2. © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Chapter 11 Safe Medication Administration PowerPoint ® Presentation to accompany: Math and Dosage Calculations for Healthcare Professionals Fourth Edition Booth, Whaley, Sienkiewicz, and Palmunen

3. 11-2 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 11.1 Recall the eight required elements of a prescription/medication order. 11.2 Apply The Joint Commission steps to receiving and writing a verbal order. 11.3 Execute safe transcription practices. Learning Outcomes

4. 11-3 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 11.4 Identify error-prone abbreviations and symbols. 11.5Identify the three checks in the medication administration procedure. 11.6Implement the “rights” of medication administration. Learning Outcomes (cont.)

5. 11-4 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 11.7Recognize the importance of observation in safe medication administration. 11.8 Describe the appropriate use of patient teaching as it relates to safe drug administration. Learning Outcomes (cont.)

6. 11-5 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Key Terms  Institute for Safe Medication Practice (ISMP)  Electronic Medication administration record (eMAR)  Physicians' Desk Reference (PDR)

7. 11-6 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Key Terms (cont.)  The Joint Commission (TJC)  Transcription  Verbal Order

8. 11-7 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Introduction  Medication administration Safety is key. The process is complex.  Elements Prescription Transcription Three “checks” “Rights” Observation Patient teaching

9. 11-8 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Prescription/Medication Order  1 st step in the medication delivery process Prescription Medication order  Components Patient name DOB Date / time written Drug name Dose Route Time/frequency Signature of AP

10. 11-9 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Prescription/Medication Order (cont.)  Prescriptions are outpatient medication orders filled at a pharmacy. May be written May be called in to pharmacist May be electronically written and communicated to the pharmacist

11. 11-10 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Prescription/Medication Order (cont.)  Must contain 8 components of medication order  Plus Quantity Prescriber number Number of refills Instructions Ellen Trent, MD 14 Southwood Blvd. Georgetown, CO 12345 989-555-1234 Prescribed Date ___July 2, 2011____ Name Arthur Simmons DOB 9/29/49 a Address a a Rx : Doxycycline 100 mg QUANTITY: #20 SIG: cap i po BID pc Refills: 0 MD123456 E. Trent MD aaaaaaa Prescriber ID# Signature

12. 11-11 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Prescription/Medication Order (cont.) Patient name DOB Date written Drug Dose Route Time / frequency Signature of AP Quantity Prescriber number Number of refills Instructions Arthur Simmons 9/29/49 July 2,2010 Doxycycline100 mg po BID pc cap i E. Trent MD 20 MD123456 0 cap i po BID pc Ellen Trent, MD 14 Southwood Blvd. Georgetown, CO 12345 989-555-1234 Prescribed Date ___July 2, 2011____ Name Arthur Simmons DOB 9/29/49 a Address a a Rx : Doxycycline 100 mg QUANTITY: #20 SIG: cap i po BID pc Refills: 0 MD123456 E. Trent MD aaaaaaa Prescriber ID# Signature

13. 11-12 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Prescription/Medication Order (cont.)  Medication orders are inpatient orders written in a patient’s chart. May be in paper form or in an electronic chart Each order entry includes:  patient name;  current date/time;  signature of AP.

14. 11-13 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Prescription/Medication Order (cont.)  For each medication order identify DOB Drug name Dose Route Frequency/time Instructions as needed

15. 11-14 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Prescription/Medication Order (cont.)  Are these orders correct?  If not, why not? Medication Order Date: 6/1/12 Correctly written Time/frequency missing Dosage strength needed Route missing Correctly written Dosage strength needed

16. 11-15 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Practice List the components of A. A prescription B. A medication order in a patient chart ANSWER: Patient name, DOB, date written, drug, dose, route, time/frequency, signature of AP, quantity, prescriber number, number of refills, and instructions ANSWER: Patient name, DOB, date written, drug, dose, route, time/frequency, and signature of AP

17. 11-16 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Practice Ellen Trent, MD 14 Southwood Blvd. Georgetown, CO 12345 989-555-1234 Prescribed Date ___July 2, 2011____ Name Arthur Simmons DOB 9/29/49 a Address a a Rx : Ampicillin Suspension QUANTITY: 200 mL SIG: i po qid Refills: 0 MD123456 E. Trent MD aaaaaaa Prescriber ID# Signature What is the dosage strength to be dispensed? Are the instructions adequate? ANSWER: none given ANSWER: No, the dosage form is not indicated.

18. 11-17 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Ibuprofin q8h prn aaaaaaa Inederol 10 mg q6haaaaaa 20 units subcut daily aa Valium 5 mg poaaaaaaaa Practice What is missing from these orders? ANSWER: dose ANSWER: route ANSWER: time/frequency ANSWER: medication name

19. 11-18 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Verbal Orders  Used when AP is unable to write the order Order must be carried out quickly  Can be given in person or by phone Must be given by an authorized person Must be received and documented in medical record

20. 11-19 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Verbal Orders (cont.)  The Joint Commission (TJC) guidelines 1. Write the order as you receive it. 2. Read the order back to the physician. 3. Confirm the order with the prescriber.

21. 11-20 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Error Alert!  Always be certain that you are dispensing the correct medication. Many drugs have names that are similar. Acular  —OcularBenadryl  —Bentyl  Darvon  —Diovan  Digitoxin—Digoxin Iodine—Lodine  Nicobid—Nitrobid  Examples

22. 11-21 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Error Alert!  Never guess what the prescriber meant! If the order is not legible, always contact the prescribing physician to clarify the order.

23. 11-22 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. When may a verbal order be given? Who may accept a verbal order? What are the TJC guidelines when receiving a verbal order? Practice ANSWER: AP is unable to write the order and the order must be carried out quickly ANSWER: a nurse or other practitioner whose scope of practice includes the authorization to receive and document such orders ANSWER: Write the order as you receive it; read the order back to the physician; and confirm the order with the prescriber.

24. 11-23 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Safe Medication Order Transcription  This is the process of transferring the information from the prescriber's order to a prescription label; or Medication Administration Record (MAR).

25. 11-24 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Safe Medication Order Transcription (cont.)  Incorrect transcription is a cause of medication errors.  Transcriber must be familiar with medical terminology; and abbreviations.  If unsure, ASK!

26. 11-25 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Safe Medication Order Transcription (cont.) Dilantin 125 mg PO q12h Cleocin 225 mg IV q6h Digoxin 0.125 mg PO every other day: even days Facility Name: RIMC Probanthine 15 mg PO tid Example of an MAR

27. 11-26 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Error-Prone Abbreviations and Symbols  These are the cause of a significant number of medication errors.  Two organizations promote patient safety in this regard. TJC – “Do Not Use” list ISMP – List of Error-Prone Abbreviations, Symbols, and Dose Designations

28. 11-27 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Error-Prone Abbreviations and Symbols (cont.)  Examples include: Trailing zero after a decimal point No leading zero before a decimal point Do not write 1.0 mg Write 1 mg Do not write.5 mg Write 0.5 mg

29. 11-28 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Practice SSRI q ac breakfast and hs 2 u bg 130-140mg/dl 4 u bg >141 mg/dl Ultra tears i gtt OU q4h PRN Digoxin.125 mg PO QOD: even days Facility Name: RIMC HCTZ 25.0 mg PO i/d Identify error- prone abbreviations

30. 11-29 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Three  s of Medication Administration RULE 11-1 RULE 11-1 Check medication label 3 times. 1 st Compare to MAR when medication is taken from storage. 2 nd Check when you prepare the medication. 3 rd Check before closing storage container or just before administering the medication.

31. 11-30 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. The Rights of Medication Administration  The set of safety checks prevents medication errors; promotes patient safety.

32. 11-31 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Rights of Medication Administration Basic Rights Right patient Right drug Right dose Right route Right time Right documentation Additional Rights Right reason Right to refuse Right to know Right technique

33. 11-32 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Right Patient  Before giving a medication to a patient check for two identifiers.  Patient’s full name  Another identifier – Date of birth SSN Medical record number

34. 11-33 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Right Drug  Administer only drugs that you prepared yourself or that are clearly and completely labeled.  Check the expiration date.  Recheck the original order if the patient questions a medication.

35. 11-34 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Right Dose  In calculating the dose, factor in the strength of the medication; the equipment used.  Use extreme caution when calculating dosages.  Pay special attention to decimal points.

36. 11-35 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Right Route  A drug intended for one route may not be safe if administered via another route. Be especially careful to distinguish between ophthalmic and otic routes.

37. 11-36 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Error Alert!  Give the right medication by the right route! Do not administer drugs by any route other than intended and as described on the drug label and on the order.

38. 11-37 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Right Time  The right time is within 30 minutes of the scheduled time.  May be absolute time  May be relative time  Order should identify special timing considerations.  PRN medications:  require a time interval and condition;  require you to check when the previous dose was given.

39. 11-38 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Right Documentation Medication administration record (MAR) Paper form Electronic format  Requires secure login  Allows for scan of medication barcode and patient’s ID bracelet  Involves documents on eMAR  Allows for tracking of medication administration

40. 11-39 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Right Documentation (cont.)  If medication administration is not documented, it is not complete.  Also document: patient refusal; partial doses; vomiting shortly after taking the medication.

41. 11-40 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Right Reason  Know the reason a medication is ordered. This assists the healthcare professional in knowing when to hold a medication.

42. 11-41 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Right to Know  Patients must be educated about their medications, including the: dose and schedule; reason for taking the medication; expected effect of the medication; side effects of the medication.

43. 11-42 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Patient Education What patients should know about their medication: 1. Purpose and side effects 2. Dose, route, frequency and time prescribed 3. Process for self-administration 4. Use of calibrated spoons and measuring cups for liquid medications

44. 11-43 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Right to Refuse A patient always has the right to refuse a medication. Notify the physician when this occurs. Document this in the patient’s medical record.

45. 11-44 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Right Technique  Be familiar with the right technique for medication administration.  If unsure of the technique, check: Physicians’ Desk Reference (PDR); facility policy or procedure manual; valid Internet source.

46. 11-45 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Rights of Medication Administration  Following these rights: should become automatic to administering medications; will help to prevent dangerous medication errors.

47. 11-46 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Practice Matching: right patient right drug right dose right time right route right documentation a.Check expiration date. b.Pay attention to decimal points. c.Check two identifiers. d.Medication administration is incomplete if not done. e.This is usually within 30 minutes of scheduled time. f.Be sure this right on the label is the same as on the order. a b c d e f

48. 11-47 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Practice Matching: right reason right to know right to refuse right technique a.Document this in the medical record and notify the physician. b.Patient education c.Administer a medication correctly. d.This helps you know why and when a medication should be held. b a d c

49. 11-48 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Observation  Observe that the medication will be, or was, safely received.  Observation is essential to medication administration.

50. 11-49 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Observation (cont.)  Before medication administration: assess the patient’s allergy status, condition, and ability to take medications via the prescribed route; determine if it is safe or appropriate to administer the medication.

51. 11-50 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Observation (cont.)  During medication administration, observe: whether or not medication is received and retained; any reactions.  After administration, observe: any reactions; whether or not medication is having desired effects.

52. 11-51 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Practice Does the observation occur before (B), during (D), or after (A) medication administration? Patient said medication helped his headache. IV is patent and there is no redness at insertion site. Patient vomited medication immediately. Rash is observed; patient is on oral penicillin. IV antibiotic is infusing; patient complains of pain at site. Patient is taking oral foods without difficulty. D A D B A B

53. 11-52 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Patient Teaching  Patient teaching promotes accuracy and compliance.  Before teaching, assess the patient’s knowledge and literacy level.

54. 11-53 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Patient Teaching  Topics How to obtain medications What to look for Steps in medication administration Patient rights – to know and to refuse Keeping an up-to-date list of medications

55. 11-54 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Patient Teaching (cont.)  Right to know Name of medication Purpose of medication Dose / use of calibrated equipment Route / self-administration guidelines

56. 11-55 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Patient Teaching (cont.)  Right to know (cont.) Schedule Drug-drug interactions Side effects Where to obtain medication Additional instructions

57. 11-56 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Medication Reference Materials  Physician’s Desk Reference (PDR) Information from package inserts Print or electronic versions of information Authoritative and current information  Other sources, including the United States Pharmacopeia/National Formulary

58. 11-57 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Medication Reference Materials (cont.)  Internet sources www.rxlist.com www.druginfonet.com  Software for use with PDA/smart phones - Epocrates

59. 11-58 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. In Summary  In this chapter you learned to: recall the eight required elements of a prescription; apply The Joint Commission steps to receiving and writing a verbal order; execute safe transcription practices.

60. 11-59 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. In Summary (cont.)  In this chapter you learned to: identify error-prone abbreviations and symbols; identify the three checks in the medication administration procedure; implement the “rights” of medication administration.

61. 11-60 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. In Summary (cont.)  In this chapter you learned to: recognize the importance of observation in safe medication administration; describe the appropriate use of patient teaching as it relates to safe drug administration.

62. 11-61 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Apply Your Knowledge  Which of the basic rights of medication administration is not listed? right patient right drug right dose right time right documentation Answer: right route

63. 11-62 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Apply Your Knowledge  Identify the error-prone abbreviations and symbols. BIDssQDPRN MSO4HCTmgmL &subcutIVu IMIJtiwID

64. 11-63 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. Apply Your Knowledge What are the three checks of medication administration? 1.Compare to MAR when taken from storage. 2.Check when you prepare the medication. 3.Check before closing storage container or just before administering the medication.

65. 11-64 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. End of Chapter 11 It is better to be safe than sorry. -American Proverb