Course
Objectives Upon
completion of this course the student will be able to:
List 3 common causes of
medication errors
State the “7
Rights” of medication administration
Give an example of a
“Red Flag” medication order
Discuss 3 different
routes of medication administration and nursing considerations
Explain the importance
of understanding the “right reason” before
dispensing medication
List 3 ways to assure
that medication administration documentation is clear, concise and
easily understood
Give 2 examples when it
is necessary to use 2 patient identifiers according to The Joint
Commission National Patient Safety Goal # 1.
Common
causes of Medication Error’s Nurses
are routinely asked to calculate dosage information and provide data
entry services for medications and intravenous infusions. Assuming the
physician's order and patient information are correct, there are three
general possibilities for mistakes when administering IV medications
via a pump: dosage miscalculation; transcription data entry error; and
titration of the wrong medication. Miscalculation Error
A miscalculation error can occur for any number of reasons, including
the use of inaccurate parameters such as dose, weight, height, drug
units, or solution volume. A misplaced decimal or missing number in
this complex calculation can result in a calculation error that may not
be immediately apparent to the clinician. While a nurse will
immediately recognize certain miscalculations, some mistakes like using
the wrong concentration data in the calculation, may go unnoticed and
may result with a medication error that is clinically significant, and
life threatening. Data Entry Error
A transcription type data entry error occurs when a nurse inadvertently
inputs the wrong data into the infusion pump. Another type of
transcription error is the inputting of an incorrect decimal point. For
example, the proper infusion rate is calculated, but the rate is
incorrectly entered as 54.0 ml/hr instead of 5.40 ml/hr. Titration Errors
According to their effect on the patient, many drug delivery rates are
changed while the infusion pump is infusing. This type of rate change
is called titration. Understanding the medication that is being ordered
and the dosage that this drug is routinely given in is key to assuring
that the patient is getting the proper dose of medication. Transcription Errors
Being able to read a physicians writing is sometimes a difficult task,
get clarity if uncertain about what has actually been written. If
taking a verbal or phone order, a "read-back" system can be instituted
in which the nurse who is taking the order, writes down the verbal
order and reads it back to the prescribing physician. Once it is read
back to the physician and both parties are in agreement, the order can
then be processed. The
“Seven Rights” of Medication Administration Most
registered nurses learned about the "5 rights" early in their careers.
The 5 rights (right drug, right client, right dose, right time and
right route) have been incorporated in their nursing practice.
Registered nurses also recognize they need to know the reason the drug
is given — the right reason. The administration of medication
is not complete until documentation has occurred — the right
documentation.
RIGHT drug
RIGHT client (Two
Identifiers)
RIGHT dose
RIGHT time
RIGHT route
RIGHT reason
RIGHT documentation
The
addition of “Right Reason” to the original
“5 Rights” of medication administration will not
only assure that the right medication was ordered, but will also assist
in assuring that it is for the right person. The following examples are
some Red Flags to consider when receiving or preparing to administer a
medication order: Your
patient’s diagnosis is Sub-Dural Hemorrhage > You
receive an order for Digoxin 0.125mg Q Day > In questioning why
this patient would need Digoxin, you go back to the original diagnosis
and history and find that the patient has no cardiac history >
You NEED to question this order. Your
patient is admitted status post Carotid Endarderectomy > You see
an order for an Insulin Sliding Scale to be done Q 6 hours > In
questioning why this patient would need Insulin > you go back to
the original diagnosis and history and find that the patient has no
history of Diabetes > You NEED to question this order. Your
patient is admitted with Abdominal Pain/rule out Small Bowel
Obstruction > You receive an order for PO medication > In
reviewing your original diagnosis or Abdominal Pain and probable need
for NPO status > You NEED to question this order. To
assure safe and accurate documentation of Medication Administration,
the “Right Documentation” has been added to the
original “5 Rights”. Remember the W's when
documenting medication administration on the patient chart:
Was (the med tolerated
and if known, helpful to the patient)
In
addition to using the W’s for safe and effective Medication
Administration Documentation, using the following techniques will
assure that your documentation is clear, concise and easily understood:
Legible writing or
printing.
Use of specified ink
color.
Correct grammar
& spelling
Correct recording of
time.
Assure patient
identification information is on each page.
No blanks and no spaces
between entry and signature.
Charting promptly after
provision of care.
Use approved
abbreviations.
Subjective data should
be in patient's own words.
What
is at the “Route” of the problem? IV
Bolus:
Drug tolerance declines
in patients with decreased cardiac output, diminished urine output,
pulmonary congestion, or systemic edema. To compensate, dilute the
prescribed drug more than usual and administer it at a slower rate.
Don't give a drug by
I.V. bolus injection if you need to dilute it in a large-volume
parenteral solution before it enters the bloodstream.
Avoid using an I.V.
bolus injection whenever the rapid administration of a drug, could
cause life-threatening complications
IVP:
Injected into the vein
Provides a rapid,
predictable absorption with minimal complications
Subcutaneous:
Inject directly into
the fatty, subcutaneous tissue under the skin that overlies the muscle
Absorption from this
route is slow, resulting in a delayed onset of action and prolonged
effect
Interocceous:
Used primarily with
pediatric patients
Inject into the bone
marrow
Medications quickly
enter the circulatory system
Inhalation:
Must be delivered
through the respiratory tract
Inhaled medication may
be administered via aerosolized treatments and inhalers
Enteral:
Digestive tract
Oral
Sublingual
Rectal
Trans-dermal:
Placed on the skin
Absorbed into the
circulatory system through the skin
Intramuscular
(IM):
Injected into the
muscle tissue
It is absorbed into the
bloodstream
Administration has a
predictable rate of absorption
Onset of action is
considerably slower than intravenous administration
Because
wrong patient medication administration errors can occur during all
stages of the diagnosis and treatment of a patient; the intent of The
Joint Commission’s NPSG #1 is actually two-fold. The first
goal is to reliably identify the patient and the second is to assure
that the service or treatment intended; is actually for the correct
patient. The following are situations where The Joint Commission
requires that two patient identifiers are used: Administering
medications, blood or blood components. Collection of all blood samples
and other specimens for clinical testing. Providing any other procedure
or test. NOTE: the patient’s room number or physical location
is no to be used as a reliable identifier.
References
The Joint Commission
(2009). National patient safety goals. Retrieved on September 6, 2009
at: http: //www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/09_hap_npsgs.htm Iyer,
Patricia, W., & Camp, Nancy, H., (1999). Nursing Documentation:
A nursing process approach. (3rd ed.). (pp. 18-25). Mosby. St. Louis Mo. Joint
Commission of Hospital Accreditation. (2006). Hospitals National
Patient Safety Goals. Retrieved on December 15, 2006 at: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/06_npsg_cah.htm Otto,
Shirley, E., (2004). Mosby’s Pocket Guide Infusion Therapy.
(5th ed). Elsevier Mosby. St. Louis Yocum,
Faye, (2004). Abbreviations: A shortcut to disaster. Retrieved on
December 13, 2006 at: www.nso.com/resources/artcls_abbrevs.php
Nursing CE Course
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