SJOG Subiaco Hospital: Medication Chart

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St John of God Subiaco Hospital - Medication Chart: uses and responsabilities

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SJOG Subiaco Hospital: Medication Chart

  1. 1. Uses and Responsibilities
  2. 2. Clients depend on educated Registered and Enrolled Nurses to safely administer the right medication at the: • Right time • In the right dose, and • Via the right route After all, this together with many other responsibilities is what we are accountable for and the rationale behind remuneration.
  3. 3. • It is clear from evidence found that increased interruptions experienced by nurses administering medications will significantly increase the risk of errors in medications. • Nurses not responsible for administering medications need to take on a role of making sure that the nurse doing the medication administration is not interrupted. • All nurses need to be prepared to meet the needs of the patients and ensure that safety is an integral part of their practice.
  4. 4. Nursing Caregiver Responsibility for the checking and administration of Medications • All Medications must be checked and/or administered as per hospital policy 030 • The overall administration of medications is the responsibility of the RN/RM/EN • The Nurse must always check against a valid order
  5. 5. Valid Oder • The following details must be checked by a nurse against a valid order: • Patients name and UR number • Allergies • Name of medication • Dosage of medication • Frequency of dosage • Route of administration • Expiry of medication • Condition of medication
  6. 6. Where to find the information? • Patients name and UR number
  7. 7. • Allergies The Alert Section incorporates the ability to record food and other alerts as well as drugs.
  8. 8. • Once Only Medication: Medication will be ordered here by the Physician when requiring the medication to be given as a once off. • Can you think of examples?
  9. 9. • Short term telephone orders: This is where the RN must document telephone/verbal orders as per policy 032. • Can you tell me the requirements for this? • Who can listen? • How long are these orders valid?
  10. 10. • Nurse Initiated Medication: This is where the RN will document the Nurse Initiated Medication as per policy 044. • Subsequent administration must be evaluated by the RN prior to another dose being given to the patient.
  11. 11. Nurse Initiated Medication cont.. • If therapy is to be ongoing – over 48 hours the Medical Practitioner must be informed of the need to review the patients medications and prescribe the necessary medication as deemed appropriate. • Where will you find the list of medications that the RN can nurse initiate?
  12. 12. • Intravenous Incremental doses: This is where the Doctor will order IV doses that will require daily reviewing and charting. • Can you think of some examples of medications that would be ordered in this section of the medication chart?
  13. 13. • Variable dose medication: This section will be used for the Medical Practitioner to order variable dose medication. • Can you think of some examples of medication that would be ordered here?
  14. 14. • Regular medication: • Regular medication orders have a prompt for medical practitioners to enter “times of administration” at the time of prescribing to assist in the clarification of the frequency of orders and reduce the likelihood of error. • A box has been added to the regular orders for pharmacists or medical practitioners to tick if the medication is slow release to alert nursing staff that these medications cannot be crushed.
  15. 15. Regular Medication cont…. • There is a section above the date on the administration section on each page for the clinical pharmacist to initial the days they have completed their pharmaceutical review. • The nurse must sign the medication chart immediately after they have witnessed the administration of the medication to the patient. • The RN/EN is legally obliged to question a medication order if it is believed to be an error. • What must you check prior to medication administration? • Which policy must you check to ensure the safe administration of medications to all patients at St John of God Hospital, Subiaco?
  16. 16. • Dose Code: all codes used must be circled to prevent them from being mistaken for a nurse’s initials. • These are the only codes to be used on the medication chart.
  17. 17. • PRN Medication: A separate PRN section with space for 5 medications has been included to highlight and separate these orders from regular medication orders. This separation allows for the following: a) the maximum dose to be administered in 24 hours and b) an indication to be specified • There are bigger administration time boxes to facilitate easier documentation of the time, dose and the administering nurse initials. • In addition, a “clinical pharmacist review” box is available to be initialled on the day of each pharmaceutical review.

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