mod 3 med admin records and med errors Flashcards
essential components of medical administration records (MAR)
Dates- date of order, start and end date for administration
med info- med full name, dosage , route, frequency
time admin- schedule such as TID, enter desired admin time and convert time periods based on intervals ( first admin for TID 0900, 1300, 1700
initials- of person transcribing med to MAR and person admin med, initials in signature section who admin med, include title of signature RN
special instructions- specific for med to pt.. “hold if BP is less than 100 systolic”
documented meds
immediately after admin\
PRN and one-time meds not given on schedule and entered on separate MAR or may be incorporated into eMAR
What may happen when documentation is not performed immediately after medication is administered?
pt may receive med twice
common cause med errors
- -Incomplete patient information (e.g., allergies, other medications the patient is taking)
- -Incomplete drug information
- -Lack of collaboration and communication or teamwork
- -Confusing sound-alike or look-alike drug names, drug labels, and packages
- -Missing or damaged drug labels
- -Inaccurate drug standardization
- -Incorrect storage or administration errors
- -Use of nonstandard, flawed, or unsafe delivery equipment
- -Dosage calculation errors
- -Incomplete orders
- -Miscommunication of orders
- -Omission of any of the seven rights of medication administration
prevent med errors
clarify orders
- -Ask the healthcare provider to rewrite or clarify any unclear medication order.
- -Use only abbreviations approved by the Joint Commission for medication dosages.
- -Do not use abbreviations for medication names.
- -Check medication orders against the MAR/eMAR.
- -Check the dose sent from the pharmacy with the MAR/eMAR.
- -Take advantage of technology by checking drug information references
prepare drugs safely
- limit interruptions
- have another check prep
- recalculate drug dosage as needed
check pt info and admin drug safely
- check id band w MAR and barcode
- -check allergies
- -check for contraindications
- -do not leave meds at bedside, stay until all meds are gone
- -never admin med prepped by another nurse
document info properly
- -record med admin on mar immediately after admin
- -report any adverse reactions
- -report MEs immediately to HCP
According to the Institute of Medicine (IOM), what should nurses do for patients to enhance efforts to prevent medication errors?
- provide ed, encourage pts speak up, suggest pt take notice care plans, encourage pt be active in own care, assist pts to partner w HCP
By encouraging nurse/patient dialogue, what does The Joint Commission’s Speak Up campaign help to generate?
a sense of teamwork
A child involved in a car accident was given an adult dose pain medication in the busy emergency department. What actions might have prevented this error?
- look up drug dosage info
- check dose sent from pharmacy
- have another rn check dosage prep
- limit interruptions when prep and admin drug
- ask hcp rewrite or clarify unclear med order
After a drug is administered, who is required to initial the medication documentation?
hcp
Zolpidem 5 mg is ordered PRN for a patient for insomnia. How are PRN orders documented?
on MAR as unschedule meds
Which statement(s) are true about the Institute for Safe Medication Practices’ (ISMP’s) error reporting system?
- info anonymous to encourage reporting
- reported errors used in nat studies to improve med safety
What action should be taken when a medication error is discovered?
info hcp
The nurse giving medications finds that the patient is in the bathroom and is not available to take the pills. What action should the nurse take next?
return when pt can be observed taking meds
A healthcare provider orders a new antibiotic for a patient. What should the nurse do to ensure patient safety before adding the medication to the MAR?
check allergies on pt record
