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- 1. Chapter 20 SAFE MEDICATION PREPARATION Copyright©2018,ElsevierInc.Allrightsreserved.
- 2. Medication Administration • The nurse must have a full understanding of medication administration and related nursing implications • Safe medication administration requires good judgment, critical thinking, and clinical decision- making skills • Nurse must perform a thorough patient assessment and have an understanding of pharmacotherapeutics, pharmacokinetics, growth and development, nutrition, and mathematics Copyright©2018,ElsevierInc.Allrightsreserved. 2
- 3. Pharmacological Concepts Medication names Chemical Generic Trade or brand Classification Indicates effect of medication on body system, symptoms the medication relieves, and desired medication effect Copyright©2018,ElsevierInc.Allrightsreserved. 3
- 4. Pharmacological Concepts (Cont.) Medication forms Determine the medication’s route of administration Pharmacokinetics Study of how medications enter the body, reach their site of action, are metabolized, and exit the body Copyright©2018,ElsevierInc.Allrightsreserved. 4
- 5. Types of Medication Action • Therapeutic effects are the intended or desired physiological responses of a medication • Adverse effects are unintended, undesirable, and often unpredictable • Side effects are predictable and often unavoidable secondary effects produced at a usual therapeutic drug dose Copyright©2018,ElsevierInc.Allrightsreserved. 5
- 6. Types of Medication Action (Cont.) • Toxic effects develop after prolonged intake of a medication, or when a medication accumulates in the blood because of impaired metabolism or excretion • Idiosyncratic reactions are those by which a patient reacts differently to a medication than is normal Copyright©2018,ElsevierInc.Allrightsreserved. 6
- 7. Quick Quiz! The nurse is interviewing a 51-year-old man upon admission. The patient states that he had a cardiac catheterization performed 5 years ago and now is in need of a kidney transplant. What type of medication action has this patient explained? Side effect Adverse effect Toxic effect Therapeutic effect Copyright©2018,ElsevierInc.Allrightsreserved. 7
- 8. Types of Medication Action Allergic reactions are unpredictable Patients with known drug allergies have their allergy information recorded in a clearly identifiable place 8 Copyright©2018,ElsevierInc.Allrightsreserved.
- 9. Types of Medication Action (Cont.) Medication tolerance and dependence Tolerance occurs over time Dependence may be physical or psychological (addiction) Medication interaction When one medication modifies the action of another medication, thus reducing or enhancing effectiveness Copyright©2018,ElsevierInc.Allrightsreserved. 9
- 10. Quick Quiz! A 25-year-old male with a history of IV drug abuse has come to the ER 6 times in the past week with different complaints of pain. The patient refuses administration of IV Ibuprofen, and insists that only IV morphine will relieve his pain. What should the nurse suspect based on the patient’s symptoms and treatment request? A.Ibuprofen has caused an allergic response in the past. B.The patient is dependent on IV morphine. C.The ER staff has not treated this patient well during his recent visits. D.Ibuprofen interacts adversely with the patient’s other medications. Copyright©2018,ElsevierInc.Allrightsreserved. 10
- 11. Types of Medication Action Medication dose response Medication goal is a constant blood level within a safe therapeutic range 11 Copyright©2018,ElsevierInc.Allrightsreserved.
- 12. Routes of Administration • The route prescribed for administering medication depends on the medication’s properties and desired effect and on the patient’s physical and mental condition • Collaborate with the prescriber in determining the best route for a patient’s medical condition Copyright©2018,ElsevierInc.Allrightsreserved. 12
- 13. Medication Distribution Verify medications before delivery using three system check: Health care provider ordering the right drug for the right purpose Pharmacist ensures appropriate drug is ordered correctly and provided to the unit correctly Nurse verifies drug before administration Copyright©2018,ElsevierInc.Allrightsreserved. 13
- 14. Medication Distribution (Cont.) Computerized provider order entry allows electronic ordering of medications Distribution systems are systems for storing and distributing medications Unit dose is the ordered dose of medication that the patient receives at one time Copyright©2018,ElsevierInc.Allrightsreserved. 14
- 15. Quick Quiz! The medication order is for amoxicillin 500-mg tablets PO bid. The hospital uses a unit-dose system. What should the nurse expect to find in the patient’s medication drawer at the start of the morning shift, to administer this medication? A.A large medication bottle containing 16 amoxicillin tablets. B.No medication—the pharmacy delivers one tablet at time of administration. C.Amoxicillin 1000-mg sustained-release tablets in easy- open packages. D.Two individual foil wrappers, each containing one amoxicillin 500- mg tablet. Copyright©2018,ElsevierInc.Allrightsreserved. 15
- 16. Medication Distribution AMDS Variation of unit- dose and floor stock systems Secure Automatic documentation 16 Copyright©2018,ElsevierInc.Allrightsreserved.
- 17. Medication Distribution (Cont.) Bar coding Required on all medications, vaccines, and over- the-counter (OTC) drugs used in health care agencies Use of bar codes improves accuracy of patient identification, alerts for potential medication error, and improves medical record keeping Copyright©2018,ElsevierInc.Allrightsreserved. 17
- 18. Systems of Medication Measurement • Metric system: a decimal system; each basic unit of measure is organized into units of 10 • Household measurements: include drops, teaspoons, tablespoons, and cups for volume, and ounces and pounds for weight • Solution: a given mass of solid substance dissolved in a known volume of fluid or a given volume of liquid dissolved in a known volume of another fluid Copyright©2018,ElsevierInc.Allrightsreserved. 18
- 19. Patient-Centered Care A nurse’s responsibility when administering medications safely must include effective communication with staff, pharmacy, patients, and family caregivers Patients are an important resource for understanding the knowledge they have about their medications Consider factors that influence patients’ ability to communicate effectively, such as anxiety, pain, hearing, and cultural background Copyright©2018,ElsevierInc.Allrightsreserved. 19
- 20. Safe Medication Administration Six Rights of Medication Administration The right medication The right dose The right patient The right route The right time The right documentation Copyright©2018,ElsevierInc.Allrightsreserved. 20
- 21. Right Medication A medication order is required for every medication that you administer to a patient Compare the prescriber’s orders with the medication administration record (MAR) or the electronic MAR (eMAR) when the medication is initially ordered Copyright©2018,ElsevierInc.Allrightsreserved. 21
- 22. Medication Orders May be written or electronic, verbal, or telephone Each order must include patient’s name, drug ordered, dosage, route of administration, and time(s) of administration Standing, prn, and single orders (stat or now) are common Copyright©2018,ElsevierInc.Allrightsreserved. 22
- 23. Right Dose Double-checking Standard measurement devices Splitting and crushing pills 23 Copyright©2018,ElsevierInc.Allrightsreserved.
- 24. Right Patient Always use at least two patient identifiers Wireless bar-code scanners 24 Copyright©2018,ElsevierInc.Allrightsreserved.
- 25. Right Route If the route of administration is missing, or if the specified route is not the recommended route, consult the prescriber immediately Recent evidence shows that medication errors involving the wrong route are common Copyright©2018,ElsevierInc.Allrightsreserved. 25
- 26. Right Time Prescribed dosage schedules Schedule alterations When is it okay to deviate from set dosage schedules? Copyright©2018,ElsevierInc.Allrightsreserved. 26
- 27. Right Documentation Allows communication Improves medication safety Always document accurately Do not document medications until after they are given Copyright©2018,ElsevierInc.Allrightsreserved. 27
- 28. Medication Preparation Interpreting medication labels Correct identification Clinical calculation Medications are not always dispensed in the unit of measure in which they are ordered 28 Copyright©2018,ElsevierInc.Allrightsreserved.
- 29. Medication Preparation (Cont.) Conversions within one system Divide or multiply in the metric system Conversions between systems Use equivalent measurements Dosage calculation methods Formula Dimensional analysis Ratio and proportion Copyright©2018,ElsevierInc.Allrightsreserved. 29
- 30. Medication Preparation (Cont.) Pediatric doses Calculation requires caution Children are at risk for ADEs due to metabolic rate Age, weight, body system maturity affects ability to metabolize and excrete medication Older adult dosages Have altered pharmacokinetics Polypharmacy Follow safety precautions Copyright©2018,ElsevierInc.Allrightsreserved. 30
- 31. Evidence-Based Practice Many medication errors are a result of workplace distraction Avoid distracting team members during medication preparation and administration Avoid distractions by: Wearing a medication safety vest Use of visible medication preparation signs Medication administration checklists Staff and patient education Use of no interruption zones Copyright©2018,ElsevierInc.Allrightsreserved. 31
- 32. Nursing Process Application ensures that critical thinking and clinical judgment are integrated into the patient’s care Copyright©2018,ElsevierInc.Allrightsreserved. 32
- 33. Nursing Process (Cont.) Assessment Physical assessment Medication allergies Current daily medications Copyright©2018,ElsevierInc.Allrightsreserved. 33
- 34. Nursing Process (Cont.) Planning Organize nursing activities to ensure the safe administration of medications Distractions and haste increase the risk of medication error Implementation Focus on safe and effective drug administration Copyright©2018,ElsevierInc.Allrightsreserved. 34
- 35. Preadministration Activities 1. Identify medication action, purpose, and side effects and nursing implications for administering and monitoring. 2. Minimize distractions during medication preparation. 3. Ensure that information on the medication computer sheet corresponds exactly with the prescriber’s written order and with the medication container label. Copyright©2018,ElsevierInc.Allrightsreserved. 35
- 36. Preadministration Activities (Cont.) 4. Read the label on the medication container and compare it with the MAR at least 3 times. 5. Double-check all calculations and high-risk medication administration processes, and verify with another nurse. 6. Review any preadministration assessments. Copyright©2018,ElsevierInc.Allrightsreserved. 36
- 37. Preadministration Activities (Cont.) 7. Use good hand-hygiene technique; avoid touching tablets and capsules. 8. Administer only those medications that you personally prepare. 9. When preparing medications, be sure that the label is clear and legible and that the drug is mixed properly; has not changed in color, clarity, or consistency; and has not expired. Copyright©2018,ElsevierInc.Allrightsreserved. 37
- 38. Preadministration Activities (Cont.) 10. Keep tablets and capsules in their wrappers, and open them at the patient’s bedside. This allows you to review each medication with the patient. If the patient refuses medication, there will be no question which one was withheld. 11. TJC has a standard for labeling syringes including before a procedure, labeling all medicines that are not labeled (e.g., medicines in syringes, cups, basins) Copyright©2018,ElsevierInc.Allrightsreserved. 38
- 39. Medication Administration 1. Follow the six rights of medication administration. 2. Inform the patient of the name, purpose, action, and common side effects of each medication. 3. Stay with the patient until the medication is taken. 4. Respect the patient’s right to refuse a medication. Copyright©2018,ElsevierInc.Allrightsreserved. 39
- 40. Postadministration Activities 1. Record medications immediately after administration (see agency policy). 2. Document data pertinent to the patient’s response. 3. Document postassessment data pertinent to patient’s response. 4. If the patient refuses a medication, document that it was not given, the reason for refusal, and when you notified the health care provider. Copyright©2018,ElsevierInc.Allrightsreserved. 40
- 41. Nursing Process Evaluation 1.Monitor for evidence of therapeutic effects, side effects, and adverse reactions. 2.When a medication is given for relief of symptoms, ask the patient to report whether symptoms have diminished or relieved. 3.Observe injection sites for bruises, localized pain, inflammation, numbness, or bleeding. 4.Evaluate patient’s and family caregiver’s understanding of medication therapy and ability to self-administer medication. Copyright©2018,ElsevierInc.Allrightsreserved. 41
- 42. Reporting Medication Errors • A written incident or occurrence report must be filed (usually within 24 hours of an incident) • The incident report is an internal audit tool and is not a permanent part of the medical record • Report all medication errors, including mistakes that do not cause obvious or immediate harm or near misses Copyright©2018,ElsevierInc.Allrightsreserved. 42
- 43. Patient and Family Teaching • A well-informed patient is more likely to take medications correctly • Thoroughly assess a patient’s learning needs and abilities • Individualize your approach to teaching • Include family caregivers or home care providers in your instruction • Evaluate teaching effectiveness Copyright©2018,ElsevierInc.Allrightsreserved. 43
Editor's Notes
- This chapter reviews safe medication preparation and pharmacology.
- Safe and accurate medication administration is a challenging and important nursing responsibility.
- Medication names The chemical name provides an exact description of its composition and molecular structure. A manufacturer who first develops a medication provides the generic name. A medication trade name or brand name is used to market the medication. Similarities among different names can cause confusion. The same medication may have a different appearance between generic and brand name forms, and even between different manufacturers of generics, causing confusion for some patients. Classification Medications with similar characteristics are categorized by their class. [Ask students: can medication be part of more than one class? Discuss: yes. For example, aspirin is an analgesic, antipyretic, and antiinflammatory medication.]
- Medication forms The composition of a medication influences its absorption and metabolism. When administering a medication, be certain to use the proper form. [Review with students Table 20-1, Forms of Medication.] Pharmacokinetics Absorption is the passage of medication molecules into the blood from the site of administration. Factors that influence the rate of absorption include the administration route, ability of a medication to dissolve, blood flow to the administration site, body surface area, and lipid solubility of a medication. After a medication reaches its site of action, it is metabolized into a less active or inactive form. Biotransformation occurs under the influence of enzymes that detoxify, degrade (break down), and remove biologically active chemicals. Most biotransformation occurs in the liver, although the lungs, kidneys, blood, and intestines also play a role. The final aspect of pharmacokinetics is excretion, the process by which medications exit the body through the lungs, exocrine glands, bowel, kidneys, and liver. The chemical makeup of a medication determines the organ of excretion. Understanding pharmacokinetics allows you to properly time medication administration, select an administration route, and judge a patient’s response to medications. [Review with students Table 20-2, Medication Absorption.]
- [Ask students: can a medication have more than one therapeutic effect? Discuss: yes, sometimes a single medication has many therapeutic effects. For example, aspirin relieves pain and reduces fever and tissue inflammation.] Every medication has the potential to harm a patient. No medication is totally safe and absolutely free of nontherapeutic effects. Adverse drug events or effects (ADEs) are sometimes apparent immediately, but often they take weeks or months to develop. ADEs range from mild (e.g., rashes, photosensitivity to light) to potentially fatal (anaphylaxis). Always assess patients who may be at high risk for an ADE such as pregnant women and patients with chronic disorders. Side effects can be harmless or can cause injury. If side effects are serious enough to outweigh the benefits of the therapeutic action of a medication, the prescriber will likely discontinue the medication. Patients commonly stop taking medications because of side effects such as anorexia, nausea, vomiting, dizziness, drowsiness, dry mouth, constipation, and diarrhea. Report any side effect to the health care provider to ensure that it is not incorrectly interpreted as a more serious adverse medication reaction.
- Toxic effects Excess amounts of a medication within the body sometimes have lethal effects, depending on the action of the medication Antidotes are available to treat specific types of medication toxicity. Idiosyncratic reactions An idiosyncratic reaction is an unpredictable effect, in which a patient overreacts or underreacts to a medication or has a reaction different from normal. Predicting which patients will have an idiosyncratic response is impossible.
- Correct answer: C Rationale: The dye from the cardiac catheterization has caused permanent kidney damage in this patient. Toxic effects develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion. Excess amounts of a medication within the body sometimes have lethal effects, depending on the medication’s action.
- An allergic reaction forms when exposure to an initial dose of a medication causes a patient to become sensitized immunologically. With repeated administration, a patient develops an allergic response to the drug, its chemical preservatives, or a metabolite. An allergic reaction ranges from mild to severe, depending on the patient and the medication. Among the different classes of medications, antibiotics cause a high incidence of allergic reactions. Severe or anaphylactic reactions, which are life threatening, are characterized by sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, severe wheezing, and shortness of breath. [Review with students Table 20-3, Mild Allergic Reactions.] Patients who are cared for in other settings, like home or community clinics, and have a known history of an allergy to a medication or substance should wear an identification bracelet or medal, which alerts all health care providers to the allergies, in case a patient is found unconscious or is unable to communicate. [Shown is Figure 20-1: Identification bracelet and medal.] Always record a patient’s allergies in the MAR.
- Medication tolerance and dependence It is usually noted clinically when patients receive the same medication for long periods and require higher doses to produce the desired therapeutic effect. Medications known to produce tolerance include opium alkaloids (e.g., morphine), nitrates, and ethyl alcohol. Patients hospitalized for acute episodes of illness usually do not develop tolerance. Medication tolerance is not the same as medication dependence. Medication dependence In psychological dependence, the patient desires the medication for benefit other than the intended effect. Physical dependence is a physiological adaptation to a medication that manifests itself by intense physical disturbance when the medication is withdrawn. [Ask students: is a patient likely to develop medication tolerance or dependence in one hospital visit? Discuss: no. It may take a month or longer for tolerance to occur. When patients receive medications over a short term, such as for postoperative pain, dependence is rare.] Medication interaction Some medications increase or diminish the actions of other medications and alter the ways in which another medication is absorbed, metabolized, or eliminated from the body. When two medications have a synergistic effect, their combined effect is greater than the effect of each drug given separately.
- Correct answer: B Rationale: Based on the patient’s history of intravenous (IV) drug abuse, his frequent visits to the emergency room (ER), and his refusal of IV ibuprofen, the nurse will need to determine whether this patient has developed a dependence on IV morphine. The patient needs further assessment and a pain consult. Two types of medication dependence exist: physical and psychological (or addiction). The nurse will need to determine whether the patient is dependent on morphine. In psychological dependence, the patient desires the medication for benefit other than the intended effect. Physical dependence is a physiological adaptation to a medication that manifests as intense physical disturbance when the medication is withdrawn.
- After administration, a medication undergoes absorption, distribution, metabolism, and excretion. When a medication is administered repeatedly, its serum level fluctuates between doses. The highest level is called the peak concentration, and the lowest level is called the trough concentration. A patient’s trough level is drawn as a blood sample 30 minutes before the drug is administered, and the peak level is drawn whenever the drug is expected to reach its peak concentration. Results of the blood test reveal whether the drug is reaching its therapeutic blood level. All medications have a biological half-life, which is the time it takes for excretion processes to lower the serum medication concentration by half. Know the following time intervals of medication action to anticipate the effect of a medication: 1. Onset of medication action: period of time it takes after a medication is administered for it to produce a therapeutic effect. 2. Peak action: time it takes for a medication to reach its highest effective peak concentration. 3. Trough: minimum blood serum concentration of medication reached just before the next scheduled dose. 4. Duration of action: length of time during which a medication is present at a concentration great enough to produce a therapeutic effect. 5. Plateau: blood serum concentration reached and maintained after repeated, fixed doses. [Shown is Figure 20-2: The therapeutic range of medication occurs between the minimum effective concentration and the toxic concentration. (From Burchum J, Rosenthal L: Lehne’s pharmacology for nursing care, ed 9, St Louis, 2016, Saunders.)]
- [Review with students Table 20-4, Routes of Medication Administration.] [Review with students Table 20-5, Factors Influencing Choice of Administration Routes.]
- A number of technologies for medication distribution have the potential for reducing medication errors and ADEs. The technologies include computerized provider order entry (CPOE), automated medication dispensing system (AMDS), and bar coding.
- CPOE increases the accuracy and legibility of medication orders; creates evidence-based order sets; and strengthens nursing documentation and coordination of care. Decision support software integrated into a CPOE system allows for automatic drug allergy checks, dosage indications, baseline laboratory result checks, and identification of potential drug interactions. [Ask students: what are some examples of distribution systems? Discuss: institutions providing nursing care have special areas for stocking and dispensing medications. Special medication rooms, portable locked carts, computerized medication cabinets, and individual storage units next to patients’ rooms are examples of storage areas used.] Medication storage areas must be locked when unattended. The unit-dose system uses an AMDS or carts containing a drawer with a 24-hour supply of medications for each patient. Each medication form is wrapped separately in a foil or paper container. Liquid doses come in prepackaged foil or plastic cups. Controlled substances are not in the individual patient drawer; they are in a larger locked drawer so they are kept secure. A unit-dose system is designed to reduce the number of medication errors and saves steps in dispensing medications.
- Correct answer: D Rationale: Unit dose is individually wrapped with one dose per package. The standard for medication distribution is the unit-dose system. This system uses AMDS or carts containing a drawer with a 24-hour supply of medications for each patient. A large volume would not be delivered in unit dosing. Amoxicillin 1000 mg is the incorrect dose.
- AMDSs control the dispensing of all medications, including narcotics. Each nurse has a security code, which allows access to the system. If your agency uses a system that requires bioidentification, you have to place your finger on a screen to access the computer. Once logged onto the AMDS, you select a patient’s name and medication profile. Then you select the medication, dosage, and route from a list displayed on the computer screen. The system opens the medication drawer or dispenses the medication to the nurse, records the event, and charges it to the patient. If the system is connected to the patient’s medical record, information about the medication (e.g., name, dose, time) and the name of the nurse who retrieved it from the AMDS are recorded in the patient’s medical record. There is evidence of an increase in reported medication errors with use of the system and a reduction in dispensing errors through the use of alerts that are embedded within the clinical decision support system. The use of AMDS has been shown to reduce the chance of medication errors. [Shown is Figure 20-3: Automated medication dispensing system.]
- Bar codes electronically link with a hospital computer system. A patient’s medication administration record (MAR) entered into the computer database and encoded in the patient’s wristband is accessible to the nurse through a handheld device. The device scans the patient’s wristband and then displays the MAR. When administering a medication, the nurse scans the bar code on the drug and the patient’s medical record number on the wristband. The computer processes the scanned information, charts it, and updates the patient’s MAR appropriately.
- Proper administration of medication depends on your ability to compute medication doses accurately and measure medications correctly. A careless mistake in placing a decimal point or adding a zero to a dosage can lead to fatal errors. The prescriber and the patient depend on you to check doses before administering medications. Medication therapy uses metric, apothecary, and household systems of measurement. The apothecary system is used infrequently today. The most common medication measurement system is the metric system. In the metric system, the basic units of measure are the meter (length), the liter (volume), and the gram (weight). For drug calculations, you will use primarily volume and weight units. Many errors happen with the use of fractions or decimal points. Use practice standards when medications are ordered in fractions to prevent errors. For example, never use a trailing zero (e.g., 1.0 mg) and always include a zero before a decimal point. Household measures are familiar to most people, but these are not recommended for medication administration because of variability in the size of household utensils. It is safe to use household measures when the accuracy of a medication dose is not critical (e.g., over-the-counter [OTC] medications). Solutions of various concentrations are used for injections, irrigations, and infusions. Solutions are available in units of mass per units of volume (e.g., g/mL or g/L). You can also express the concentration of a solution as a percentage. [Review with students Table 20-6, Equivalents of Measurement.]
- A new scientific field, pharmacogenetics, involves the study of the genetic influence on drug response that occurs from inherited metabolic defects or deficiencies. The most common mechanism of genetic influence on medications is the alteration in drug metabolism. As a nurse, you cannot detect a genetic abnormality. [Ask students: how can cultural background influence medication adherence? Discuss: a patient’s level of education, prior experience with medication therapy, and the family’s influence on actions significantly influence medication adherence. For example, in some cultures, it is not acceptable to complain about gastrointestinal problems; so it is common for patients to not report nausea, vomiting, and bowel changes related to medication use. Use of herbal and homeopathic remedies in some cultures alters response to medication. Ethnicity needs to be considered when medications are prescribed and administered. The effectiveness of some drugs varies depending on the patient’s ethnicity.]
- Standards are actions that help ensure safe nursing practice. They are set by health care agencies and the nursing profession. Most agencies have procedure manuals that contain policies about which medications nurses can and cannot deliver. To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors are linked in some way to an inconsistency in adhering to the six rights. Each “right” is discussed on the following slides.
- A strategy to reduce medication errors at transition points is the process of medication reconciliation. When patients enter a health care agency, it is critical for health care providers to have an accurate list of the medications patients are currently prescribed to take as well as any over-the-counter (OTC) medications being used. A medication order is required for every medication that you administer to a patient. Nurses verify medication information whenever new MARs are written or distributed, or when patients transfer from one nursing unit or health care setting to another. The Institute for Safe Medication Practices (ISMP) and The Joint Commission (TJC) have published a list of error-prone and prohibited abbreviations that have been found to increase the incidence of errors in medication administration. You are responsible for using correct abbreviations and verifying that the order was transcribed accurately. [Review with students Table 20-7, Institute for Safe Medication Practice List of Error-Prone Abbreviations.]
- When you receive a verbal or telephone order, write or enter the order on the physician’s order sheet. The name of the prescriber and your signature should be included. The prescriber will countersign the order at a later time, usually within 24 hours after making it (see agency policy). [Review with students local agency policy on verbal or telephone orders.] [Review with students Box 20-3, Guidelines for Verbal and Telephone Orders.] Five common types of orders based on frequency and/or urgency of medication administration orders are standing orders; prn orders; and single (one-time) orders, which include stat orders and now orders. You carry out a standing order until the health care provider cancels it with another order, or until a prescribed number of days elapse. A prn order states that a medication can be ordered to be given only when a patient requires or requests it. Single (one-time) orders are common for preoperative medications or medications given before diagnostic procedures. The medication is ordered to be given only once, at a specified time. A stat order means that you give a single dose of medication immediately and only once. A now order is more specific and is used when a patient needs a medication quickly but not as soon as a stat order. Once you determine that information on the patient’s MAR is accurate, use the MAR to prepare and administer medications. When preparing medications from bottles or containers, compare the label of the medication container with the MAR 3 times: before removing the container from the supply drawer or shelf, as the amount of medication ordered is removed from the container, and at the patient’s bedside before administering the medication to the patient. Never prepare medications from unmarked containers or containers with illegible labels. With unit-dose prepackaged medications, check the label with the MAR when taking medications out of the medication dispensing system. Finally, verify all medications at the patient’s bedside with the patient’s MAR and use at least two identifiers before giving the patient any medications. If a patient questions a medication, stop and recheck to make sure there is no mistake.
- After calculating the doses of high-risk medications such as insulin or warfarin, compare the calculation with one done independently by a second nurse. This is especially important if it is an unusual calculation or involves a potentially toxic drug. After calculating doses, prepare the medication using standard measurement devices. ISMP now recommends only using graduated cups that measure in mL. If the cup still measures in drams, ISMP recommends the use of an oral syringe that measure in mL. Key principles to observe when using measuring receptacles include the following: Pour liquid medication into a medication cup with the cup on a flat surface at eye level, so you can see the desired amount accurately. The amount of poured liquid must be even with the base of the meniscus. Pour liquid medications away from a label to ensure that liquid will not run down it, making it difficult to read. Draw liquid medication into a syringe (without a needle) slowly to prevent air bubbles from entering the syringe. Air displaces medications and leads to inaccurate measurement of doses. [Shown is Figure 20-4: A, Pour desired volume of liquid so base of meniscus is level with line on scale. B, Place cup on flat surface and read at eye level to confirm volume poured.] To promote patient safety in inpatient settings, pharmacists split medications, label and package them, and return them to the nurse for administration. Be sure to clean the crushing device completely before crushing the tablet. Remnants of previously crushed medications increase the concentration of the medication or result in a patient’s receiving a portion of an unprescribed medication. Refer to the “Do Not Crush List” (ISMP, 2010c) to ensure that a medication is safe to crush.
- Acceptable patient identifiers include the patient’s name, an identification number assigned by a health care agency, and date of birth. [Shown at top is Figure 20-5: Before administering any medications, check patient’s identification and allergy bracelets.] In addition to using two identifiers, some agencies use a wireless bar-code scanner to help identify the right patient. This system helps prevent medication errors because it provides another step to ensure that the right patient receives the right medication [Shown at bottom is Figure 20-6: Nurse using bar-code scanner to identify patient during medication administration.]
- Recent evidence shows that medication errors involving the wrong route are common. For example, enteral and parenteral medications may become confused in the pediatric setting, where liquid medications are frequently given orally. When oral medications are prepared in parenteral syringes, the risk of giving an oral medication through the parenteral route is increased.
- [Ask students: when is it okay to deviate from set dosage schedules? Discuss.] Some agencies set schedules for medication administration. However, nurses are able to alter this schedule based on knowledge about a medication. For example, if the set time for daily medications is 9 a.m., but the nurse knows that a medication is more effective at bedtime, the nurse administers it before the patient goes to sleep. Always know why a medication is ordered for a certain time of the day and whether you are able to alter the time schedule. Hospitals must determine which medications are time-critical scheduled and which are non–time-critical scheduled. With time-critical medications (e.g., antibiotics, anticoagulants, insulin, immunosuppressives), early or delayed administration of maintenance doses of more than 30 minutes before or after the scheduled dose will most likely cause harm or result in subtherapeutic responses in a patient. Non–time-critical medications include medications in which the timing of administration most likely will not affect the desired effect of the medication if the medication is given 1 to 2 hours before or after its scheduled time. Give priority to medications that must act at certain times. When preparing patients for discharge, help them plan schedules based on preferred medication intervals, pharmacokinetics of the medication, and the patient’s daily schedule. For patients who have difficulty remembering when to take medications, make a chart that lists the times when the patient should take each medication or prepare a special container to hold each timed dose.
- Many medication errors result from inaccurate documentation. Always document accurately at the time of administration and verify any inaccurate documentation before administering medications. To ensure the right documentation, first make sure that the information on your patient’s MAR corresponds exactly with the prescriber’s order and the label on the medication container. If there is any question about a medication order because it is incomplete, illegible, vague, or not understood, contact the health care provider before administering the medication. Document on the patient’s MAR the name of the medication, the dose, the time of administration, and the route. Also document the site of any injections and the patient’s response to medications.
- It is legally advisable to administer only medications that you prepare. Administering a medication prepared by another nurse increases the opportunity for error. The importance of checking similar names and verifying the correct drug cannot be overemphasized. Medication labels include several basic pieces of information: the trade name of the drug in large letters, the generic name in smaller letters, the form of the drug, the dosage, the expiration date, the lot number, and the name of the manufacturer. [Shown is Figure 20-7: Interpreting medication label. (Courtesy Dr. Reddy’s Laboratories, Inc.)] To administer medications safely, use your mathematics skills to safely calculate dosages and mix solutions. Medication companies package and bottle medications in standard dosages. For example, a patient’s health care provider orders 20 mg of a medication that is packaged in 40-mg vials. You are responsible for converting available units of volume and weight to the desired doses. Therefore, be aware of approximate equivalents in all major measurement systems and make use of conversion tables. In addition to medication administration, nurses use volume and weight conversions in a variety of other nursing activities, including converting fluid ounces to milliliters to measure intake and output (I&O) or converting volume equivalents to calculate IV flow rates.
- Converting measurements within one system is relatively easy; simply divide or multiply in the metric system. To change milligrams to grams, divide by 1000 or move the decimal three points to the left. To convert liters to milliliters, multiply by 1000 or move the decimal three points to the right. To convert units of measurement within the household system, consult an equivalency table. Tables of equivalent measurements are available in all health care agencies. The pharmacist is also a good resource. Before making a conversion, compare the measurement system available with that ordered. The most common methods of dosage calculations are ratio-proportion or use of a formula.
- Pediatric Other factors that influence medication dosages in children include the difficulty in evaluating the desired effect and the hydration status of the child. In most cases the health care provider will calculate the dose for a child before ordering the medication. However, it is your responsibility to be aware of the safe dosage range for any medication administered and should recheck/recalculate to confirm correct dose. The two most common methods of calculating pediatric dosages are based on the child’s weight or body surface area (BSA). Refer to a pediatric pharmacology resource, a pharmacist, or the health care provider if you have to calculate a medication based on BSA. Most of the time you calculate medications based on the child’s weight. Older adults The changes of aging alter pharmacokinetics. In addition to physiological changes of aging, behavioral and social/economic issues influence the older adult’s use of medications. A common problem for older adults is polypharmacy. Safety precautions include assessing a patient’s health status, current medication regimen (including OTC drugs and herbal products), the reason for existing and proposed medications, and any environmental factors that influence accurate and safe medication administration by the patient and family caregiver(s).
- Many medication errors occur when nurses become distracted or lose focus during medication administration, or fail to follow best-practice protocols and procedures related to medication administration.
- You are responsible for monitoring patients’ responses to medications; providing education to the patient and family; and informing the health care provider when medications are effective, ineffective, or no longer necessary.
- Assessment Before administering medications, perform a physical assessment, which will reveal physical findings for any indications or contraindications for medication therapy. Determine whether the patient has a history of medication allergies. When assessing for medication allergies, you must differentiate between actual allergic reactions, which can be life threatening, and drug sensitivities, which are uncomfortable side effects. Never give a patient a medication when there is a known allergy. Identify medications that the patient takes every day at home, including prescriptions, OTC preparations, and herbal supplements. By assessing the patient’s level of knowledge, you determine the need for teaching. If a patient is unable to understand or remember pertinent information, it may be necessary to involve a family member. Complete appropriate assessments, which may include vital signs, laboratory data, and the nature and severity of symptoms. If data contraindicate medication administration, hold the drug and notify the prescriber. When in doubt about medication information, check available medication references or the pharmacy.
- Planning The following are general goals of medication administration: Patient achieves therapeutic effect of the prescribed medication. No patient complications are related to the prescribed medication. Patient and/or family understand medication therapy. Patient and family self-administer medication safely (when appropriate). Safe implementation includes careful medication preparation, accurate and timely administration, and patient education.
- Ensure that the medication order has not expired. Follow agency policy for medication order renewal. Distractions during medication preparation may include discussion with staff, phone call, or pager. Close the door of the medication room or post “Do Not Disturb” signage, and do not perform other tasks while preparing a medication. Do not interpret illegible handwriting; clarify with prescriber.
- The 3 times that the label should be read and compared with the MAR include before the container is removed from the supply drawer, when the medication is placed in an administration cup/syringe, and just before the medication is administered to the patient. An example of a high-risk medication administration process is patient-controlled analgesia. Examples of preadministration assessments are vital signs and review of laboratory results.
- Use sterile technique for parenteral medications. Wear clean gloves when administering parenteral medications and certain topical medications. Do not ask another person to administer medications that you prepare. Keep medications secure. [Discuss ways to determine whether the medication has changed in color, clarity, or consistency.]
- Opening tablets and capsules at the patient’s bedside allows you to review each medication with the patient. This should be done in the area where medicines and supplies are set up.
- [Ask students to recall the six rights.] Evaluate the patient’s knowledge of the medication and provide appropriate teaching. Provide assistance as necessary. Do not leave medication at the bedside without a prescriber order. For example, some patients may take their own vitamins while in the hospital. If the medication wrapper remains intact, return the medication to the patient’s unit-dose drawer. When medication is refused, determine the reason and take action accordingly.
- Include the drug name, dose, route, and time, and your signature. Documenting patient response is especially important when giving prn drugs. This is especially important when giving prn drugs. [Discuss ways to handle a patient’s refusal.]
- After you administer a medication, consider how the medication is expected to affect the patient, and evaluate his or her condition and response to it. Look for therapeutic and adverse effects. If adverse effects develop, you need to recognize the clinical signs and respond quickly. Monitoring includes physical responses such as heart rhythm, blood pressure, urine output, or laboratory results.
- Medication errors often harm patients because of inappropriate medication use. [Ask students: what is considered a medication error? Discuss: errors include inaccurate prescribing; administering the wrong medication, by the wrong route, and in the wrong time interval; and administering extra doses or failing to administer a medication.] When an error occurs, the patient’s safety and well-being are the top priorities. The nurse assesses and examines the patient’s condition and notifies the health care provider of the incident as soon as possible. Once the patient is stable, the nurse reports the incident to the appropriate person in the agency (e.g., manager or supervisor). To legally protect the health care professional and the institution, do not refer to an incident report in the nurses’ notes. Depending on the circumstances and the severity of the outcome, the nurse or agency may be responsible for reporting the incident to TJC, MedWatch (FDA Medical Products Reporting Program), or USP Medication Errors Reporting Program. You should feel comfortable in reporting an error and not fear repercussions from managerial staff. [Review with students Box 20-8, Steps to Prevent Medication Errors.]
- Many patients have limited health literacy, meaning that they do not understand how to read medication labels and calculate doses. Evaluate the patient’s learning needs and abilities, and tailor your instructions accordingly. It is legally mandated by the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in health care to provide easy-to-understand print and multimedia materials in the languages commonly used by the populations in a service area. When teaching patients about their medications, include people identified as being significant to the patient’s recovery (e.g., family caregivers or home care providers). Begin instruction as soon as possible, so you can have several teaching sessions. Have the patient demonstrate preparation of each medication. Evaluate the effectiveness of your teaching. If the patient correctly identifies the name of the medication, ask him or her the following questions: Why are you taking this medication? How often do you take this medication? What side effects can occur with this medication? If this side effect occurs, what are you going to do about it? Be sure to also assess the patient’s sensory, motor, and cognitive functions (e.g., ability to open medication bottles). Impairments may affect the patient’s ability to safely self-administer medications, and family caregivers or home health aides may need to assist with medication administration. Many self-help devices are also available for purchase (e.g., pill boxes with times displayed and electronic dispensers).