Preparation for Safe Medication Administration

Idiosyncratic Reactions

- an unpredictable overreaction or under-reaction to a drug for example: Lorazepam, an anti-anxiety medication, when given to an older adult may worsen anxiety and cause agitation and delirium

Side effects

- are predictable and often unavoidable secondary effects produced at a usual therapeutic dose - they are not the same as adverse effects - some side effects may be harmless, whereas others cause injury - if side effects are serious enough to outweigh the beneficial effects of the therapeutic action of a drug, the health care provider may discontinue the drug - report any side effects to a health care provider or pharmacist so that they can determine if the symptoms indicate a serious adverse reaction

Adverse Effects

- are unintended, undesirable, and include allergic reactions, side effects, overmedication and medication errors - always assess patients who may be at high risk for an ADE, such as pregnant women and patients with chronic disorders - when adverse responses to medications occur the health care provider discontinues the medication IMMEDIATELY

Pharmacist's Role

- assess the medication plan and ensure that orders are valid - responsible for preparing the correct medications and delivering the to the nursing unit, where they are stocked in a medication administration station

Toxic Effects

- develop after prolonged intake of high doses of medication, after ingestion of drugs intended for external application, or when a drug builds up in the blood because of impaired metabolism or excretion - toxic effects may be lethal, depending on the action of a drug

Common Cause of Medication Errors

- distraction while preparing medications - ambiguous strength designation on labels or in packaging - drug product nomenclature (look-alike or sound alike names, use of lettered or numbered prefixes and suffixes in drug names) - equipment failure or malfunction (e.g., infusion pumps) - illegible handwriting - improper transcription - inaccurate dosage calculation - inadequately trained personnel - inappropriate abbreviations used in prescribing - labeling errors - excessive workload - lapses in individual performance - medication unavailable

Common Abbreviations

AC = before meals PC = after meals PRN = as needed Daily = every day STAT = give immediately PO = by mouth SL = sublingual ID = intradermal IM = intramuscular IV = intravenous top = topical NPO = nothing by mouth

Common allergic reactions to medications

Angioedema: acute, painless, dermal, subcutaneous, or submucosal welling involving the face, neck, lips, larynx, hands, feet, or genitalia Eczema (rash): small, raised vesicles that are usually reddened; often distributed over the entire body Pruritus: itching of the skin; accompanies most rashes Rhinitis: inflammation of mucous membranes lining the nose, causing swelling and clear, watery discharge Urticaria (hives): raised, irregularly shaped skin eruptions with carrying sizes and shapes; eruptions have reddened margins and pale centers Wheezing: constriction of smooth muscles surrounding bronchioles that decreases diameter of airways; occurs primarily on expiration because of severely narrowed airways; development of edema in pharynx and larynx further obstructs airflow

Three Checks

Check #1: - compare the medication label to the MAR as you remove the medication from the storage area Check #2 - Compare the medication label to the MAR as you prepare each medication Check #3 - Compare the medication label to the MAR at the patient''s bedside before you administer each medication

Can all solid forms of oral medication be crushed or chewed?

No. Enteric-coated tablets are covered with a hard surface that delays absorption until the tablet leaves the stomach and enters the small intestines. - this form of tablet should never be chewed or crushed because the coating is designed to protect the patients stomach from the irritating effects of the active ingredient Sustained (SR), extended release (XL), controlled release (CR-CRT), and sustained action (SA) = should NOT be chewed or crushed either

Medication Orders

Oxycodone 5mg PO q4h PRN for pain 1. the name of the medication 2. the dose 3. the route 4. the frequency 5. orders of medications to be given PRN also include the reason they are to be given 6. signature of the healthcare provider *when you receive a NOW order you have 90 minutes to give the medication *STAT orders = immediately *PRN orders = as needed * a range order should include specific indications such as a pain rating score or temperature level, especially for use of a medication indicated for more than one reason

What impact has the failure to identify patients correctly had on the healthcare industry?

misidentification has been the root cause of many errors missing armbands and inaccurate information also contribute to errors and limit the efficiency of a standardized patient identification process The Joint Commission identified and introduced improving patient identification accuracy as the first of its National Patient Safety Goals TWO IDENTIFIERS: Patient's first and last name, and date of birth

To minimize the risk of a medication error, you must....

observe the patient's "RIGHTS" - right medication - right dose - right patient - right time - right route - right documentation *do not administer a medication when you have any doubt about the appropriateness or accuracy of the original order * the person who wrote the prescription is the only one who can clarify any possible misinformation about the medication

Guidelines to Prevent Medication Errors:

- everyone administering medications should review the medication list at each patient encounter - be vigilant when handling and administering high-risk medications - consider medications as the cause of any new symptoms - use computerized physician order entry (CPOE) when possible to: 1. standardize practice 2. improve the legibility of orders 3. alert and update health care providers on side effects, drug-drug interactions, and new orders - use EHR when possible and interface this with CPOE if available to improve communication and alert all providers to administration times - bar coding of medications inked to patient identification bracelets improves safety and provides one last opportunity to identify a medication error - medication reconciliation identifies medication discrepancies and prevents errors - patient, family caregiver, and provider education can be used to prevent medication errors

Steps to Prevent Medication Errors

- follow the seven rights of medication administration - only prepare medications for one patient at a time - be sure to read labels at least 3 times (comparing MAR with label): when removing medication from storage, before taking to patient's room, before giving medication - use at least two patient identifiers every time you administer medications - double check all calculations and other high risk medication administration processes and verify with another nurse - do not attempt to interpret illegible handwriting; clarify with the health care provider - question unusually large or small doses - document all medications as soon as they are given - when you made or discovered an error, reflect on what went wrong, and ask how you could have prevented it. complete an occurrence report per agency policy - evaluate the context or situation in which a medication error occurred. this helps to determine if nurses have the necessary resources for safe medication administration - when repeated medication errors occur within a work area, identify and analyze the factors that may have caused the errors, and take corrective action - attend in-service programs on the medications you commonly administer - ensure that you are well rested when caring for patient. nurses make more errors when they are tired - involve and educate patient when administering medications. address patient's concerns about medications before administering them (e.g., concerns about their appearance or side effects) - follow established agency policies and procedures when using technology to administer medications (e.g., automated medication dispensing system [AMDS] and bar-code scanning). Medication errors occur when nurses "work-around" the technology (e.g, override alerts without thinking about them)

Medication erros include:

- inaccurate prescribing - administration of the wrong medication, by the wrong route, or at the wrong time interval - administration of extra doses or failure to administer a medication

MAR

- includes the patient's name, room, and be number and the names, doses, frequencies, and routes of administration for each medication ** if the medication order is incomplete, incorrect, or inappropriate or if there is a discrepancy between the written order and what is on the MAR, consult with the health care provider **do not give a medication until you are certain that you are able to follow the seven rights of medication administration

Chemotherapy Medications

- nurses must undergo certification to administer IV chemotherapy - oral chemo has the same exposure risks to health care providers, patient's and their family caregivers as IV forms - it is critical for health care providers, patients and family caregivers to use proper protective techniques to avoid exposure to oral chemotherapy tablets - a patient excretes chemotherapy chemicals through urine, stool, vomit, sweat, and saliva - when patients self-administer chemotherapy at home, families, should be warned of the dangers of exposures - for example, patient's toilets should be double flushed after use, during and 48 hours after discontinuing chemotherapy - toilets are a hazard for children and pets - accidental exposure to oral chemotherapeutic agents can occur during handling (i.e., unpacking, storage, handling, administration, and disposal)

Guidelines for Telephone Orders and Verbal Orders

- only authorized staff members receive and record telephone or verbal orders - clearly identify patient's name, room number, and diagnosis - read back all orders to health care provider - use clarification questions to avoid misunderstandings - write TO (telephone order) or VO (verbal order), including date and time, name of patient, and complete order; sign the name of the health care provider and nurse - follow agency policies; some agencies require documentation of the "read back" or require two nurses to review and sign telephone or verbal orders - health care provider co-signs the order within the time frame required by the agency (usually 24 hours; verify agency policy)

Medication Dose Responses

- pharmokinetics affects how much of a drug dose reaches the site of action - the GOAL in administering a medication is to achieve a constant blood level within a safe therapeutic range - the minimum effective concentration (MEC) is the plasma level of the medication below which is the effect of the medication does not occur - the toxic concentration is the level at which toxic effects occurs - the safe therapeutic range is between the MEC and the toxic concentration - Peak Concentration: the highest level - Trough Concentration: the lowest level ** you obtain a patients trough level in a blood sample drawn 30 minutes before administering the drug ** you draw a peak level whenever the drug is expected to reach its peak concentration --> results of peak and trough tests reveal if a drug is reaching its therapeutic level 1. Onset of action: the time interval between when a drug is given and the first sign of its effect 2. Peak action: the time it takes for a drug to reach its highest effective concentration 3. Duration of action: the time period from onset of drug action to the time when a response is no longer seen 4. Plateau: blood serum concentration reached and maintained after repeated, fixed doses 5. Therapeutic range: the range of plasma concentration that produces the desired drug effect without toxicity

Follow these tips:

- reduce distractions and interruptions around automate medication dispensing machines - in areas where medications are being prepared, use a brightly colored sign or tape to alert staff to avoid interruptions ** when an error occurs, acknowledge it immediately, and then assess the patient

Therapeutic Effects

- the intended or desired physiological response of a medication

Pharmacokinetics

- the study of how drugs enter the body (absorption), reach the side of action (distribution), are metabolized, and are excreted from the body - absorption describes how a drug enters the body and passes into body fluids and tissues - absorption influences the route of drug administration - distribution is the way drugs move to the sites of action in the body - metabolism refers to the chemical reactions by which a medication is broken down (e.g., in the liver) until it becomes chemically inactive - excretion is the process of drug elimination from the body through the gastrointestinal tract, kidneys, or lungs - understanding pharmacokinetics enables you to make the decisions necessary to ensure that drugs are given by the appropriate route and to recognize and act based on the nature and extent of drug actions, interactions, and adverse actions - this knowledge helps in planning drug administration schedules For example, knowing when the peak action of an analgesic occurs allows you to administer the drug at a time when you anticipate that the patient's pain will increase

Allergic Reactions

- unpredictable responses to medications - taking a medication for the first time may cause an immunological response

Medication Administration in Home Care

1. Assess all of the patient's prescription an non prescription medications at each visit, including herbal medications. Review information about medications, including desired effect, dose, frequency adverse effects, and what to do if adverse effects develops 2. Teach the complications and interactions of all food, over the counter medications, and herbal medications to patient's and family caregivers 3. Collaborate with social workers to identify community resources for financial assistance with pharmaceutical needs 4. Monitor and evaluate the effectiveness of the prescribed medications: a. note changes in physical and functional status (e.g., vital signs, sleeping, elimination) b. not changes in mental status (e.g., level of alertness, memory) c. monitor blood levels as needed d. communicate potential problems to health care provider 5. monitor urinary output status of patients because changes in renal excretion may require a decrease or increase in medication dosage 6. for patient's who cannot remember when to take medications, make a cart that lists the times to take each medication, or prepare a special container that organizes and stores medications according to days and times when the patient needs to take them. Collaborate with family caregivers to assist in organization and administration of medications 7. Reduce the chance of medication error by labeling or color coding medication bottles 8 Keep an accurate record of a homebound patient's weight, especially an older-patient, because many medication dosages are calculated by body weight 9. Teach medication safety in the home environment a. keep medication sin original, labeled containers. read labels carefully and follow all instructions b. follow specific disposal instructions on the prescription drug label or patient information that comes with the medication. DO NOT FLUSH medications down the sink or toilet unless this information specifically instructs you to do so. have patients use community drug take back programs that allow the public to bring unused drugs to a central location for proper disposal. if there are no disposal instructions on a prescription drug label and no take back program is available, have patient throw the drugs in the household trash following these steps: (1) remove undesirable substance, such as used coffee grounds or kitty litter (2) place the mixture in a sealable bag, empty can, or other container to prevent the drug from leaking or breaking out of the garbage bag 10. never "share" medications with friends or family members 11. always finish a prescribed medication; do not save it for a future illness 12. Instruct patients with arthritis or debilitating illness who have difficulty opening child-proof containers to request non-childproof containers from their health care providers

Drug Administeration

1. Follow the seven rights for medication administration 2. Inform the patient of the name, purpose, action, and common side effects of each medication. Evaluate the patient's knowledge of the medication, and provide appropriate teaching using teach back technique 3. Stay with the patient until the medication is taken. Provide assistance as necessary. Do not leave medication without a heath care provider's order at the beside. For example, some patients may take their own vitamins or birth control pills while in the hospital 4. Respect the patient's right to refuse medication. If the medication wrapper is intact, the medication may be returned to the patient's storage bin. When medication is refused, determine the reason for this and take action accordingly. For example, if the patient has unpleasant side effects, it may be possible to eliminate them by giving the pills with food or using a different time schedule

Pre-administeration Activities

1. Identify the medication action, purpose, side effects and nursing implications for administering and monitoring. Ensure that the medication order has not expired 2. Make sure the information on the electronic MAR or printed MAR corresponds exactly with the health care provider's order and with the medication container label. Clarify orders that are unclear or illegible 3. Calculate medication doses accurately and use appropriate measuring devices. Verify that the dose prescribed is within a safe dosage range and is appropriate for the patient's situation 4. Take medications to the patient at the correct time 5. Review any preadministration assessments (e.g., vital signs, lab test results) 6. Use thorough hand hygiene technique. Avoid touching tablets and capsules. Wear clean gloves if you are administering topical medications, parenteral medications, or oral chemotherapy agents 7. Use sterile technique for parental medications 8. Keep medications secure. Administer only medications that you personally prepare. Never ask another nurse to administer medications that you prepare 9. When preparing medications, be sure that the label is clear and legible and that the drug is properly mixed; has not changed in color, clarity, or consistency; and has not expired 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 a patient refuses medication, there is no question about which one is withheld 11. TJC has a standard for labeling syringes, including before a procedure labeling all medications that are not labeled (e.g., medications in syringes, cups, and basins). This should be done in the area where medications and supplies are set up

If the client refuses medication

1. If a client refuses a medication, return it to the storage area as long as the wrapper is intact 2. If you have removed the wrapper discard the medication 3. If the patient refused any of the medications, be sure to document that and the reason why in your nurses notes

Evaluation

1. Monitor for evidence of therapeutic effects, die effects, and adverse reactions. Monitor physical responses 2. When a medication is given for relief of symptoms, ask the patient within 30-60 minutes of drug administration to report if symptoms have diminished or been relieved. in the case of pain, has severity lessened? 3. Observe injection sites for bruises, inflammation, localized pain, numbness, or bleeding 4. Evaluate patient's understanding of medication therapy and ability to self administer

Preparing Narcotic Medicaitons

1. Perform Hand Hygiene 2. Obtain the clients medication administration record, or MAR 3. Determine which narcotics you will administer 4. Refer to a drug guide or consult with a pharmacist if any of the drugs are unfamiliar to you 5. Determine whether or not the client has any drug allergies or any other contraindications to receiving the medications 6. Enter your identification number and password 7. From the list of clients that appears on the screen, select your client to access his or her medication file 8. Compare the clients MAR to the information on the screen to confirm that you have selected the correct client 9. Select from the clients medication lists the medication you will administer 10. A drawer will automatically open with that particular medication in it 11. Before you remove the medication, count the number of pills, ampules, or pre-filled syringes in the drawer 12. Compare your count to the count on the scree. If both numbers are the same, remove the drug

Step by Step Preparing Medication

1. Perform Hand hygiene 2. Obtain the client's medication administration record, or MAR 3. Determine which medications you will administer 4. Refer to a drug guid or consult with a pharmacist if any of the medications are unfamiliar to you 5. Determine whether or not the client has any drug allergies or any other contraindications to receiving the medications 6. Enter your identification number and password 7. From the list of clients that appears on the screen, select your client to access his or her medication file 8. As you remove each drug, compare the medication label to the MAR 9. Check to make sure that it is the right drug, the right dose, the right route, and the right time 10. Once you have retrieved the medications, it may be necessary to perform medication calculations 11. Have another nurse double check your calculations 12. Next, prepare the medications according to the route indicated on the MAR 13. As you prepare each drug, compare the medication label to the MAR 14. Check to make sure that it is the right drug, the right dose, the right route, and the right time 15. After you have prepared the medications, take the MAR and the medications to the clients bedside 16. Check medication for the third time

Step by Step administering narcotic medication

1. Place the MAR and the medication near the clients bedside 2. Perform hand hygiene 3. Ask patient if they have any allergies, also ask them about the pain they are having (pain scale) 4. Use two acceptable identifiers to confirm that you have the right client 5. Before administering each medication, compare the medication label to the MAR 6. Check to make sure that it is the right drug, the right dose, the right route, and the right time 7. Provide the client with a fresh cup of water and administer the medication 8. Stay at the bedside until the client has taken all of the medications - do not leave them at the bedside for the client to take later 9. Discard the medication wrappers, syringes, and medicine cups in the appropriate receptacles 10. Perform hand hygiene 11. Document the medications you gave in the MAR -- if the patient refused any of the medications, make sure to document that and the reason why in your nurses notes -- wasting a narcotic requires that another nurse witness the narcotic being discarded -- the witnessing nurse signs his or her name next to the administering nurses signature indicating that the drug was discarded properly

Step by Step Administering Medications

1. Place the medication administration record, or MAR, and the medications near the client's bedside 2. Perform hand hygiene 3. Ask patient if they have any allergies to medications 4. Use two acceptable identifiers to confirm that you have the right client 5. Before administering each medication, compare the medication label to the MAR 6. Check to make sure that it is the right drug, the right dose, the right route, and the right time 7. Provide the client with a fresh cup of water 8. Administer the medications 9. Stay at the bedside until the client has taken all of the medications 10. Do not leave them at the bedside for the client to take later 11. Discard the medication wrappers, syringes, and medicine cups in the appropriate receptacles 12. If you wore gloves, remove them and discard them appropriately 13. Perform hand hygiene 14. Document the medications you gave on the MAR

Post Administeration Activities

1. Properly document medications administered 2. Document data pertinent to a patient's response; this is especially important when giving drugs ordered PRN. Include that ability of patient and family caregiver to teach back the education provided 3. If a medication is refused, document that it was not given the reason for the refusal, and when the health care provider was notified

The Rights

1. Right Medication 2. Right Dosage 3. Right Route 4. Right Time 5. Right Patient 6. if it's PRN it must have indication (under what circumstances 7. Educate the patient on the medication 8. documentation, what did they take, did they have a reaction, and if it's the first time they are given the medication, go back in an hour to make sure they have no reactions REMEMBER TO CHECK EXPIRATION DATE - make sure to tell the patient if they are experiencing any wheezing, swelling, in the neck etc., to call the nurse

Guidelines for handling chemotherapy drugs:

1. in health care agencies, cytotoxic agents should be stored in a designated area per the manufacturer's instructions and separate from noncytotoxic agents 2. use disposable gloves when preparing and handling chemo therapy medications and after handling any body secretions 3. perform thorough hand hygiene before and after glove application 4. do not crush, cut, or split chemo drugs 5. Use separate equipment to prepare chemo and regular medications 6. all disposable protective clothing as well as any disposable materials used while handling oral chemotherapeutic agents should be disposed of as cytotoxic waste according to the local waste disposal regulatory guidelines 7. Patients and their family members should avoid deep kissing and sharing food or drinks because chemotherapy can be in saliva. clean flatware and dishes thoroughly with soap and warm water and rinse well before washing a second time with other dishes 8. any clothes or sheets that have body fluids on them should be washed in a washing machine - not by hand. Wash them twice in hot water with regular laundry detergent. do not wash them with other clothes. if they cannot be washed right away, seal them in a plastic bag