Medication Safety and Administration

1. Medication Safety and Administration Medication administration for nursing students in clinical at Seattle Children’s Update June 2009, K.Klee

2. Objectives • Describe appropriate methods of medication delivery for different ages. • Accurately document medications per hospital policies and procedures. • Safely administer medications. • Know standards of practice specific to caring for children at Seattle Children’s • Know limitations of student responsibilities at Seattle Children’s

4. What you need to know…. • Medication errors happen • Near misses happen (when an error is discovered before it gets to the patient) • Injury and even death happens from medication errors. You are part of the team and you can help prevent errors by talking with your instructor when you are unsure, overwhelmed, or new to a task

5. What Can You Do To Decrease Medication Errors? • Check and double check, if in doubt check it out, again! • Follow the 5 R’s: right patient, right drug, right dose, right time, right route • Never assume, “pharmacy put the medication in the drawer so this must be right”, pharmacy makes errors too. • Never assume, “the resident ordered this large dose so it must be right”, Residents make errors too. • Know the correct mg/kg dose of medications you are administering. • Know why you are giving the medication, the expected action, and any potential side effects.

6. Time for a story

7. 3 month old admitted with respiratory distress most likely due to bronchiolitis Admitting Nurse: “I did his admission assessment and then it was time for change of shift so I gave report to the next nurse” Oncoming Nurse: “I received report at 7 p.m. and was reviewing the orders and saw that he had some medications due” Story: Admission of a patient…

8. Infants Nurse: “The infant had reglan and digoxin ordered BID. They were due at 8pm. I went to the medication room and the meds were in the drawer so I took them into the infants room”. What are the next steps to take? 5 R’s What questions do you have? What are the clinical indications for these two meds in this infant You go into the room to give the medications…what steps do you take? Patient ID check, tell patient and family what meds you are administering and what they are for “I saw that he had some medications due…”

9. “I looked at the online formulary for reglan and digoxin and saw that they were ordered in the correct dose and route. I checked the labels on the syringe and double checked the dose against the order on the medication administration record. I took the medications into the infants room, checked his ID band, and told mom I was giving digoxin and reglan”. Looked meds up on the online formulary Checked the dose Checked the med Took labeled syringes to pts room Checked the ID band against the name on the med and asked mom to verify date of birth Told mom what meds were about to be administered “I took the medication into the room…” EXCELLENT PRACTICE, Never short cut this!

10. “She said, at home I give the reglan, the other medication must be a new one.” “I told her it was ordered by the doctor for the baby’s heart”. “Mom said, is there something wrong with his heart?” What do you do? “I told mom I was giving Digoxin and Reglan..”

11. “I said let me double check his chart”. I left the room and looked at the chart, he was here for respiratory distress. I did not see anything about a heart problem. I called the resident and he said “he did not know of any heart problems in this patient”. I called my charge nurse. The charge nurse called the senior resident who said the child had no cardiac issues and should not have an order for Digoxin. Turns out the order was electronically placed in the wrong chart. “Mom said is there something wrong with his heart?”

12. “What if mom had not been there?” • Always! Ask yourself…what were the indications for digoxin in this infant? • Know why you are giving a medication and the indication in your patient!

14. What Else Can You Do To Decrease Medication Errors? • Stop the line, if you have concerns or questions do not give the medication until you feel the concerns/questions have been answered. • If a patient or caregiver says, “hmm, that pill does not look familiar”, or “the doctor said not to take that today”, or “I already took that pill today”, or anything that might indicate an error is about to occur….stop, pick up the medication and leave the room. Double check the medication and if necessary call the MD to clarify the orders. • If you have to pull 2 vials of a medication out of omnicell or need a large quantity of a medication stop and recalculate with a peer. This is pediatrics! Medications doses are smaller then adults and are given in mg/kg! • Harried? Tired? Distracted? Triple check yourself!

15. Medication administration documentation • Documentation of medication dose, time, date, route must occur every time a medication is administered, at the time of administration. • Documentation occurs on the medication administration record (eMAR) in CIS • If you give a scheduled med late you must document the actual time given. • If a scheduled med is not given you must document not given and document the reason why.. • You must have medications cosigned by an instructor or the RN caring for the child

16. Nursing Student Responsibility and Patient Safety Follow all Children’s Hospital policies and procedures especially those related to Patient Safety.

17. Nursing Student Responsibility • Nursing students do not take verbal/telephone orders from physicians • Nursing students do not receive critical lab values from the Laboratory • Nursing student do not alter alarm settings(change alarm parameters,turn off alarms…) • Nursing students do not administer any chemotherapy agents (oral or IV)

18. Nursing Student Responsibility and Patient Safety • Nursing students do not give IV push medications EVER! (exception: normal saline (NS) and heparin flush in a PIV only) • Nursing students do not administer blood or blood components • Nursing students do not do Ventriculostomy care or maintenance • Nursing students do not administer narcotics, paralytics, or vasopressors via pump or drip • Nursing students may not independently program any infusion pumps

19. Medication administration documentation • You must give medication under the direct supervision of a nursing instructor unless supervision has been prearranged with the instructor and the RN caring for your patient. • If you give a scheduled med late you must document the actual time given. • If a scheduled med is not given you must document not given and document the reason why.. • You must have medications cosigned by an instructor or the RN caring for the child

20. Faculty Responsibility… • Directly supervise the administration of medications. When the student has demonstrated adequate knowledge and good technique, s/he may give medications (except IV meds) with staff nurse availability. This must be pre-arranged between the faculty and staff RN. • All student medication administration is to be directly supervised by clinical faculty or staff nurse. The supervising RN (faculty or staff RN) will co-sign the MAR. • From P&P:    RN reviews and co-signs documentation and medication administration. Writes “I agree/concur with above documentation” and/or add any additional documentation. (Note: LPNs may not co-sign RN student nurse medication administration documentation).

21. Wow, that is a lot of to do’s and not to do’s…but ultimately keeping kids safe is our goal!

22. Documentation • If you do not chart it, it didn’t happen. • What if you gave tylenol at 0630 and forgot to chart it. The next nurse comes on and the child has a fever so the child gets tylenol again at 0730…

23. Some hints from the wise • Always check name band prior to giving any medications. • Always check to see that ordered dose is appropriate based on weight. • Always look up medications unfamiliar to you before leaving the medication room.

24. Pt Safety • Never leave medications unattended at the bedside or at the nursing station. • Never leave medications unattended! • We are protecting the patients, siblings, friends, and young visitors that may be curious and ingest a medication left unattended. Think Safety!

25. Pt Safety • Never leave the medication room with a syringe unless it has a label on it that includes the patients name, dose, and name of medication. JJ Amoxicillin 250 mg

26. On line order entry is great…but • It is not fool proof • Errors still occur • Always know when the last dose was given and frequency of dosing • Note start and stop dates especially on weaning schedules • Watch for duplicate orders

27. Patient Safety • Check and double check • 2 patient identifiers (name/DOB or name/MRN) before any medication or intervention • Know why you are giving the medication and that the reasoning matches the pts clinical state/diagnosis • Listen to your instinct • Listen to the family

28. Thanks!