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Lesson 18: Nurses Responsibilities in Medication Administration

Terms in this set (16)

(PP slide, Taylor pg 834-838)

CHECKING THE MEDICATION ORDER
- various systems are used, nurse should check facility guidelines for checking a medication order.
- The patient's medication record, often called a MAR (medication administration record) is a complete list of all medications prescribed for the patient
- The nurse is also responsible for double-checking the dosage and appropriateness os the medication

QUESTIONING THE MEDICATION ORDER
- nurses are legally responsible for the drugs they administer
- it is important to question any drug order suspected to be in error
- factors that impact nurse's questioning an order: the working environment, their perceived responsibility to do the right thing, and their knowledge about medications
- ask yourself why the patient is receiving the medication
- do the therapeutic and pharmacological classes link with your patient's condition(s)?
- legal implications are serious when there is an error in a drug order: nurses can be expected, based on knowledge and experience, to have noted and reported the error
- a "0" should always precede a decimal point
- use of a trailing zero (ex. 1.0) is not considered good practice and has been included in The Joint Commission's "do not use" list
- before giving a medication, ask the patient if they have ever received the medication and if they have ever had an adverse reaction to the medication
- if a nurse has difficulty reading an order, guessing is gross carelessness; checking with the provider who wrote the order is the only safe procedure
- nurses have the right to refuse to administer any medication that, based on their knowledge and experience, may be harmful to the patient

CALCULATING THE CORRECT DOSE
- the nurse is responsible for calculating the correct dose and assuring the dose on the medication order is correct

USING SAFETY MEASURES WHILE PREPARING THE MEDICATIONS
- a medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use
- errors are more common with certain classes of medications, such as analgesics, antibiotics, anticoagulants, chemotherapeutic agents, diabetic medications, and cardiovascular agents
- possibly due to the pharmacological properties of the drugs that result in more adverse effects, toxicities, and interactions
- common in drugs with narrow therapeutic levels and in drugs prescribed frequently
- 3 checks of medication administration (see next slide)
- 11 rights of medication administration (see next slide)

MAINTAINING GOOD PHYSICAL WORKING CONDITIONS/MAINTAINING A SAFE ENVIRONMENT
- Nurses should be aware of the higher risk of making an error when their work flow is distracted or interrupted
- if a distraction or interruption occurs, decide whether to deflect defer or address the distraction
- the environment is determined by clinical activity factors such as staffing, workload, interruptions/distractions, and patient characteristics
- hospital/unit structure, leadership, teamwork, communication, and required safety measures also impact the environment
- if it is imperative to leave for a short time, place the prepared drugs in a locked area, such as in the medication cart


DO NOT LEAVE MEDICATIONS UNATTENDED
- watch patient take the medication
- again, if it is imperative to leave for a short period of time, place the prepared drugs in a locked era, such as in the medication cart
Table 29-3 pg 842

WHEN PREPARING TO GIVE MEDICATION
RIGHT MEDICATION
- Questions to ask: Has the patient been given this medication before?, Given the patient's symptoms and diagnosis, does it make sense for the patient to have this medication?
- Actions to take: Determine if the patient has any known drug allergies or sensitivities, assess the patient's other medications to detect possible contraindications, make sure it is the right medication; packaging, labeling, and spelling of some drugs look alike—watch for visual cues on packing or in how the drug name is written, have another person double-check medications and mathematical calculations (per policy)

RIGHT REASON
- Questions to ask: Do the patient's condition, symptoms, and health status warrant receiving this medication?
- Actions to take: Determine if the patient has the condition the medication is used for

RIGHT DOSE/ROUTE/PREPARATION
- Questions to ask: Is the correct dose being administered?, How is the medication administered?, Does administration require medication math to calculate the dose?
- Actions to take: Ensure that labeling is legible and clearly understood, follow institution medication protocols as written

RIGHT PATIENT
- Questions to ask: Is this the right patient to receive this medication?
- Actions to take: Verify the identity of the patient using at least two identifiers: name and DOB (check wrist band, ask patient to state name and DOB)

RIGHT TIME
- Questions to ask: Is this the correct time for the medication to be administered?
- Actions to take: Check when the medication was last administered, If the drug is new, document when it is first given

RIGHT ROUTE
- Questions to ask: Is it appropriate to administer the medication orally, intravenously, by injection, or other route?
- Actions to take: Check the original orders to verify the route of administration

RIGHT ASSESSMENT DATA
- Questions to ask: Is it appropriate to administer the medication based on the specific data collected?
- Actions to take: Collect appropriate assessment data related t0 mechanism of action and/or therapeutic effect

RIGHT EDUCATION
- Questions to ask: Is the patient familiar with the medication?, Does the patient understand the purpose, dosing, and administration information, as well as other information specific to medication?
- Actions to take: Assess patient's level of knowledge. Provide patient education as necessary.

RIGHT TO REFUSE
- Questions to ask: Has the patient verbally agreed to take the medication? Has the patient expressed any concern with the medication?
- Actions to take: Acknowledge the patient's right to self-determination. Provide education, then verify, document, and notify the provider about the refusal as needed.

AFTER THE MEDICATION IS ADMINISTERED

RIGHT DOCUMENTATION
- Questions to ask: Has the correct documentation been completed according to facility policy?
- Actions to take: Complete documentation according to facility policy immediately after administering any medication, document and communicate to the appropriate health care provider any signs and symptoms indicative of any adverse effects

RIGHT RESPONSE
- Questions to ask: How is the patient responding to the medication?
- Actions to take: Monitor the patient to determine the efficacy of the drug, detect and prevent complication, and evaluate and document changes in health status; When applicable, assess the patient's laboratory values to detect changes; provide patient education, when possible, so patient is alert to adverse effects and changes in how he or she feels
Pg 832-833

PATIENT'S NAME AND SECONDARY IDENTIFIER (DATE OF BIRTH MEDICAL RECORD NUMBER)
- full name
- middle name or initial should be included to avoid confusion with other patients
- be extremely careful when administering medications when there is more than one patient on the unit with the same last name (provider may enter the order into the wrong patient's medical record)

DATE AND TIME THE ORDER IS WRITTEN
- help to prevent errors of oversight as different nurses take charge of the patient's care
- if order is to be followed for a specific number of days, date and time is important to know when to D/C the medication
- state law determines the length of time an order for a narcotic remains valid, so starting date and time must be clearly documented
- EHR's help to improve patient safety, but it also requires that nurses monitor the computer system for patient updates, including new medication orders

NAME OF DRUG TO BE ADMINISTERED
- the practice of using the generic name is considered safest and is required by many health care facilities
- United States Pharmacopeia and National Formulary is the official source of information about a particular drug
- Physician's Desk Reference (PDR) is another source of information that is supplied by pharmaceutical companies

DOSAFE OF THE DRUG
- can be stated in either the metric or household system
- the metric system has been adopted internationally, is the most widely used, and is the safest measurement system for drug dosages
- self-administered drugs are commonly labeled in household measurements
- household measurements: use measuring spoons NOT silverware

ROUTE BY WHICH THE DRUG IS TO BE ADMINISTERED
- some drugs can be given in more then one way and others may be used safely through only one route

FREQUENCY OF ADMINISTRATION OF THE DRUG
- to lessen the risk for error, many health care facilities use the 24-hour clock (or military time)
- it is a nursing and pharmacy responsibility to check that times for medication administration correspond to save practice for that drug
- it given only once or twice a day, the decision about which hours to use depends on the nature of the drug and the patient's plan of care, as well as the standard facility administration times (whenever possible, consider the patient's choice of time)
- common practice is that drugs should be administered within a half-hour before or after the indicated hour —> does not apply to all drugs, a preoperative medication ordered to be given at 0730 should be administered at that hour because the time was planned in relation to the time that surgery is to begin, also holds true when the patient is given certain drugs before diagnostic procedures and with STAT order

SIGNATURE OF THE PRESCRIBING PROVIDER
- when it is necessary to hand write a prescription, the signature and title of the person writing the prescription follows the order
- many facilities also require providers to print their name following their signature
Pg 838-839

- depending on the system used, controlled substances may be kept in a locked drawer or container as an added safety measure, providing for a double locked system
- A record must be kept for each narcotic that is administered (* this is not the same as a medication order. This information is required when administering the narcotic medication). The following information is usually required:
Name of the patient receiving the controlled substance
Amount of the substance used
Hour the controlled substance was given
Name of the prescribing provider
Name of the nurse who administered the substance

- it is a common practice to check controlled substances daily at specified intervals
- usually performed at shift change
- the amount of controlled substances on hand is counted and must be accounted for in the administration records
- unless the controlled substance count is incorrect, this eliminates the need to manually check the narcotic count at specific intervals each day
- a controlled substance count that does not check properly must be reported immediately
- the law requires these special precautions
- if for any reason a controlled substance prepared for administration has to be discarded, a second nurse should act as a witness
- Document with a witness any time a full dosage is not given and some of the controlled substance needs to be discarded
- remaining/unused narcotic medication should be dismissed of (also known as "wasted") while a witness is watching and both nurses should record the transaction, according to facility policy and medication system in use
Pg 825-827

- adverse drug reactions (ADRs): harmful effects that lead to injury (ex. Should morphine cause a sudden drop in blood pressure which may require interventions and discontinuation of the morphine)

TYPES OF ADVERSE DRUG REACTIONS
- side effects: unintended, secondary effects that are mild, predictable and may be tolerated as part of the therapy (ex. Morphine - constipation. The benefit of the pain relief usually outweighs the side effect, so side effects are often accepted and managed)
- iatrogenic disorder: illness caused by medical examination or treatment ex. Neutropenia (presence of abnormally few neutrophils in the blood, leading to increased susceptibility to infection) caused by chemotherapy
- allergic reactions: an immune system response that occurs when the body interprets the administered drug as a foreign substance and forms antibodies against the drug, can be minor to serious, can occur immediately after the patient receives the medication or be delayed for hours to days, symptoms may become more severe each time the drug is introduced into the body, S/S: rash, urticaria (skin rash), fever, diarrhea, nausea, and vomiting
- anaphylactic reaction (anaphylaxis): life threatening allergic reaction and results in respiratory distress, sudden severe bronchospasm, and cardiovascular collapse. It is treated with vasopressors, bronchodilator, corticosteroids, oxygen therapy, intravenous fluids, and antihistamines
- drug tolerance: occurs when the body becomes accustomed to the effects of a particular drug over a period of time, larger doses must be taken to achieve desired effect
- toxic effects (toxicities): specific groups of symptoms related to drug therapy that carry risk for permanent damage or death. The organ system affected is what is used to name the toxicity ex. Nephrotoxicity if drug is toxic to the kidneys. A cumulative effect occurs when the body cannot metabolize one dose of a drug before another dose is administered. Older adults are at risk for experiencing a cumulative effect, related to altered drug metabolism and elimination due to impaired hepatic metabolism and renal clearance related to normal changes with aging
- idiosyncratic effects/paradoxical effect: any unusual or peculiar response to a drug that may manifest itself by overresponse, underresponse, or even the opposite of the expected response. Related to a patient's unique response to a drug and are thought to be the result of genetic enzyme deficiencies that lead to an abnormal mechanism of drug breakdown. Older adults often have unpredictable or erratic responses to medications.
- serious ADRs/adverse events/sentinel events: an action that is life threatening, requires intervention to prevent death or permanent impairment, and/or leads to death, hospitalization, disability or congenital anomaly - must be documented according to facility policy and should be reported to a national database, such as MedWatch

DRUG INTERACTIONS
- occur when one drug is affected in some way by another drug, a food, or another substance that is taken at the same time. May be advantageous when a medication is given to decrease the adverse effects of a drug or increase its therapeutic effects. Not advantageous when there is a decrease in therapeutic effect.
- Additive effect: drugs with similar pharmacologic actions; results in an increase in the overall effect
- Synergistic effect: drugs with different sites or MOA; results in greater effects when taken together (one drug potentials the other); ex. Alcohol and barbiturates. When taken together, there is the potential for significantly increased CNS depression
- antagonist effect: combined drugs alter the overall sum effect or negate each other; results in an effect less than that of each drug alone
- interference: one drug interferes with the metabolism of another; leads to the buildup of a medication (that cannot be metabolized) and can result in toxicity or an ADR
- displacement: one drug binds to protein-binding sites and forces another drug to be displaced; results in the released drug becoming pharmacologically active and can lead to an increase in the effect of the unbound drug
- black box warning (BBW): a specific warning placed on the label of some prescription drugs (such as antidepressant drugs and immediate-release opioid analgesics) to indicate the risk for serious ADRs and safety information