Drug Administration, MD Orders, and Medication Errors

Drug Administration

• Ten Rights of Medication Administration: Crucial for preventing medication errors. These will be tested in lab and on exams.
  • Right medication
  • Right amount (dosage)
  • Right patient
  • Right time
  • Right route
  • Right assessment
  • Right documentation
  • Right to education
  • Right evaluation
  • Right to refuse

Right Medication

• Ensure the patient receives the prescribed drug.
• Three Checks:
  • Check the medication label against the MAR (Medication Administration Record) three times:
    • When removing from storage
    • Before preparing the medication
    • Prior to giving the medicine
• Generic vs. Brand Name:
  • Generic name: Chemical composition of the drug.
    • Not capitalized.
    • Typically written after the trade name in parentheses.
    • Example: furosemide
    • Cost: Typically less expensive
    • Same ingredients, potency, dosage, quality, and purity as brand name.
  • Trade/Brand name: Given by the manufacturer.
    • Can only be used by the registering company.
    • Followed by the trademark symbol.
    • Capitalized.
    • Example: Lasix (brand name for furosemide)
• Importance of Correct Spelling:
  • Prevents confusion and medication errors.
  • Examples of easily confused drug names: Celebrex vs. Celexa, Xanax vs. Zantac.
• Knowledge of Suffixes and Categories:
  • Helpful in identifying drug classes.
  • Example: -semide indicates loop diuretics (e.g., furosemide).
• Precautions:
  • Double-check the order if the patient questions the medicine.
  • Never administer a medication prepared by someone else.
  • Never use or prepare an unlabeled medication.

Right Amount/Dosage

• Ensure the patient receives the correct amount of the drug as prescribed.
• Dosage Definition: Amount of the drug to be given at a specific time.
  • Example: 100 mg of Dilantin orally three times a day; the dose is 100 mg.
• Medication Order Terms:
  • Stat: Give immediately.
    • High priority; used in emergency conditions.
    • Administer before any other orders.
    • Typically a one-time dose.
  • Now: Also high priority but follows stat orders.
    • Administer promptly.
    • Usually a one-time dose.
  • One-time only: Single dose administration.
  • PRN: Give as necessary.
    • The patient can request, or the nurse can offer.
    • Must specify a time interval between doses (e.g., every four hours).
• Important Practices:
  • Look up unfamiliar medicines in a nursing drug handbook before administration.
  • Know conversions and calculate dosages correctly.
  • Recalculate if unsure, and have another nurse double-check if still in doubt.
  • Pour liquids correctly:
    • Set medicine cup on a flat surface.
    • Hold the container and pour away from the label.
    • Read the line at eye level.
  • Break scored tablets evenly.
  • Follow hospital policy on medications requiring double-checks (e.g., insulin).

Right Patient

• Verify patient identity before administering medication.
• Methods:
  • Check the ID band for name and date of birth.
  • Ask the patient to state their name and date of birth.
  • Scan the barcode on the ID band.
  • Check ID band even on unconscious or confused patients.
  • Compare with the Medication Administration Record (MAR).
• Long-Term Care Facilities:
  • Use chart pictures if patients don't wear ID bands.
  • Nurses typically learn patient identities.

Right Time/Frequency

• Administer the medication at the correct frequency and time.
• Common Abbreviations:
  • QD: Every day
  • BID: Twice a day
  • TID: Three times a day
  • QID: Four times a day
  • HS: At bedtime/hour of sleep
  • Q# hours: Every # hours (e.g., Q4 hours = every four hours)
• Facility Policy:
  • Actual administration times vary by facility policy.
  • Know your facility's specific times for medication administration.
• Timing Window:
  • Medication can be given within 30 minutes before or after the scheduled time.
  • Example: For a 7 AM dose, administer between 6:30 AM and 7:30 AM.
• PRN Medications:
  • Cannot be administered before the specified time interval.
  • Administer only if the patient needs it; PRN means “as needed.”

Right Route

• Administer the medication via the correct route.
• Common Routes:
  • Oral (PO)
  • Buccal
  • Sublingual
  • Topical
  • Transdermal
  • Mucous membranes (eyes, ears, nose)
  • Inhalants (administered through the airway)
  • Parenteral: Anything other than oral (injections like IM, SubQ, IV).
• Important Considerations:
  • Injectable medications should be labeled as “injectable only.”
  • Do not administer oral liquid medications parenterally.
  • If the route is missing from the order, contact the provider immediately.
  • Do not change the route without an order.

Right Assessment

• Obtain necessary data before administering medication.
• Examples:
  • Digoxin: Check pulse rate before administration; hold if below a certain level.
  • Insulin: Check blood glucose levels before administration; avoid giving if blood sugar is already low.

Right Documentation

• Chart medication administration immediately after giving, never before.
• Charting Information:
  • Drug name
  • Dose
  • Time
• PRN and Stat Orders:
  • Chart on the MAR and in the nurse's notes.
• Refusals:
  • Document in the nurse's notes why the patient refused the medication.
• Other Considerations:
  • Never chart for someone else or ask someone else to chart for you.
  • If omitting a dose based on nursing judgment, consult with an RN or charge nurse.
  • Document the reason for omission objectively and exactly.
  • Report the omission to the healthcare provider.

Right to Education

• Educate the patient about their medications.
• Information to Provide:
  • Purpose of the medicine
  • Potential side effects
  • Dietary restrictions
  • Reason for giving the medication

Right Evaluation

• Evaluate the medication's effectiveness and any side effects.
• Assess:
  • Did the medication achieve the desired effect?
  • Were there any side effects?

Right to Refuse

• Patients have the right to refuse medication.
• Actions to Take:
  • Explain the risks of refusing the medication.
  • Reinforce the reasons for taking the medication.
  • Document the refusal and notify the healthcare provider.
  • Do not force the patient to take the medication.
  • Document the patient's reasons for refusal in their own words.
  • Discard the dose; do not return it to the container.

Reading Drug Labels

• Drug labels must contain certain information by law.
• Key Components:
  • Trade/Brand Name:
    • Capitalized and often in bold print.
    • Followed by the trademark symbol (e.g., Depakote ER).
  • Generic Name:
    • Typically listed under the trade name.
    • Non-capitalized (e.g., valproate sodium).
  • Dosage Strength:
    • Amount of medication per unit (e.g., 250 mg).
  • Form:
    • How the medication is supplied (tablet, capsule, liquid, etc.).
  • Route:
    • How the medication should be administered (oral, injectable, etc.).
  • Amount:
    • How many units are in the container (e.g., 100 tablets).
  • Directions:
    • Instructions for dilution, if necessary.
  • Manufacturer Name:
  • Expiration Date:
  • Special Storage Instructions:
    • (e.g., store at 25 degrees Celsius).
  • National Drug Code (NDC) Number:
    • Unique identifier for each medication.

Medication Distribution Systems

• Healthcare facilities have designated areas for medication storage.
• Types of Systems:
  • Floor Stock:
    • Medications stored on the patient care unit.
    • Often kept in a separate room or automated dispensing machine (e.g., Pixis).
  • Unit Dose System:
    • Portable medication cart with drawers for each patient.
    • The cart is moved from room to room.
    • Locked when unattended.
    • Ordered amount of medicine for prescribed time.
  • Locked Cabinets:
    • Medications stored in locked cabinets in each patient's room.
  • Computer-Controlled Dispensing Systems:
    • Combination of unit doses and floor stock.
    • Medications in individual compartments.
    • Access via computer and code (e.g., Pixis).
• Nurses are responsible for storing medications according to policies and procedures.

Drug Administration and the Nursing Process

• Assessment:
  • Medication History:
    • Prescriptions
    • Herbal medicines
    • Over-the-counter medications
    • Street drugs
  • Allergies
  • Baseline Physical Assessment:
    • To identify changes after medication administration.
  • Symptoms and Disease:
    • Underlying conditions requiring medication.
• Planning:
  • Why does the patient need the medication?
  • What is the purpose of the medicine?
  • What is the patient's current condition?
  • What is the expected response to the medication?
  • What should I look for after medication administration?
  • How to prepare the medication.
  • Is there any teaching needed with that medicine?
    • Adverse effects
    • Drug, actions and normal dosing
• Implementation:
  • Wash hands before, between, and after patient contact.
  • Check the order: date, time, drug name, dose, route, frequency.
  • Ensure a signed order.
    • Written orders are best.
    • Verbal orders should be signed by the provider as soon as possible.
    • Telephone orders can be taken by licensed personnel.
  • Identify the patient.
  • Administer medications, providing interventions as indicated.
  • Document administration.
  • Evaluate the patient's response.

Routes of Administration

• Important Considerations:
  • If you didn't pour it, don't give it.
  • If you gave it, chart it.
  • Do not transport or accept unlabeled containers.
  • Do not put down unlabeled syringes; keep them in your hand or label them.
  • Write down verbal orders and repeat them back to the provider.
  • Never leave medication carts unattended or unlocked.
  • Do not leave medications with patients or family members; watch them take it.

Interim Administration

• Oral (PO):
  • Slower absorption rate, making it safer.
  • Can be irritating to the GI tract.
  • Large tablets can be difficult to swallow.
  • Liquid medicines are often chosen for children, older adults, or those with swallowing difficulties.
  • Do not administer PO liquids to unconscious patients due to risk of aspiration.
• Administering Tablets and Pills:
  • Use unit dose packaging, placing the unopened package in a medicine cup.
  • If using multi-dose bottles, pour tablets into the cap without touching them, then transfer to the medicine cup.
  • With scored tablets, break evenly along the line.
  • If a patient needs crushed medicines, let them mix with applesauce, yogurt, or pudding
  • Disposal of Medications that have dropped must follow your facility policy
• Administration of Liquid Medicine:
  • Use a graduated medication cup (typically 30 mL).
  • Hold the bottle with the label facing your palm to prevent spills on the label.
  • Place the medicine cup on a flat surface and pour at eye level.
  • Place the cap with the inner rim upward to prevent contamination.
  • Read the dosage amount at the lowest level of the meniscus.
• Administration Through Tubes:
  • NG tubes, gastrostomy tubes, jejunostomy tubes
  • Crush pill form medication to mix with water before administering through the tube.
  • Do not crush enteric-coated or time-release capsules.
• Sublingual:
  • Place medication under the tongue.
  • Instruct the patient not to chew or swallow; allow it to dissolve.
  • Avoid eating or drinking until the medication is completely dissolved.
• Buccal:
  • Place medication in the inner cheek to dissolve and be absorbed through mucous membranes.
• Oral Inhalation:
  • Patient exhales fully.
  • Grasp the mouthpiece with teeth and lips while holding the inhaler.
  • Press down on the inhaler while inhaling slowly over two to three seconds.
  • Hold breath for 10 seconds.
  • Wait two to five minutes between puffs of the same medication.
  • Wait five to ten minutes between different inhalers.
• Spacers
  • Prevents rapid inhalation and reduces airway irritation, helping the medicine fully go through their GI tract.

Other Methods of Administration

• Suppositories:
  • Insert rectally beyond the internal sphincter (about an inch).
  • Hold buttocks together to help the patient retain the suppository.
• Vaginal Irrigation:
  • Use a tube connected to a bag of liquids.
  • Insert the tubing pointing toward the sacrum along the floor of the vagina and release the solution.

Percutaneous Administration

• Through the skin or mucous membranes.
• Topical:
  • Creams: Rub into the skin following directions.
  • Lotions: Pat onto the skin.
• Transdermal:
  • Choose a clean, dry area.
  • Avoid impaired skin, areas with body hair, or oily spots.
  • Rotate sites for patches after removal and before reapplying.
  • Cleanse the area thoroughly.
  • Always wear gloves to prevent absorption into your skin. (e.g., nitroglycerin patch).
• Instillation:
  • Eye Drops: Sterile ophthalmic drops; room temperature.
    • Do not touch the eye with the dropper.
    • Do not share eye drops between patients.
  • Ointments: Thicker ointment for the eyes.
    • Do not touch the eyeball with the ointment tube.
• Irrigation:
  • Go from the inner eye to the outer eye (canthus).
    • Lessens the chances of contaminants being absorbed through the nasolacrimal duct.
  • Do not allow the syringe to touch the eye.
  • Irrigate for about 15 minutes continually with tap water to remove chemical contaminants.
  • Morgan Lens: Connected to a bag of fluids; allows for continuous irrigation with a large amount of solution.
    *Eye Compresses may be used to treat and reduce swelling.
• Ears:
  • Ear Drops: Labeled “otic;” room temperature.
    • Do not share between patients.
    • Ear Irrigations: Use a syringe with the solution at body temperature.
    • Be slow and gentle to avoid dizziness or rupturing the eardrum.
• Nose:
  • Nose Sprays: Individual use only.
  • Irrigation: Neti pot or bulb syringes.
  • Instruct the patient to breathe through their mouth and avoid speaking or swallowing.

Parenteral Administration

• Routes other than through the GI tract.
• Reasons:
  • Inability to take oral medications (e.g., intubated patients or those with vomiting).
• Considerations:
  • More rapid onset.
  • Shorter duration of action compared to oral medications.
  • Smaller doses can be given because they are not reduced by action of the GI tract or liver.
• Methods (using a needle and syringe):
  • Intradermal (ID):
    • Into the dermis (top layer of skin).
  • Intramuscular (IM):
    • Into the muscle.
    • Large blood supply.
    • Sites: Deltoid, vastus lateralis, ventrogluteal, or dorsal gluteal.
    • Avoiding pain, infection, any necrosis, bruising, or any kind of abrasions.
  • Subcutaneous (SubQ):
    • Into the subcutaneous tissue (fat between dermis and muscle).
    • Areas: Outer aspects of the arm, abdomen, thighs, or scapula.
  • Intravascular (IV):
    • Straight into the vascular system.
    • Used for fluids, electrolyte maintenance, medications, blood products, chemotherapy, analgesics, etc.
  • IV Methods:
    • IV push: Administering medication directly into the vein with a syringe.
    • Intermittent venous access device: Saline lock or heplock.
    • Intermittent IVs: Piggybacks (e.g., antibiotics).
    • Continuous infusion: Normal saline running continuously.
• Butterfly Needles vs. Over-the-Needle Catheters:
  • Butterfly Needles: Short-term basis; stainless steel needle stays in the arm.
  • Over-the-Needle Catheters: Better for long-term use; a plastic catheter is inserted over the needle into the vein, and the needle is removed.

Interpreting MD Orders

• Nurses are legally and ethically responsible for ensuring patients receive the correct medication.
  *Clarify confusing orders with the physician before carrying it out.
• Order Components:
  • Patient's name
  • Date the order was written
  • Name of the drug
  • Dose of the drug
  • Frequency/time
  • Route
  • Signature of the ordering provider
• Types of Orders:
  • Standing Orders:
    • Pre-written orders for patients admitted to a particular unit.
    • Allows nurses to enact orders without contacting the provider for new orders.
  • Verbal/Telephone Orders:
    • Taken when the provider cannot write an order.
    • Must be entered into the computer and electronically signed as soon as possible.
    • Repeat the order back to the provider for clarification.
  • Stat Orders:
    • One-time order to be done immediately.
  • Single Orders:
    • One-time order to be given at a specific time.
  • PRN Orders:
    • As-needed orders.
      *Documentation for all orders or changes of orders must contain a date, time, and the individual's name.
• Abbreviations:
  • Medication orders contain many abbreviations.
    • You must be able to interprete them correctly and prevent medication errors.
  • Need to know measurements, their equivalence, and commonly used abbreviations.
  • The Joint Commission has a list of abbreviations that are not allowed to be used.

Medication Errors

• Types of Errors:
  • Receiving the wrong drug.
  • Receiving a drug intended for someone else.
  • Receiving an extra dose of a drug.
  • Receiving the drug via the wrong route.
    • Epinephrine can be given for allergic reactions (IM) and heart attacks (IV).
  • Omission of a medication.
  • Administration at the wrong time: Too early (toxicity), too late (level drops).
• Causes of Drug Errors:
  • Poorly written orders.
  • Illegible handwriting.
  • Incorrect interpretation of the order.
  • Incomplete orders (missing route, dosage, or frequency).
  • Confusing labels.
• Actions to Take if a Medication Error Occurs:
  • First: Assess the client's condition.
  • Notify the physician.
  • Notify the supervisor or head nurse.
  • Complete an incident report or medication error form.