chapter 9
The components of a drug order are
Patient name and birth date • Date the order is written • Provider signature or name if an electronic order, T/O, or V/O Signature of licensed staff who took the T/O or V/O, if applicable • HCPs who wish to prescribe controlled drugs must register with the federal Drug Enforcement Agency (DEA). When prescribing controlled substances, the HCP's DEA number must be on the prescription. • Drug name and strength • Drug frequency or dose (e.g., once daily) • Route of administration • Duration of administration (e.g., × 7 days, × 3 doses, when applicable) • Number of patient refills • Number of pills to be dispensed. Any special instructions for withholding or adjusting dosage
documenting the patients response to the MAR includes
(1) opioid and nonopioid analgesics (Ask, how effective was pain relief?); (2) sedatives (How effective was relaxation?); and (3) antiemetics (Was nausea/vomiting decreased or eliminated?). The nurse 87 continues to assess the patient's response to the medication (Was there any gastrointestinal irritation or skin sensitivity?) and documents this in the patient's plan of care. Keep in mind that patient responses are not necessarily verbal; they could be physiologic (e.g., blood pressure decreasing in response to an antihypertensive). With the paper MAR and a pen, the nurse documents the response in the nursing notes.
"Five-Plus-Five" Rights of Medication Administration
(1) the right patient (2) the right drug in (3) the right dose via (4) the right route at (5) the right time. The "plus five" refers to the five additional rights that have been recommended: (1) right assessment, (2) right documentation, (3) the patient's right to education, (4) right evaluation, and (5) the patient's right to refuse
The nurses' six rights are
(1) the right to a complete and clear order; (2) the right to have the correct drug, route (form), and dose dispensed; (3) the right to have access to information; (4) the right to have policies to guide safe medication administration; (5) the right to administer medications safely and to identify problems in the system; and (6) the right to stop, think, and be vigilant when administering medications. These rights can assist in increasing the safety of medication administration.
informed consent
, which is the individual having the necessary knowledge to make a decision. Informed patients and families are critical to preventing medication errors.
safety feature is the U.S. Food and Drug Administration's (FDA) black-box warning system
. When a prescription drug is known to be effective for some patients but may cause serious side effects in others, the FDA will require the drug's printed materials to carry a warning about the adverse effects surrounded by a black box. A black-box warning is the 89 strongest form of warning issued by the FDA about a drug.
specific strategies can optimize safety when dealing with high-alert drugs
: 1. Simplify the storage, preparation, and administration of high-alert drugs. 2. Write policies concerning safe administration. 3. Improve information and education. 4. Limit access to high-alert medications. 5. Use labels and automated alerts. 6. Use redundancies (automated or independent double-checks). 7. Closely monitor the patient's response to the medication (possibly the most important step).
aceptable abbreviations
Capsule elix Elixir ER Extended Release g Gram gtt Drops kg Kilogram L Liter m2 Square meter mcg Microgram mEq Milliequivalent mg Milligram mL Milliliter NKA No known allergies NKDA No known drug allergies oz Ounce SR Sustained release One-Half tablet Half-tablet supp Suppository susp Suspension Tbsp, tbs, or T Tablespoon tsp Teaspoon
Routes of Medication Administration
ID Intradermal Inj Injection IM Intramuscular IV Intravenous IVPB Intravenous piggyback KVO Keep vein open PO By mouth subQ, subcut, or subcutaneous Subcutaneous Subling Sublingual (under tongue) TKO To keep open vag Vaginal
sentinel event
If a patient dies as the result of a drug error, an unanticipated event in a health care setting that results in death or serious harm to a patient unrelated to the natural course of the patient's illness.
right patient
TJC requires two forms of identification before drug administration. • Ask the patient to state his or her full name and birth date, and compare these with the patient's identification (ID) band and the medication administration record (MAR). Verify the patient's identification each time a medication is given. • If the patient is an adult with a cognitive disorder or a child, verify the patient's name with a family member. In the event a family member is unavailable and the patient is unable to self-identify, follow the facility's policy. Many facilities have policies that include a photo ID on the band with the patient's name and birth date affixed to the band. • Distinguish between two patients with the same first or last name by placing "name-alert" stickers as warnings on the medical records.
Nursing interventions related to drug orders
The nurse should verify the identity of the patient by comparing the name on the wristband with the name on the MAR for accuracy. • Always use two patient identifiers, such as having patients repeat their name and date of birth. • The nurse should be familiar with the patient's health history and should have performed a head-to-toe assessment on the patient, including a complete set of vital signs. • Always review the patient's lab work prior to the administration of drugs. • Read the drug order carefully. If the order is unclear, verify it with the HCP before administering the drug. • Know the patient's allergies. • Know the reason the patient is to receive the medication. • Check the drug label by identifying the drug name, the amount of the drug (tablet or volume), and its suitability for administration by the intended route. • Check the dosage calculations. • Know the date the medication was ordered and any ending date (e.g., for controlled substances and antibiotics and for limited or a specific number of doses). Some agencies have automatic stop orders that are generally facility specific. Examples of such orders include controlled drugs that need to be renewed every 48 hours, antibiotics to be renewed every 7 to 14 days, and cancellation of all medications when the patient goes to surgery. • All orders—including first-dose, one-time, and as-needed (PRN) medication orders—should be checked against the original orders.
root cause analysis (RCA),
a method of problem solving used to identify potential workplace errors. Such analysis presents opportunities for learning and focuses on strategies that can be put in place to correct problems.
Do not crush
any extended- or sustained-release drugs because this will change the pharmacokinetic phase of the drug. There is no industry standard for sustained- or extended-release abbreviations, which can cause confusion and drug errors.
automated dispensing cabinets (ADCs),
computerized drug storage cabinets that store and dispense medications near the point of care while controlling and tracking drug distribution. The patient's drugs are stocked in the cabinet by the pharmacist and are accessed under the patient's name, and the nurse is able to select and pull the patient's drugs from the cabinet. This technology improves patient care by promoting accurate and quick access to medications, locked storage for all medications, and electronic tracking for controlled substances. Automation of drug administration saves time and decreases costs associated with drug administration.
If in doubt about the amount to be administered,
consult with a nurse peer to validate the correct amount. In some settings, two registered nurses (RNs) are required to check the dosage for certain medications, such as insulin and heparin.
right evaluation
determines the effectiveness of the drug based on the patient's response to the drug. Evaluation in this context asks whether the medication did for the patient what it was supposed to do. It is essential that the nurse evaluate the therapeutic effect of the medication by assessing the patient for side effects and adverse drug reaction
unit dose method,
drugs are individually wrapped and labeled for single-dose use for each patient. The unit dose method has reduced dosage errors because no calculations are required. Some facilities still use a multidose vial from the ADC. If this occurs, the nurse will have to complete a calculation in order to retrieve the correct amount ordered by the physician from the vial. If there is any medication left in the vial, it is disposed of according to the facility's policy for disposal of drugs.
Specific high-alert medications as listed by the Institute for Safe Medication Practices (ISMP) include
epinephrine, subcutaneous; epoprostenol, IV; insulin; magnesium sulfate injection; methotrexate, nononcologic oral use; opium tincture; oxytocin, IV; nitroprusside sodium for injection; potassium chloride concentrate for injection; potassium phosphate injection; promethazine, IV; and vasopressin, IV or IO. Please note that all forms of insulin, subcutaneous 92 and IV, are considered high-alert medications.
National Patient Safety Goals (NPSGs),
focus on problems in health care safety and how to solve them. The goals are written for a variety of health care settings including ambulatory health care, behavioral health care, critical access hospitals, home care, hospitals, laboratory services, long-term care (Medicare/Medicaid), and office-based surgery. These goals are updated and published annually. Once a goal becomes a standard, the goal number is retired and is not used again, and the standard must be adopted by all Joint Commission-accredited agencies. Two important goals that have already become standards for all TJC-accredited organizations are the "do not use" abbreviations
the right drug
given prior to administration. When working with an EHR, once the bar code on the patient's wristband has been scanned, the patient's drug profile will appear on the computer screen. The nurse will then scan the patient's medication label, and it will automatically validate the time, date, and the nurse administering the patient's medication. If it is not the correct medication, the nurse will receive an alert and will be unable to proceed in the MAR until the correct medication is scanned.
Just Culture
in its position statement (2010), and it encourages organizations to avoid using punitive approaches in reporting drug errors because they focus on punishing individuals for reporting such errors. In a Just Culture, individuals would be encouraged to report drug errors so the system can be repaired and the problem fixed. A Just Culture does not hold individual practitioners responsible for a failing system, although it does not tolerate disregard for a patient or gross misconduct. (For more information on Just Culture,
The right dose depends on
is based on the patient's physical status. Many medications require the patient's weight in order to determine the right dose. Usually pediatrics, medical-surgical, and critical care situations require weight to complete the drug calculation and determine the correct dose (heparin and digoxin drip are examples of medications calculated according to weight). The nurse determines if the drug is safe to administer according to the drug's pharmacodynamics (action) and the patient's vital signs. Renal and hepatic functions are important considerations because many drugs are cleared through the kidneys and metabolized by the liver.
if a high-alert medication is given in error,
it can have a major effect on the patient's organs; this includes cardiac, respiratory, vascular, and neurologic systems. A medication can also affect the sympathetic and parasympathetic nervous systems.
Counterfeit drugs
look like the desired drug but may have no active ingredient, the wrong active ingredient, or the wrong amount of active ingredient. Improper packaging and contamination can also be problems.
common routes of absorption include
oral, with drug in the form of a liquid, elixir, suspension, pill, tablet, or capsule; sublingual, under the tongue for venous absorption; buccal, between the cheek and gum; via a feeding tube; topical, applied to the skin; by inhalation (aerosol sprays); via otic (eye), ophthalmic (ear), or nasal (spray) instillation; by suppository (rectal or vaginal); and through the five parenteral routes: (1) intradermal, (2) subcutaneous (subcut), (3) intramuscular (IM), (4) intravenous (IV), or (5) intraosseous (IO).
right route is
ordered by the health care provider and indicates the mechanism by which the medication enters the body.
Drug reconciliation was created to
provide drug continuity during care transitions, thereby promoting patient safety. For this reason, the nurse should advise patients to do the following: • Always carry a list of personal drug information in case of an emergency. • Update this list of drugs whenever a change occurs. • Bring a list of medications to each doctor appointment.
do not use list
q.d., Q.D. Write "daily" or "every day." q.o.d., Q.O.D. Write "every other day." U Write "unit." IU Write "International Unit." MS, MSO4 Write "morphine sulfate." MgSO4 Write "magnesium sulfate." .5 mg Use a zero before a decimal point when the dose is less than a whole unit (e.g., write 0.5 mg). 1.0 mg Do not use a decimal point or zero after a whole number (write 1 mg).
right time
refers to the time the prescribed dose is ordered to be administered. Daily drug dosages are given at specified intervals, such as twice a day (bid), three times a day (tid), four times a day (qid), or every 6 hours (every 6hrs); this is so the plasma level of the drug is maintained at a therapeutic level. Every drug cannot be given exactly when ordered, therefore health care agencies have policies that specify a range of times within which drugs can be administered (check your agency's policy). When a drug has a long half-life, it is usually given once a day. Drugs with a short half-life are given several times a day at specified intervals. Some drugs are given before meals, whereas others must be given with meals.
right to education
requires that patients receive accurate and thorough information about the drugs they are taking and how each drug relates to their particular condition. Patient teaching also includes why the patient is taking the drug, the expected result of the drug, possible side effects of the drug, any dietary restrictions or requirements, skill of administration with return demonstration, and laboratory test result monitoring.
right documentation
requires the nurse to record immediately the appropriate information about the drug administered. Many systems are available for documenting drug administration. The most common is the paper medication administration record (MAR), which the pharmacy will furnish. Facility policies vary, but when nurses administer a drug, they place their initials next to the name of the drug on the paper MAR. The nurse's initials verify that the medication was administered. Both paper and computerized MARs include information about the drug to be administered, including (1) the name of the drug, (2) the dose, (3) the route, (4) the time and date, and (5) the nurse's initials or signature.
right assessment
right assessment requires the collection of appropriate baseline data before administration of a drug. Examples of assessment data include taking a complete set of vital signs and checking lab levels prior to drug administration. This may also include both apical heart rate and potassium level prior to administering digitalis; blood pressure level prior to administering an antihypertensive drug; blood glucose levels before insulin administration; or respirations with blood pressure prior to administering an opioid. It is also important for the nurse to identify high-risk patients, such as patients with medication allergies, patients on dialysis, those with liver disease, diabetic patients, cardiac and pulmonary patients, and the elderly and pediatric populations. If at-risk patients are identified, precautions can be taken to reduce risk.
right to refuse
right to refuse the medication, and it is the nurse's responsibility to determine the reason for the refusal, explain to the patient the risks involved with refusal, and reinforce the important benefits of and reasons for taking the medication. When a medication is refused, the refusal must be documented immediately, and follow-up is always required. The primary nurse and health care provider should be informed because the omission may pose a specific threat to the patient. discontinuation of medication or IV fluid that was not ordered to be discontinued can result in medication error
risks to safety
tablet splitting and buying drugs over the internet
To avoid drug errors,
the drug label should be read three times: (1) when you pick up the medication and remove it from the drug cabinet, (2) as you prepare the drug for administration, and (3) when you administer the drug.
Prior to drug administration, it is important that the nurse carefully review
the patient's most current lab results. A chemistry panel includes renal and liver function and sodium and potassium levels. Also, the nurse should review the hematology labs, which include a complete blood count (CBC), red blood cells (RBCs), hemoglobin, hematocrit, and platelets. It is most important that the nurse check the drug's correct dose range in a reliable drug resource book or by consulting with a pharmacist. In most cases, the right dose for a specific patient is within the recommended range for the particular drug. Nurses must calculate each drug dose accurately.
drug reconciliation
the process of identifying the most accurate list of all medications that the patient is taking at transitions in care, which includes admissions and discharges from a hospital to another health care setting such as long-term care. Correct drug reconciliation is important because it prevents discrepancies that can cause a drug error. One in five patients experience an adverse event transitioning from hospital to home
Times of Administration
ã before ac before meals ad lib as desired bid (Twice a day) bid image with hr (hour) hr or hrs hs bedtime NPO (nothing by mouth) NPO pc after meals PCA (patient-controlled analgesia) PCA per (Through, by [route]) per prn (As needed) PRN q every or each qh or q1h every hr or every 1 hr qid (Four times daily) qid q2h, q4h, etc. every 2 hrs, every 4 hrs, etc. image (Without) without stat immediately, at once tid (Three times a day) tid
Nursing interventions related to the right time include
• Administer drugs at the specified times (refer to agency policy). • Administer drugs that are affected by food, such as tetracycline, 1 hour before or 2 hours after meals. • Give food with drugs that can irritate the stomach (gastric mucosa)—for example, potassium and aspirin. Some medications are absorbed better after eating. • Adjust the medication schedule to fit the patient's lifestyle, activities, tolerances, or preferences as much as possible. • Check whether the patient is scheduled for any diagnostic procedures that contraindicate the administration of medications, such as endoscopy or fasting blood tests. Determine whether the medication should be given before or after the test based on the policy. • Check the expiration date. If the date has passed, discard the medication or return it to the pharmacy, depending on the policy. • Administer antibiotics at even intervals (e.g., every 8 hours rather than three times daily) throughout the 24-hour period to maintain therapeutic blood levels. 86 • Patients who require dialysis usually have blood pressure medications stopped prior to dialysis because dialysis can decrease blood pressure. However, some doctors order the medications to be given prior to dialysis. If any questions arise, check with the HCP before proceeding.
Nursing interventions related to the right route include the following
• Assess the patient's ability to swallow before administering oral medications; make sure the patient has not been ordered nothing by mouth (NPO). • Do not crush or mix medications in other substances without consulting a pharmacist or a reliable drug reference. Do not mix medications in an infant's formula feeding. • If the medication must be mixed with another substance, explain this to the patient. For example, elderly patients may use applesauce or yogurt to mix their medications to make them easier to swallow. Medications should be administered one at a time in the substance. • Best Practice Guidelines and TJC state that drugs must be identifiable up until the point of delivery. When administering many drugs at one time, it is not recommended to mix drugs together. The correct practice is to administer one pill at a time. When a patient has an enteral tube, it is important to follow these guidelines; this allows the nurse to flush the tube before and after each pill or liquid is administered to prevent the tube from clogging. In the event that a patient's drug inadvertently falls to the ground, the nurse will be able to identify, discard, and replace the pill. • Instruct the patient that medications must be swallowed with water and not juice, which can interfere with the absorption of certain medications; however, it is recommended that iron be taken with orange juice or vitamin C supplements to aid in the absorption of the iron. • Use aseptic technique when administering drugs. Sterile technique is required with the parenteral routes. • Administer drugs at the appropriate sites for the route. • Stay with the patient until oral drugs have been swallowed.
disposal of medication
Consumers who do not have DEA-authorized collectors or medicine take-back programs can follow these simple steps: 1. Remove medications from the original packaging and mix them (do not crush tablets or capsules) with an unpalatable substance such as dirt, kitty litter, or used coffee grounds. This method is intended to make medications less attractive to people and animals. 2. Place the mixture in a container such as a sealed plastic bag. 3. Throw the container in the household trash. 4. Scratch out all personal information on the prescription label before disposing of the empty container.
