This document discusses medication orders and administration. It covers the rights of medication administration, interpreting physician orders, medication administration records, and reference materials. Key points include the basic rights being right patient, right drug, right dose, right time, right technique, and right documentation. Physician orders must include patient name, drug, dosage, route, frequency and prescriber information. Medication administration records must match orders and allow documentation of each dose given. Reference materials help ensure safe medication practices.

1. Math and Dosage Calculations for Health Care Third Edition Booth & Whaley McGraw-Hill 5- Chapter 5: Drug Orders Edited by B. Holmes MSN/Ed, RN

2. Learning Outcomes Summarize the Rights of Medication Administration. Interpret a written drug order. Identify on physicians’ orders and prescriptions the information needed to dispense medication.

3. Learning Outcomes (cont.) Locate on medication administration records or electronic medication records the information needed to administer medication. Recognize drug orders that do not contain all of the necessary information to carry out the orders safely. Select appropriate action for confusing, incomplete, or illegible drug orders.

4. Introduction It is important to be able to read and understand a drug order to correctly calculate medication dosages. You can be held responsible for medication errors regardless of the source.

5. Rights of Medication Administration Basic Rights Right patient Right drug Right dose Right route Right time Right documentation Additional Rights Right reason Right to refuse Right to know Right technique

6. Right Patient Before giving a medication to a patient Check for two identifiers. Patient’s full name Another identifier – date of birth, SSN, or medical record number Ask the patient state his/her full name and second identifier.

7. Right Patient (cont.) Check that the name on medication order is exactly the same as the name of the patient. Outpatient – photographic identification Inpatient – identification number, identification bracelet, bar code scanning Check the bed number.

8. Right Drug To be sure a patient receives the right drug. Only give drugs that you prepared yourself Check the expiration date. Check original order before administration If the patient questions a medication, make sure you are able explain the drug, purpose, and side effect

9. Right Drug (cont.) A patient always has the right to refuse a medication. Dispose of refused medications according to facility guidelines.

10. Right Drug (cont.) Rule 5 – 1 C heck medication three times: 1. when you take it off the shelf 2. when you prepare it when you replace it on the shelf Check it three times even if it is prepackaged, labeled, and ready to be administered. 3

11. Right Dose Preparing and administering the right dose may require calculations. Conversion from dosage ordered to desired dose Amount to administer Use extreme caution when calculating dosages. Pay special attention to decimal points

12. Right Route A drug intended for one route may not be safe if administered via another route. Be especially careful between ophthalmic and otic routes.

13. Right Route (cont.) Some medications are produced in different versions for different routes. Example aspirin is available as tablets or as suppositories Check that route listed on drug label matches route ordered.

14. Right Time Most often within 30 minutes of schedule Absolute time – 9:00 a.m. Relative time – before breakfast Drug order should identify special timing considerations if needed. PRN medications Given when needed with a specified time interval. Check when previous dose was given.

15. Right Documentation Sign the medication administration record (MAR) immediately after the patient takes the medication. Do not document prior to giving the medication. If documentation not done, medication administration is not complete Also document if the patient Refuses a medication Consumes only part of the dose Vomits after taking the drug

16. Right Reason Know why a medication is being given. Check medication record Check order Check with prescribing physician

17. Right to Know Patients must be educated about their medications, including the Reason for taking the medication Expected effect of the medication Side effects of medications

18. Right Technique Medications must be given correctly according to the order. For example: Buccal -- between cheek and gum Sublingual -- under the tongue If unsure of technique Physicians’ Desk Reference (PDR) Facility policy or procedure manual Valid Internet source

19. Roman Numerals Are used sometimes in drug orders. Calculating dosages may involve changing Roman numerals to Arabic numbers. Letters represent numbers. Commonly used Roman numerals ss = ½ I = 1 V = 5 X = 10

20. Combining Roman Numerals Rule 5 – 2 When reading a Roman numeral containing more than 1 letter, follow these two steps: 1. If any letter with a smaller value appears before a letter with a larger value, subtract the smaller value from the larger value. 2. Add the value of all the letters not affected by Step 1 to those that were combined.

21. Combining Roman Numerals (cont.) IX = 10 –1 = 9 XIV = 10 + (5-1) = 14 XXVIII = 20 + (5+3) = 28 Doctor’s orders are most likely to contain Roman numerals from 1 to 30. Most common Roman numerals are: V & X Examples

22. Practice 1. Convert the following Roman numerals to Arabic numbers: viiss XII XIX ixss 2. Provide the answers to the following in Arabic numbers: V + V xxii – vii XXXV – XIV xvi + xii 7½ 12 19 9½ 10 15 21 28

23. Physician’s Orders and Prescriptions Abbreviations used when writing orders: General abbreviations Form of medication Route Frequency Approved abbreviations vary among facilities Memorize commonly used abbreviations Keep facility's approved list available

24. Commonly Used General Abbreviations

25. Abbreviations Commonly Used for Form of Medication

26. Abbreviations Commonly Used for Routes of Administration

27. Abbreviations Commonly Used for Frequency

28. Abbreviations Joint Commission on Accreditation of Healthcare Organization (JCAHO) “ Do Not Use” abbreviations “ Undesirable” abbreviations Check abbreviations carefully in drug orders. Q.O.D

29. “ Do Not Use” Abbreviations

30. Undesirable Abbreviations

31. Undesirable Abbreviations (cont.)

32. Undesirable Abbreviations (cont.) Do Not Use Potential Problem Use Instead > (greater than) < (less than) Misinterpreted as the number “7” (seven) or the letter “L” Confused for one another Write “greater than” Write “less than” Abbreviations for drug names Misinterpreted due to similar abbreviations for multiple drugs Write drug names in full Apothecary units Unfamiliar to many practitioners Confused with metric units Use metric units @ Mistaken for the number “2” (two) Write “at” cc Mistaken for U (units) when poorly written Write &quot;mL&quot; or “milliliters” µg Mistaken for mg (milligrams) resulting in one thousand-fold overdose Write &quot;mcg&quot; or “micrograms”

33. Physician’s Drug Order Essential elements Full name of the patient Full name of the drug Dosage Route Time Frequency Signature of prescribing physician Date PRN order must include the reason

34. Outpatient Settings Physicians’ orders are given as prescriptions. Prescriptions include all the elements of a physician’s order plus Physician’s name and prescriber number Quantity to be dispensed Number of refills Instructions for the label

35. Prescription Form Drug and dose Quantity to dispense Instructions to appear on the label Number of refills permitted Patient’s full name Date Physician name

36. Inpatient Settings Physicians’ order form Multiple orders on one form Essential elements of a medication order Patient’s name and physician signature appear once Orders may be entered into a computer

37. Physician’s Order Form

38. Error Alert! Never guess what the prescriber meant! If the order is not legible, always contact the prescribing physician to clarify the order.

39. Verbal Orders Acceptable if the physician is unable to write an order that must be carried out quickly Governed by state laws If permitted to accept a telephone order Write it carefully and legibly as you receive it Read the order back to the physician Ask for clarification of spelling if unsure

40. Error Alert! Always be certain that you are dispensing the correct medication. Many drugs have names that are similar. Acular—Ocular Benadryl—Bentyl Cafergot—Carafate Darvon—Diovan Digitoxin—Digoxin Eurax—Urex Iodine—Lodine Nicobid—Nitrobid Examples

41. Practice What, if anything, is wrong with this prescription? Allen Capsella, MD Westtown Medical Clinic 989-555-1234 Name: M Ward Date: 8/15/2008 Address: Rx: Lopressor QUANTITY: SIG: 1 tab BD Refills: 2 MD398475 A Capsella, MD Prescriber ID # Physician Signature

42. Practice ANSWER 1. It does not include patient’s full name. 2. There is no dosage strength for the lopressor. 3. There is no quantity to be dispensed. 4. No route is given. Click to return to prescription

43. Medication Administration Systems Standard schedule for administering medication Varies by facility Verifier Ensures that the times listed for administration are appropriate Adjust times as necessary Mealtimes Conflicting medication schedule

44. Sample Times for Medication Administration Frequency Ordered Times to Administer qd 0800 bid 0800 – 2000 tid 0800 – 1400 – 2000 qid 0800 – 1200 – 1600 – 2000 q 12 hrs 0800 – 2000 q 8 hrs 2400 – 0800 – 1600 q 6 hrs 2400 – 0600 – 1200 – 1800 Every night at bedtime 2000

45. Medication Administration Records (MAR) Legal documents that may be handwritten or computerized Contain same information as the order form Specify the times to administer the medication Provide a place to document each medication administration

46. Medication Administration Records (MAR) (cont.) Rule 5-3 MARs must include the following information: 1. Name of medication, dose, route, frequency 2. Times that accurately reflect the frequency specified 3. Name and identification number of patient 4. Date order was written (including start and end dates as necessary) 5. Special instructions or information required by the facility

47. Practice Is the following MAR complete? If not, what is missing? ANSWER The order is transcribed correctly and all information is complete. Date init. Medication, dose, duration, frequency, route D/C date init Admin time 2/5 CS Vasotec 10 mg po BID hold for systolic BP < 100 0800 x 2000 x

48. Practice Is the following MAR complete? If not, what is missing? Date init. Medication, dose, duration, frequency, route D/C date init Admin time 2/5 CS Synthroid 50 mcg PO Bid 0800 x x x 2/5 CS Erythromycin tab i po q6h 0800 x 2000 x 2/5 CS Persantine 75 mg po q6h 2400 0800 1600 x 2/5 CS heparin 10,000 units q 8 hr 2400 0800 1600

49. Practice ANSWER 1. Order A is correct. 2. Order B does not include the strength of the medication and there is an error in the times listed. The “hours” reflect only a q 12 hr dosing rather than a q 6 hr dosing. 3. Order C contains an error in the times listed. There are only 3 times listed and it should be q 6 hours (4 times). 4. Order D does not include a route. Click to return to MAR

50. Medication Cards Rarely used One drug per card Disadvantages Easily misplaced Increased potential for omitting a medication Do not list allergies or diagnoses

51. Medication Card (cont.) Patient’s name Room number Full name of drug Dose, route, frequency Special instructions Administration times Date ordered

52. Computerized Medical Records Patient information is entered directly into a computer. Information is easily updated and accessible. Includes Orders Lab results Allergies Appointments Discharge plans

53. Computerized Medical Record

54. Computerized Medical Records (cont.) Electronic Medication Administration Records (eMARs) Ongoing working document Records medications as they are administered Users must log into system using secure passwords

55. eMAR

56. Medication Reference Materials To dispense or administer medications Know effects of the drugs Be familiar with drug information sources

57. Medication Reference Materials (cont.) Resources Package inserts Physicians’ Desk Reference (PDR) United States Pharmacopeia National Formulary Drug handbooks Reputable Internet sites Software programs used with personal digital assistant (PDA)

58. Apply Your Knowledge Which of the basic rights of medication administration is not listed? Right patient Right drug Right dose Right time Right technique Right documentation Answer right route

59. Apply Your Knowledge What do the following abbreviations mean? pc Bid hs supp BP Click for each answer. after meals Twice a day At bedtime suppository blood pressure

60. Apply Your Knowledge Even though these are inappropriate abbreviation, what do they mean? Qd Au MSO4 cc ug

61. Apply Your Knowledge Qd = daily Au = both ears MSO4 = Morphine cc = milliliters ug = microgram

62. End of Chapter 5 You must motivate yourself EVERYDAY! ~Matthew Stasior