The “Rights” (and Wrongs) of Medication Administration Module 2

A Nurse’s Role in Drug Therapy Nurses are often a patient’s first point of contact in a health care setting and usually spend the most time per day with patients. Nurses should be able to identify signs & symptoms (S/S) that may require drug therapy Nurses should also recognize those S/S that may signal adverse reactions/outcomes of drug therapy.

Nursing Knowledge Nursing responsibilities related to drug therapy require an extensive knowledge of the following: Pharmacology The Nursing Process Use of Critical Thinking and Priority Skills Nurses assist physicians/practitioners in ensuring that patients achieve the best possible outcome from their drug regimen.

Let’s Begin with the Basics Among the many responsibilities a nurse has, they are legally responsible for safe administration of medications. Unfortunately, medication errors can occur if there is a “breakdown” in the process of med administration. As a standard of care, five rights of medication administration are used to ensure patient safety.

Five Rights of Medication Administration Although there are several other factors to consider, the five basic rights of medication administration include: Right PATIENT Right DRUG Right DOSE Right ROUTE Right TIME

Right Patient A patient’s identity should be confirmed prior to any procedure, including drug administration. Ask the patient to state their name and check the patient’s ID band/bracelet before giving any medication. **Be sure the name a patient states matches the name on their ID band and the name on the chart— what you see may not always be what you get!

Right Patient It is important to not only verify the patient’s name, but also their date of birth, and any allergies prior to administering the medication. Errors in administering the right drug to the wrong patient can easily occur if a patient is not identified correctly. Some Hospitals use the following Patient Identifiers when administering medications: Patient’s Name Medical Record Number (MR number or MRN) Account Number Last four numbers of the patient’s SSN

Right Drug Many drugs have similar names & look alike… Verify that you are administering the correct drug (the drug that has been ordered for that patient) Check packaging labels and verify that they match the prescribed medication order Be sure to check the expiration date of the drug as well **Administration of the wrong drug is the most common error that can occur during med administration!

Right Dose If medication dosages need to be calculated, always re-check your math and have someone else (i.e. another RN) verify the final dosage. Newborns, Pediatric, and Geriatric patients can be very sensitive to slight changes in med dosages. Important Considerations to determine if a dose is appropriate: Age Height Weight Vital Signs ** Do the Math! ** Med errors commonly occur r/t incorrect dosage calculations

Right Route Medications are administered in a variety of different ways or routes. The route prescribed by the physician depends on the patient’s condition and the speed at which the therapeutic effect needs to occur. Various administration routes include: Oral (PO), intravenous (IV), subcutaneous (SQ), Rectal (PR), intramuscular (IM), and sublingual (SL)

Right Route Prescribed dosages are based on the route by which the meds are given. **IV medications are absorbed far more quickly than PO meds In general, dosages for oral medications are greater than dosages for injections of the same medication (because of the absorption rate) Route Errors can occur when a dose that is intended to be given via one route but is actually given via another (ex: oral med is given as an injection ) **Consider the implications if an oral dose is given via injection route… harmful effects such as respiratory depression, respiratory or cardiac arrest, and/or even death may occur as a result of such an error!

The IV Route Take special caution when administering medications given via the intravenous (IV) route. IV administration includes meds given via: IV injection (IV push or IVP) IV piggyback (IVPB) Continuous IV infusion *Important* assess the IV site and check for blood return from the IV prior to giving any IV meds IV meds have a rapid onset of action Monitor the patient during the first few minutes of infusion to assess for adverse reactions. Soft tissue injury can occur if the IV becomes infiltrated.

Right Time Medications should be given at scheduled times. Delay or omission of a medication at a scheduled time may have harmful effects for a patient. **Military time is used to prevent errors in AM vs PM dosages. As a general rule, medications must be given within half an hour of the scheduled time. This means medications can be given up to 30 minutes before or 30 minutes after the actual time they were ordered/prescribed . Ex: a med that is due at 13:00 can be given anywhere between 12:30 & 13:30.

Right Time Many drugs interact with the absorption of other drugs when given simultaneously. Some foods and herbal medications (even those that are non-prescription) can also interact or interfere with drug absorption. Considerations when scheduling administration times: consider any drug-drug or food-drug interactions appropriate spacing of med doses Bioavailability—consistent dosing around the clock Scheduling of diagnostic tests (either prior to med administration or post administration)

Beyond the Five Rights The five rights of med administration should be accepted as a goal of the medication process . These five rights should not be considered the “be all end all” of medication administration or medication safety.

Added Rights The five med rights focus on individual performance; they do not focus on human factors or system defects that may make medication administration challenging. Some literature moves beyond the 5 basic rights and includes some additional rights such as… Right Reason/Indication Right Documentation Right Drug Formulation (solution, cream, gel, patch, capsule, tablet, etc.) Right Line Attachment (attachment to appropriate IV line) The Right to Refuse

Current Practice There are several factors that can interfere with a nurse’s ability to carry out the five (plus) rights and safely administer meds. The five rights are considered broadly stated goals or desired outcomes of safe medication practice. Unfortunately these practices offer no procedural guidance for nurses on how to achieve these goals Simply following the five rights (and/or any additional rights), is not enough to ensure medication safety (ISMP, 2007)

Verification & Accountability Nurses are accountable for following the processes that their organizations have designed and held out as the best way to verify the five (plus) rights of medication administration. In other words, a nurse’s duty is not exactly to achieve the five rights, but to follow the protocols & procedures designed by their organization to produce the outcomes of the 5 (plus) rights. **For example, a nurse cannot verify 100% that a patient is who they say they are… but they can verify the two patient identifiers that were assigned to that patient upon hospital admission (which is a common procedure of health care organizations)

Avoiding the WRONG Things **Poor communication can be a common cause of any med error** Use the following precautions to help avoid med errors: NEVER ASSUME ANYTHING! Repeat verbal orders Avoid dosage and product abbreviations Never assume the route of administration Call & Clarify! Don’t try to decipher illegible orders When in doubt, double check! (w/ physician, pharmacist, and/or current literature) Check drug labels and doses against a doctor’s order several (3) times prior to med administration Only administer drugs that you are sure of the intended use for the patient

References: Cohen, M.R. (2006). Medication errors. American Pharmacists Association, pp. 77, 363, 385, Retrieved July 17, 2009, from http://books.google.com/books?id=Gpj7ZaptUDcC&pg=RA1- PA471&lpg=RA1- PA471&dq=medication+line+attachment&source=bl&ots=i2jzDsoKXg&si g=L0Lwskuior332MdBmYCi8Rno5gw&hl=en&ei=fE1lSpagDIiEtgeywN3_ Dw&sa=X&oi=book_result&ct=result&resnum=3 ELCH.org, Education department. (2008). Preventing medication errors. Retrieved June 30, 2009, from elch.org Web site: http://www.elch.org/Education/Mederrors-selfstudy.pdf Federico, F. (2007). The Five Rights of Medication Administration. Retrieved July 10, 2009, from Institute for Healthcare Improvement Web site: http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Improve mentStories/FiveRightsofMedicationAdministration.htm

References ISMP, (2007). The five rights: A destination without a map . Retrieved July 10, 2009, from Institute for Safe Medication Practices Web site: http://www.ismp.org/newsletters/acutecare/articles/20070125.asp Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O'Brien, P.G., & Bucher, L. (2007). Medical-surgical nursing: Assessment and management of clinical problems 7th Ed. St. Louis, MO: Mosby Elsevier.