What are the different types of errors that could occur in medication administration?
1) error of execution (failure of a planned action to be completed as intended)
2) error of planning (use of a wrong plan to achieve an aim)
3) act of commission
4) act of omission
Define a medication error
Any error occurring in the medication-use process
What are some examples of a medication error?
* wrong dosage prescribed
* wrong dosage administered for a prescribed medication
* failure to give (by the provider) a medication
* failure to take (by the patient) a medication
Define an adverse drug event
Any injury due to medication
What are some examples of an adverse drug event?
* wrong dosage leading to injury (e.g. rash, confusion, or loss of function) or an allergic reaction occurring in a patient not known to be allergic to a given medication
What are some strategies to prevent errors in the hospital setting?
* computerized order entry with clinical decision support systems
* clinical decision support systems
* pharmacist participation on hospital rounds
* bar coding and smart IV pumps
What are some strategies to prevent errors in the long-term care setting?
* educational visits to improve prescribing practices and patient outcomes
* involve pharmacists in the management of medications
Do patients have the right to be the source of control for all medication management decisions that affect them (that is, the right to self-determination)
Do patients have the right to accept or reject medication therapy on the basis of their personal values
Do patients have the right to ask questions to better understand their medication regimen?
Do patients have the right to receive consultation about their medication regimen in all health settings and at all points along the medication-use process?
Do patients have the right to designate a surrogate to assist them with all aspects of their medication management?
Do patients have the right to expect providers to tell them when a clinically significant error has occurred, what the effects of the event on their health (short- and long-term) will be, and what care they will receive to restore their health?
Do patients have the right to ask their provider to report an adverse event and give them information about how they can report the event themselves?
Eights Rights of Medication Administration?
Client's Right to Know
Client's Right to Refuse
Should you give anything intravenous that you cannot see through?
Given directly in the IV over a short period.
Known as IVP or IV push.
Given diluted over a longer period of time.
Known as IV piggyback or IVPB
What can IV anti-infectives be reconstituted with?
> 0.9% NaCl
> D5/0.25% NaCl
> D5/0.45% NaCl
> D5/0.9% NaCl
If the patient is allergic or has had a reaction to PCN, what should you also ask about?
Any previous use, allergy or reaction to CEPHALOSPORINS
What is the generic name for ANCEF?
Ancef (cefazolin) classification
Anti-infective, 1st generation cephalosporin
Which bacteria does Ancef work on?
> Gram + positive cocci
> Strep pneumoniae
> Group A B-hemolytic streptococci
Does Ancef have any therapeutic effects on Gram - rods?
MINIMAL activity against:
> klebsiella pneumoniae
> proteus mirabilis
> E. coli
What would you watch for with an anaphylaxis reaction?
IV Ancef needs to be infused over what period of time?
What is the generic name for GARAMYCIN, G-MYCIN?
GARAMYCIN (gentamicin) - classification
When giving gentamicin, what cranial nerve would the nurse need to evaluate?
* Evaluate 8th cranial nerve & vestibular dysfunction (ataxia, vertigo, N&V)
With gentamicin, when would you draw blood for a culture?
BEFORE giving the gentamicin
IV GENTAMICIN needs to be infused over what period of time?
30 min to 2 hr
What is the generic name for LEVAQUIN?
Levaquin (levofloxacin) - classification
Which bacteria does Levaquin work on?
Gram + and Gram - pathogens;
What labs do you need to monitor with Levaquin?
IV Levaquin needs to be infused over what period of time?
at least 60 minutes. Avoid rapid bolus injection.
What is the generic name for ROCEPHIN?
Rochephin (ceftriaxone) - classification
Anti-infective, 3rd generation cephalosporin
Which bacteria does Rochephin work on?
Similar to 2nd generation, but greater Gram - coverage;
some active against anaerobes - Bacteroides fragilis
What other allergy should the nurse ask about when giving Rochephin?
penicillin and cephalosporins
IV Rochepin should be infused over what period of time?
What is the generic name for VANCOCIN?
Vancocin (vancomycin) - Classification
Which bacteria does Vancomycin work on?
Bactericidal action against susceptibile organisms including:
Gram + and Group A B-hemolytic streptococci
What does the nurse need to do ask about with VANCOMYCIN?
* Ask about allergy to PCN & cephalosporins
What is the generic name for ZINACEF, KEFUROX?
Zinacef (cefuroxime) - classification
Anti-infective, 2nd gen. cephalosporin
Which bacteria does Zinacef work on?
Bactericidal action against susceptible bacteria, similar to 1st gen. but increased Gram - coverage of:
> Haemophilus influenzae
> E. coli
> Klebsiella pneumoniae
> Neisseria gonorrhae
> moraxella caterrhalis
What are the nursing implications with ZINACEF?
> Ask about PCN and cephalosporin allergy
> Monitor IV site frequently for thrombophlebitis
IV Zinacef should be infused over what period of time?
What is the generic name for ZOSYN?
ZOSYN - Classification
Anti-infective, extended-spectrum penicillin
Which bacteria does Zosyn work on?
Death of susceptible bacteria, similar to PCN but greatly extended, including several Gram (-) negative aerobic pathogens
What labs should be monitored with Zosyn?
1. Renal function
2. Hepatic function
5. bleeding times
IV Zosyn should be infused over what period of time?
at least 30 mins
What are the general considerations for diuretics?
* Monitor daily weights
* amount and location of edema
* lung sounds
* skin turgor
* mucous membranes
* Assess allergy to sulfonamides
* Assess for tinnitus or hearing loss
What is the generic name for DEMADEX?
DEMADEX (torsemide) - Classification
What are the therapeutic effects of Demadex?
Diuresis and subsequent mobilization of excess fluid, lowers blood pressure
What should the nurse do when giving Demadex?
Monitor BP and pulse BEFORE and DURING administration
IV Demadex should be infused over what period of time?
DIRECT > Undiluted slowly over 2mins
INTERMITTENT > Over 12hrs for patients with renal impairment
What is the generic name for Lasix?
Lasix (furosemide) - Classification
What are the therapeutic effects of Lasix?
Diuresis and subsequent mobilization of excess fluid, lowers BP
Lasix - Nursing Implications
* Monitor daily weights, I&O, amount and location of edema, lung sounds, skin turgor, and mucous membranes
* Labs to monitor: electrolytes, Ca, Mg, BUN, creatinine, and uric levels
* Assess allergy to sulfonamides
* Assess for tinnitus or hearing loss
IV Lasix should be infused over what period of time?
DIRECT > Undiluted over 2 mins
INTERMITTENT > over 12hrs with renal impairment
What are the general considerations for Antiemetics?
1) Assess for:
a. nausea & vomiting
b. abdominal distention
c. bowel sounds
2) Assess for EPS (parkinsonian-difficulty speaking or swallowing, loss of balance control, pill rolling, mask-like face, shuffling gait, rigidity, tremors, dystonic muscle spasms, twisting motions, twitching, inability to move eyes, weakness of arms or legs
What is the generic name for ANZEMET?
ANZEMET (dolasetron) - classification
5 HT3 antagonist
What are the therapeutic effects of Anzemet?
Decreased incidence & severity of nause and vomiting with chemotherapy or surgery
What are the nursing implications with Anzemet?
Assess for N&V, abdominal distention and bowel sounds
Monitor VS after administration
IV route may cause severe HYPOTENSION, BRADYCARDIA and SYNCOPE
IV Anzemet should be infused over what period of time?
DIRECT > undiluted over at least 30secs
INTERMITTENT > Over 15mins
What is the specific age limit with Phenergan (promethazine)?
DO NOT ADMINISTER PHENERGAN TO PEDIATRIC PATIENTS UNDER AGE 2
What is the generic name for Phenergan?
PHENERGAN (promethazine) - Classification
What are the therapeutic effects of Phenergan?
- Relief of symptoms of histamine excess usually seen in allergic conditions
- Diminished nause and vomiting
What does the nurse need to do with Phenergan administration?
> Monitor BP, pulse & respiratory rate frequently
> ASSESS LEVEL OF SEDATION AFTER ADMINISTRATION
> Monitor for onset of EPS
> Do not administer to pediatric pts UNDER AGE 2
IV Phenergan should be infused over what period of time?
1. should not exceed concentration of 25mg/mL
2. administer each 25mg slowly OVER AT LEAST 1 MINUTE
What is the generic name for REGLAN?
Reglan (metoclopramide) - Classification
How does Reglan (metoclopramide) work?
By antagonizing dopamine >>> patient may show SIGNS OF DEPRESSION
What are the therapeutic effects of Reglan?
1. Decrease N&V
2. Decrease symptoms of gastric stasis
3. Ease in passage of NG tube into small intestine
What are the nursing implications with Reglan?
* Assess for N&V, abdominal distention & bowel sounds
* Monitor for EPS, tardive dyskinesia & signs of depression
IV Reglan should be infused over what period of time?
DIRECT > Give over 1-2 mins
Rapid admin may cause transient but intense ANXIETY AND RESTLESSNESS followed by drowsiness
INTERMITTENT > at least 15mins
What could happen if Pepcid (famotidine) is given too fast?
What is the generic name for Pepcid?
Pepcid (famotidine) - Classification
2. Histamine H2 antagonist
What are the therapeutic effects of Pepcid?
- Healing and prevention of ulcer
- decrease symptoms of gastroesophogeal reflux
- decrease secretion of gastric acid
What does the nurse need to do when administering Pepcid?
1. Assess for epigastric or abdominal pain
2. Asess for frank or occult blood in the stool, emesis or gastric aspirate
Pepcid - IV Administration
DIRECT > over at least 2 minutes (RAPID INJECTION MAY CAUSE HYPOTENSION)
INTERMITTENT > over 15-30 mins
What is the generic name for Protonix?
Protonix - Classification
1. Antiulcer agent
2. Gastric acid pump inhibitor
What are the therapeutic effects of Protonix?
Diminish accumulation of acid in gastric lumen, healing of duodenal ulcer and esophagitis, decrease acid secretion in hypersecretory conditions
What does the nurse need to do when administering Protonix?
Assess routinely for:
a. epigastric or abdominal pain
b. frank or occult blood in the stool, emesis or gastric aspirate
IV Protonix should be infused over what period of time?
INTERMITTENT > over 15mins
What is the generic name for Lanoxin?
Lanoxin (digoxin) - classification
What are the therapeutic effects of Lanoxin (digoxin)?
Increase cardiac output and slowing of the heart rate
What does the nurse need to do when administering Lanoxin (digoxin)?
* Monitor apical pulse for 1 minute before administration
>>(withhold and call MD if pulse <60 adult/<70 child/<90
* Monitor BP
* Monitor ECG throughout IV administration
* Observe IV for redness or infiltration
* Monitor I&O and daily weight.
IV Lanoxin (digoxin) should be infused over what period of time? - IV Administration
DIRECT > over minimum of 5 mins
What is the generic name for Vasotec?
Vasotec (enalapril) - Classification
2. ACE inhibitor
What are the therapeutic effects of Vasotec?
1. Lowers blood pressure in hypertensive patient
2. Decreases afterload in CHF
3. Decreases development of overt heart failure
4. Increases survival after an MI
What does the nurse need to do when administering Vasotec?
* MONITOR BP and PULSE FREQUENTLY during INITIAL DOSE, ADJUSTMENT, and PERIODICALLY THROUGHOUT THERAPY
* Monitor weight for resolution of fluid overload
IV Vasotec should be infused over what period of time?
DIRECT > undiluted over AT LEAST 5 MINUTES
INTERMITTENT > diluted GIVE SLOWLY
What is the generic name for HALDOL?
HALDOL (haloperidol) - Classification
What are the therapeutic effects of Haldol?
Diminished s/s of psychoses; improved behavior in children with Tourette's syndrome or other behavioral problems
What does the nurse need to do when giving Haldol?
1. Assess mental status prior and periodically to therapy
2. Monitor BP & pulse (possible QTchanges)
3. Monitor I&O and daily weight
4. Monitor for s/s dehydration
5. Monitor for akathesia, EPS, TARDIVE DYSKINESIA, neuroleptic malignant syndrome
Haldol - IV Administration
DIRECT > undiluted at rate of 5mg/min
INTERMITTENT > diluted in 30-50mL D5W and infuse over 30mins
What is the annual incidence rate of medication errors in the HOSPITAL?
What is the cost per error of medication errors in the hospital?
What is the estimated total cost for medication errors in the hospital setting?
$3.5 billion (in 2006)
What is the annual incidence rate of medication errors in the LONG-TERM CARE setting?
What is the estimated cost per error of medication errors in the ambulatory care setting?
$1,983 (in 2000)
What is the estimated total cost for medication errors in the ambulatory care setting?
How often do you change the IV site when giving antibiotics?
What labs do you need to monitor with GENTAMICIN?
What are the peak and trough levels for GENTAMICIN?
PEAK (not to exceed 10mcg/mL)
TROUGH (not to exceed 2mcg/mL
What about the IV site with Vancomycin?
Monitor very closely. Very irritating to tissues and causes NECROSIS and SEVERE PAIN with extravasation
What other nursing considerations with Vancomycin?
Evaluate 8th cranial nerve function
Monitor I & O
What are the peak and trough levels for VANCOMYCIN?
What reaction could occur with VANCOMYCIN?
"red man syndrome"
Sudden severe hypotension
Flushing and/or maculopapular rash of face, neck, chest and upper extremities
IV Vancomycin needs to be infused over what period of time?
60mins <60min increases chance of "red man syndrome"
What drugs must be checked by two licensed nurses prior to administration?
In general, what labs should be monitored with diuretics?
What labs should be monitored with Reglan?
What labs should be monitored with Pepcid?
What labs should be monitored with Lanoxin (digoxin)?
2. Hepatic function
3. Renal function
What is the therapeutic level of Lanoxin (digoxin)?
0.5 - 2mg/mL
Observe for toxicity!
What labs should be monitored with Vasotec?
5. Urine protein
What labs should be monitored with Haldol?
2. Liver function