2. Today’s Objectives…
Differentiate the roles of various health team members in
medication preparation and administration.
State the essential parts of a drug order.
Describe nursing actions which maintain physical safety
of clients receiving medications.
Discuss factors that determine appropriate routes for
drug administration.
Demonstrate preparation, administration, and charting of
medications.
Identify the most common medication errors made by
nurses and what can be done to decrease errors in the
clinical setting.
3. Roles of Health Team Members
Physicians
Advanced practice nurses
Pharmacists
Unit Secretaries
Registered nurses
LPN
Medical technicians
4. Medication Order Components
Full name of client
Date and time order is written
Name of the drug to be given
Dosage of the drug
Route of administration
Frequency of administration
Reason for medication (PRN meds)
Signature and licensure of the person writing the order
Atenolol 50mg po daily Nathan Bowler, MD
9/3/2010, 1500
5. Types of Orders
Based on frequency/urgency of order
Standing orders
PRN orders
One time orders
Stat orders
Now orders
Prescriptions
6. Nursing Actions r/t Med Administration
Review medical history
Check the MAR
Assess for “poly-pharmacy”
Check for allergies
Know normal dose ranges
Critical lab values
K+ (3.5-5.0)
Mg+ (1.8-2.6)
AST, ALT, (<50) albumin (3.1-5)
Creatinine (0.6-1.4)
7. Nursing Actions r/t Med Administration
Assess:
ability to swallow
GI motility
muscle mass (for injection)
venous access (for IV)
vital signs
BP, HR, O2 sats
Evaluate response
8. Patient Medication Education
Name-dose-action
When to take?
With/without meals
Coping with expected/most common SE
Warnings of toxic effects
9. The Six Rights
Right medication
Avoid verbal orders
Does drug make sense with pt’s history?
Right dose
Double check all drug calculations
Right time
Timing of critical meds
10. The Six Rights
Right route
Best route considering needs
Right client
2 identifiers
Check for allergies
Drug-drug interactions
Right documentation
Always AFTER med given
11. Practice Guidelines
These guidelines are necessary for the safe
administration of all medications
Patient assessment (HR-BP-LOC)
6 rights
3 checks before administration
#1 - Check with MAR as pull drugs
#2 -Recheck drugs to be administered with MAR
#3 - Recheck drugs to be administered with MAR at bedside
– Verify Pt ID
– Verify MAR with patient at bedside
12. Practice Guidelines
Give medications one at a time
Keep in unit dose wrapper til given
Educate on meds while giving
“do you know why you are taking_______?”
If knowledge deficit apparent incorporate in plan
of care that day
Why taking & what it does…at their level
Most common side effects
With food?
When to take and how often
13. What to do if…
Your patient is lethargic and confused
after receiving a prn dose of Morphine
Patient drops a tablet on the floor
Drops his HR from 72 to 52 after Atenolol
Develops a red raised rash with itching
after a first dose of Ampicillin
Refuses his medication that is ordered by
the physician
14. Medication Safety Tips
Nursing responsibilities
Follow the 6 rights of med administration
Read med labels comparing with MAR 3 times
Use 2 client identifiers
Name, DOB or MR#
Avoid interruptions during the med admin
process
Clarify illegible handwriting with prescriber
Question unusually large or small doses
15. Medication Safety Tips
Nursing responsibilities
Double check all calculations – verify with another RN
as needed
When you have made an error, reflect on what went
wrong and how it could have been prevented.
Follow extra care and safeguards around High Alert
meds – these have a high potential for error and
adverse effects.
– Heparin
– Insulin
16. What Influences Med Errors…
Nurses <5 yrs or >20 yrs highest error %
Shift with most med errors?
Average amount of med errors annually by
RN’s?
1-2/year
Which violation of the 5 rights most common?
Wrong time
Wrong dosage
Interruptions during med pass
Each interruption increased liklihood of error 12.7%
17. Are These med Errors???
Crushing tablets that should not be crushed.
Use of discontinued or out-of-date medications.
Pushing an IV medication too rapidly or undiluted (when it
should be diluted for patient safety).
Giving a patient (with a K+ 5.2) the prescribed KCL 20
meq po daily.
Administering Furosemide 40 mg po to a patient with a
BP of 84/40.
Not documenting the site of an intramuscular injection
18. Would you ? these orders…
Tamsulin (Flomax) 0.4 mg po now
54 yr old female with current kidney stone
Hydromorphone (Dilaudid) 12 mg IV now
28 yr male-pain with sickle cell disease 9/10
Morphine 10 mg IV now
32 yr female with acute abd pain 10/10
19. What can Be Done to Decrease…
No interruptions during med pass
Critical thinking & questioning
Healthy collaborative physician
relationships
EMR: computerized MD order entry
20. What if Med Error made???
Assess pt. response/safety
Contact physician
Document in chart just the facts
Do not mention a safety report was filled out
Document in facilities Safety Report (incident
report)
Risk management reviews
Manager provides follow up/remediation
If severe incident, notify nurse manager or
supervisor ASAP
21. Cognitive Skills Required
Basic knowledge of pharmacology
Drug name
Types of preparation
Types of orders
Drug classification and action
Side effects/adverse effects
Drug dose calculations
Knowledge of how to prepare and administer
drugs safely
22. Technical skills
Ability to implement
techniques for safe
and effective
preparation and
administration of
meds
23. Interpersonal skills
Ability to communicate clearly and
effectively
Ability to establish trusting relationships as
a basis for teaching and counseling
The student nurse is also an EDUCATOR
24. Ethical/legal Skills
Commitment to safety and quality; strong
sense of responsibility and accountability
Knowledge of institutional policy and
procedure manual related to
administration of meds
Commitment to report medication errors
and to follow agency policy for working to
prevent their recurrence
Editor's Notes
#3:Roles of health team members : abide by a system in ordering and administering drug therapy
Prescriber – such as a Doctor, NP or PA Orders must include the reason for the order. ( with diagnosis, condition or need)
Orders can be direct verbal or telephone order. The physician verifies/ signs the order within 24 hours. The
nurse must write the complete order, repeats it back to the prescriber and verifies/confirm it with the prescriber before hanging up or leaving the conversation. Student nurses are not allowed to take verbal or telephone orders
Pharmacists – fill the prescriptions and make sure they are valid. In a health care setting, they evaluate the medication orders, watch for inconsistencies, on the alert for medication allergies, medication interactions, Makes sure that they are dispensing the correct med, dose and amount all properly labeled.
Unit secretary takes orders off a paper chart and submits them to pharmacy, writes them on the MAR, kardex. The RN verifies the transcription
RN – makes no assumptions….Administers medications using knowledge, experience, attitude and skill( demonstrates willingness to use critical thinking skills). Takes the necessary time to look up the medications, know the history, Looks over the chart and history, physical exam and orders. Looks up meds he/she doesn’t know, follows safe procedure consistently, and follows standards of nursing practice) uses the nursing process to integrate med administration with nursing care. Must follow institutional policies. The nurse follows ANA Nursing Scope and standards of nursing practice to prevent medication errors.
Uses 6 rights and 3 checks to assure safe medication administration. Educates the patient and family
RN IS ULTIMATELY RESPONSIBLE FOR EACH MED ADMINISTERED!!!
LPN certain defined responsibilities with med administration – mostly around IV push meds. Med tech is trained for medication administration and is used primarly in the SNF setting.
#4:READ ABOVE – components of a medication order
Order of drug order – name of client, then date and time order is written, followed by name of drug, dose, route, frequency then sugnature and licensure of the prescriber
Look at page 118 of dosage calc book for commonly used abbreviations for route and frequency. Learn these
Ex: pc, ac, hs
Example on board:
EX: 10/4/2008 0730 - Valium 10 mg po q 8 hours PRN anxiety. DR Smith
#5:Standing orders – (also called routine orders) – med orders by the prescriber will continue until prescriber cancels the order – can also can also be cancelled after a prescribed number of days has passed.
Usually indicates a final date, number of treatments – or doses.
EX: Ampicillin 500 mg po 4 times a day X 7 days.
PRN - Pro re nata is a Latin phrase that literally means "for the thing born". It is commonly used to mean "as needed" or "as the situation arises."
PRN is often added to the prescribed directions for medication used to treat symptoms (as above: pain/fever, constipation, insomnia, anxiety, nausea/vomiting), but generally never as a maintenance drug.
One time only – med ordered only once – EX: antibiotic ordered as a preop med. Or a one time medication order in response to a lab value such as PT INR. Ex: Give coumadin 2.5 mg po at 1800.
STAT orders – are orders that need to be given immediately. And only once. This type of order often given in an emergency situation. Give Vasotec (enelopril) 0.625 mg IV STAT.
Now orders – The nurse has a little more time to respond – in general 90 minutes. But as soon as is possible. The start of an antibiotic IV once the results of blood cultures are received or order for potassium supplement based on low K+ result.
Prescriptions: These are written orders for patients who are going to take medications out of the hospital. This order has more detail for patient information. Including refills.
#6:Prior to administering meds
check MAR for completeness( orders are verified by nurse and complete)
check allergies
know the diet and fluid orders ( any restrictions)
know critical lab values
check pt ability to swallow (any N&V?) GI motility (bowel sounds)
V/S
after administration, assess for response
#9:Right Medication - verify that the order has been checked by another nurse per institution policy.( verification process includes comparing with MD orders)
Right dose - use appropriate equipment – standards measuring devices. Cups, syringes, dropper, only break scored tablets. – use clean crushing devices if crushing pills for oral administration – make sure they can be crushed
Right time – nurses use critical thinking when scheduling meds – ABX need to be given TID – round the clock whereas other meds are given TID during the waking hours. Can change times if needed. Nurses are aware of the action and timing with meals. Insulins are given in a timely manner with onset and peak in mind. PRN meds require nursing judgment. ( sleep meds, analgesics
#10:Right patient – 2 pt identifiers – The name and MR # on the name bracelet. Birthday or phone numbers are used. The TJC does not require that the patient state their name. If done it serves as a third check. Sometimes a bar code system is also used
Right Documentation – accurate documentation assures appropriate and safe communication to other health care providers - errors occur if there is incomplete information – nurse is responsible to document med, dose, time and initials. Any assessments taken prior to administration such as B/P pulse labs. The site where an injection was given. Document any adverse responses.
Always and nevers:
Only document after the med is given. Never document for another nurse.
Always document when the med was given and not when it was due.
#11:
In addition to 6 rights:
Read about the 3 checks
Verify MAR
Pull the meds and place them in the med cup (1st check)
Verify meds in cup with MAR ( 2nd check)
Verify pt ID
Verify MAR with pt at bedside
Verify meds with MAR at bedside (3rd check)
#12:WHAT IF PT COMMENTS THAT MED SEEMS UNUSUAL IN ANY WAY…NURSE SHOULD HOLD UNTIL CAN DOUBLE CHECK ORDER, MED AND MAKE SURE ARE ALL CORRECT
DO YOU LEAVE PILLS AT THE BEDSIDE TABLE IF DOES NOT WANT TO TAKE RIGHT NOW???
#15:
When a Med error occurs: Follow Institutional policies on submitting an occurrence (variance) report. Purpose is to find the root cause and fix the problem.
The purpose is not to issue blame. Errors are most often a result of a break in the system – the process of safe medication administration.
If something doesn’t seem quite right – STOP – trust your gut. Start over, recheck. Until you are sure. Find out what is causing you to be unsure. What part doesn’t seem right.
#21:The next three slides are a summary of the basic but very important characteristics of a nurse who is skilled in the administration of medications.
Safe administration of medications requires a trained person with cognitive skills which include those listed above.
#22:Requires technical skills
Proper use of equipment, and the ability to safely prepare meds
#23:Interpersonal skills includes correct Documentation
And the ability to effectively educate patients and family
#24:Safe medication administration is accomplished if the nurse is committed to safety, quality, and assumes responsibility and accountability in the process.
Is aware of legalities, and is willing to report medication errors as needed and work to prevent any further occurance.
