Safe Medication Administration & Nursing Process Lecture

In-Class Worksheet (Week 1) – Correct Answers

• Q1 ADME sequence: Absorption, Distribution, Metabolism, Excretion/Elimination.
• Q2 Drug half-life.
• Q3 Pharmacodynamics.
• Q4 Site of action after administration: bloodstream / tissues.
• Q5 Antagonist.
• Q6 Receptors (wording “enhanced drug actions” can mislead to “agonist,” but receptors must exist first).
• Matching 7–14: C E H G F D B A.
• Q15 Most rapidly absorbed oral form: suspension / liquid (already dissolved).
• Q16 Primary site of most oral absorption: small intestine.
• Q17 Repeat of ADME.
• Q18 Primary organ of drug metabolism: liver.
• Q19 Fastest, complete bioavailability: IV / intravenous.

Nurse Responsibilities for Safe Medication Administration

• Perform a holistic assessment each time medication is prepared:
  • Physical data (vitals, weight, pain, breath, neuro, etc.).
  • Current home and in-house medications (prescription, OTC, herbal, recreational).
  • Allergies (drug, food, environmental) + nature of previous reactions.
  • Pertinent labs (e.g., platelets before heparin; AST/ALT for hepatotoxic drugs; BUN/Cr for renally-cleared meds).
• Possess medication knowledge before giving:
  • Therapeutic purpose and expected outcome.
  • Mechanism of action (MOA).
  • Normal dosage range for age/weight/renal-hepatic function.
  • Route(s) and technique (IV push vs piggyback, PO, topical, etc.).
  • Common side effects vs true adverse / toxic effects.
  • Precautions & formal contraindications.
• Technical proficiency: IV starts, syringe pumps, rate calculations.
• Patient education:
  • Indication, dose, schedule.
  • Expected side-effects; when to report danger signs.
  • Rights to refuse and process for questions.

Legal Framework

• Practice is governed by each state’s Nurse Practice Act & enforced by State Board of Nursing.
• Federal Controlled Substances Act regulates schedule drugs (storage, wasting, inventory, e-Prescribing monitoring websites).
• Medication errors → facility incident report + possible BON investigation → negligence/malpractice charges.
• RNs can refuse unsafe verbal orders; provider must write/enter order for clarity.

Six Rights of Medication Administration = Safety Core

1. Right Person – 2 identifiers (full name & DOB; in hospital = scan armband).
2. Right Medication – confirm generic/brand spelling/look-alike issues; never administer a drug someone else prepared.
3. Right Dose – compare to ordered dose; consider unit conversions; question unusually large/small amounts; re-calculate then verify with prescriber.
4. Right Time – follow frequency & critical windows:
   • Routine meds: \pm 1\,\text{h}.
   • Critical meds (e.g., antibiotics, insulin, anticoagulants): \pm 30\,\text{min}.
   • STAT = immediately; NOW = within 90\,\text{min}.
5. Right Route – PO, IV, IM, SQ, PR, SL, transdermal, inhalation, etc.; route affects onset & risk.
6. Right Documentation – chart after administration (name, dose, route, time, assessment data, signature). Include refusal + reason debrief; education given.

Types of Prescriptions/Orders

• Routine (Standing Daily) – continuous until cancelled (e.g., lisinopril 10\,\text{mg}\;\text{PO}\;\text{daily}).
• Standing Protocol – pre-authorised set triggered by criteria (e.g., insulin sliding scale; ICU vasopressor orders).
• Single / One-Time – given once at a specified time (e.g., pre-op antibiotic).
• STAT – single dose given immediately.
• PRN – “as needed”; order must state drug, dose, route, minimal interval, and situation (e.g., acetaminophen 1000\,\text{mg}\;\text{PO}\;q4h\;PRN\;T>100.4\,^{\circ}\text{F}).
• NOW – less urgent than STAT; administer within 90\,\text{min}.

Elements That MUST Appear on Every Prescription

• Date & exact time written.
• Client’s full legal name + second identifier if in-house (MRN).
• Medication name (prefer generic).
• Strength & dose (e.g., 500\,\text{mg}).
• Route.
• Frequency / times.
• Quantity / dispensing instructions (# tablets, refills).
• Prescriber signature & credentials.

Nursing Process (ADPIE) Applied to Medication Administration

• Assessment / Recognize Cues – collect vitals, labs, allergies, meds list, ability to swallow, IV patency, etc.
• Analysis / Prioritize Hypotheses – decide if order appropriate; identify high-risk clients.
• Planning / Generate Solutions – calculate doses, gather equipment, verify high-alert meds with 2nd nurse, set goals (e.g., pain ↓ to ≤ 3/10).
• Implementation / Take Action – perform 6 Rights; educate; delay or withhold if unsafe; contact provider for clarification.
• Evaluation / Evaluate Outcomes – reassess pain, BP, blood glucose, labs; document response; if ineffective/unwanted effect → loop back to planning.

Frequent Medication Errors & Root Causes

• Wrong drug / strength / rate / IV fluid / dilution.
• Wrong patient, route, time; omitted dose; known allergy ignored; expired drug.
• Prevention & response:
  • If error suspected → FIRST assess patient (vitals, safety); implement needed treatment.
  • Notify charge nurse & provider.
  • Complete facility incident report (non-punitive, internal; not charted in medical record).

Additional Strategies to Prevent Error

• Never administer:
  • Drugs prepared by others.
  • Meds transferred to unlabeled container.
  • A dose the patient questions (“looks different”).
  • Meds left by family/visitors.
• Label every syringe/cup immediately: initials + date + time.
• Pull/prepare only one patient’s meds at a time.
• High-alert meds (heparin, insulin, chemo, opioids, KCl, TPN) require independent double check.
• “Tall-man” lettering (e.g., hydrOXYzine vs hydrALAzine) distinguishes look-/sound-alike names.

Placement of Zeros – Critical Math Safety

• Always use a leading zero: write 0.5\,\text{mg} not ".5 mg".
• Never use a trailing zero: write 5\,\text{mg} not "5.0 mg".

Error-Prone & Acceptable Abbreviations

• Unacceptable (write it out): QD, QOD, HS, DC, IU, U, MS, MgSO₄, trailing/leading zeros.
• Acceptable examples: PO, IV, IM, SQ, BID, TID, Q4H, kg, GTT (drops), ID (intradermal), IVPB.
• Refer to ISMP “Do Not Use” list (2024 update) for exhaustive set.

Adverse Drug Reactions (ADR)

• Definition: any undesired, harmful response at normal doses – may be immediate, delayed, or cumulative (hypersensitivity after repeated exposure).
• Critical systems to recognise:
  • Respiratory: bronchospasm, laryngeal edema, dyspnea, cough, wheeze, cyanosis.
  • Cardiovascular: hypotension, tachycardia, palpitations, syncope, cardiac arrest.
• High-risk populations: older adults (polypharmacy, ↓ renal/hepatic), pediatrics (immature organs, weight-based dosing), clients with multiple comorbidities.
• Nursing actions: anticipate, educate, monitor labs/vitals, have reversal agents ready (e.g., naloxone for opioids, epinephrine for anaphylaxis).

Medication Reconciliation (Joint Commission Mandate)

• Steps at every transition (admit, transfer, discharge):

1. Compile a complete, accurate home list (drug, dose, route, frequency, purpose).
2. Obtain in-hospital orders list.
3. Compare → identify omissions, duplications, interactions, dosing errors.
4. Clarify discrepancies with provider/pharmacist & document changes.
5. Communicate updated list to patient & next care level.

Quality & Safety Organisations to Know

• Joint Commission (TJC) – accredits facilities; sets National Patient Safety Goals; mandates medication reconciliation.
• Institute for Safe Medication Practices (ISMP) – non-profit providing error-prevention education, toolkits, error reporting.
• QSEN (Quality and Safety Education for Nurses) – defines competencies (patient-centered care, safety, EBP, informatics, teamwork).
• Institute of Medicine (now National Academy of Medicine) – landmark patient-safety reports (e.g., “To Err Is Human”).

Technology Supports

• Electronic Medical Record (EMR) order entry → reduces handwriting issues.
• Automated Dispensing Cabinets (ADC): drawer opens for one drug; requires login & patient scan.
• Bar-code Medication Administration (BCMA): scan nurse ID → drug → patient wristband; alerts for wrong drug/time/dose.
• Smart pumps: drug libraries & dose error reduction systems (DERS).

Drug Labels – What to Recognise Quickly

• Brand vs Generic name.
• Dosage form (tablet, capsule, suspension, vial, ampule).
• Strength per unit (e.g., 250\,\text{mg}\;\text{/}\;5\,\text{mL}).
• Total amount in container (# tablets, volume).
• Route specific wording ("for IV use only").
• Lot number & expiry date – NEVER use past expiration.

High-Alert: “Do Not Crush” Considerations

• Extended-release (XL, XR), SR, CR, LA formulations, enteric-coated tablets – crushing destroys delivery technology → toxicity or ineffectiveness.

Exam / Course Logistics (from Transcript)

• Study Hall today: 13{:}00 – 14{:}00; instructor available beyond 14:00 if needed; review via Bingo & Q-A.
• Tomorrow’s exam: 45 items, 60 minutes, random seating, laptops only, no hats/smart-watches.
  • Formats: multiple-choice, select-all-that-apply (partial credit), hotspot.
  • No back-tracking; show green NCLEX screen before leaving.
  • Content strictly from lectures, slides, ATI modules, worksheets—no surprises; mechanism of action detail not required.
• Grading: test analysed before release; incident report style learning—focus on understanding, not memorising trivia.

Worksheet 2 (Medication Safety Competencies) – Key Matchings & Decisions

• Nursing-process column matches:
  • Current health history → Assessment.
  • Goal setting → Planning.
  • Patient environment (room safety, distractions) → Assessment.
  • Actions to accomplish goals → Implementation.
  • Drug allergies/reactions → Assessment.
  • Referral → could appear under Implementation (carry out) or Evaluation (after ineffective therapy).
  • Patient education → Implementation.
  • Administration of medication → Implementation.
  • Effectiveness of therapy → Evaluation.
  • Review lab results → Assessment or Analysis (context-dependent).
• Six-Rights quick-fire:
  • “Amount of drug given as prescribed” → Right Dose.
  • “Verification of Pt ID” → Right Person.
  • “Drug given at time prescribed” → Right Time.
  • “Verification of medication” → Right Drug.
  • “Nurse charts all meds immediately” → Right Documentation.
• Give / Do Not Give scenarios:
  • Prepared by others → DO NOT administer.
  • Patient says “looks different” → DO NOT (re-verify first).
  • Transferred to unlabeled container → DO NOT.
  • Your initials/date/time on syringe → Safe to give.
  • Drugs brought by family → DO NOT give; return or send to pharmacy for verification.
• Acceptable vs Unacceptable abbreviations examples (per ISMP list):
  • ID – acceptable; MS, QD, QOD – unacceptable; GTT, kg – acceptable; “1.0 mg” – bad (trailing zero); “mg” written as \textit{mg} not "MG"; KVO – acceptable; IVPB – acceptable; BID – acceptable.
• Practice scenario keys:
  1. Large opioid dose → first action: re-calculate & verify dose (use drug reference), THEN call HCP if still questionable.
  2. Patient refuses pill → document refusal; also educate & ascertain concerns (assessment + teaching), respecting autonomy.

Real-World Examples & Anecdotes from Lecture

• Night-shift BP crisis: nurse sensed IV hydralazine dose too large, checked drug book, prevented overdose—illustrates “trusted gut + verify.”
• Color/shape changes in generics (lisinopril white at home vs yellow in hospital) → requires patient education; never force.
• Doctor verbal orders at bedside: nurse may request written/entered order to avoid “your word vs theirs.”
• Nurse John TikTok reference—humorous but underlines need for written clarification.

Ethical & Professional Implications

• Patient autonomy: right to refuse; nurse obligation = inform, assess understanding, document.
• Non-maleficence (do no harm): drives 6 Rights, double checks, refusal to give unlabeled or questionable meds.
• Justice & public safety: report errors, participate in QI committees (Joint Commission, ISMP reporting).
• Accountability: nurses may face civil/criminal action & BON discipline for severe errors; meticulous documentation & adherence to protocols safeguard practice.

Numerical / Statistical Nuggets Mentioned

• Critical med timing window: \pm30\,\text{min} of scheduled time.
• Routine med window: \pm60\,\text{min}.
• NOW orders: administer within 90\,\text{min}.
• Example sliding scale insulin uses BG intervals (institution specific) to select dose.

Connections to Prior & Future Content

• ADME, half-life, pharmacodynamics reviewed today echo foundational pharmacology concepts from previous lecture.
• Concepts of bar-coding, smart pumps will link to upcoming informatics & med-math sessions (next week dosage-calc).
• Respiratory & CV adverse reactions integrate with upcoming pathophysiology units (shock, anaphylaxis, arrhythmias).
• Legal/ethical frameworks reinforce professional practice course.

Quick Memory Aids

• 6 Rights mnemonic: “DR TIM D.” (Drug, Route, Time, Individual, Medication/dose, Documentation).
• ADPIE sequence: “A Delicious Pie” (Assessment, Diagnosis, Planning, Implementation, Evaluation).
• High-Alert double-check list: “PINCH” – Potassium, Insulin, Narcotics, Chemotherapy, Heparin/anticoagulants.
• Error-prone abbreviations: think “QD is quickly deadly” – reminds you not to use QD.

Study Tips (Instructor Guidance)

• Work objectives → they map directly to test blueprint.
• Focus on concepts & actions, not memorising every drug MOA.
• Use ATI modules for interactive 6 Rights, med-error cases.
• Form peer groups; come to study hall; play Bingo for spaced repetition.
• Sleep well; arrive with only laptop; random seating reduces anxiety cheats.

Bottom Line

Safe medication administration rests on a triad:

1. Knowledge – drug, patient, systems.
2. Process – ADPIE, 6 Rights, reconciliation, documentation.
3. Culture of Safety – question, clarify, report, continuous improvement (TJC, ISMP, QSEN).
   Master these and both licensure exams and bedside practice become far safer—for you and, most importantly, for the patient.