Safe Medication Administration and Error Reduction PDF

CHAPTER 47 UNIT 4 PHYSIOLOGICAL INTEGRITY PRESCRIPTION MEDICATIONS SECTION: PHARMACOLOGICAL AND PARENTERAL THERAPIES Nurses administer prescription medications...

CHAPTER 47 UNIT 4 PHYSIOLOGICAL INTEGRITY PRESCRIPTION MEDICATIONS SECTION: PHARMACOLOGICAL AND PARENTERAL THERAPIES Nurses administer prescription medications under the Safe Medication supervision of providers. These medications can be CHAPTER 47 habit forming, ha e potential harmful effects, and Administration and require monitoring. Error Reduction Uncontrolled substances These medications require monitoring by a provider, but do not generally pose a risk of misuse or The providers who can legally write prescriptions addiction. Antibiotics are an example of uncontrolled prescription medications. in the United States include physicians, advanced practice nurses, dentists, and physician assistants. Controlled substances Medications that have a potential for misuse and dependence PROVIDER RESPONSIBILITIES and ha e a schedule classi cation. Heroin is in chedule I and has no medical use in the United States. Medications Obtaining clients’ medical history and performing in Schedules II through V have legitimate applications. a physical examination Each subsequent level has a decreasing risk of misuse Diagnosing and dependence. For example, morphine is a Schedule II Prescribing medications medication that has a greater risk for misuse and dependence Monitoring the response to therapy than phenobarbital, which is a Schedule IV medication. Modifying medication prescriptions as necessary NURSE RESPONSIBILITIES KNOWLEDGE REQUIRED PRIOR TO MEDICATION ADMINISTRATION Having knowledge of federal, state (nurse practice acts), and local laws, and facilities’ policies that govern the Medication category prescribing, dispensing, and administration of medications Medications have a pharmacological action, therapeutic use, Preparing and administering medications, and body system target, chemical ma eup, and classi cation evaluating clients’ responses to medications for use during pregnancy. For example, lisinopril is an Developing and maintaining an up-to-date knowledge angiotensin-converting enzyme inhibitor (pharmacological base of medications they administer, including uses, action) and an antihypertensive (therapeutic use). mechanisms of action, routes of administration, safe dosage range, ad erse effects, precautions, Mechanism of action contraindications, and interactions Maintaining knowledge of acceptable practice and This is ho the medication produces its therapeutic effect. skills competency For example, glipizide is an oral hypoglycemic agent Determining the accuracy of medication prescriptions that lowers blood glucose levels primarily by stimulating Reporting all medication errors pancreatic islet cells to release insulin. Safeguarding and storing medications Therapeutic effect This is the e pected effect physiological response for MEDICATION CATEGORY hich the nurse administers the medication to a speci c AND CLASSIFICATION client. One medication can have more than one therapeutic effect. or e ample, one client might ta e diphenhydramine NOMENCLATURE to relieve allergies while another takes it to induce sleep. Chemical name: A medication’s chemical composition Adverse effects (N-acetyl-para-aminophenol). These are undesirable and potentially dangerous responses Generic name: fficial or nonproprietary name the nited to a medication. Ad erse effects can be inad ertent or States Adopted Names Council gives a medication. Each predictable. Some are immediate; others take weeks or medication has only one generic name (acetaminophen). months to develop. For example, the antibiotic gentamicin Trade name: Brand or proprietary name the company that can cause hearing loss. manufacturers the medication gives it. One medication can have multiple trade names (Tylenol, Tempra). Toxic effects edications can ha e speci c ris s and manifestations of toxicity. For example, nurses monitor clients taking digoxin for dysrhythmias, a manifestation of cardiotoxicity. Hypokalemia places these clients at greater risk for digoxin toxicity. FUNDAMENTALS FOR NURSING CHAPTER 47 SAFE MEDICATION ADMINISTRATION AND ERROR REDUCTION 277  Interactions Stat prescriptions Medications can interact with each other, resulting in A stat prescription is only for administration once and bene cial or harmful effects. or e ample, gi ing the immediately. For example, a stat prescription instructs the beta-blocker atenolol concurrently with the calcium nurse to administer digoxin 0.125 mg IV bolus stat. channel bloc er nifedipine helps pre ent re e tachycardia. Medications can also increase or decrease the actions of Now prescriptions other medications, and food can interact bene cially or A now prescription is only for administration once, but up harmfully with medications. to 90 min from when the nurse received the prescription. For example, a now prescription instructs the nurse to Precautions, contraindications administer vancomycin 1 g intermittent IV bolus now. These are conditions (diseases, age, pregnancy, lactation) that make it risky or completely unsafe for clients to take PRN prescriptions speci c medications. or e ample, tetracyclines can stain A PRN (pro re nata prescription speci es at hat dosage, hat developing teeth; therefore, children younger than 8 years frequency, and under what conditions a nurse can administer should not take these medications. Another example is the medication. The nurse uses clinical judgment to that heart failure is a contraindication for labetalol, an determine the client’s need for the medication. For example, antihypertensive medication. a PRN prescription instructs the nurse to administer morphine 2 mg IV bolus every hour PRN for chest pain. Preparation, dosage, administration It is important to no any speci c considerations for Other prescriptions preparation, safe dosages, and how to administer the Pro iders might rite prescriptions for speci c medication. For example, morphine is available in many circumstances or for speci c units. or e ample, a critical different formulations. ral doses of morphine are care unit has standing prescriptions for treating clients generally higher than parenteral doses due to extensive who have asystole. rst pass effect. Clients ho ha e chronic se ere pain (with cancer) generally take oral doses of morphine. COMPONENTS OF A MEDICATION PRESCRIPTION MEDICATION PRESCRIPTIONS The client’s full name Each facility has written policies for medication prescriptions, The date and time of the prescription including which providers can write, receive, and transcribe The name of the medication (generic or brand) medication prescriptions. The strength and dosage of the medication The route of administration The time and frequency of administration: exact times TYPES OF MEDICATION PRESCRIPTIONS or number of times per day (according to the facility’s policy or the speci c ualities of the medication Routine or standing prescriptions The uantity to dispense and the number of re lls A routine or standing prescription identi es medications The signature of the prescribing provider nurses give on a regular schedule with or without a termination date. Without a termination date, the prescription ill be in effect until the pro ider COMMUNICATING discontinues it or discharges the client. MEDICATION PRESCRIPTIONS Providers must re-prescribe some medications (opioids Origin of medication prescriptions and antibiotics ithin a speci c amount of time or they will automatically discontinue. Providers or nurses who take verbal or telephone prescriptions from a provider write medication Single or one-time prescriptions prescriptions on the client’s medical record. If the nurse writes a medication prescription on the client’s A single or one-time prescription is for administration once medical record, the facility s policy speci es ho much at a speci c time or as soon as possible. These prescriptions time the provider has to sign the prescription. Nurses are common for preoperative or preprocedural medications. transcribe medication prescriptions onto the medication For example, a one-time prescription instructs the nurse to administration record (MAR). administer warfarin 5 mg PO at 1700. 278 CHAPTER 47 SAFE MEDICATION ADMINISTRATION AND ERROR REDUCTION CONTENT MASTERY SERIES  View Video: Safe Administration of Medications Taking a telephone prescription RIGHTS OF SAFE Only when absolutely necessary MEDICATION ADMINISTRATION Ensure that the prescription is complete and correct by Right client reading it back to the provider: the client’s name, the name of the medication, the dosage, the time to give it, erify clients identi cation before each medication the frequency, and the route. administration. The Joint Commission requires two client To ensure correct spelling, use aids (“b as in boy”). State identi ers. Acceptable identi ers include the client s numbers separately (“one, seven” for 17). name, an assigned identi cation number, telephone Remind the provider to verify the prescription and sign it number, birth date, or other person speci c identi er ithin the amount of time the facility s policy speci es. a photo identi cation card. Nurses also use bar code Write or enter the prescription in the client’s scanners to identify clients. Check for allergies by asking medical record. clients, checking for an allergy bracelet or medal, and If possible, have a second nurse listen on an checking the MAR. extension or on a speaker in a private area (to ensure con dentiality. Right medication Correctly interpret medication prescriptions, verifying MEDICATION RECONCILIATION completeness and clarity. Read medication labels and compare them with the MAR three times: before removing The Joint Commission requires policies and procedures for the container, when removing the amount of medication medication reconciliation. Nurses compile a list of each from the container, and in the presence of the client client’s current medications, including all medications before administering the medication. Leave unit-dose with correct dosages and frequency. They compare the medication in its package until administration. list with new medication prescriptions and reconcile it to resolve any discrepancies. This process takes place at Right dose admission, when transferring clients between units or facilities, and at discharge. Use a unit-dose system to decrease errors. If not available, calculate the correct medication dose; check a drug reference to make sure the dose is within the usual range. Ask another PRE-ASSESSMENT FOR nurse to verify the dose if uncertain of the calculation. MEDICATION THERAPY Prepare medication dosages using standard measurement devices (graduated cups or syringes). Some medication Nurses obtain the following information before initiating dosages re uire a second eri er or itness some cytoto ic medication therapy and update it as necessary. medications). Automated medication dispensing systems use a machine to control the dispensing of medications. Health history Age Right time Health problems and the current reason for seeking care Administer medication on time to maintain a All medications clients currently take (prescription consistent therapeutic blood level. Refer to the drug and nonprescription): the name, dose, route, and reference or the facility’s policy for exceptions; general frequency of each recommendations follow. Any une pected ndings possibly from Administer time-critical medications within 30 min of medication therapy the prescribed time. acilities de ne hich medications Use of herbal or “natural” products for are time-critical; usually this includes medications that medicinal purposes require a consistent blood level (antibiotics). se of caffeine, tobacco, alcohol, or illicit drugs Administer non-time-critical medications prescribed Clients’ understanding of the purpose of once daily, weekly, or monthly within 2 hr of the the medications prescribed time. All medication and food allergies Administer non-time-critical medications prescribed more than once daily (but not more than every 4 hr) Physical examination within 1 hr of the prescribed time. A systematic physical examination provides a baseline for e aluating the therapeutic effects of medication therapy Right route and for detecting possible ad erse effects. The most common routes of administration are oral, topical, subcutaneous, intramuscular (IM), and intravenous (IV). Additional administration routes include sublingual, buccal, intradermal, transdermal, epidural, inhalation, nasal, ophthalmic, otic, rectal, vaginal, intraosseous, and via enteral tubes. Select the correct preparation for the route the provider prescribed (otic vs. ophthalmic topical ointment or drops). FUNDAMENTALS FOR NURSING CHAPTER 47 SAFE MEDICATION ADMINISTRATION AND ERROR REDUCTION 279  Online Video: Look-Alike, Sound-Alike Medications Right documentation RESOURCES FOR Immediately record pertinent information, including MEDICATION INFORMATION the client’s response to the medication. Document the Nursing drug handbooks medication after administration, not before. Pharmacology textbooks Professional journals Right client education Physicians’ Desk Reference (PDR) Professional websites Inform clients about the medication: its purpose, Pharmacists what to expect, how to take it, and what to report. To individualize the teaching, determine what the clients already know about the medication, need to know about the medication, and want to know about the medication. MEDICATION ERROR PREVENTION Right to refuse COMMON MEDICATION ERRORS Respect clients’ right to refuse any medication. Explain rong medication or I uid the consequences, inform the provider, and document Incorrect dose or IV infusion rate the refusal. Wrong client, route, or time Administration of a medication to which the client Right assessment is allergic Omission of a dose or extra doses Collect any essential data before and after administering Incorrect discontinuation of medication or I uid any medication. For example, measure apical heart rate Inaccurate prescribing before giving digoxin. The Institute for Safe Medication Practices (ISMP) is a Right evaluation nonprofit organization working to educate health care providers and consumers about safe ollo up ith clients to erify therapeutic effects as ell medication practices. The ISMP and the FDA as ad erse effects. identify the most common medical abbreviations that result in misinterpretation, mistakes, and injury. For a complete list, go to the ISMP website. 47.1 Error-prone abbreviation list Some abbreviations cause a high number of medication errors. DO NOT USE USE DO NOT USE USE q.o.d., QOD every other day MS, MSO4 morphine 6 p.m. daily or Q6PM, etc. daily at 6 p.m. MgSO4 magnesium sulfate TIW, tiw 3 times weekly abbreviated medication names (AZT, KCl, full name of medication mg., mL. mg, mL (no period) HCT, PTU, HCTZ) half-strength, bedtime HS nitro nitroglycerin (hour of sleep) decimal points without smaller units (500 mcg) or BT, hs, HS, qhs, qn bedtime or hour of sleep a leading zero (.5 mg) a leading zero (0.5 mg) SC, SQ, sub q subcutaneously trailing zero (1.0 mg, without a trailing IN intranasal 100.0 g) zero (1 mg, 100 g) IJ injection u, U, IU units OJ orange juice μ, μg mcg or microgram > or < greater than or less than x3d times 3 days @ at cc mL &, + and apothecary units metric units / per daily or intended time od, O.D., OD AD, AS, AU right ear, left ear, both ears of administration q.d, qd, Q.D, QD, q1d, i/d daily OD, OS, OU right eye, left eye, both eyes D/C, dc, d/c discharge or discontinue 280 CHAPTER 47 SAFE MEDICATION ADMINISTRATION AND ERROR REDUCTION CONTENT MASTERY SERIES  NURSING PROCESS Use verbal prescriptions only for emergencies, and follow the facility’s protocol for telephone prescriptions. Nursing Use the nursing process to prevent medication errors. students cannot accept verbal or telephone orders. Follow all laws and regulations for preparing and Assessment/data collection administering controlled substances. Keep them in a Ensure knowledge of medication to administer and why. secure area. Have another nurse witness the discarding Obtain information about the clients’ medical diagnoses of controlled substances. and conditions that relate to medication administration Do not leave medications at the bedside. Some facilities’ (the ability to swallow, diet, allergies, and heart, liver, policies allow exceptions (for topical medications). and kidney disorders). ◯ Identify allergies. Evaluation ◯ Obtain necessary preadministration data (heart rate, Evaluate clients’ responses to medications, and blood pressure) to assess the appropriateness of the document and report them. medication and to obtain baseline data for evaluating ecogni e ad erse effects, and document and the effecti eness of medications. report them. ◯ mit or delay doses according to ndings, and notify Notify the provider of all errors, and implement the provider. corrective measures immediately. Determine if the medication prescription is complete: ◯ Complete an incident report ithin the speci ed with the client’s name, date and time, name of time frame, usually 24 hr. Include the client’s medication, dosage, route of administration, time and identi cation, the time and place of the incident, frequency, and signature of the prescribing provider. an accurate account of the e ent, ho you noti ed, Interpret the medication prescription accurately. Refer what actions you took, and your signature. Do not to the ISMP lists for error-prone abbreviations, confused reference or include the incident report in the client’s medication names, and high-alert medications. medical record. Question the provider if the prescription is unclear or ◯ Medication errors relate to systems, procedures, seems inappropriate for the client’s condition. Refuse to product design, or practice patterns. Report all errors administer a medication if it seems unsafe, and notify to assist the facility’s risk managers to learn how the charge nurse or supervisor. errors occur and what changes to make to avoid Providers usually make dosage changes gradually. similar errors in the future. Question the provider about abrupt and excessive changes. Determine clients’ learning needs. Planning Identify clients’ outcomes for medication administration. Prioritize medication administration to administer critical medications rst, or to no hich medications need to be given prior to treatment, procedures, or meals. Implementation Avoid distractions during medication preparation (poor lighting, phones). Interruptions increase the risk of error. Prepare medications for one client at a time. Check the labels for the medication’s name and concentration. Read labels carefully. Measure doses accurately, and double-check dosages of high-alert medications (insulin and heparin) with a colleague. Check the medication’s expiration date. Doses are usually one to two tablets or one single-dose vial. Question multiple tablets or vials for a single dose. Follow the rights of medication administration consistently. Take the MAR to the bedside. Only give medications that you have prepared. Encourage clients to become part of the safety net, teaching them about medications and the importance of proper identi cation before medication administration. Omit or delay a dose when clients question the size of the dose or the appearance of the medication. Follow correct procedures for all routes of administration. Communicate clearly both in writing and speaking. FUNDAMENTALS FOR NURSING CHAPTER 47 SAFE MEDICATION ADMINISTRATION AND ERROR REDUCTION 281  Application Exercises Active Learning Scenario 1. A nurse prepares an injection of morphine to A nurse educator is teaching a group of newly administer to a client who reports pain, then asks a licensed nurses. Use the ATI Active Learning second nurse to give the injection because another Template: Basic Concept to complete this item. assigned client needs to use a bedpan. Which of the following actions should the second nurse take? RELATED CONTENT: List the rights of safe medication administration. A. Offer to assist the client who needs the bedpan. B. Administer the injection the other nurse prepared. UNDERLYING PRINCIPLES: List at least three acceptable identifiers to use to verify the client’s identity. C. Prepare another syringe and administer the injection. D. Tell the client who needs the bedpan to wait while the nurse gives someone else medication. 2. A nurse is reviewing a client’s prescribed medications at the beginning of the day shift. Which of the following 0900 medications can be given anytime between 0700 and 1100? (Select all that apply.) A. A once-daily multivitamin B. Eye drops prescribed every 3 hr C. An antibiotic prescribed every 8 hr D. A blood pressure pill prescribed twice daily E. A subcutaneous injection prescribed once weekly 3. A nurse orienting a newly licensed nurse is reviewing the procedure for taking a telephone prescription. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands the process? A. “A second nurse enters the prescription into the client’s medical record.” B. “Another nurse should listen to the phone call.” C. “The provider can clarify the prescription when they sign the health record.” D. “I should omit the ‘read back’ if this is a one-time prescription.” 4. A nurse educator is teaching newly licensed nurses about safe medication administration. Which of the following statements indicates understanding? (Select all that apply.) A. “I will observe for adverse effects.” B. “I will monitor for therapeutic effects.” C. “I will prescribe the appropriate dose.” D. “I will change the dose if adverse effects occur.” E. “I will refuse to give a medication if I believe it is unsafe.” 5. A nurse reviewing a client’s health record notes a new prescription for lisinopril 10 mg PO once every day. The nurse should identify this as which of the following types of prescription? A. Single B. Stat C. Routine D. Now 282 CHAPTER 47 SAFE MEDICATION ADMINISTRATION AND ERROR REDUCTION CONTENT MASTERY SERIES  Application Exercises Key Active Learning Scenario Key 1. A. CORRECT: The second nurse should offer to assist the Using the ATI Active Learning Template: Basic Concept client who needs the bedpan. This will allow the nurse RELATED CONTENT: Rights of Safe Medication Administration who prepared the injection to administer it. Right client: Verify clients’ identification before each B. Only administer medications that were personally prepared. medication administration. The Joint Commission requires C. Preparing another syringe will delay the administration of two client identifiers. Acceptable identifiers include the the pain medication and adds extra cost for the client. client’s name, an assigned identification number, telephone D. Telling the client to wait is not an acceptable option for a number, birth date, or other person-specific identifier (a photo client who needs a bedpan if other assistance is available. identification card). Nurses also use bar-code scanners to NCLEX® Connection: Management of Care, identify clients. Check for allergies by asking clients, checking Legal Rights and Responsibilities for an allergy bracelet or medal, and checking the MAR. Right medication: Correctly interpret medication prescriptions, verifying completeness and clarity. Read medication labels 2. A. CORRECT: Administer a once-daily non-time-critical and compare them with the MAR three times: before medication within 1 to 2 hr of the prescribed time. removing the container, when removing the amount of B. Administer medications prescribed more frequently than medication from the container, and in the presence of every 4 hr within 30 min of the prescribed time. the client before administering the medication. Leave C. Administer time-critical medications (antibiotics) unit-dose medication in its package until administration. within 30 min of the prescribed time. Right dose: Use a unit-dose system to decrease errors. If not D. Administer medications prescribed more frequently available, calculate the correct medication dose; check a drug than once daily within 1 hr of the prescribed time. reference to make sure the dose is within the usual range. Ask E. CORRECT: Administer medications prescribed once another nurse to verify the dose if uncertain of the calculation. weekly within 1 to 2 hr of the prescribed time. Prepare medication dosages using standard measurement NCLEX® Connection: Pharmacological and Parenteral Therapies, devices (graduated cups or syringes). Some medication Medication Administration dosages (some cytotoxic medications) require a second verifier or witness. Automated medication dispensing systems use a machine to control the dispensing of medications. 3. A. The nurse who accepts the telephone prescription Right time: Administer medication on time to maintain a consistent should enter it into the client’s medical record therapeutic blood level. It is generally acceptable to administer to prevent errors in translation. the medication 30 min before or after the scheduled time. Refer B. CORRECT: A second nurse should listen to a telephone to the drug reference or the facility’s policy for exceptions. prescription to prevent errors in communication. Right route: The most common routes of administration are C. Verify that the prescription is complete and oral, topical, subcutaneous, intramuscular, and intravenous. accurate at the time they take it by reading Additional administration routes include sublingual, buccal, it back to the prescribing provider. intradermal, transdermal, epidural, inhalation, nasal, ophthalmic, D. A telephone prescription includes reading back otic, rectal, vaginal, intraosseous, and via enteral tubes. all types of medication prescriptions. Select the correct preparation for the route the provider NCLEX® Connection: Pharmacological and Parenteral Therapies, prescribed (otic vs. ophthalmic topical ointment or drops). Medication Administration Right documentation: Immediately record pertinent information, including the client’s response to the medication. Document the medication after administration, not before. 4. A. CORRECT: The nurse is responsible for Right client education: Inform clients about the medication: its observing for adverse effects. purpose, what to expect, how to take it, and what to report. To B. CORRECT: The nurse is responsible for individualize the teaching, determine what the clients already monitoring therapeutic effects. know, need to know, and want to know about the medication. C. The provider is responsible for prescribing the appropriate dose. This is outside of the nurse’s scope of practice. Right to refuse: Respect clients’ right to refuse any D. The provider is responsible for changing the dose if adverse medication. Explain the consequences, inform effects occur. This is outside of the nurse’s scope of practice. the provider, and document the refusal. E. CORRECT: The nurse is responsible for identifying Right assessment: Collect any essential data before when a medication could harm a client. It is the and after administering any medication. For example, nurse’s responsibility to refuse to administer the measure apical heart rate before giving digoxin. medication and contact the provider. UNDERLYING PRINCIPLES NCLEX® Connection: Pharmacological and Parenteral Therapies, Acceptable identifiers include the client’s name, an Expected Actions/Outcomes assigned identification number, telephone number, birth date, or other person-specific identifier. The nurse can use bar-code scanners to identify clients. 5. A. A single or one-time prescription is for administration once at a specific time (prior to a procedure). NCLEX® Connection: Pharmacological and Parenteral Therapies, B. A stat prescription is only for administration Medication Administration once and immediately. C. CORRECT: A routine or standing prescription identifies medications to give on a regular schedule with or without a termination date or a specific number of doses. Administer this medication every day until the provider discontinues it. D. A now prescription is used when a client needs medication soon, but can wait a short time, and can be given within 90 min. NCLEX® Connection: Management of Care, Client Rights FUNDAMENTALS FOR NURSING CHAPTER 47 SAFE MEDICATION ADMINISTRATION AND ERROR REDUCTION 283 284 CHAPTER 47 SAFE MEDICATION ADMINISTRATION AND ERROR REDUCTION CONTENT MASTERY SERIES