike the other health care team cause or lead to inappropriate medication use or patient harm members, nurses are always in close contact with the patient while the medication is in the control of the health professional, throughout the course of their treatment. Therefore, they are well patient, or consumer. Such events may be related to professional aware about the actual condition of patient before and after drug practice, health care products, procedures, and systems, administration and can actively report adverse drug reactions. The including prescribing, order communication, product labeling, most common nursing-associated medication errors are related to packaging, and nomenclature, compounding, dispensing, administrations of drugs (Choi et al., 2016). Published data showed distribution, administration, education, monitoring, and use” that the major reasons of medication administration errors by (NCCMERP, 2015). There are several ways to classify these nurses are related to medication packaging e.g. similarities in errors. One way is to classify these errors in the sequence of packaging, appearance and names (Mrayyan et al., 2007; Dumo, medication use process: prescribing, transcribing, dispensing, 2012; Mrayyan, 2012; Hammoudi et al., 2018), and poor administration, or monitoring (WHO, 2016). Another communication between physicians and nurses (Kim et al., 2011; approach is to classify them according to whether they occur Dumo, 2012; Topcu et al., 2017; Hammoudi et al., 2017). With from mistakes in planning actions (knowledge-based or rule- regards to the barriers of medication errors reporting, important based errors) or errors in carrying out an action (action-based factors are the administrator’s responses to medication errors, fear, errors, also called “slips,” or memory-based errors, also called reporting efforts, disagreements on the definitionsoferrors(Chiang “lapses”)(Ferner and Aronson, 2006; Aronson, 2009). A further et al., 2010; Petrova et al., 2010; Kim et al., 2011; Aboshaiqah, 2013; approach is to classify medication errors as wrong patient, Shamim et al., 2016; Hammoudi et al., 2018). Pakistan is a resource- medication, dose, frequency, duration, and route of limited country where disease burden is very high. The current administration (WHO, 2016). Medication errors pose life status of country’shealthcaresystemisworrying.Deathsdueto threatening risk to the patient and a high economic loss medications errors are common but these are not reported due to (Perrone et al., 2014; Tshiamo et al., 2015; Akhideno et al., the lack of required mechanism and fear of patient relatives’ 2018; Formica et al., 2018). Medication error is the prime patient reaction or adverse career-related repercussions (DAWN News, safety and quality care concern nowadays. Globally, 2–5% 2017). Recently, the death of a 9 months old baby in a private sector hospital admissions are due to medication errors and most of hospital of Karachi (Capital city of Sindh, Pakistan) due to abrupt them are preventable (Roughead et al., 2013; Perrone et al., 2014; administration of 15% potassium chloride (KCl) injection had AHRQ, 2015; Latimer et al., 2017; Iftikhar et al., 2018). highlighted the issue of high alert related medication errors in the According to the statistics of Centers for Disease Control and country (Jafferi, 2019; Geo News, 2019; 92 News, 2019). According Prevention, medications errors are the third leading cause of to the Pakistan economic survey 2017–2018, 108,474 registered mortality in United States with 98,000 deaths per annum (Pham nurses were performing duties across the country (FDGOP, 2019). et al., 2012; Makary and Daniel, 2016). Their awareness about the high alert medication is of vital High alert medications (HAMs) cause serious health injuries importance as these drugs possess greater potential to cause or even death to the patient if use improperly. As compared to serious consequences, if administered inappropriately. To the best ordinary drugs, HAMs carry greater risks of adverse events of our knowledge and literature survey, there is no published data (Labib et al., 2018; Shen et al., 2018). The American regarding the knowledge of HAMs among registered Pakistani Pharmaceutical Association categorizes HAMs into following nurses. Therefore, current study was carried out to estimate the classes, chemotherapeutic agents, cardiovascular medications, knowledge about administration and regulation of HAMs among anticoagulants, opioids and their derivatives, neuromuscular registered nurses of Pakistan. Moreover, the possible barriers faced blocking agents, benzodiazepines, and some electrolytes like in the administration of HAMs were also evaluated. potassium chloride (15%) (Zyoud et al., 2019). Majorly, these medications are used in acute and emergency rooms. Others places of HAMs usage are intensive care unit, coronary care unit, METHODS hemodialysis unit, pediatrics ward, medical ward, as well in labor room and surgical ward. Study Design and Setting Nurses are the nucleus of health care system. Being a vital This cross-sectional study was conducted among the registered member of health care provision team, they are actively involved in nurses