This course is designed to provide educational information to assure safe medication administration. Focus will be placed on the major causes of medication errors as well as thenow “7 Rights” of medication administration.Examples of “Red Flag” medication orders that should be questioned will be presented as well as discussing nursing considerations depending on the actual route of administration. The “5W’s” to assure that nursing documentation is complete and accurate and the 2005 and 2006 JCAHO standards for safe medication administration will be also be presented. Responsibility of reporting medication errors, special safety needs of specific populations and public education will be the final focus of this course.
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
Describe the 2005 and 2006 JCAHO standards for safe medication administration
Discuss the responsibility of reporting medication errors
List 3 specific age specific population considerations when administering medication
Discuss the need for public education regarding safe medication administration
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 and have incorporated them in their practice (right drug, right client, right dose, right time and right route). 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 5W’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 (Includes the following routes):
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.
The following are the 2006 JCAHO standards for safe medication administration that must be followed whether medication is being distributed PO, IM or Intravenously:
Goal # 3: is to improve the safety of using medication by:
Remove concentrated electrolytes (including but not limited to potassium chloride, potassium phosphate and sodium chloride > 0.9 from the patient care units
Standardize and limit the number of drug concentrations available with in an organization
Identify and at least annually review a list of look alike/sound alike drugs used in the organization. Take measures to prevent errors involving these drugs
Label all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field in perioperative and other procedural settings
Responsibility of Reporting Medication Errors and Other Patient Safety Issues:
JCAHO who is committed to patient safety states that significant reduction of medication errors can occur if the following practices are put into place:
Identification of all medical errors.
Analysis of each individual error (factors, root causes, actions to reduce similar situations).
Data collection of each incident (to monitor trends).
Periodic assessment of the effectiveness of efforts to reduce errors.
Based on data collection, set priorities for error reduction.
Make medication error reporting a non-punitive event.
In order to effectively measure medication errors JCAHO also recommends the creation of an effective medical/health care error reporting system that includes the following:
It must be a mandatory reporting system.
It must include root causes for analysis.
It must be legally protected information (free from subpoena, discovery or testimony).
JCAHO and other healthcare oversight agencies must have access.
Important Considerations for Medication Administration of Specific Patient Populations:
Pediatric
Drug dosages for children are calculated on a per weight basis that is significantly different from calculating dosages for adults. A computation error can result in a significant under or over-dosage.
The “ten-fold error” that is often harmful to pediatrics must also be a focus of pediatric medication administration. The “ten-fold error” occurs simply by the wrong placement of a decimal point. This can cause a pediatric patient to receive 10 times the ordered amount of medication.
Geriatrics
The increased risk of adverse reactions to medications by older people can potentially be life threatening. The following are special considerations when prescribing or administering medications to the elderly:
Consider the amount of medication already being taken.
Drug-drug interactions.
Increased sensitivity to medications with age and diseases often associated with aging further increase sensitivity to medications.
Geriatric patients are known to have an increased sensitivity to medications that treat anxiety, insomnia, pain and or depression (this can cause confusion, altered thinking ability and falls).
Public Education:
Evidence suggests that on a national level, medication errors alone are thought to be the cause of approximately 98,000 deaths per year. With numbers this staggering the need to take safe medication administration beyond the walls of the hospital and into the community becomes apparent. The following are collaborative areas of focus when educating the public to safe medication practices:
Safe medication education classes.
Disease specific support groups.
Health information computers in community libraries.
Free safe medication administration publications in key community locations (physician offices, senior and community centers for example).
Health safety on video.
Pharmacists play a key role in public education regarding the avoidance of adverse drug reactions. Patients receiving prescription medication should receive the following education:
What the name of the medication is?
What it is used for?
How it should be taken?
How long it should be taken?
What are the side-effects?
How much does this medication cost?
Is there a generic equivalent available for this medication?
What the medication is for (the pharmacist should discuss this with the patient each and every time the prescription is filled).
Note: Using just one pharmacy is also recommended.
References
AmericanAcademy for Pediatrics. (2005). Summit: Setting a research agenda for patient safety. Retrieved on January 20, 2006 at:
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