Medication Administration Part 3: When Medications Go Wrong!

Medication Administration: When Medications Go Wrong!

Introduction

• Hospital medical errors are a significant concern, reportedly causing approximately 98,000 American deaths annually.

Patient-Centered Care

• Effective communication is crucial between nurses, staff, pharmacy, patients, and family caregivers to ensure medication safety.
• Patients are valuable sources of information regarding their medications.
• Factors such as anxiety, pain, hearing impairments, and cultural background can influence a patient's ability to communicate effectively and should be considered.
• Pharmacogenomics: Understanding how a patient's genetic makeup affects their response to medications.
• Adherence to medication plans is essential, but not always guaranteed. Nurses should follow up if patients struggle with adherence or experience unexpected side effects.

Drug Reactions

• Therapeutic Effect: The desired and beneficial outcome of a medication.
• Adverse Effect: An unintended and harmful response to a medication.
• Side Effect: A predictable, secondary effect of a medication, which can be harmless or cause injury.
• Toxic Effect: A dangerous and damaging accumulation of medication in the body, potentially leading to organ damage or failure. Acetaminophen, while intended for therapeutic effect, can lead to potentially fatal disorders with excess intake over time.
• Idiosyncratic Reactions: Uncommon, unpredictable, or even lethal reactions to a medication, representing an individual's unique response.

Allergic Reactions

• Allergic reactions are unpredictable and can manifest in varying degrees of severity.
  • Mild Reactions: Include urticaria (hives), rash, pruritus (itching), and rhinitis (stuffy or runny nose).
  • Severe Reactions: Anaphylaxis, a life-threatening condition characterized by swelling, edema, wheezing, shortness of breath (SOB), and bronchiolar constriction.
• It is imperative to verify allergies with the patient and compare the information against the patient's chart during every medication administration.

Allergic Reactions: Reducing Harm

• Always verify allergies! Use two identifiers (Name, DOB).

Medication Tolerance vs. Dependence

• Medication Tolerance:
  • Develops over time, requiring higher doses to achieve the same therapeutic effect.
  • Example: Morphine for chronic cancer pain.
• Medication Dependence:
  • Can be physical or psychological (addiction).
  • Example: Heroin use in place of prescribed hydromorphone.
• Patient education is critical regarding the potential for tolerance and dependence, especially with pain medications.
• Use the least amount possible for the shortest amount of time (post op).

Medication Interaction

• Occurs when one medication modifies the action of another, altering its effectiveness.
• Examples include interactions with:
  • Herbals
  • Over-the-counter (OTC) medications
  • Drug-drug interactions
  • Drug-food interactions
• Medication reconciliation is crucial to identify potential interactions and ensure safe medication administration.

Medication Errors

• Medication safety is paramount. Reflection questions on a patient story:
  • How do you feel if you are the parents?
  • How do you feel if you are the nurse?
  • What is the role of the nurse to ensure medication safety?
  • What can other healthcare workers/systems do to prevent mistakes like this from happening in the future?
• It's essential to foster a culture of accountability and transparency to prevent errors.

Preventing Medication Errors

• Biggest Goal: Prevent Errors.
• Follow policies and procedures.
• Report errors.
• High Alert: Double Check.
• Avoid Medication Errors.

Steps to Prevent Medication Errors

• Follow the six rights of medication administration.
• Prepare medications for one patient at a time.
• Read labels at least 3 times, comparing the Medication Administration Record (MAR) with the label:
  • When removing medication from storage.
  • Before taking it to the patient's room.
  • Before administering the medication.
• Use at least two patient identifiers (e.g., name, birthday, hospital number) for every medication administration.
• Avoid interruptions during medication administration (e.g., phone calls, discussions).
• Double-check calculations and high-risk medication processes (e.g., patient-controlled analgesia) with another nurse.
• Clarify illegible handwriting with the healthcare provider.
• Question unusually large or small doses.
• Document all medications immediately after administration.
• Reflect on errors to prevent recurrence and complete an occurrence report.
• Analyze repeated errors within a work area and take corrective action.
• Attend in-service programs on commonly administered medications.
• Ensure adequate rest to minimize errors due to fatigue.
• Involve and educate patients, addressing their concerns before administration.
• Follow agency policies when using technology (e.g., automated dispensing systems, bar-code scanning), avoiding workarounds.

Reporting Medication Errors

• File a written incident or occurrence report, usually within 24 hours.
• The incident report is an internal audit tool, not part of the medical record.
• Report all medication errors, including mistakes that do not cause obvious harm or near misses.
• First thing to do is to check on Patient and see if they're Okay.

Nursing Process

• Application of the nursing process ensures that critical thinking and clinical judgment are integrated into the patient’s care.

Nursing Process: Assessment

• Assessment includes:
  • Physical assessment
  • Medication allergies
  • Current daily medications
• Contact the provider if a medication is ordered that the patient is allergic to.
• Assess therapeutic effects, vital signs, and blood sugar.

Nursing Process: Planning and Implementation

• Planning involves organizing nursing activities for safe medication administration.
• Minimize distractions and avoid haste.
• Implementation focuses on safe and effective drug administration.
• Refer to drug guides for comprehensive information.

Preadministration Activities

1. Identify medication action, purpose, side effects, and nursing implications for administering and monitoring.
2. Minimize distractions during medication preparation.
3. Ensure that information on the medication computer sheet corresponds exactly with the prescriber’s written order and with the medication container label.
4. Read the label on the medication container and compare it with the MAR at least 3 times.
5. Double-check all calculations and high-risk medication administration processes, and verify with another nurse.
6. Review any pre-administration assessments.
7. Use good hand-hygiene technique; avoid touching tablets and capsules.
8. Administer only those medications that you personally prepare.
9. When preparing medications, be sure that the label is clear and legible and that the drug is mixed properly; has not changed in color, clarity, or consistency; and has not expired.
10. Keep tablets and capsules in their wrappers, and open them at the patient’s bedside. This allows you to review each medication with the patient. If the patient refuses medication, there will be no question which one was withheld.
11. TJC has a standard for labeling syringes including before a procedure, labeling all medicines that are not labeled (e.g., medicines in syringes, cups, basins).

Medication Administration

1. Follow the rights of medication administration. ALWAYS!
2. Inform the patient of the name, purpose, action, and common side effects of each medication.
3. Stay with the patient until the medication is taken.
4. Respect the patient’s right to refuse a medication.

Post-Administration Activities

1. Record medications immediately after administration (see agency policy).
2. Document data pertinent to the patient’s response.
3. Document post-assessment data pertinent to patient’s response.
4. If the patient refuses a medication, document that it was not given, the reason for refusal, and when you notified the health care provider.
5. Note if therapeutic effect is achieved or not.

Nursing Process: Evaluation

1. Monitor for evidence of therapeutic effects, side effects, and adverse reactions.
2. When a medication is given for relief of symptoms, ask the patient to report whether symptoms have diminished or relieved.
3. Observe injection sites for bruises, localized pain, inflammation, numbness, or bleeding.
4. Evaluate patient’s and family caregiver’s understanding of medication therapy and ability to self-administer medication.
5. Iv med can infiltrate causing swelling.

Practice Questions

• Which step is included when assessing an older adult’s medications? Select all that apply.
  • A. Discuss medication dose adjustment if needed
  • B. Obtain a complete list of medications
  • C. Reminder the patient is only permissible to share medications if the medication is not expired
  • D. Identify medications on the Beers Criteria
  • E. Provide oral and written teaching on medications and verify the patient’s understanding
  • F. Emphasize the importance of taking medications as prescribed
• Which evidence-based method would the nurse implement to decrease medication discrepancies resulting in negative patient outcomes?
  • A. Medication recall
  • B. Medication Screening
  • C. Medication discharge
  • D. Medication reconciliation
• Which nursing action will be implemented by the emergency department nurse to prevent an adverse event when preparing to administer penicillin?
  • A. Incorporate standard precautions
  • B. Check the medical alert bracelet
  • C. Perform a head-to-toe assessment
  • D. Teach the patient about the medication
• Order: 45 mg Nifedipine PO daily. Supply:
  • How many tablets will the nurse give?
  • Do you have any concerns about this medication?