2007 National Patient Safety Goals

1. 2007 National Patient Safety Goals Goal 3 Improve the safety of using medications. 3B Standardize and limit the number of drug concentrations used by the organization 3C Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs. 3D Label all medications, medication containers, or other solutions on and off the sterile field.

2. MEDICATION ADMINISTRATION Christie M. Candelaria, BSN, MA, RN,CCRN.

3. Evidence-based Nursing Medications hurt or kill more than 400,000 Americans per year from preventable mistakes in the hospital. Twice that many happen in long-term care facilities Dayton (Ohio) Daily News

4. FDA facts: Medication errors cause at least 1 death per day and 1.3 – 1.5 million people injured each year. This costs well in excess of $3.5 billion to treat. Causes: Poor communication Job stress Lack of training Poor understanding of the directions for use

5. Important Information Medication a substance administered for the diagnosis, cure, treatment, mitigation (relief), or prevention of disease. Drug Used interchangeably with medication; has the connotation of an illicitly obtained substance such as heroine, or cocaine. Prescription Written direction for the preparation and administration of a drug Drug Names: Chemical Name: describes constituents of the drug Official Name: name under which it is listed in one of the official publications (e.g. US Pharmacopeia) Generic Name: name given before a drug becomes official E.g. Acetaminophen Trade or brand name: given by the drug manufacturer E.g.: Tylenol

6. Legal Aspects of Drug Administration The administration of drugs in the USA is controlled by law. See Table 26-2, p. 501, Kozier & Erb for a summary of US drug legislation. Nurses need to: 1. know how nursing practice acts in their areas define and limit their functions 2. recognize the limits of their own knowledge and skills Under the law: Nurses are responsible for their own actions therefore question/clarify any order that appears unreasonable and refuse to give the medication until the order is clarified

7. NCLEX TIME: A nurse is to give a patient a medication for pain. The order is for Morphine 40 mg. The PDR states the normal dose is 5-10 mg. The nurse should: Administer the ordered amount. Administer the normal dose. Contact the physician concerning the written order. Confirm the order with the charge nurse.

8. Use of Controlled Substances Kept in double-locked drawer, cupboard, medication cart, or computer-controlled dispensing system Inventory forms Wasted with another RN Counted before & after the shift

9. Biologic Effects of Drugs Absorption: the movement of the drug from the administration site into the bloodstream Local: confined to one area of the body PO: cough med., antacid Topical: skin (dermal), eye (ophthalmic), ear canal (otic) Systemic: absorbed by the vascular system & distributed to body tissues Mucous membranes (both local & systemic) Sublingual or buccal areas Nose or respiratory tract (inhalation) Eye, vagina, rectum Parenteral route Intradermal Subcutaneous (sub Q) Intramuscular (IM) Intravenous (IV) Distribution: process by which a drug is transported by the blood to the site of action. Requires adequate cardiac output and tissue perfusion. Metabolism or biotransformation: enzymatic process by which a “free” drug is converted to an inactive and harmless form that can be excreted. Sites of drug metabolism: liver, lungs, kidney, plasma, and intestinal mucosa. Excretion: final process by which the drug is eliminated from the body. Routes of excretion: kidneys, GI tract, saliva, sweat, breast milk.

10. Medication Order Components Client’s Name Date medication was ordered Medication Name Dosage Route of Administration Time & frequency medication is to be given Physician Signature NOTE: If there is a specific route indicated and patient’s condition changes, you must get an order to change the route You will be responsible for knowing the abbreviations on page 503, Kozier & Erb or page 573, Clinical Skills Text.

11. SYSTEMS OF MEDICATION DISTRIBUTION Stock Supply – Large quantities of medications for that particular unit Unit-Dose-Prepackaged and prelabeled individual client doses Automated Medications Dispensing-Technologically enhanced combination of stock supply and unit-dose

12. TYPES OF ORDERS Standing Orders May or may not have a termination date. May be carried out indefinitely or in some agencies standing orders are automatically cancelled after a specific number of days and must be reordered. PRN Given as needed Single Order One time order, to be given once at a specified time STAT- single order to be given immediately

13. NCLEX TIME The order reads, “Give Morphine 10 mg. IM x 1 at 0800.” This is called a: Stat order Prn order Single order Standing order

14. Communicating a Medication Order A drug order is written on the chart by a physician or by a nurse receiving a telephone or verbal order from a physician. This order should be read back by the nurse to the physician and written as: Example: Demerol 25 mg. IM every 4 hours PRN for pain. TORB or VORB Dr. Doctor/Nurse, RN This should be co-signed by the physician within a specified time frame The nurse or clerk copies the medication order to a Kardex or MAR or a computer printout may be generated.

15. MEDICATION ASSESSMENT Medication History Allergies and Intolerances To avoid potential fatal anaphylaxis; written on client’s record, outside of chart and medication record (ideally in RED ink) Medical History Pregnancy and Lactation

16. ASSESSMENT BEFORE ADMINISTRATION Medication Record (MAR) Check for dual meds and possible interactions Diet/Fluid Orders – NPO Laboratory Data Monitor serum Levels Monitor Direct Effects

17. Physical Assessment Ability to swallow- Have you seen the patient swallow Gastrointestinal Motility – If GI status is abnormal or recent abdominal surgery, check for bowel sounds Adequate Muscle Mass – For injections Adequate Venous Access – for IV Fluids Vital Signs Body System- To see if medication is having a therapeutic effect Knowledge and Compliance

18. SAFE ADMINISTRATION Interpretation of order If not clear, consult physician Evaluate order to see if it is safe Calculating Dosage If calculation seems strange or too much, consult pharmacist or another nurse for verification

19. Seven Parts of Medication Orders Client’s Name Date medication was ordered Name of medication Medication dosage Route of administration and any special instruction for administration Time & frequency medication is to be given Signature of individual ordering the drug

20. Safety Precautions The Six Rights Right Medication: Compare drug container label to the MAR three times. Note expiration date, action, dosage, method of administration, side effects of drugs. Right Client: Check room, bed number, identaband; have client state his/her name Right time: Medications given within the 30 min. window is acceptable. Right Method or route of administration Right Dose: Validate calculations. Know usual doses; question unusual doses. Check certain drug with another RN. Documentation: proper documentation of the med. Administered; include client’s reaction to medication Two new rights under consideration: Right to know Right to refuse

21. Documentation Done AFTER medication is given Must be exact time administered Response to medication Medication Errors When it is not given When order is unsafe When not documented Wrong Rate for IV Not following five rights Medications given at home Most important aspect is education of client and family

22. ROUTES OF ADMINISTRATION – NONPARENTERAL: By Mouth Client should be standing, Sitting or with HOB ? to facilitate swallowing May crush/ dissolve in liquid/mix in soft foods May give in syringe NEVER CRUSH ENTERIC COATED OR SUSTAINED RELEASE TABLETS Tubes - NG or Gastric Check for placement prior to giving meds Crush med. Individually Administer by gravity Flush with 30-45 ml warm water before and after giving. Review pp. 531-532, Clin. Skills Text Sublingual under tongue Buccal – Under upper lip or in cheek

23. TOPICAL MEDICATIONS Medication Applied to the Skin Lotions, Creams, Ointments Used for wounds or skin disease Clean and dry skin prior to application Transdermal- Systemic Effect Remove previous patch and all signs of medication Fold patch in half to avoid medication Rotate Sites Apply immediately Wash hands before and after Note time date and your initials on patch

25. Ophthalmic Eye infections, glaucoma, and irritations. Retract lower eyelid and place liquid or ointment in lower conjunctival sac Inhaled for anesthesia and inhalation treatments Review pp. 544-546 for administering MDI medications and using MDI with spacer Otic Treat Ear Infections or soften and remove wax Warm to room temperature Gently pull ear up and back for adults and down and back for infants up to age 3 Nasal Sprayed in nostril to relieve congestion Have client sit up and lean head back When client inhales, squeeze bottle Review pp. 543-544 Rectal Insert beyond internal anal sphincter Vaginal May be creams, suppositories or applicators.

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27. ADMINISTRATION OF MEDICATIONS Wash Hands Arrange MAR on Medication Cart or System Prepare Medication for one client at a time Remove medication from cart. Compare label with MAR and recheck the five rights Liquid Medication hold bottle with label against your palm Hold Medication cup at eye level Fill until bottom of meniscus is at desired dosage

28. Take medication directly to client’s room Compare name on MAR to client’s ID band Check swallowing ability if unknown Compare medication to MAR again as you open the package assuring 5 rights. Explain medication purpose and side effects to client Stay with client until he has swallowed medication Record the medication as administered and clean up soiled items.

29. NCLEX TIME The patient is in the bathroom when the nurse came to administer the AM medications. The patient asks her to leave the medications on his bedside table. What should the nurse do? Leave the medication on the bedside table Go into the bathroom and give the medications to the patient. Throw the medications and pour another set when the patient is ready. Tell the patient she will return in a little while with the pills

30. FACTS TO REMEMBER Antibiotics are usually absorbed, utilized and excreted quickly and therefore should be given around the clock If a client states a medication looks different than usual, hold medication and check it out. Remember the difference between allergies and side effects. If there are unpleasant side effects a drug can be used. If there is a true allergy , drug cannot be used.

31. GOOD LUCK TO YOU ALL