Med admin and safe injection/safety and security

Nursing drug knowledge

• generic names

• trade names

• classifications

• indications

• pharmakinetics

  • metabolism

  • excretion

• effects

  • adverse effects

  • allergic reactions

    • mild

    • anaphylactic

  • tolerance

  • toxic

  • idiosyncratic

Drug dose and serum drug levels: therapeutic range

concentration of drug in the blood serum that produces the desired effect without causing toxicity

Drug dose and serum drug levels: peak level

the point when the drug is a its highest

Drug dose and serum drug levels: trough level

the point when the drug is at its lowest concentration, indicating the rate of elimination

Drug dose and serum drug levels: half-life

amount of time it takes for 50% of blood concentration of a drug to be eliminated from the body

Medication reconciliation: administration assessment

• prescribed medications

• PTA medications

• allergies

• pregnancy and lactation status

• dietary supplements and herbal and “natural” remedies

Aging and drug response

• decreased gastric motility

• decreased total body water

• decreased lipid content in skin

• decreased liver function

• decreased kidney function

• adverse CNS effects 

• altered peripheral vascular tone

Critical thinking

• proper order

• calculating adult medication dosages

• patients condition

• equipment decisions

• documenting medication administration

• patient teaching

Medication orders

• verbal orders

• telephone orders

• standing orders

• PRN orders (as needed)

• stat orders

• one time order

Parts of the medication order

1. patients name and a secondary identifier (date of birth, medical record number)

2. date and time the order is written

3. name of drug to be administered

4. dosage of the drug

5. route by which the drug is to be administered

6. frequency of administration of the drug

7. signature of the prescribing provider

Parts of the medication order: how often?

• daily

• BID (twice a day)

• TID (3 times a day)

• QID (4 times a day)

• ac (before meals)

• pc (after meals)

• HS (at bedtime)

5 rights: dr tim

• dose

• route

• time

• individual/patient

• medication

6 other rights

• reason

• assessment

• documentation

• response

• refuse

• educate

3 checks

1. removing medication from med cart

2. comparing medication to MAR

   1. students have an additional check: instructor checks ALL meds

3. rechecking to EMR/MAR at bedside prior to admission

Identifying the patient

• utilizing 2 patient identifiers

  • name

  • birthdate

  • MRN

• comparing with the EMR

Right time (when is my medication administration considered late?: medications given more frequently than Q6 hours Q1, Q2, Q3, Q4 or short acting insulin (regular, Aspart/novolog)

administer within 30 minutes before or after the scheduled time

Right time (when is my medication administration considered late?: medications given Q6 hours or less frequently (Q6, Q8, Q12)

administer within 60 minutes before or after the scheduled time

Right time (when is my medication administration considered late?: daily, weekly, or monthly medications

administered within 2 hours before or after the scheduled time

Mechanisms of drug action?

• physiologic effect

• pharmacokinetics

• absorption (w/food?)

• lipid solubility

• pH

• blood flow (patho?)

• protein binding

• metabolism

• excretion

• weight

• biologic sex

Oral medication administration: enteral

• PO

• Feeding tubes

• sublingual and buccal routes

• solid

• liquid

• scored (breaking the pill)

• SR, XL, CR

• enteric coated

For oral medications..

brown syringes mean oral dose ONLY

Topical medications

• lotions, creams, ointments and medicated powders

• trans-dermal patches

• eye drops

• nose drops/mists

• ear drops

• rectal-suppositories

• vaginal creams + suppositories

Parenteral medications: intradermal (ID)

• TB tests

• allergy test

Parenteral medications: subcutaneous administration (SubQ)

• insulin administration

• heparin

Parenteral medications: intramuscular administration (IM)

• deltoid site

• ventral gluteal

• vastus lateralis sites

Needles

• length

• gauge

• needleless systems

• safety guards

• sharps containers

Injection specifics: intradermal

• ¼ - ½ inch

• 25G, 27G

• LESS THAN 0.5 mL

• angle 5-15 degrees

• no aspiration and no massage of sites

Injection specifics: subcutaneous

• DRUG SPECIFIC SYRINGES

• 3/8 - 5/8 inch

• 25G - 30G

• 1 mL maximum volume

• 45-90 degree angle

• to pinch or not to pinch

• no aspiration and no massage of sites

• don’t forget to rotate sites

Injection specifics: intra-muscular

• 5/8 inch - 1.5 inch needle

• 20G - 25G

• know your sites

• up to 3 mL volumes in large muscles

• gentle pressure NOT massage

• what is the z-track method?

• NEVER recap used needles

• no aspiration

Z-track method

for intramuscular injections

• to prevent leakage of medication into the needle track, thus minimizing discomfort

There is no reported evidence that aspiration with or without blood return

• confirms needle placement

• eliminates the possibility of an intramuscular injection into a non-subcutaneous blood vessel

Aspiration

• not indicated for SC injections

• not indicated for IM injections of vaccines and immunizations

• may be indicated for IM injections of large molecule medications, such as penicillin

Organizations which state aspiration is NOT necessary for immunizations and vaccines are:

• centers for disease control (CDC)

• advisory committee on immunization practices (ACIP)

• department of health services (DHS)

• american academy of family physicians (AAFP)

• U.K. department of health (DoH)

• world health organization (WHO)

NEVER:

recap, bend or break a used needle - straight to the sharps container

Controlled substances

• locked

• narcotic counts

• report any discrepancies

• record partial doses

What we need to document

• electronic charting

• incident reports for medication errors

• patient education/teaching

Electronic charting: drugs given

sites and parameters

Electronic charting: doses missed

explanation of why

Electronic charting

• drugs given

• doses missed

• refused medications

Medication errors

• check patients condition immediately; observe for adverse effects

• obtain a set of VS

• notify nurse manager and primary care provider

• complete form used for reporting errors, as dictated by the facility policy. (SHARE) not indicate that this form was completed in the patient chart

Needles: vastus lateralis

5-8” to 1”

Needles: deltoid (adults)

5/8” to 1½”

Needles: ventrogluteal (adults)

1” to 1½” 

Intramuscular site selection: infants and toddlers and biological (infants and toddlers)

vastus lateralis

Intramuscular site selection: children

vastus lateralis or deltoid

Intramuscular site selection: adults

ventrogluteal or deltoid

Intramuscular site selection: biologicals (children and adults)

deltoid

Intramuscular site selection: medications that are known to be irritating, vicious, or oily solutions

ventrogluteal

Vastus lateralis injection site

Deltoid injection site

Vastus gluteal injection site

NEVER:

recap, bend or break a used needle → STRAIGHT TO THE SHARPS CONTAINER

Controlled substances

• locked

• narcotic counts

• report any discrepancies

• record partial doses

What we need to document

• electronic charting

  • drugs given

  • doses missed

  • refused medications

• incident reports for medication errors (SHARE)

• patient education/teaching

What we need to document: drugs given

sites and parameters

What we need to document: doses missed

explanation of why

Medication errors

• check patients condition immediately; observe for adverse effects

• obtain a set of VS

• notify nurse manager and primary care provider

• complete form used for reporting errors, as dictated by the facility policy. (SHARE) not indicated that this form was completed in the patient chart

Healthcare failures which lead to laps in safety

• failure to recognize

• failure to rescue

• failure to plan

Maintaining emergency preparedness avoiding failure to plan: general preparation

• CPR training

• fire drills

• code pink drills

• preparing for mass trauma terrorism

Maintaining emergency preparedness avoiding failure to plan: course specific preparation

• skills check offs

• competency based education grading

• medication calculation quizzes

QSEN competencies

• patient-centered care

• teamwork and collaboration

• evidence based practice

• quality improvement

• safety

• informatics

QSEN defines safety as:

minimizing risk of harm to patients and providers through both system effectiveness and individual performance

TJC 2024 National patient safety goals for hospitals

• identify patients correctly

• improve staff communications

• use medications safety

  • label medications

  • medication reconciliation

• use alarms safety

• prevent infection

  • hand hygiene

• identify patient safety risks

• prevent mistakes in surgery

Fire safety RACE: R

rescue anyone in immediate danger

Fire safety RACE: A

activate the fire code and notify appropriate person

Fire safety RACE: C

confine the fire by closing doors and windows

Fire safety RACE: E

evacuate patients and other people to safe area

BIG 3 in safety errors: #1

medication errors

• a medication error is a breakdown or failure at any point in the medication use process

Types of medication errors: omission

• drug not prescribed

• drug not dispensed

• drug not administered

• drug not taken

Types of medication errors: communication

vague instructions

Types of medication errors: commission

• wrong drug or dose prescribed

• wrong drug or dose dispensed

• wrong drug administered

• wrong patient

• frequency timing or duration of the drug is incorrect

• wrong route

• allergic reaction

• drug interaction

Student barriers to building a safer culture

• near miss 

• no harm to patient 

• lack of learning

how do we overcome these barriers?

• acceptance of corrective feedback

BIG 3 in safety errors: #2

falls

• one of the never events

Fall risk factors

• > 65 years old

• history of fails

• females

• cognitive impairment

• altered gait

• medications - which ones?

• incontinence

• unsafe environment

• sensory deficits

• orthostatic hypotension

• depression

• assistive devices

• confusion or disorientation

• new environment

Fall prevention interventions

• complete fall assessments

• frequent rounding

• place on fall precautions

• treaded socks

• offer assistance to the toilet Q2

• bed in low position and bed alarms ON

• personal items within reach

• call light within reach/answer call lights promptly

BIG 3 in safety errors: #3

improper use of restraints

• a restraint is any involuntary method chemical or physical of restricting an individuals freedom of movement, physical activity, or normal access to the body

• ANA believes only when no other viable option is available should restraint be employed 

Recommended use of restraints

• imminent danger to others

• imminent danger to the patient

• profound disruption of treatment 

The hazards of restraints and side

• impaired circulation

• altered skin integrity

• altered nutrition and hydration

• aspiration/difficulty breathing

• incontinence

• increased possibility of serious injury due to fall

• depression

• anxiety

• death

What the evidence shows: routine use of restraints

does not lower the risk of falls or fall injuries

• they should NOT be used as a fall prevention strategy

What the evidence shows: restraints can add

to the risk of fall-related injuries and deaths

• limiting a patient’s freedom to move around leads to muscle weakness and reduces physical function

Safety event reports

must be completed after any accident or incident in a health care facility that compromises safety

• describes the circumstances of the accident or incident

• details the patient’s response to the examination and treatment of the patient after the incident

• completed by the nurse immediately after the incident

• is not part of the medical record and completion of a safety event report should not be mentioned in EMR documentation