History, Chronic Conditions, Drug Use, Allergies, Level of Education and Understanding, Social Supports, Finical Supports, Pattern of Health Care, Weight, Age, Physical Parameters Related to Disease or Drug Effects. is part of the continuing process of patient care that leads to changes in assessment, diagnosis, planning, and intervention. The patient is continually evaluated for therapeutic response, the occurrence of adverse drug effects, and the occurrence of drug-drug, drug-food, drug-alternative therapy, or drug-laboratory test interactions. Some drug therapy requires evaluation of specific therapeutic drug levels. In addition, the efficacy of the nursing interventions and the education program also are evaluated. In some situations the nurse evaluates the patient simply by reapplying the beginning steps of the nursing process and then analyzing for changes, either positive or negative. The process of evaluation may lead to changes in the nursing interventions being used to provide better and safer patient care. With the increase in the older adult patient population, the increase in the number of available drugs and OTC and alternative therapy preparations, and the reduced length of hospital stays for patients, the risk for medication errors is ever increasing. In 2000 the Institute of Medicine published a large-scale study of medication errors in the United States, entitled To Err Is Human: Building a Safer Health System. It reported that 44,000 reported deaths in hospitals each year occurred from medication errors, and that the number could probably be closer to 98,000. The study brought to light the many places in the system where a medication error could occur and suggested methods for improving the problem.
The drug regimen process, which includes prescribing, dispensing, and administering a drug to a patient, has a series of checks along the way to help to catch errors before they occur. These include the physician or nurse practitioner who prescribes a drug, the pharmacist who dispenses the drug, and the nurse who administers the drug. Each serves as a check within the system to catch errors—the wrong drug, the wrong patient, the wrong dose, the wrong route, the wrong time, the wrong storage, or the wrong documentation. Often the nurse is the final check in the process because the nurse is the one who administers the drug and is the one responsible for patient education before the patient is discharged to home.
The monumental task of ensuring medication safety with all of the potential problems that could confront the patient can best be managed by consistently using the "rights" of medication administration. These rights are as follows:
FOCUS ON Safe Medication Administration
Right patient. It is always important to make sure that you are giving the drug to the correct patient. Checking the patient's wrist band and asking the patient to repeat his/her name and often birthdate are good policies to make sure it is the patient you think it is. Avoid the error of asking a patient, "Are you Mr. Jones?" The patient could respond yes without thinking or may not have heard you correctly. Rely on the patient telling you his/her name and read it from the identification band. It is also important to make sure this patient does not have allergies to the drug being given and that the patient is not taking interacting drugs, food, or alternative therapies.
Right drug. To prevent medication errors, always check to make sure the drug you are going to administer is the one that was prescribed. Many drugs may look alike and or have sound-alike names. Ask for the generic as well as the brand name if you are unsure. Never assume the computer is correct; always double-check. Avoid abbreviations, and if you are not sure about abbreviations that were used, ask. Make sure the drug makes sense for the patient for whom it is ordered.
Right storage. Be aware that some drugs require specific storage environments (e.g., refrigeration, protection from light). Check to make sure that general guidelines have been followed.
Right route. Determine the best route of administration; this is frequently established by the formulation of the drug. Nurses can often have an impact in modifying the route to arrive at the most efficient, comfortable method for the patient based on the patient's specific situation. For example, perhaps a patient is having trouble swallowing, and a large capsule would be very difficult for the patient to handle. The nurse could check and see if the drug is available in a liquid form and bring this information to the attention of the person prescribing the drug. When establishing the prescribed route, check the proper method of administering a drug by that route. Review drug administration methods periodically to make sure you have not forgotten important techniques. If you have instructed a patient in the proper administration of a drug, be sure to have the patient explain it back to you and demonstrate the proper technique. This should be done not only when the patient first learns this technique, but also periodically to make sure he or she has not forgotten any important points. Throughout this book, Focus on Safe Medication Administration boxes will provide review of proper medication administration technique.
Right dose. Always double-check calculations, and always do the calculations if the drug is not available in the dose ordered. Calculate the drug dose appropriately, based on the available drug form, the patient's body weight or surface area, or the patient's kidney function. Do not assume that the computer or the pharmacy is always right; you are one more check in the system. Do not cut tablets to get to a correct dose without checking to make sure the tablet can be cut, crushed, or chewed. Many tablets cannot be altered this way. Be very cautious if you see an order that starts with a decimal point; these orders are often the cause of medication errors. You should never see .5 mg as an order because it could be interpreted as 5 mg, 10 times the ordered dose. The proper dose would be 0.5 mg. If you see an order for 5.0 mg, be cautious; it could be interpreted as 50 mg. If a dose seems too big, question it. Throughout this book, Focus on Calculations boxes will provide review for calculating dose properly.
Right preparation. Know the specific preparation required before administering any drug. For example, oral drugs may need to be crushed or shaken; parenteral drugs may need to be reconstituted or diluted with specific solutions; and topical drugs may require specific handling, such as the use of gloves during administration or shaving of a body area before application. Many current oral drugs cannot be cut, crushed, or chewed. Checking that information can help to prevent serious adverse effects. If a drug needs to be diluted or reconstituted, check the manufacturer's instructions to make sure that this is done correctly.
Right time. When drugs are studied and evaluated, a suggested timing of administration is established. This timing takes into account all aspects of pharmacokinetics to determine a dosing schedule that will provide the needed therapeutic level of the drug. Recognize that the administration of one drug may require coordination with the administration of other drugs, foods, or physical parameters. In a busy hospital setting, getting the drug to the patient at the prescribed time can be a real challenge. As the caregiver most frequently involved in administering drugs the nurse must be aware of and manage all of these factors, as well as educate the patient to do this on his or her own. Organizing the day and the drug regimen to make it the least intrusive on a patient's lifestyle can help to prevent errors and improve compliance.
Right recording. Always document drug administration. If it isn't written, it didn't happen. Document the information in accordance with the local requirements for recording medication administration after assessing the patient, making the appropriate nursing diagnoses, and delivering the correct drug, by the correct route, in the correct dose, and at the correct time. Accurately record the drug given and the time given only once you have given the drug to avoid inadvertent overdoses or missing doses, which would lead to a lack of therapeutic effect. Encourage patients to keep track of their drugs at home, what they take, and when they take it, especially if they could be confused.
With so many patients managing their drug regimens at home, one other very important check in the system also exists: the patient. Only the patient really knows what is being taken and when, and only the patient can report the actual as opposed to the prescribed drug regimen being followed. Patient and family education plays a vital role in the prevention of medication errors. Encourage patients to be their own advocates and to speak up and ask questions. Doing so helps to prevent medication errors. The following teaching points help to reduce the risk of medication errors in the home setting:
Keep a written list of all medications you are taking, including prescription, OTC, and herbal medications. Keep this list with you at all times in case you are in an emergency situation and to keep your health care providers up to date. This list can be essential if you are traveling and need to refill a prescription while away from home.
Know what each of your drugs is being used to treat. If you know why you are taking each drug, you will have a better understanding of what to report, what to watch for, and when to report to your health care provider if the drug is not working.
Read the labels, and follow the directions. It is easy to make up your own schedule or to just take everything all at once in the morning. Always check the labels to see if there are specific times you should be taking your drugs. Make a calendar if you take drugs on alternating days. Using a weekly pillbox may also help to keep things straight.
Store drugs in a dry place, away from children and pets. Humid and hot storage areas (like the bathroom) tend to cause drugs to break down faster. Storing drugs away from children and pets can prevent possible toxic effects if these drugs are inadvertently ingested by children or your family pet.
Speak up. You are the most important member of the health care team, and you have information to share that no one else knows. Don't be shy about reporting the use of OTC or herbal therapies; these are your choices and are important to you. Sharing information about the use of these products will help your health care provider to incorporate them into your total drug regimen in a safe and effective way.
Children present unique challenges related to medication errors. Children often cannot speak for themselves and rely on a caregiver or caregivers to manage their drug regimen. Because their bodies are still developing and respond differently than those of adults to many drugs the risk of serious adverse reactions is greater with children. The margin of safety with many drugs is very small when dealing with a child. When teaching parents about their children's drug regimens, be sure to include the following instructions:
Keep a list of all medications you are giving your child, including prescription, OTC, and herbal medications. Share this list with any health care provider who cares for your child. Never assume that a health care provider already knows what your child is taking.
Never use adult medications to treat a child. The body organs and systems of children, primarily their livers and kidneys, are very different from those of an adult. As a result, children respond differently to drugs.
Read all labels before giving your child a drug. Many OTC drugs contain the same ingredients, and you could accidentally overdose your child if you are not careful. In addition, some OTC drugs are not to be used with children younger than a certain age. Doses also may differ for children.
Measure liquid medications using appropriate measuring devices. Never use your flatware teaspoon or tablespoon to measure your child's drugs. Always use a measured dosing device or the spoon from a measuring set.
Call your health care provider immediately if your child seems to get worse or seems to be having trouble with a drug. Do not hesitate; many drugs can cause serious or life-threatening problems with children, and you should act immediately.
When in doubt, do not hesitate to ask questions. You are your child's best advocate.
Nursing is a complex art and science that provides for nurturing and care of the sick, as well as prevention and education services.
Components of the nursing assessment (history of past illnesses and the current complaint, as well as a physical examination) provide a database of baseline information to ensure safe administration of a drug and to evaluate the drug's effectiveness and adverse effects.
Nursing assessment must include information on the history of past illnesses and the current complaint as well as a complete drug history and a physical examination; this provides a database of baseline information to ensure safe administration of a drug and to evaluate the drug's effectiveness and adverse effects.
Nursing diagnoses are developed from the information gathered during the assessment phase of the nursing process. A nursing diagnosis states the actual or potential response of a patient to a clinical situation.
Planning uses the information gathered and the resultant nursing diagnoses to determine the desired patient outcomes, setting goals for safe and effective drug administration. The plan will lead to the necessary nursing interventions.
Implementation puts the nursing interventions into action. Interventions related to drug therapy include safely administering the drug, providing comfort measures to help the patient cope with the therapeutic or adverse effects of a drug, and providing patient and family education to ensure safe and effective drug therapy.
Evaluation is part of the continuing process of patient care that leads to changes in assessment, diagnosis, and intervention. The patient is continually evaluated for therapeutic response, the occurrence of adverse drug effects, and the occurrence of drug-drug, drug-food, drug-alternative therapy, or drug-laboratory test interactions.
A nursing care guide and patient education materials can be prepared for each drug being given, using information about a drug's therapeutic effects, adverse effects, and special considerations.
Prevention of medication errors is a complicated task that involves the prescriber, the pharmacist, the nurse administering the drugs, and the patient. The nurse needs to be vigilant in administering drugs to check the seven "rights" of drug administration. The patient needs to be educated to be his or her own advocate and to take steps to avoid medication errors.