MEDICATION SAFETY Administration of Medications

1. MEDICATION SAFETYAdministration of Medications Meeting HFAP Accreditation Standards for Pharmacy Services and Medication Use Part Three

2. MEDICATION SAFETYAdministration of Medications • HFAP Chapter 25 keeps you in compliance with the Medicare Conditions of Participation

3. Medication Safety Series • Using CPOE: Challenges and Solutions to Address HFAP Standards • Procurement, Preparation and Dispensing • Administration of medications – timing, unit dose, bedside medication verification • Monitoring of therapy, Medication Use Evaluations • TBD

4. Outline • The 6 rights • Collaborative Process (nurses, RT, pharmacists, physicians) • Routes of administration • BMV • Advantages • Disadvantages • What to do if you see medication errors (wrong patient, wrong drug, wrong time) • Patient process • Hand hygiene • Identification • Education of the patient • Verification of the medication (double verification) • Medications at the bedside and self-administration • Observe for reactions

5. Routes of Administration • Oral: sublingual, buccal • Parenteral: intradermal, subcutaneous, intramuscular, intravenous • Topical • Inhalation • Intraocular

6. Systems of Measurement • Metric • Apothecary (grains) • Household

7. Metric System • Grams (g), milligrams (mg), kilograms (kg) • Liters (L), milliliters (ml)

8. Household Measurements • Tablespoons • Teaspoons • Ounces • Cups • Pints • Quarts

9. Clinical Calculations • Conversions within systems • Conversions between systems

10. Role of the Nurse, and others who administer medications • Six rights • Triple-check before administration • Patient assessment

11. Six Rights • Right medication • Right dose • Right patient • Right route • Right time • Right documentation

12. Patient’s Rights • Information • Refusal • Careful assessment • Informed consent • Safe administration • Supportive therapy • No unnecessary medications

13. MEDICATION ADMINISTRATION • Collaborative process • Nurses • Pharmacists • Respiratory Therapists • Psychiatric Technicians • Physicians

14. Special Considerations • Infants and children • Older adults • Polypharmacy • Self-prescribing • Over-the-counter medications • Misuse • Noncompliance

15. Evaluation • Patient response to medications • Patient and family ability to administer medications

16. Oral Administration • Presence of GI alterations • Ability to swallow • Use of gastric suction • Positioning

17. Topical Administration • Skin applications • Use of gloves or applicators • Preparation of skin • Thickness of application

18. Nasal Instillation • Assessment of nares • Patient instruction and self-administration • Positioning

19. Eye Instillation • Drops, ointments, disks • Assessment of eyes • Asepsis • Positioning

20. Ear Instillation • Assessment of ear canal • Warming of solution • Straightening of canal for children and adults • Positioning

21. Inhalation • Metered-dose inhalers (MDIs) and dry powder inhalers (DPIs) • Patient assessment and instruction • Use of spacer • Determination of doses in canister

22. Irrigation • Medications used to wash out a body cavity delivered with a stream of solution (sterile water, saline, or antiseptic) • Asepsis

23. Parenteral Administration • Equipment • Syringes: sizes (volume), types • Needles: length, gauge • Disposable units: Tubex, Carpuject • Ampules • Vials

24. Parenteral Administration (cont’d) • Mixing medications • Determine compatibility of the medications • Do not contaminate one medication with another • Ensure the final dose is accurate • Maintain aseptic technique

25. Parenteral Administration (cont’d) • Insulin • Syringes and needle sizes • Types of insulin • Mixing of insulins • Rotation of vials before withdrawal of solution

26. Administration of Injections • Minimize discomfort • Use smallest suitable needle • Position client comfortably • Select proper site • Divert client’s attention • Insert the needle quickly and smoothly • Hold the syringe steady • Inject the medication slowly and steadily

27. Administration of Injections (cont’d) • Subcutaneous injections • Sites: condition of area, rotation of use • Amount of solution • Length and gauge of needle • Pinch or spread skin • Angle of insertion

28. Administration of Injections (cont’d) • Intramuscular injections • Sites: landmarks, condition of area • Amount of solution • Length and gauge of needle • Angle of insertion • Aspiration • Air-lock method • Z-track technique

29. Administration of Injections (cont’d) • Sites • Ventrogluteal • Vastuslateralis • Deltoid

30. Administration of Injections (cont’d) • Intradermal injections • Skin testing • Sites • Length and gauge of needle • Angle of insertion • Formation of small bleb

31. Prevention of Needle Sticks • Needleless devices • Sharps disposal • One-handed recapping technique

32. Intravenous Administration • Large volume infusions • Bolus injection • Volume-controlled infusions Piggyback • Tandem • Volume-control set • Mini-infusor pump

33. MEDICATION ADMINISTRATION PROCESS • Hand hygiene • Identification • Education of the patient • Verification of the medication (double verification) • Medications at the bedside and self-administration • Observe for reactions

34. HAND HYGIENE • Wash hands with soap and water or with waterless hand sanitizer before and after patient contact • Gloves

35. IDENTIFICATION OF PATIENT • Must use at least two patient identifiers whenever administering medications. • Acceptable identifiers may be the person’s name, an assigned identification number, a telephone number, a photograph, or another personal identifier. • If bar code scanning is available, scan the patient’s armband

36. VERIFICATION OF THE MEDICATION • Scan barcode • Verify that this is the correct medication • Verify dose • Double verify • High risk medications (heparin, insulin) • Controlled substances

37. Why barcode medications? More people die in a given year as a result of medical errors than from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516). Kohn, Corrigan & Donaldson, “To Err is Human”, Institute of Medicine, 1999

38. Where do medication errors occur? Bates, Cullen, Laird, et al. “Incidence of Adverse Drug Events and Potential Adverse Drug Events.” JAMA, 1995, 274, 29-34.

39. Why barcode medications? Nationally 2 of every 100 admissions experienced a preventable adverse drug event, resulting in increased hospital costs of $4,700 per admission. This is $2.8 million annually for a 700-bed teaching hospital. Kohn, Corrigan & Donaldson, “To Err is Human”, Institute of Medicine, 1999

40. Effect of BCMA *Barcode Medication Administration (BCMA) in VA Medical Centers*: • Right drug 75% improvement • Right dose 62% improvement • Right patient 93% improvement • Right time 87% improvement • Missed meds 70% improvement *Johnson, Carlson, Tucker, & Willette Using BCMA in VA Medical Centers Journal of Healthcare Information Management-Vol 16, No.1

41. Why barcode medications? *Eastern Kansas Health Care System (VA) 1994-2001*: • 8,000,000 doses dispensed • 549,000 errors prevented • 0 documented errors

42. BCMA Steps • Physician order received • Order faxed to Pharmacy • Pharmacists edit and verify electronic orders into patient profile • Pharmacy dispenses ordered medications in Bar-Coded packages • Nurse accesses BMCA software on computer via log on • Nurse scans unique patient bar-coded ID band

43. BCMA Steps (cont) • Nurse utilizes two unique patient identifiers to verify armband • Nurse verifies patient profile medications as per order • Nurse scans bar-code on medications • Nurse administers medications

44. BCMA Advantages: Reduction in medication errors The FDA estimated that over a 20 year period the number of medication errors would be reduced by 50% and up to 500,000 adverse events would be avoided by utilizing BCMA (Food and Drug Administration, 2004). Ease of checking the five rights of medication administration Automatic MAR creation Lab results can be displayed at the point of care Alerts for missed medications

45. BCMA Disadvantages: • Estimated to cost $1,799 per bed to implement BCMA, with an additional $1,000 yearly for maintenance • No universally accepted bar codes • Bar codes that are unable to be scanned • Equipment malfunction • Over reliance on BCMA to catch errors • Stat medication turnaround time (ZIH, 2006)

46. BCMA Workarounds • Over 15 types have been identified that could potentially lead to errors • For example: • Nurses override alerts for 4.2 % of patients cared for and for 10.3% of meds charted (Karsh, Koppel, Telles, & Wetterneck, 2008)

47. MEDICATIONS AT THE BEDSIDE • Require special order from physician • Must be stored in a secure manner • Avoid using home medications unless they are unavailable from the hospital pharmacy • If using home medications, they must be stored in and dispensed from the hospital pharmacy only upon positive identification • Patient education on self-administration • Example: inhalers

48. BEFORE GIVING THE DRUG • Assessment • Vital signs • Blood glucose • Pain level • Education • What drug is for • Side effects

49. AFTER MEDICATION IS GIVEN • Reassessment

50. DIRECT OBSERVATION OF MEDICATION ADMINISTRATION • Types of errors: • Omissions • Drug administration without a physician’s order • Wrong drug • Wrong dose • Wrong time • Failure to follow manufacturer specifications • Do not crush • Shake well • Inadequate fluids