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medication reconciliation
is the process of comparing the medications a patient is currently taking with the ones the provider orders.
This is done at every transition in care (admission, transfer, discharge) to avoid:
Duplications
Omissions
Wrong dosages
stat
Give immediately, one time only
prn
"As needed" — nurse decides based on symptoms (e.g., pain, nausea).
one time
Given once at a specific time (e.g., before surgery).
standing orders
Routine meds for common conditions (e.g., nitroglycerin for chest pain).
scheduled/standard
Given at set times (e.g., every 8 hours).
written order
Handwritten (rare now).
cpoe
Computerized Prescriber Order Entry — safer, reduces handwriting errors.
telephone order
Provider gives order over phone, nurse writes and repeats back.
verbal order
Spoken orders (used in emergencies). Must be written and signed later.
safe order
Medication name
Dosage
Route (how it's given)
Frequency (how often)
Special instructions or parameters (e.g., “Hold for BP < 90/60”)
abbreviations
Some abbreviations are unsafe and not approved (e.g., "U" for units can be mistaken for 0).
Nurses must know and use approved abbreviations only.
look sound alike medications
Hydralazine vs. Hydroxyzine, MSO4 vs. MgSO4
These can easily be confused — always double-check.
mar/Medication Administration Record
Document showing all prescribed meds.
Used to track what was given, when, and by whom.
Can be paper or electronic.
Must be updated and checked before giving meds.
variance
Any deviation from the standard or expected process (could include wrong time or late dose).
near miss
A mistake caught before reaching the patient.
error
A mistake that reaches the patient (e.g., wrong med, dose, time, route).
types of error
Prescribing errors (wrong drug or dose written)
Omission (missed dose)
Wrong patient/route/time
Unauthorized drug
Extra dose or wrong rate
barcode medication administration
Scans patient’s ID band and the med to ensure a match.
smart pump
IV pumps that alert you if you program a dose that’s too high or too fast.
high risk medications
These meds can cause serious harm if used incorrectly.
Examples: Insulin, anticoagulants (heparin), opioids, chemotherapy, IV potassium.
Extra precautions are needed:
Double-checking dosages
Second nurse verification
Specific protocols for administration and monitoring