Injectable medication comprises all medications that can be injected, such as intravenous infusions and subcutaneous or intramuscular injections. Over 90% of all hospitalized patients receive some form of infusion therapy, including injectable medication. Administering injectable medication is also associated with an increased risk of patient harm. This high risk is caused by the fact that injectable medication has an immediate therapeutic effect and can reach dangerous drug levels in a short period of time. Besides, errors with injectable medication are often irreversible. When errors do occur, this can lead to an adverse event. An adverse event (AE) is an unintended injury that results in prolongation of a hospital admission, temporary or permanent disability or death and was caused by healthcare management instead of the patient’s disease. About 19-44% of adverse events involve medication, in particular at the stage of medication administration. It is estimated that approximately 10% of all injectable medication administrations are associated with at least one error.
Measuring the number of adverse events is one perspective for looking at patient safety; it is called the Safety-I perspective. Safety-I has been the standard for years and most research is done from this perspective. Safety-II is a relatively new perspective and focuses on understanding how work that often goes well is performed in clinical practice. It also focuses on understanding resilience and variability in the process. The main differences between Safety-I and Safety-II are that Safety-II focuses on all healthcare outcomes instead of only the negative outcomes (e.g. AEs), and Safety-II is more proactive and sees humans as a part of the solution instead of part of the problem.
Administering injectable medication is a primary task of nurses. In the past decade, the role of nurses in the medication administration process has changed due to an increase in training-related interventions, interventions that prevent interruptions, various implemented protocols and the use of information technology. Most previous studies focused on just one of these aspects of the process. However, the medication process is complex and it is important to understand the whole healthcare system in which healthcare professionals work.
To increase the safety of administering injectable medication in Dutch hospitals, a protocol was implemented between 2008 and 2012. In 2020, that protocol is still the prevailing protocol. It contains 25 steps for the safe administration of injectable medication of which nine most important and identifiable proceedings were selected by an expert group. The first evaluation of this protocol was conducted in the year 2011/2012. It was found that protocol compliance (achieved when all nine proceedings are conducted correctly) was achieved in only 19% of all observed administrations. The lowest compliance was observed in three proceedings: conducting hand hygiene, identifying the right patient and the check by a second nurse. These findings gave rise to questions such as: what are the reasons for poor compliance, is the protocol feasible or too complex to follow in daily practice, and what barriers and facilitators are related to protocol compliance?
To understand the whole injectable medication administration system, including the complexity, the Systems Engineering Initiative for Patient Safety (SEIPS) model can be used as a theoretical base. The model was introduced in 2006 (SEIPS 1.0) and revised in 2013 (SEIPS 2.0). By using SEIPS, we can understand interactions between the work system, processes and outcomes. Furthermore, an adaptation phase was incorporated in the SEIPS 2.0 model. With this phase, the model takes into account the fact that processes are not linear but dynamic, and that nurses need to react and adapt constantly to unexpected situations in the process (e.g. complexity). Therefore, the adaptation phase is in line with the Safety-II perspective.

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