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Pharmacology Ch. 7 - Principles of Medication Administration and Medication Safety

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Standards of care
Developed by each state's nurse practice act, state and federal law, The Joint commission, professional organizations. Nurses must be familiar with the nurse practice act in their state; claiming unfamiliarity with its contents is considered negligence. Each state has limitations imposed on medication administration. Each agency that employs nurses has procedures and policies specific to the administration of medication.
When administering medication, the nurse must:
- Have a current license to practice
- Clear policy statement that authorizes the act
- Medication order signed by a practitioner licensed with prescriptive privileges
-Understand the individual patient's diagnosis and symptoms that correlate with the rationale for drug use
- Know why a medication is ordered, expected actions, usual dosing, proper dilution, route and rate of administration, adverse effects, and contraindications for the use of a particular drug
- Be accurate in calculating, preparing, and administering medication
- Assess the patient to be certain that therapeutic and adverse effects associated with the medication regimen are reported
- Take an active role in educating the patient, family, and significant others in preparation for discharge from the health care environment
Patient Charts
The record serves as the communication link among all members of the health care team regarding the patient's status, care provided, and progress. The chart is a legal document that describes the patient's health, lists diagnostic and therapeutic procedures initiated, and describes the patient's response to these measures.
Contents of patient charts
Summary sheet; Consent forms; Physician's order form; History and physical examination form; Progress notes; Critical pathways; Core measures; Nurses' notes; Nursing care plans; Laboratory tests record; Graphic record; Flow sheets; Consultation reports; Other diagnostic reports; Medication administration record (MAR); PRN or Unscheduled medication record; Case management; Patient education record; Kardex records
Summary Sheet
Gives the patient's name, address, date of birth, attending physician, gender, marital status, allergies, nearest relative, occupation and employer, insurance carrier and other payment arrangements, religious preference, date and time of admission to the hospital, previous hospital admission, and admitting problem or diagnosis. The date and time of discharge are added when appropriate
Consent Forms
Grant permission to the health care facility and health care provider to provide treatment. Other types of consent forms include an operative procedure permit or consent, invasive procedure consent, and blood product consent, and consent to bill to patient's insurance carrier
Physician's Order Form
All procedures and treatments are ordered by the health care provider on the physician's order form. These orders include general care, laboratory tests to be completed, other diagnostic procedures, and all medications and treatments such as physical therapy or occupational therapy
History and Physical Examination Form
On admission to the hospital, the patient is interviewed by a health care provider and given a physical examination. The health care provider records the findings on the history and physical examination form and lists the problems to be corrected
Progress Notes
The attending health care provider records frequent observations of the patient's health status in the progress note
Critical Pathways
This document is a comprehensive standardized plan of care that is individualized at admission by the health care provider and nurse case manager. It is describe a multidisciplinary plan used by all caregivers to track the individual's progress toward expected outcomes within a specified period. The use of standardized outcomes is designed to improve the quality of care provided, reduce the costs of care, and document the effect on patient outcomes influenced by the nursing care
Evidence-Based Medicine (Core Measures)
These are measures of care that are tracked to show how often hospitals and health care providers use the care recommendations identified by evidence-based practice standards for patients being treated for conditions such as heart attack, heart failure, and pneumonia, or for patients having surgery.
Nurses' Notes
Nurses record the following in their notes: ongoing assessments of the patient's condition; responses to nursing interventions ordered by the physician or those initiated by the nurse; evaluations of the effectiveness of nursing interventions; procedures completed by other health care professionals; and other pertinent information, such as physician or family visits and the patient's responses after these visits. Entries may be made on the nurses' notes throughout a shift, but general guidelines include the following:
1. Completing records, including vital signs, immediately after making contact with and assessing of the patient
2. Recording all PRN medications immediately after administration and the effectiveness of the medication
3. Change in a patient's status and who was notified
4. Treatment for a sudden change in patient's status
5. Transfer, discharge, or death of a patient
Nursing Care Plans
Care plans incorporate nursing diagnoses, critical pathway information, and physician-ordered and nursing-ordered care. Care plans are evaluated and modified on a continuum throughout the course of treatment.
Laboratory Tests Record
Hospitals using computerized reports may list consecutive values of the same test once that test has been repeated several times. Other hospitals may attach small report forms to a full sized backing sheet as each report returns from the laboratory .
Graphic Record
Recording of temperature, pulse, respiration, blood pressure, and pain
Flow Sheet
Condensed form for recording information for quick comparison of the data. Examples of flow sheets in common use are diabetic, pain, and neurologic flow sheets
Consultation Report
When other physicians or health professionals are asked to consult on a patient, the specialist's summary of findings, diagnoses, and recommendations for treatment are recorded in the consultation reports section
Other Diagnostic Reports
Reports of surgery, electroencephalography, electrocardiography, pulmonary function tests, radioactive scans, and radiography reports are usually recorded in the other diagnostic reports section
Medication Administration Record or Medication Profile
It lists all medications to be administered. The medications are usually grouped according to the following categories: those scheduled on a regular bases, parenteral, stat, and preoperative orders. In the acute care setting, a new MAR is generated every 24 hours at the same time that the unit dose cart is refilled. In the long-term care setting, the MAR uses the same principles; however, it generally provides a space for medications to be recorded for up to 1 months
PRN or Unscheduled Medication Record
(Latin for pro re nata) Some clinical settings use a PRN medication record rather than nurses' notes to record the date, time, PRN medication administered and dose, reason for administering the PRN medication, and patient's response to the drug given. In most clinical settings, using MAR sheet, sometimes referred to as unscheduled medication orders
Case Management
The goal is to coordinate patient care provided to individuals, their families, and significant others on a continuum and to provide efficient transitions to services that may be needed after discharge at home, in clinics, or in other health care facilities, such as rehabilitation units or nursing homes.
Patient Education Record
Provides a means of documenting the health teaching provided to the patient, family, or significant others and includes statements regarding the learner's mastery of the content presented.
Kardex
Large index type card usually kept in a flip file or separate holder that contains pertinent information such as the patient's name, diagnosis, allergies, schedules of current medications with stop dates, treatments, and the nursing care plan.
Floor or Ward Stock System
Some advantages of this system are:
- Ready availability of most drugs
- Fewer inpatient prescription orders
- Minimal return of medications
Some disadvantages of this system are:
- Increased potential for medication errors because of the large array of stock medications from which to choose and the lack or review by the pharmacist of a patient's medication order
- Increased danger of unnoticed passing of expiration dates and drug deterioration
- Jeopardizing patient safety
- Economic loss caused by misplaced or forgotten charges and misappropriation of medication by hospital personnel
- Increased amounts of expired drugs to be discarded
- Need for larger stocks and frequent total drug inventories
- Storage problems on the nursing units in many hospital
Individual Prescription Order System
Medications are dispensed from the pharmacy on receipt of a prescription or drug order for an individual patient. One received at the nurses' station, medications are placed in the medication cabinet in accordance with institutional practices. The medication containers are arranged alphabetically by the patient's name, but they may be arranged numerically by the patient's room or bed number. This system provides
-Greater patient safety because of the review of prescription orders by the pharmacist and nurse before administration
- Less danger of drug deterioration
- Easier inventory control
- Smaller total inventories
- Reduced revenue loss because of improved charging systems and less pilferage
The major disadvantages of this system are the time-consuming procedures used to schedule, prepare, administer, control, and record the drug distribution and administration process
Computer Controlled Dispensing System
When a drug order is received in the pharmacy for a patient, it is entered into the computerized system. The nurse accesses the system and selects the patient's name, medication profile, and drugs due for administration. The drug order appears on the screen, and a specific section of the cart automatically opens so that the nurse can take the single dose of medicine out of the cart. This process continues until all drugs ordered for a specific time of administration are retrieved. During the actual administration process at the bedside, the nurse uses a handheld scanner that reads the bar codes on the nurse's identification badge, the patient's wristband, and the unit dose medication packet, linking this information with the patient database. If there is an error, an alarm sounds would go off. Controlled drugs are also kept in this automated dispensing cart. The system provides a detailed record of the controlled substance dispensed. A second qualified nurse must witness the disposal of a portion of a dose of a controlled substance or the return to the automated dispensing cart of any controlled substance not used. It's the safest and most economical method of drug distribution in hospitals and long-term care facilities.
Unit Dose System
Each package is labeled with generic and brand name. The pharmacist refills the drawers every 24 hours. In long-term care facilities, they usually exchanged on 3 or 7 day schedules. Advantages of the system include the following:
- The time normally spend by nursing personnel in preparation of drugs for administration is drastically reduced
- The pharmacist has a profile of all medications for each patient and is therefore able to analyze the prescribed medications for drug interactions or contraindications.
- No dose calculations are necessary because of unit-of-use packaging, thus reducing errors
- It is the nurse's responsibility to check drugs and calculate dosages, thus reducing errors
- There is less waste and misappropriation because single units are dispensed
- Credit is given to the patient for unused medications because each dose is individually packaged
Long-Term Care Unit Dose System
It is designed with individual drawers to hold one resident's medication containers for 1 week. At the time of administration, the nurse or medication aide checks all aspects of the medication order against the medication container that has been removed from one of the drawers. The number of doses remaining in the holder is checked against the days of the week that remain for the medication to be administered. Medications should be charted as soon as administered
Narcotic Control Systems
It is standard policy that controlled substances are issued in single-unit packages and are kept in a lock cabinet. When controlled substances are issued to a nursing unit, they are accompanied by an inventory sheet that lists each type of controlled substance being supplied. At the end of each shift, the contents of the controlled substances cabinet or controlled substances cart are counted by two nurses, one from the shift that is about to end and the other from the oncoming shift. Discrepancies are carefully checked; if the inaccuracy is not resolved by checking the patient's chart, the pharmacy and nursing service office should be contacted in accordance with institution policy. If the count appears to be accurate but tampering with the contents of the containers is suspected, a report should be made to the pharmacy and the nursing service office. When the controlled substances inventory is complete, the two nurses who are counting sign the inventory control shift record to verify that the records and inventory are accurate that that time.
Disposal of Unused Medicines
The FDA issued the first guidelines on prescription and nonprescription medication disposal in February 2007:
- Follow specific disposal instructions on the drug label or in the patient information leaflet that accompanies the medication. Do not flush prescription drugs down the toilet unless specifically instructed to d so by the manufacturer.
- If no instructions are given, throw the drugs in the household trash, but first empty from the container and mix with undesirable substance and put it in a container to prevent the medication from leaking out of the garbage bag.
- Use community drug take-back programs that allow the public to bring unused drugs to a central location for proper disposal. The drugs are often destroyed using a biohazard-controled incinerator.
- Before throwing out an empty prescription bottle, scratch out all identifying information on the label to make it unreadable
- Controlled substances such as opiate analgesics should be flushed down the toilet to reduce the danger of unintentional use or overdose and illegal abuse. An example is the fentanyl patch, which even after being used by the patient for 3 days, can still contain enough medicine to cause severe respiratory depression in babies, children, and pets
The Drug Order
All prescriptions must contain the following elements:
- The patient's full name
- Date
- Drug name
- Route of administration
- Dose
- Duration of the order
- Signature of the prescriber
Stat Order
Generally used on an emergency basis, but only once
Single Order
Administration at a certain time but only one time
Standing Order
Given for a specified number of doses
Renewal Order
Must be written and signed by the physician before the nurse can continue to administer the medication
PRN order
Administer if needed
Verbal Orders
The practice should be avoided whenever possible to prevent medication errors, but when a verbal order is accepted, the person who took the order is responsible for accurately entering it on the order sheet and signing it. The physician must cosign and date the order, usually within 24 hours
Electronic Transmission of Patient Orders
With the advent of fax machines, many physicians' offices fax new orders to the area where the patient is admitted or transferred. These fax transmissions must have an original signature within a specified time.
Medication safety
Freedom from accidental injury from medications
Medication errors
Failure of a planned action to be completed as intended or the use of a wrong plan to achieve a goal. Medication errors include:
- Prescribing errors
- Transcription or order communication errors
- Dispensing errors
- Administration errors
- Errors of monitoring or education for proper use
Prescribing errors
- Suboptimal drug therapy decisions
- Drug for patient with known allergy or intolerability
- Incorrect dose for diagnosis
- Unauthorized drug prescribed
Transcription errors
- Misinterpretation of misunderstanding of drug ordered or of directions
- Illegible handwriting
- Unapproved abbreviations
- Omission of orders
Dispensing
- Wrong drug or dose sent to nursing unit
- Wrong formulation or dosage form
Administration
- Incorrect strength (dose) given
- Extra dose given or missed dose
- Wrong administration time
- Incorrect administration technique
Monitoring
- Suboptimal monitoring
- Suboptimal assessments of drug response or revision of regimen
- Suboptimal patient education
Several practices to promote medication safety
1. Use of technology, including CPOE, use of bar-code drug administration and smart pumps for controlled administration
2. Restriction of high-alert medication in the dispensing process removing neuromuscular blocking agents from readily available floor stock
3. Avoidance of verbal orders for high-alert medicines
4. Use of checklists for high-alert drugs
5. Use of generic and brand names on the MAR to avoid errors with sound-alike drugs
6. Standardizing drug concentrations and dosing infusion charts
7. Performing double-checks prior to administration and patient education
Medication reconciliation
Process of comparing a patient's current medication orders with all the medications that the patient is actually taking. It avoids errors such as omissions, duplications, differences in dosing, and drug interactions. It is a five-step process:
1. Develop a list of current medications being administered
2. Develop a list of medications that were prescribed
3. Compare the medication on the two lists
4. Make clinical decisions based on the comparison
5. Communicate the new list to appropriate caregivers and to the patient
Verification
Judgements must be made regarding the type of drug, therapeutic intent, usual dose, mathematical calculations, physical preparation of the dose, allergies, and contraindication. If it is inappropriate to administer the medication as ordered, the prescriber should be notified immediately. An explanation should be given as to why the order should not be executed. The the prescriber cannot be contacted or does not change the order, the nurse should notify the DON, the nursing supervisor on duty, or both.
Transcription
After verification of an order, a nurse or another designated person transcribes the order from the physician's order sheet onto the Kardex or MAR. When this process is delegated to a ward clerk or unit secretary, the nurse is still responsible for verifying all aspects of the medication order. The nurse must sign the original medication order indicating that the order has been received, interpreted, and verified. The nurse then send a copy of the original order to the pharmacy. When the supply arrives from the pharmacy, it is stored in the medication room or in the patient's medication drawer of a medication cart
Six Rights of Drug Administration
Right Drug
Right Time
Right Dose
Right Route
Right Patient
Right Documentation
Right Drug
Before Administering a medication, it is imperative to compare the exact spelling and concentration of the prescribed drug with the medication card or drug profile and the medication container. The drug label should be read at least three times
Right Time
When scheduling the administration time of a medication, factors such as time abbreviation, standardized times, maintenance of consistent blood levels, maximum drug absorption, diagnostic testing, PRN medication
Right Dose
Double check supplied med matches ordered dose, calculate accurately, verify if dose is appropriate for the client, listen to the client if he has concerns, questions on the size, shape and color of the medication
Right Patient
When using the medication card system, the name of the patient on the medication card should be compared with the patient's identification bracelet. Always check for allergies. The Joint Commission recommends that at least two patient identifiers be used, such as the patient stating his or her name and birth date
Right Route
The IV route delivers the drug directly into the bloodstream. This route provides not only the fastest onset but also the greatest danger of potential adverse effects, such as tachycardia and hypotension. The intramuscular route provides the next fastest absorption rate, based on availability of blood supply. This route can be painful. The subcutaneous (subcut) route is next fastest, based on blood supply. Oral route may be as fast as the IM route, depending on the medication being given, the dose form, and whether there is food in the stomach. The oral route is safe if the patient is conscious and able to swallow. The rectal route should be avoided, if possible, because of irritation of mucosal tissues and erratic absorption rates.
Right Documentation
The char should always have the following information: date and time of administration, name of medication, dose, route, and site of administration. An incident report related to a medication error should include the following: date, time the drug was ordered, drug name, dose, and route of administration. Information regarding the date, time, drug administered, dose, and route of administration should be given, and the therapeutic response or adverse clinical observations present should be noted. Finally, the date, time, physician notified of the error, and any physician's orders given should be recorded. It is important to be factual and avoid stating opinions on the incident report