Safe Medication Administration and Error Reduction

Fundamental Nursing Functions and Healthcare Provider Roles

• Administering medications is a critical nursing function requiring a comprehensive knowledge base.
• Nurses must be familiar with the following components for every medication administered:
  • Recommended administration routes.
  • Appropriate dosages.
  • Desired therapeutic actions.
  • Possible side effects.
  • Nursing considerations and specific patient-centric interventions.

Healthcare Provider and Nursing Responsibilities

• Healthcare Provider Responsibilities:

  • Obtaining the medical history of the client and performing a thorough physical examination.
  • Diagnosing the client's condition.
  • Prescribing specific medications.
  • Monitoring the client's response to the therapeutic regimen.
  • Modifying medication prescriptions as medically necessary.

• Nursing Responsibilities:

  • Preparing and administering medications.
  • Evaluating the client's response to administered medications.
  • Developing and maintaining an up-to-date knowledge base regarding medications, including their uses, mechanisms of action, routes, safe dosage ranges, adverse effects, precautions, contraindications, and interactions.
  • Maintaining knowledge of acceptable clinical practices and demonstrating ongoing skills competency.
  • Determining the accuracy of medication prescriptions.
  • Reporting all medication errors immediately.
  • Safeguarding and storing medications according to official protocols.

The Medication Administration Record (MAR)

• The MAR is a central document used to track medication administration and contains:
  • The client's full name.
  • The generic name of the medication.
  • The prescribed dosage.
  • The administration route.
  • Scheduled administration times.
  • Prescribed PRN (pro re nata or "as needed") medications.
• Nurses must compare the MAR against the original provider’s order to ensure accuracy.
• The nurse must cosign or provide acknowledgment for each new medication order.
• At the conclusion of a shift, the MAR must be double-checked to ensure all medications were administered as ordered.
• Documenting medication must happen immediately after administration, never before. If an action is not documented, it is legally considered not to have been performed.
• Clinical documentation typically utilizes the 24-hour clock or military time (e.g., $0800$, $1630$, $2000$).

Protocols for Telephone Prescriptions

• Telephone prescriptions should only be used when absolutely necessary.
• Nurses must ensure the prescription is complete and correct by reading it back to the provider.
• The read-back must include:
  • Client’s name.
  • Medication name.
  • Dosage.
  • Time of administration.
  • Frequency.
  • Route of administration.
• To ensure correct spelling, aids should be used (e.g., "B as in Boy").
• Numbers should be stated separately to avoid confusion (e.g., stating "one, seven" for $17$).
• If possible, a second nurse should listen to the telephone order on an extension or speaker in a private area to serve as an independent verifier. This helps:
  • Identify miscommunication from sound-alike drug names (e.g., Dopamine vs. Dobutamine).
  • Confirm correct dose or frequency despite background noise.
• The original prescriber must sign, date, and time the transcribed order within the timeframe specified by facility policy, which is often within $24\,\text{hours}$.
• The nurse is responsible for flagging the order to ensure appropriate follow-up.

Institute for Safe Medication Practices (ISMP) Guidelines and LASA Drugs

• The ISMP provides lists of confused drug names, including look-alike and sound-alike (LASA) pairs.
• Strategies to reduce errors with these medications include:
  • Using both brand and generic names on prescriptions and labels.
  • Including the purpose of the medication on the prescription.
  • Configuring computer systems to require a minimum of the first five letters during a product search.
  • Changing the visual appearance of look-alike names to highlight differences.
• Tall Man Letters: This mixed-case lettering draws attention to the differences in similar names (e.g., acetaZOLAMIDE vs. acetoHEXAMIDE).
• Examples of Frequently Confused Drug Names:
  • Abelcet and amphotericin B.
  • Accupril and Aciphex.
  • Alka-Seltzer and Alkeran.
  • ALPRAZolam, clonazePAM, and LORazepam.
  • Advicor, Advair, and Altocor.
  • Amiodarone and amlodipine.

Medication Reconciliation Process

• Medication reconciliation is a verification process designed to prevent errors during points of transition:
  • Admission to the facility.
  • Transfer between different units.
  • Discharge from the facility.
• The process involves:
  • Compiling a complete list of all current medications, including accurate dosages and frequencies.
  • Comparing the current list with new prescriptions.
  • Reconciling the lists to resolve any found discrepancies.
• The Joint Commission requires formal policies and procedures for medication reconciliation to enhance patient safety.

The Ten Rights of Safe Medication Administration

• 1. Right Patient: Use two identifiers before administration, such as the name, birth date, assigned ID number, or government ID. Always ask the client's name and check the ID band. Bar-code scanners are often utilized for identification.
• 2. Right Drug: Confirm the order, drug name, and form. Verify the expiration date. Compare the label with the MAR three times: before removal from the container, during preparation, and before administration.
• 3. Right Dose: Use unit-dose systems when available. Use standard measurement devices like graduated cups or syringes. High-alert medications (Insulin, Heparin, Opioids, IV medications) require a second nurse to verify the calculation or concentration.
• 4. Right Route: Ensure the preparation matches the prescribed route (e.g., otic vs. ophthalmic). Common routes include oral, topical, subcutaneous ($SC$/$SQ$), intramuscular ($IM$), and intravenous ($IV$).
• 5. Right Time: Administer medications on time to maintain consistent therapeutic blood levels. Facility policies define time-critical medications (e.g., antibiotics), which must usually be given within $30\,\text{min}$ of the prescribed time.
• 6. Right Knowledge and Understanding: Practitioners must understand the clinical purpose and characteristics of every drug they handle.
• 7. Right Questions or Challenges: Nurses must use clinical judgment and raise doubts or questions before administration.
• 8. Right Advice: Patients must receive all relevant information and advice regarding their drugs during and after their hospital stay.
• 9. Right Response or Outcomes: Observe and document the therapeutic and adverse effects after medication administration.
• 10. Right to Refuse: Patients have the right to refuse medication after being provided with information to make an informed decision. The nurse must document the refusal and inform the provider.

Specific Medication Administration Timing and Considerations

• Insulin Lispro: Give within $15\,\text{minutes}$ of a meal (before or immediately after) to prevent hypoglycemia.
• Levothyroxine: Administer in the morning on an empty stomach, approximately $30$ to $60\,\text{minutes}$ before breakfast to ensure absorption.
• Alendronate: Administer first thing in the morning with plain water. The client must stay upright for $30\,\text{minutes}$ to prevent esophageal irritation.
• Nitroglycerin: Administer promptly during chest pain; delays can postpone angina relief.
• Enteric-Coated Medications: These should never be crushed. The coating is designed to protect both the stomach and the drug; crushing destroys this protection.
• Unit-Dose Packaging: Keep medications in their original package until the point of administration.

Route-Specific Procedures and Site Selection

• Enteral Tubes: Used for nutritional and medication delivery.
  • Nasogastric ($NG$) Tube: Inserted through the nose into the stomach; used for shorter periods.
  • Gastrostomy ($G-tube$) or Percutaneous Endoscopic Gastrostomy ($PEG$) Tube: Inserted directly into the stomach; used for long-term management.
• Parenteral Injection Types and Angles:
  • Intradermal ($ID$): Injected into the dermis at $10^{\circ}$ to $15^{\circ}$.
  • Subcutaneous ($SC$): Injected into subcutaneous tissue at $45^{\circ}$ to $90^{\circ}$.
  • Intravenous ($IV$): Injected into a vein at a $25^{\circ}$ angle.
  • Intramuscular ($IM$): Injected deep into muscle at a $90^{\circ}$ angle.
• Ventrogluteal IM Injection: Considered the safest adult site as it lacks major nerves or vessels.
  • Landmarks (Palm-finger method): Place the palm on the greater trochanter, thumb toward the groin, index finger on the anterior superior iliac spine, and middle finger along the iliac crest. The injection site is the center of the "V" formed by the index and middle fingers.
• Z-track Technique: Used for $IM$ injections to prevent medication from tracking back through the needle path. Pull the skin and subcutaneous tissue by $2.5$ to $3.75\,\text{cm}$ before inserting the needle. Release the skin after injection to seal the drug inside the muscle in a zig-zag path.

Assessment and Programming Requirements

• Right Assessment: Essential data must be collected before and after administration:
  • Digoxin: Measure the apical heart rate for a full $60\,\text{seconds}$.
  • Morphine: Monitor respiratory rate and blood pressure.
  • Insulin: Check blood glucose levels.
  • Metoprolol: Check blood pressure.
  • Furosemide: Monitor blood pressure, potassium levels, kidney function, and daily weight.
  • Albuterol: Assess lung sounds, respiratory rate, and heart rate.
• Right Programming: Correctly setting delivery devices like $IV$ infusion pumps and PCA ($Patient-Controlled Analgesia$) pumps is an RN responsibility.