Module 13: Medication Administration And Errors Flashcards
Alarming trends for medication in nursing
each year there are 1 mil emergency dept visits and hospitalizations due to adverse drug effects
approx 82% of American adults take at least one med and nearly 29% take five or more
We have aging pop with more chronic illnesses - so theres age related changes in drug response
Are side effects and adverse drug effects different?
yes, adverse are harmful and unintended unlike side effects which are manageable
Causes of medication errors
Transcription
prescribing
documentation
not adhering to the medication rights
trailing zeros and not placing a zero in front of the decimal
confusing names (similar names)
inappropriate use of abbreviations
distractions (poor lighting, heat, noise, interruptions, wrong medications, expired/discontinued or contaminated medications)
Prescribing Errors can be in the form of …
wrong times or dosages - nurse should double check
Safe Medication Administration includes understanding of …
generic/trade names
DEA schedules
pregnancy/lactation category
safety of dosage
medication of action
side effects
rate/route of excretion
interaction of medications
nursing considerations (lab values, effectiveness)
What is generic v trade name
Generic name is the chemical name
Trade name is the name on the label
DEA schedule describes …
level of addictiveness
What are nurses responsibilities for medication administration?
Legally responsible for medication they administer, so if they suspect an error they must question it
The nurse assumes individual accountability for safe drug administration by following the standards
Understand policy and procedures for safe medication handling and administration at each facility
No medication can be administered without being …
prescribed by a licensed practitioner !!!
Safe practice dictates that a nurse only follow what types of orders?
written, typed, or order entry orders
What situation allows for verbal orders
emergency
Student nurses are NOT allowed in any circumstance to accept ___ orders
verbal
There are ___ ___ for verbal Orders
legal implications for verbal orders
Medication reconcilitation
a process specifying and maintaining an accurate list of medications
When should the 3 checks of the 11 rights of medication administration be done?
First, when nurse reaches for the unit dose package or container
Second, after retrieval from drawer and compared with CMAR/MAR or compared immediately before pouring from multi dose container
Third, before giving unit dose to patient or when replacing the multi dose container in drawer or shelf
It is ___ for students to dispense medications
illegal
11 Rights of Medication Adminstration
Right Patient Right Medication Right Dose Right Route Right Time Right Reason Right Assessment Right Documentation Right Response Right to education Right to refuse
Right #1
Right Patient:
check patient name and DOB, compare to ID bracelet and what is stated
verify allergies
Right #2
Right Medication:
Perform triple check of all rights and medication label
(brand v generic names, be aware of similar sounding names, be familiar with medicine)
Never administer medication when…
it was prepared by another person
it was not labeled or had its labeled tampered with
Right #3
Right Dose:
check label for med concentration and compare dose with order
triple check med calculations
verify dose is in appropriate dose safe range for patient and in therapeutic range
Right #4
Right Route:
verify med route with order before administering
medication can only go via route specified
ID and use appropriate tools needed
Right #5
Right Time:
Verify schedule of med with the order
check for stop date and what time of day (in regard to order and institution policy
check for frequency and prior dosages
eval patient within 30 minutes or sooner per medication/policy
When performing Right Time, really focus on…
specified frequency and evaluation
Right #6
Right Reason:
Confirm the rationale for the ordered med
What is the pt hx, why are they taking it, revisit reasons for long term med use
Right #7
Right Assessment:
properly assess the patient and tests to see if med is safe and appropriate
if contraindicated, NOTIFY provider ASAP
If med was NOT administered, document and report
Right #8
Right Documentation:
completely document per facility policy immediately following administration
doc and report to approp provider any related S/S
Right #9
Right Response:
Monitor patient
Detect and prevent complications
evaluate any health changes
assess lab values and detect changes
document patients response to medication
provide patient education
Right #10
Right to Education:
Assess patients knowledge level
Provide education regarding: dosage, administration times, med side effects, confusion, contraindications
Right 11
Right to Refuse:
can refuse, but inform them on consequences of refusing
ensure that they understand consequences of refusal
notify the provider that the ordered medication was not given and document
document refusal and that they fully understand the consequences
Important considerations for medication administration?
Do not administer expired meds
Do not administer beyond stop date
Do not administer a medication that has had some chemical change`
Administer only medications labeled correctly and not tapered
What to do in the case of medication errors?
All med errors need to be reported; and all “near” misses need to be reported per facility policy
NEVER HIDE an error - it is important to get immediate attention
Errors can do what for patient safety
can highlight system flow issues and help facilitate changes to improve patient safety
Times you should not give medications
When the entire order is incomplete
Order should be signed by the provider
If the patient is showing any abnormal/physical concerns
When any of the 11 rights are missing
if the patient refuses
Any questions that are unanswered need to be double checked
Important Tips for Infection Control with med Administration
Infection control techniques
Hand washing
scrub hub for 15-30 seconds
1 needle/1 syringe/ 1 patient - EVERYTIME
per guidelines always insert a new sterile needle and syringe into a vial
Avoid distractions in red zone
follow policy for cosigning of meds
never pre pour meds
perform all rights 3 times
document now, not later
__ needle, syringe, patient
1 (EVERYTIME)
Best practice is to _____ multi dose vials
not use
When you administer meds, always do what
double check allergies
When you administer meds, never…
leave medications at the bedside
How many times should the 11 right be checked?
3 times
Ways to ensure safe medication administration
keep head elevated
make sure patient swallows and does not pocket the medication
consider oral motor concerns
difficulty or delayed swallowing (aspiration/choking) - check for it
“tonic” biting
age related changes
special needs for some patients
appropriate land marking for injectable medications
What are some other considerations regarding medications?
Reconcile medications as frequent as necessary but also per facility policy
cont monitoring of meds is essential for safety
watch for signs of DELIRIUM (confusion and disorientation)
med metabolism and absorption may be impacted by chronic illness and infection
What is the most common form of medication error
Omitted doses
Most common cause of medication errors is …
transcription errors
What contributes to the perpetuation of errors?
failure to do required double checks
Reliance on newer medication systems is changing the nature of medication errors how?
because nurses are becoming reliant on them rather than doing the 6 steps to minimize errors
What are the single most preventable cause of patient injury?
medication errors
What types of medication errors are there?
Prescribing Errors
Dispensing Errors
Administration errors
Prescribing Errors
Wrong patient, wrong dose, etc
failure to comply with legal requirements for prescription writing. The prescriber must specify the information which the pharmacist needs to dispense the drug in the correct dosage and form
Dispensing Error
Wrong thing given
errors that occur at any stage during the dispensing process from the receipt of a prescription in the pharmacy through to the supply of a dispensed product to the patient.
Administration Error
incorrect administration of the drug
discrepancy between the drug therapy received by the patient and the drug therapy intended by the prescriber.
What are some examples of prescribing errors?
incorrect drug dose, strength, route, quantity
adverse patient effects, drug allergies, wrong drug name, dosage form or abbreviation
incorrect dosage calculations
incorrect frequency
What are some examples of dispensing errors?
the selection of the wrong strength/product (two or more drugs have a similar appearance or similar name)
The use of computerized labeling which has led to the emergence of transposition and typing errors which are now among the most common causes of dispensing error
wrong dose
wrong drug
wrong patient
What is considered the highest risk area in nursing practice
drug administration (administration errors)
Administration errors largely involve what?
Errors of omission where administration is omitted due to a variety of factors
e.g. wrong patient, lack of stock
What are some examples of administration errors
wrong administration technique
administration of expired drugs
wrong preparation administered
What are some contributing factors to medication errors/prescribing error occurrence?
Illegible handwriting
Inaccurate drug history taking
Drug name confusion
Inappropriate use of decimal points
Use of abbreviations
Use of verbal orders
Lack of knowledge of the prescribed drug, recommended dose, and the patient may also contribute to prescribing errors
MAR
Medication administration record
What are the 3 general rules for med administration?
- Before giving a drug, nurse must be familiar with all information on that drug
- Check to see if patient has any allergies
- Student must check ORIGINAL physicians order against med sheet before giving med as it could be different between the order and MAR
A complete order from a physician includes what things?
Medication Type
Dosage
Frequency
route
Patient Name
Date and Time
Physician Signature
immediately after giving a medication …
document that it was given
Right time includes what things
What time IS it,
has it been signed for as given,
is the drug time limited
What should be observed and done while pouring medications?
Silence!
Do not allow distractions when pouring or preparing medications
Always check the dose on each individual ___
Tablet
What are the 4 types of time limited drugs
Anti Infectives (biotics, virals, etc)
Narcotics/Controlled Substances
Anti Coagulants
Steroids
Excess meds refused from stock supply refused by patient should be … EXCEPT…
discarded per agency policy
EXCEPT controlled drugs which may need to be saved for verification of count
Another nurse should go with you to see that the drug is properly been ridden of
Medications are not to be poured..
from one bottle to another
Is pouring from one bottle to another dispensing?
yes - do not do
Only administer medicines which ___ have prepared
YOU
When a patient goes to the operating room, what happens to med orders?
they must be discontinued and new orders must be written post op by the physician
What should be provided for teeth staining drugs or irritating drugs
Straws
Until when should you remain with the patient during med administration
UNTIL IT WAS CONSUMED - face ambulatory patients while they swallow and check for pocketing
Can medication be left at the bedside?
only if specifically ordered, otherwise DO NOT LEAVE IT BY THE BEDSIDE
Be aware of what in regard to food and co-pharmacy when giving drugs?
Beware of incompatible drugs
Some meds can and some cannot be given with good
What should happen if a medication error occurs immediately?
report to instructor and nurse in charge and fill out an incident report
Poured medications or medication cart must be ..
under direct observation until all medications have been given
medication cart should be locked if unattended
How should recording med administration be done?
AFTER NOT BEFORE being given
Sign initials on med sheet/EMR but also use legal signature and title on bottom of med sheet or a designated “signature sheet”
Is Susan Murphy, SUNY-SN a correct signature?
yes
Is S. Murphy or Sue Murphy correct signatures?
no
Controlled drugs must be what at the time they are removed from the locked area
signed for on a registry or computer
Controlled medications must be ___ ___ in a ___ ___ at all times
double locked in a stationary cupboard at all times
What should be done with a surplus of medication?
it should be returned to pharmacy for billing credit after order is discontinued or patient is discharged
can a patient give medications to patient/family to take home
NO
What does the term “time limited” mean for drugs?
can only be given for a certain number of days and then must be reordered by a physician
DEA schedule tells what about meds
addictiveness and usefulness
Unit Dose System
a system used by most agencies where it is individual wrap and labeled meds that are opened at the bedside and nothing is wasted if refused
Tips for Tablet or capsule administration from multi dose supply
a. Pour or tap required number into container cap.
b. transfer to paper or soufflé cup.
c. For certain medications, pour into separate cup (e.g., digitalis preparations).
d. Do not touch with fingers or palm of hand.
e. Do not return excess to bottle by touching (pour or tap it in).
f. Only break scored tablets. Do not crush enteric coated tablets.
Tips for liquid medication administration
Is it a solution or suspension. Adequately shake a suspension.
Pour away from the label into plastic calibrated medicine cup.
Hold the medicine cup at eye level.
Read the bottom of the meniscus.
Wipe “drip” off top of bottle before replacing the cap.
straw route if can stain teeth or difficult to take
syringe with needle removed may be used to measure and administer a SMALL amount of liquid in pediatrics - given to side of mouth with head elevated and spitting is likely so squeeze cheeks
Do not do what with liquid medications?
hide them in beverage or food to trick a patient into taking it
Absorption
drug is transferred from site of entry into bloodstream
Distribution
drug is distributed throughout the body
Metabolism
drug is broken down into an inactive form
Excretion
drug is excreted from the body
Oral Drugs
Capsule
pill
tablet
extended release
elixir
suspension
syrup
Topical Drugs
liniment
lotion
ointment
suppository’s
transdermal patch
What are the 3 main types of drugs (routes)
Oral
topical
injectable
Subcutaneous Injection
goes into subcut tissue
Intramuscular Injection
goes into muscle tissue
Intradermal Injection
goes into corium (epidermis)
Intravenous Injection
goes into vein
Intraarterial injection
goes into artery
Intracardial Injection
goes into heart tissue
Intraperitoneal injection
goes into peritoneal cavity
Intraspinal injection
goes into spinal canal
Intraosseous Injection
goes into bone
Steps for Administering an Injection
Go to med supply
remove med from supply - read label for the first time and compare with order
calculate dosage and validate
choose equipment
Criteria for Choosing Equipment for Injections
Route of administration
Viscosity of the solution
Quantity to be administered
Body size
Type of medication
What are cartridges to get ready for injections?
ampules
vials
prefilled cartridges
When angling the syringe, where should the bevel be ?
Bevel Up
What is the lumen of the needle
the inner part of the needle shaft where liquid travels
What are the different types of syringes
Standard (3 mL)
Tuberculin (1 mL)
insulin (in units)
Tubex (metal case or blue plastic case)
Standard needles measure to …
the 10ths place
Tuberculin needles measure to …
measure to 100ths place
Insulin needles are the only needle measuring in…
units (not mL)
5 cc or 10 cc needles are usually for
IV
Standard, Insulin, tuberculin, and tubex needles are typically for what route?
subcutaneous
Gauge
defines lumen of the needle
the larger the gauge, the smaller the lumen
The ___ the gauge, the ___ the lumen
larger, smaller
IM injections need what sort of gauges
smaller numbers (bigger gauges)
Common Needle Lengths
1/5 inch, 5/8 inch, 1 inch, 1.5 inch
Common Gauge Sizes
27, 25, 23, 22, 21, 20
After choosing the appropriate needle, do what?
Obtain alcohol swabs and recheck medication label the second time
What is sterile technique for injection
Draw up correct amount of air in syringe.
Cleanse top of vial or pull cover off vial (clean with alcohol).
Inject air into the airspace of the vial.
Withdraw accurate amount of medication into syringe. (upside down)
Eject air bubbles. (flick)
Remove needle from vial.
Cap needle.
Mixing insulin should follow..
facility policy
What are the different types of Insulin
Fast Acting
Slow Acting
Regular
Do not put ___ into an ampule
air
Subcutaneous Injections can go in what areas …
2 fingers from umbilicus
deltoid
loins
buttocks
thighs
What are the 4 different intramuscular injection sites?
Ventrogluteal
Vastus Lateralis
Deltoid Muscle
Dorsogluteal - No longer recommended
What are the steps before inserting the needle
Apply clean glove(s).
Once proper area for injection is identified, clean area from center outward with alcohol wipe.
Place alcohol wipe next to area. Let alcohol dry.
Hold skin correctly (stretch taut for IM or pinch for SC).
At what angle and how should an intramuscular needle be inserted?
90 degrees with a darting motion
At what angle and how should a subcutaneous needle be inserted?
45 degrees with the BEVEL UP (or 90 degrees with short needle; insulin pen)
At what angle should an intradermal needle be inserted?
15 degrees (just under the skin)
What are the steps after needle in inserted?
Stabilize the needle.
Aspirate unless contraindicated
Inject medication slowly & smoothly (check patient’s facial expression).
Remove needle quickly using counter‑pressure.
Massage area ONLY if appropriate.
Do NOT recover needle or remove needle. Place syringe into the “sharps” container located in room immediately
Do not do what to needles?
Recap
What is aspiration
Where you inject in an pull back to check for blood returned
Do most injections aspirate?
No
If there is blood with aspiration, it must be …
disposed of and not injected
What sort of injections get aspirated and which do not?
IM injections are aspirated to check if they are in muscles and not in a vessel
SQ/SC do not get aspiration since they are not that long and the chance for being in IM is less (but may need to be done if the person is skinny/malnourished)
What should be worn during injections
gloves
Intradermal Injection
small amount of fluid under epidermis
You go flat to the skin and tip of the bevel only goes under to make the injection and subsequent “wheel”
Z Track
For IM Injections - prevents skin irritation
ID the site, and pull the skin to one side to insert the needle and inject then withdraw
Release the skin and the medication is then prevented from oozing back out since the way is no longer straight out
When drawing medications there is a risk for what?
Medicine staying in the drawing needle or the needle dulling, so a new one needs to go on after drawing up medications
What is done after an injection is done?
Reposition patient for comfort
Wash hands before leaving patient’s room
Chart medication given
Assess for response to med and document (after appropriate time)
Even though meds are applied locally with non-injectable and non-oral meds, they…
may have systematic effects
Topical medications
applied to skin
decreased absorption on cornified (hardened) skin (i.e. soles, palms) but increased on inner limbs and trunk
do not apply to open cuts
concentration of med more important than amount applied
wear gloves
Subcutaneous injections should be under what amount
1 cc or 1 mL
Deltoids should not be used for…
infants and newborns (its too small)
The preferred adult injection site is..
the vastus lateralis
What needle size is usually used for IM injections?
5/8 inch to 1.5 inch (but a baby needs smaller and so do adults with loss muscle mass)
If you hit bone with an IM injection what should you do?
Withdraw and retry with new needle
Anything less than 5/8 inch is usually for what type of injection?
less than 5/8 inch
What are some examples of gauge sizes for IM
20 21 22 23 - larger lumens (since larger numbers = smaller lumen)
When giving subcutaneous injections what should be considered
shorter needle size
large gauge number (small lumen)
angle injecting into
What is the angle range for insulin
45 to 90 degrees in a darting motion
Do you aspirate for insulin, anticoagulants, and other subcutaneous injections
Do Not Aspirate
What to do for Patches/Transdermal meds?
Check for the presence of the old patch and remove before applying new patch. Cleanse skin.
Check skin for any sign of irritation and promptly report.
Apply new patch to appropriate body sites as recommended by the manufacturer and rotate sites.
If a patch requires date and time of application on the patch, mark the patch before applying to the skin.
Wash hands after application
Use only what kinds of nasal medications to prevent pneumonitis (inflammation of lungs)?
water soluble meds
How to instill nose drops?
Supine position
Push tip of nose up
Position dropper above nostril directing tip toward midline of nose
Count drops
Keep head back for 5 minutes
Clean and flush dropper
Steps for Nasal Sprays
Sit patient upright and tilt head back slightly
Occlude one nostril with finger
Insert tip into open nostril
Ask patient to inhale while squeezing atomizer
Repeat as ordered
Administer in other nostril
Wash atomizer tip
Wash hands
Instilling Eye Drops
Wash Hands
Glove
Offer Tissues
Clean Eye / Eyelids / Eyelashes
Tilt head back
Hold the dropper close but DON’T touch eye
Let drop(s) fall in as prescribed in the conjunctival sac
Press lightly on inner canthus to decrease systemic effect.
Applying Eye Ointment
Perform rights for medication Administration
Wash Hands
Wear Gloves
Clean Eye / Eyelids / Eyelashes
Tilt head back
Apply pressure downward to expose lower eye
Apply prescribed amount along the conjunctival sac
Close eyes gently
Administering Ear Drops
Perform 6 rights for medication Administration
Wash Hands
Glove
Position patient / affected ear toward you / Unaffected ear is down
Clean any drainage
Stabilizer dropper hand to avoid ear canal damage
For adult, pull ear up and back before instilling drops.
For child under three, pull ear down and back before instilling drops.
Have patient remain for 5-10 minutes to allow medication to go into ear canal.
Important things to keep in mind with respiratory medications
rapid absorption occurs due to much vascularity and one layer of epithelial tissue
must be water soluble (or pneumonitis can occur)
Steps for Metered Dose Inhalers
Wash hands.
Explain steps to patient:
Assemble unit, inspect mouthpiece (remove mouthpiece cover).
Have patient exhale fully.
Shake unit to disperse medication.
Place mouthpiece in front of mouth or in mouth
according to manufacturer’s recommendations.
While inhaling slowly and deeply through mouth, depress medication canister fully.
Have patient hold breath for 10 seconds or as long as possible or according to manufacturer’s recommendations and exhale through pursed lips
Wait 5 minutes between puffs or as ordered by physician or according to manufacturer’s recommendations.
Use sequential inhalers according to doctor’s orders.
RINSE MOUTH
Rinse mouthpiece and wash hands
Tips for Rectal Medication
Often used for nausea, vomiting, unconsciousness, foul odor/taste, infants.
Usually a suppository, may be a retention enema.
Do not use an oral med for this route.
Lubricant; insert past sphincter; if sphincter control is poor, hold buttocks closed after inserting.
Be aware of possible vagal stimulation.
Wear gloves.
Tips for Vaginal Medication
Usually an applicator is used; keep patient supine (e.g., give at H.S.).
Wear gloves.
In nursing, ___ ___ is our priority
medication safety
What are important things to teach patients about in regard to medication
Review techniques of medication administration.
Remind the patient to take the medication as prescribed for as long as prescribed.
Instruct the patient not to alter dosages without consulting a physician.
Caution the patient not to share medications.
