reconciliation and prescriptions

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21 Terms

1
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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

2
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stat

Give immediately, one time only

3
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prn

"As needed" — nurse decides based on symptoms (e.g., pain, nausea).

4
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one time

Given once at a specific time (e.g., before surgery).

5
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standing orders

Routine meds for common conditions (e.g., nitroglycerin for chest pain).

6
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scheduled/standard

Given at set times (e.g., every 8 hours).

7
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written order

Handwritten (rare now).

8
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cpoe

Computerized Prescriber Order Entry — safer, reduces handwriting errors.

9
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telephone order

  • Provider gives order over phone, nurse writes and repeats back.

10
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verbal order

  • Spoken orders (used in emergencies). Must be written and signed later.

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safe order

  • Medication name

  • Dosage

  • Route (how it's given)

  • Frequency (how often)

  • Special instructions or parameters (e.g., “Hold for BP < 90/60”)

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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.

13
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look sound alike medications

  • Hydralazine vs. Hydroxyzine, MSO4 vs. MgSO4

  • These can easily be confused — always double-check.

14
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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.

15
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variance

Any deviation from the standard or expected process (could include wrong time or late dose).

16
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near miss

A mistake caught before reaching the patient.

17
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error

A mistake that reaches the patient (e.g., wrong med, dose, time, route).

18
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types of error

  • Prescribing errors (wrong drug or dose written)

  • Omission (missed dose)

  • Wrong patient/route/time

  • Unauthorized drug

  • Extra dose or wrong rate

19
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barcode medication administration

Scans patient’s ID band and the med to ensure a match.

20
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smart pump

IV pumps that alert you if you program a dose that’s too high or too fast.

21
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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