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Clinical Nursing Skills

11.1 Rights of Medication Administration

Clinical Nursing Skills11.1 Rights of Medication Administration

Learning Objectives

By the end of this section, you will be able to:

  • Identify components of a medication order
  • List safety measures important in the administration of medication
  • Verbalize the rights of medication administration

Fifty percent of medication errors occur during the medication ordering process (Tariq et al., 2023). These errors are commonly attributed to an incorrect or incomplete medication order. Medication errors may also occur during the process of transcribing, dispensing, administering, and monitoring. Because 30 to 70 percent of medication-ordering errors are identified by nurses and pharmacists, nurses must be equipped with the knowledge to be able to identify these medication-ordering errors before they reach the patient (Tariq et al., 2023). Nurses hold great responsibility in preventing medical errors and need to be aware of how to apply safety measures throughout the medication administration process.

Types of Medication Orders

Medication orders are prescriptions ordered within clinical practice. When administering medications, it is important for the nurse to be aware of the various types of medication orders that may be written. Common types of medication orders include routine orders, one-time orders, standing orders, STAT orders (to be completed now), and PRN (as needed) orders. Each order type has indications for nursing practice. Identifying the order type helps the nurse to prepare for medication administration by knowing which medications to administer, when to administer them, as well as specific indications for administration.

A medication order that is continuously followed until canceled is known as a routine order. For example, “Aspirin 81 mg PO Q day” is a routine order. For the order to be canceled, the provider would need to discontinue the order. An order for a medication to be administered just one time is known as a one-time order. An example of a one-time order is “Cefazolin (Ancef) 2 g IV × 1 dose before surgery.” A standardized order that may be implemented under certain circumstances is known as a standing order. Standing orders are written to address protocols in which the nurse can intervene in a timely manner without having to wait on the provider to write orders, or there are general guidelines for treating a certain condition. For example, surgical procedures often utilize standing orders that allow the nurse to administer medications for pain, nausea or vomiting, constipation, and venous thrombosis prophylaxis. A STAT order is a one-time order that is administered as urgently as possible. An example of a STAT order may be to administer “Lorazepam (Ativan) 1 mg IV STAT” when the patient is having a seizure. Medication orders to be administered as needed are known as PRN orders. PRN medications are commonly ordered for symptoms such as pain, nausea or vomiting, itching, sleep, cough, or fever greater than 101°F. An example of a PRN order is “Diphenhydramine (Benadryl) 25 mg PO Q4 hours PRN itching.” It is important to note that a PRN medication may only be administered for the ordered indication. For instance, an order that reads “Acetaminophen 500 mg PO PRN headache” cannot be administered for mild arthritic pain.

Components of a Medication Order

According to the Centers for Medicare and Medicaid Services (2014), all medication orders must contain the following:

  • patient’s full name and date of birth
  • name of the drug
  • drug dose, route, and frequency
  • date and time medication order was written
  • name and signature of the prescriber

The following additional requirements must also be included when applicable:

  • weight of the patient if dose calculation is based on weight (kilograms for children and adults, grams for newborns)
  • dose calculation requirements
  • exact strength or concentration of medication
  • specific quantity or duration to be administered
  • specific instructions for use
  • reason for use if medication is ordered PRN

An example of a complete medication order is shown in (Figure 11.2).

A snapshot of a medication order with patient name and age, date of birth and room number, and medical record number. Also included is the date and time of medication dispensed as well as the names of the medications and the name of the prescriber.
Figure 11.2 A complete medication order includes the patient’s information as well as the date, medication and dosage, and prescriber’s name. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Drug Nomenclature

Drugs are provided with three categories of names: (1) a chemical name, (2) a generic name, and (3) a brand name (Table 11.1). The chemical name is assigned upon discovery of the drug. It is a scientific name that describes the chemical structure of the drug and is typically complex. Once approved by the U.S. Food and Drug Administration (FDA), the drug is assigned a generic (nonproprietary) name and a brand (proprietary) name (Merck & Co., 2023).

Chemical Name Generic Name Brand Name
N-acetyl-para-aminophenol Acetaminophen Tylenol
Dihydroxy monocarboxylic acid Atorvastatin Lipitor
3-(α-Acetonylbenzyl)-4-hydroxycoumarin sodium salt Warfarin Coumadin
Table 11.1 Examples of Drug Chemical Names, Generic Names, and Brand Names

The generic name is assigned by the United States Adopted Names (USAN) Council and utilizes the drug’s “family name” as the suffix (e.g., -olol, -pril, -statin, -vir). Once approved, the USAN submits the generic name to the World Health Organization (WHO). The WHO then adds the drug name to the recommended International Nonproprietary Names list as a means of promoting global standardization of drug names. The brand name is assigned by the drug company and is often short, catchy, easy to remember, and suggestive of the intended use. Given the goal of standardizing drug names, it is recommended that medication orders be written using the generic drug name. However, it is important for the nurse to be aware of both the generic and brand names, as patients are more likely to resonate with the brand name.

Dosage of the Drug

The dosage of the drug refers to how much of a drug a patient should receive. Drug dosages may be written using three systems of measurements: metric system, household, or apothecary. According to the Institute for Safe Medication Practices (ISMP, 2021), household and apothecary measurements should only be used to provide directions for mixing dry ingredients to prepare a topical product. In all other circumstances, the metric system should be used. Common units of measurement for drug doses include the following:

  • milliliter (mL)
  • liter (L)
  • units
  • microgram (mcg)
  • milligram (mg)
  • kilogram (kg)
  • gram (g)

Special care should be given to orders that contain a zero. Drug dosages should not be written with trailing zeros. For example, 1 milligram should be written as 1 mg instead of 1.0 mg to reduce the risk of the dosage being mistaken for 10 mg. However, if the dose is less than one unit, a zero must be included before the decimal point, often called a leading zero. For example, half a milligram should be written as 0.5 mg instead of .5 mg to reduce the risk of the dosage being mistaken for 5 mg.

Real RN Stories

Ensuring Correct Dosage

Nurse: Sarah, BSN
Clinical setting: Orthopedic unit
Time in practice: 2 months
Facility Location: The inner city of a small metropolitan area in New Jersey

I was a newly graduated nurse who had been working on the orthopedic floor for several weeks. Being new to the department, I had not yet become familiar with the typical medication orders written by the orthopedic surgeons. After morning rounds, Dr. Black notified me that Mrs. James was experiencing severe pain, and a new order was placed for IV Dilaudid. Dr. Black requested that Mrs. James receive a dose right away, without delay.

I opened the chart and read the order as hydromorphone (Dilaudid) 5 mg IV Q2 hours PRN severe pain. A copy of the order was sent to the pharmacy for processing. Remembering the medication could be overridden in the automated medication dispensing machine, I decided to go ahead and administer the medication before the pharmacy processed the order, because Mrs. James was in severe pain and shouldn’t have to wait for pain medicine.

After retrieving the medication from the automated medication dispensing machine, I noticed that Dilaudid was stored in 1 mg vials. Given the order was for 5 mg, I requested to remove five vials. An alert popped up notifying me that an unsafe amount of the drug had been requested and questioned me if the requested amount was correct. I was unsure why the message was being generated and didn’t know what to do. Upon discussing the situation with my preceptor, she pointed out in the chart that there was actually a decimal point in front of the 5 that merged with the tail of the number. The order actually read: “hydromorphone (Dilaudid) .5 mg IV Q2 hours PRN severe pain.” Had the order been written as “hydromorphone (Dilaudid) 0.5 mg IV Q2 hours PRN severe pain,” I wouldn’t have misread the order. Thankfully, we recognized the intended dose prior to administering the medication, and the patient was not administered 10 times the intended dose.

Route of Drug

The route of the drug is the method by which the drug should be administered. Common routes of drug administration include oral (by mouth), sublingual (beneath the tongue), buccal (toward the cheek), subcutaneous (beneath the skin), intramuscular (within a muscle), intravenous (within a vein), nasal (by nose), inhalation (by respiratory tract), vaginal (by vagina), rectal (by rectum), transdermal (through the dermal layer of skin), topical (on the skin), otic (by ear), ophthalmic (by eye), and enteral (through nose and into stomach via a tube). Commonly used abbreviations for medication routes can be found in (Table 11.2). A drug may only be administered via the ordered route. In the event the medication cannot be administered via the route ordered, the nurse must notify the provider.

Abbreviation Definition
AD Right ear
AS Left ear
AU Each ear; both ears
BU or BUC Buccal
EPI Epidural
IA Intra-arterial
IC Intracardiac
ID Intradermal
IM Intramuscular
INH Respiratory (inhalation)
IT Intrathecal
IV Intravenous
IVP Intravenous push
IVPB Intravenous piggyback
NAS Nasal
NG Nasogastric
NGT Nasogastric tube
OD Right eye
OS Left eye
OU Each eye; both eyes
PO Per mouth
PR Per rectum
SC or SQ Subcutaneous
SL Sublingual
TD Transdermal
TOP Topical
PV Per vagina
Table 11.2 Abbreviations for Routes of Administration

Frequency of Drug

The frequency of the drug refers to how often or how many times per day the medication should be administered. Examples of drug frequency include Q30 minutes (every 30 minutes), Q4 hours (every 4 hours), Q12 hours (every 12 hours), Q day (daily), BID (twice daily), TID (three times daily), QID (four times daily), and QHS (at bedtime). If the frequency is denoted in terms of number of times per day, the frequency can be determined by dividing 24 hours per day by the number of times the drug should be administered. For example, a medication ordered twice daily should be administered every 12 hours (24 hours in a day/2 administrations = every 12 hours), and a medication ordered three times daily should be administered every 8 hours (24 hours in a day/3 administrations = every 8 hours).

Date, Time, and Signature of Provider

For the medication order to be complete, it must include the date and time the order was written, along with the prescriber’s signature (electronic or handwritten). Best practice is for the provider to enter the order; however, there may be times when the provider is not able to do so, and a verbal order is required (Patient Safety Authority, 2006). When taking a verbal order, the nurse must restate the order back to the provider to ensure the message was received correctly, immediately document the verbal order in the patient’s chart, and the provider must review and sign the order according to the agency’s policy. Nurses should be aware that both state and organizational policies will dictate required verbal order components. Be sure to follow the organization's policies.

Safety Measures for Medication Administration

Given the risk of medication errors, there are many safety measures that should be implemented when administering medications. These safety measures fall into four categories: ensuring correct identification of the patient, checking the medication order for errors, maintaining a safe environment, and monitoring for adverse reactions. Medication administration safety is a priority; therefore, these safety checks may be confirmed by the nurse, provider, and pharmacist. By using an interdisciplinary team approach, safety measures may be assessed at multiple checkpoints and by several professionals, thereby reducing the opportunity for medication errors to occur.

In addition, there are several organizations that work to support safety measures for medication administration. The ISMP is a nonprofit organization dedicated to preventing medication errors. Known for being the gold standard in medication safety, the ISMP is responsible for developing safe medication standards, drug packaging and labeling recommendations, tools, and resources for the healthcare community, as well as leading public policy efforts. For example, the ISMP developed a list of look-alike and sound-alike drugs, recommended use of tall man lettering for labeling of products with look-alike and sound-alike names, published recommended abbreviations, developed a list of high-alert medications, and established a medication error reporting program, just to name a few accomplishments (ISMP, n.d.).

Another organization that works to support safety measures for medication administration is The Joint Commission. The Joint Commission evaluates and accredits healthcare organizations across the United States. The organization develops practice standards that are essential to providing safe, high-quality care. In addition, they establish national patient safety goals, issue sentinel event alerts, and provide evidence-based practice recommendations aimed at addressing identified safety concerns. Some of these recommendations include a “Do Not Use” list of abbreviations and requiring accredited healthcare organizations to provide a written process for managing high-alert and hazardous medications.

Other organizations that work to promote patient safety throughout the medication administration process include the Centers for Disease Control and Prevention (CDC), Poison Control, the National Institutes of Health (NIH), and the FDA. For example, the CDC offers a Medication Safety Program that monitors national data related to adverse drug events as well as other initiatives to support medication safety. Poison Control offers recommendations and assistance in situations of accidental or intentional ingestion or overdose. The NIH support research and funding to develop evidence and best practices for improving medication safety. The FDA centralizes approval of drug names to minimize the confusion among drug names as well as reviews medication labeling, packaging, and product design to identify and minimize potential sources of medication errors. As you can see, safe administration of medications requires a team effort to ensure policies, procedures, and recommendations for evidence-based practice are in place to adequately safeguard the patient.

Patient Identification

According to The Joint Commission’s National Patient Safety Goals, at least two patient identifiers are required to correctly identify the patient. The two most commonly used identifiers are full name and date of birth. The patient should be asked to state their name and date of birth, while the nurse confirms the stated identifiers on the patient armband and medication administration record. Other unique patient identifier options include medical record number, phone number, social security number (if noted in medical record), address, or photo. If a patient is unable to verbalize their identity, for instance, they are unconscious, the nurse should verify the patient’s identity using a photo ID. It is important to note that room number is not a unique identifier and should not be used to confirm the patient’s identity. Although it may seem redundant, it is important to confirm the patient’s identity every time medications are administered (The Joint Commission, 2022).

Verifying Order for Errors

The nurse must ensure all parts of the medication order are complete prior to administering medication. If any part of the medication order is missing, there are any questions about the order, or the writing is illegible, the nurse must contact the prescriber to clarify and correct the order. When verifying the medication order for errors, assessing patient allergies is a key safety consideration. If the patient has a documented allergy to the drug ordered, the nurse should provide notification of the allergy to the provider, who will consider alternative drugs and/or treatments.

With implementation of the electronic medical record (EMR), most medication orders are prescribed electronically using computerized provider order entry (CPOE) which has reduced the number of medication errors by offering technical safeguards, such as allergy alerts; drug-drug, drug-food, and drug-disease interaction checks; suggestions for safe medication dose ranges and intervals; evidence-based practice order sets; and hard stops to ensure the order is complete. Additionally, CPOE reduces the risk of erroneously transcribing handwritten medication orders.

Drug Classification

Drug classification refers to groupings of medication based on how they work (mechanism of action), what they treat (physiological effect), or chemical structure. By grouping like drugs together in classes, expected drug effects of each class may be anticipated, and drug-drug interactions may be predicted for classes of drugs with the same mechanism of action. Drugs from the same therapeutic class are typically assigned names that use the same stem. Table 11.3 displays commonly used stems based on drug classification. Multiple drugs from the same class or those that affect the same organ system should be avoided.

Stem Definition Examples
-ac NSAID (nonsteroidal anti-inflammatory drug) Diclofenac, bromfenac
-atadine Antihistamines Loratadine, olopatadine
-axine Antianxiety, antidepressant Venlafaxine
-azepam Benzodiazepine antianxiety agent Lorazepam, diazepam
-barb- Antiseizure agent Phenobarbital, secobarbital
-caine Local anesthetics Lidocaine, Dibucaine
-cillin Beta-lactam antibiotic Ampicillin, penicillin, oxacillin
-conazole Antifungals Fluconazole, oxiconazole
-cycline Antibiotics Tetracycline, minocycline
-dipine Calcium channel blocker antihypertensive agent Amlodipine, nicardipine
-dralazine Vasodilator antihypertensive agent Hydralazine
-ide Diuretics Furosemide, hydrochlorothiazide
-lol Beta-blocker antihypertensive Metoprolol, atenolol
-olone Steroids Minaxolone
-osin Alpha blockers Doxazosin, terazosin
-oxacin Fluoroquinolone antibiotics Ciprofloxacin, difloxacin
-peridol Antipsychotics Haloperidol
-peridone Antipsychotics Risperidone
-pidem Hypnotics/sedatives Zolpidem, alpidem
-prazole Proton pump inhibitors Omeprazole
-pril Angiotensin-converting enzyme inhibitor antihypertensive Captopril, lisinopril
-profen Anti-inflammatory/analgesic Flurbiprofen
-sartan Angiotensin II receptor antagonist (antihypertensive) Losartan, valsartan
-statin Renal dehydropeptidase inhibitor, pepsin inhibitor Pepstatin, cilastatin
-terol Bronchodilators Albuterol
-vastatin Antihyperlipidemics Lovastatin, simvastatin
-vir Antivirals Ganciclovir
Table 11.3 Common Drug Classification Stems

Drug Action

Drug action refers to the mechanism in which a drug works. For example, beta blockers block beta adrenoceptors, which blocks the release of adrenaline. As a result, the heart beats slower and with less force, thereby lowering blood pressure, widening the veins, and improving arterial blood flow. Another example are loop diuretics promoting diuresis by blocking reabsorption of sodium and chloride in the proximal and distal tubules, as well as in the loop of Henle. Understanding the drug mechanism of action helps the nurse to understand what occurs within the body once it is administered. The nurse can then anticipate the intended response of administering the medication and report instances in which the drug does not produce the intended effect. For example, the provider should be notified if an antihypertensive does not lower the patient’s blood pressure.

Drug Indication

A drug indication refers to the use of the drug for a particular disease or condition. Drugs often have more than one indication. Using a drug for an FDA-approved reason is called a “labeled” indication. In contrast, using a drug for a reason other than that approved by the FDA is referred to as an “off-label” indication. For a drug to have a “labeled” indication, the drug must have been thoroughly researched and shown to be effective in treating the disease or condition. Drugs ordered for “off-label” indications must have demonstrated reasonable evidence to support effectiveness in treating the indication (Ogbru, n.d.). For example, megestrol is a progestin medication that has a “labeled” indication for treating advanced breast and endometrial cancer. Due to the side effect of increased hunger, even with small doses, Megestrol was used “off label” as an appetite stimulant. Once researched and thoroughly studied, the medication is now “labeled” for use as an appetite stimulant. When administering medications, it is important to know and understand what medication the patient is taking, why they are taking it, and to question the provider if it is unclear as to why a drug is ordered.

Medication orders may also contain an indication for administration. For example, medications ordered on a PRN basis must contain an indication for when to administer the medication. Common indications for PRN medications include symptoms such as pain, itching, headache, nausea, or fever. If more than one medication is ordered for the same indication, the order must contain additional details to inform the nurse of when the nurse is to administer each medication. For example, if the patient is ordered Percocet and ibuprofen for pain, the order may state to administer “ibuprofen PRN pain rated 0–5 out of 0/10 scale give ii 200 mg tabs PO Q8 hours” and administer “Percocet PRN pain rated 6–10 out of 0/10 scale give ii 2.5/325 mg tabs PO Q8 hours.”

Maintaining a Safe Environment

To ensure safe medication administration, it is critical to maintain a safe environment. One way to maintain a safe environment is by securing medications. All medications must be kept in a locked cart or cabinet. Medications should not be left at the patient’s bedside unless there is an order by the provider to do so. Narcotics should be kept in a double-locked cabinet or automated dispensing cabinet (Figure 11.3), counted at the beginning and end of each shift, as well as counted each time the narcotic is accessed. Another way to maintain a safe environment is by restricting access to medications so that only approved staff have access to medications. For example, those approved to administer medications may be granted electronic log-on access or keys to medication carts and cabinets, whereas those who are not approved to administer medications do not have access to these areas or devices.

An image of an automated dispensing cabinet at a hospital.
Figure 11.3 Automated dispensing cabinets provide an electronic means of controlling medication storage, dispensing, and tracking of drugs. (credit: “Pyxis SupplyStation automated dispensing cabinet at Campbell County Memorial Hospital in Gillette, Wyoming” by Mr. Satterly/WTF Public License Version 2)

The nurse must take precautions to safeguard medications once they are gathered from the medication cabinet. This includes gathering and administering medications for only one patient at a time, clearly labeling all prepared medications, and immediately administering medications once they are gathered. If there is a delay in administering the medications, the medications should be returned to the medication cabinet until they are ready to be administered. The nurse should avoid placing patient medications in clothing pockets at any time throughout the medication administration process. This is a risky practice that may result in medication errors (administering medication to the wrong patient or administering the wrong dose), medication damage from body heat, losing or forgetting to administer the medication, and accidental needlesticks.

Safeguards must also be in place when administering “high-alert” drugs, which are drugs that can cause significant harm if an error occurs. Examples of high-alert drugs include insulin, anticoagulants, chemotherapy drugs, and opioids. Automated dispensing cabinets may also include built-in measures to safeguard other high-alert drugs, such as limiting access to the drug, incorporating visual cues such as red text, tall man lettering (Table 11.4) to more easily differentiate similar drug names, or requiring two nurses to enter their credentials to be able to access the medication.

Established Name Recommended Name
Hydromorphone HYDROmorphone
Mitoxantrone mitoXANTRONE
Table 11.4 FDA List of Established Drug Names Recommended to Use Tall Man Lettering (TML)

Another way to maintain a safe environment is by minimizing distractions and interruptions. Studies have found that nurses are distracted or interrupted approximately every two minutes. Distractions are a major cause of medication errors, with approximately 75 percent of medication errors being associated with distractions (ISMP, 2012). Common sources of interruptions are people (coworkers, patients, visitors), computers, phones, missing medications, and searching for supplies. Common sources of distractions include phone calls, alarms, pop-up alerts, and life events (e.g., home life, death in the family, finances, buying a house, illness). Intentional efforts to reduce distractions and interruptions in the workplace are important to reduce the risk of medication errors. Examples of intentional efforts to reduce distractions and interruptions include placing a sign on the workstation or patient door to notify others that medication administration is in progress, labeling medication preparation zones as “no talking” zones, and not accepting phone calls when administering medications.

Should a drug administration error occur, actual or potential, it is important to report the situation immediately according to the agency’s policy. In the event of an actual error, the patient should be closely monitored for any adverse effects, and the patient’s response should be documented. Potential errors are important to report as evaluating these are a means of education for nurses and understanding potential risks. If addressed, potential errors can allow interventions to be implemented to reduce the risk of the situation becoming an actual error in the future.

Real RN Stories

Error with an Automated Dispensing Machine

Nurse: RaDonda, RN
Clinical setting: Neuro Intensive Care Unit (ICU)
Years in practice: 14
Facility location: Nashville, Tennessee

It was December 26, 2017, and I was working in the Neuro ICU at Vanderbilt University Medical Center in Nashville, Tennessee. Ms. Charlene Murphey, a 75-year-old female patient, was a bit anxious about an upcoming medical test scheduled that day. Trying to calm Ms. Murphey, I went to the automated dispensing cabinet, typed in V-E, and removed what I thought was Versed. I administered the medication, hoping the sedative would calm Ms. Murphey. Unfortunately, much worse happened.

Instead of removing Versed from the medication cabinet, I removed vecuronium, which is a powerful paralyzer. The effects of this medication were detrimental to Ms. Murphey, causing her to stop breathing and ultimately causing brain damage before the medication error was recognized. I know the reason this patient is no longer here is because of me. There won’t ever be a day that goes by that I don’t think about what I did (Kelman, 2022).

Even though it was a mistake, I lost my nursing license and was criminally charged with reckless homicide and felony abuse of an impaired adult for the medication error that eventually led to the death of Ms. Murphey. I was sentenced to eight years in prison, which was later overturned to three years of probation. I attribute the mistake to being complacent and distracted while removing medications from the automated dispensing cabinet. Had I took the time to perform the “rights” of medication administration, the medication error would have never occurred, and Ms. Murphey would not have died.

It has since been recommended that the first three letters of the medication name be typed into the automated dispensing cabinet before the medication appears and the nurse can remove it. Since this legal case was nationally publicized, most automated dispensing cabinets have since been programmed with enhanced safety features, including requiring the nurse to type three to five letters of the medication name prior to being able to remove the medication. However, older machines may not have this feature and rely on the prudent nurse to ensure the correct medication is administered.

Adverse Reactions

When unwanted and undesirable effects related to a drug occur, these are called adverse reactions. Unlike side effects, which are predictable undesirable effects related to a drug, adverse reactions are unpredictable. Adverse reactions may occur when starting a new drug, stopping a drug, or changing the dose of the drug (FDA, 2022). The incidence and severity of adverse drug reactions may be impacted by factors such as age, sex, genetics, underlying conditions, drug type, dose, route of administration, and use of other drugs, vitamins, or supplements (Merck & Co., 2023).

Adverse drug reactions may be classified as mild, moderate, severe, and lethal. Mild adverse reactions do not require treatment or prolonged hospitalization. Moderate adverse reactions require a modification of the treatment plan or prolonged hospitalization; however, the drug does not necessarily have to be discontinued. A severe adverse reaction can potentially be life threatening and requires immediate treatment and discontinuation of the drug. A lethal adverse reaction directly or indirectly leads to death (Merck & Co., 2023).

Allergic Reactions

An allergic reaction occurs when the immune system responds to a substance, including a drug. Symptoms may include rash, hives, fever, itching, wheezing, runny nose, and watery eyes. A serious drug allergy will typically cause symptoms to appear within one hour after taking the drug. The nurse should notify the provider immediately if the patient develops any symptoms of an allergic reaction. Nurses should remember to always follow the organization's protocol for adverse reactions to a medication.

The most severe type of allergic reaction is anaphylaxis. Anaphylaxis is a rare, life-threatening reaction that causes symptoms such as difficulty breathing, nausea, vomiting, diarrhea, dizziness, tachycardia, hypotension, seizure, and loss of consciousness. Anaphylaxis is considered a medical emergency. The nurse should discontinue the drug and urgently notify the provider if anaphylaxis is suspected. The nurse will also initiate emergency protocols according to agency policy.

Clinical Judgment Measurement Model

Analyze Cues: Recognizing a Potential Allergic Reaction

The patient reports a new complaint of itching. Although itching is a cue, there is not enough information to analyze the significance of the cue. The nurse may ask the patient additional questions, such as “Is the itching all over or specific to one area of the body?” and “When did the itching start?” as well as perform a physical assessment to learn more about the cue. Upon assessment, it is noted that the patient itches “all over,” the itching started about 10 minutes ago, and there is a newly formed red rash covering the body. Using critical thinking, the nurse considers factors that could potentially cause the symptoms, such as skin conditions, dermatitis from contact with the sheets, or an allergic reaction.

To narrow down a potential hypothesis, the nurse may need to ask additional questions. The nurse asks the patient, “Have you had any recent changes in laundry detergent, diet, or medications?” The patient responds there have been no changes to laundry detergent or diet but does mention that the provider ordered a new antibiotic earlier that morning. The nurse analyzes the medication administration record (MAR) and recognizes the antibiotic was first administered about 40 minutes ago. By recognizing and analyzing the cues of itching, rash, and a new medication order, the nurse forms a hypothesis that the patient may be experiencing an allergic reaction.

Toxic Effect

Drug toxicity is the degree to which a drug can be poisonous or harmful to the body. It is a serious event that causes the medication to build up in the body and can often cause harm to the body or even death. For example, digoxin has a half-life of 30 to 40 hours and is excreted via the kidneys. Patients with poor kidney function, such as older adults or those with chronic kidney disease, are more likely to develop a buildup of digoxin that may result in toxicity. As a result, the patient may experience signs of digoxin toxicity, such as gastrointestinal upset, dyspnea, syncope, palpitations, or the appearance of yellow halos around lights. Reasons for drug toxicity may be accidental, such as the dose being too high or slowed metabolism of the drug, or intentional, such as a suicide attempt. If drug toxicity is suspected, the nurse should immediately notify the provider. Typically, in a serum drug level situation, the drug will not be administered until the provider states it is safe to give to the patient. This usually occurs when the amount of the drug in the body has been reduced. Other forms of toxicity occur when a patient has ingested too much medication, often called an overdose. In these situations, treatment options may include stomach lavage or activated charcoal to remove large amounts of the ingested medication (Merck & Co., 2023).


Over time, there can be a decrease in the effectiveness of a drug due to repeated use, this is known as tolerance. For example, patients on long-term opioid use due to cancer or chronic pain may require higher doses of opioids over time or additional pain relief therapies to be added to their regimen to adequately treat their pain. It is important to note that tolerance is not the same as dependence, which is when a patient depends on the drug to function. If a patient becomes tolerant to a drug, the provider may need to increase the dose of the drug or use an alternative drug to achieve the desired effect (Merck & Co., 2023).

Drug Interaction

A drug interaction is when a drug reacts with another drug, food, supplement, or with the patient’s medical condition. This interaction may affect the action of the drug(s) or result in unwanted adverse effects (Figure 11.4). For example, taking opioids and central nervous system depressants together may increase the risk of respiratory depression, while eating leafy greens may decrease the effects of warfarin.

A hierarchical diagram titled Drug Interaction with an oval on the top level labeled “drug”. The second level has four rectangles labeled drug(s), food, supplement, and medical condition. All four rectangles on the second level point to the third level. The third level is titled Possible Effects and has three rectangles labeled decrease action of drug(s), increase action of drug(s), and cause adverse effects.
Figure 11.4 A drug interaction is a type of adverse reaction that causes undesirable effects. (credit: data source: National Institutes of Health; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Paradoxical Effect

A paradoxical effect occurs when the effect of a drug is opposite from the intended effect. For example, a stimulant causing drowsiness, an antidepressant leading to suicidal thoughts, or a pain relief medication causing increased pain. Paradoxical effects should be documented and reported to the provider for consideration.

Rights of Medication Administration

Nurses are responsible for ensuring patient safety during medication administration. The Rights of Medication Administration are a set of guidelines to adhere to when administering medications in an effort reduce adverse medication events. The five core “rights” of medication administration include the following: right patient, right drug, right route, right time, and right dose. To enhance safety, the American Nurses Association (2021) recommended the addition of right reason, right documentation, and right response (Table 11.5).

Right patient Validate correct patient by confirming two or more patient identifiers (e.g., patient’s full name, date of birth, medical record number). Identifiers must be confirmed verbally by the patient, by the patient wristband, or other acceptable means according to the agency’s policy.
Right drug Compare the medication label to the medication order to ensure correct drug name, note expiration date, and confirm patient allergies.
Right route Ensure medication is administered via the prescribed method (i.e., oral, sublingual, intravenous). If the route needs to be altered, consult the provider, and obtain a new order.
Right time Medication is administered according to the prescribed frequency. Confirm when last dose was administered.
Right dose Confirm dose matches the prescribed dose and is within a safe dosage level. Confirm dosage calculations and question doses outside of the safe dosage range.
Right reason Confirm why the patient is taking the medication and ensure the mechanism of action aligns with the indication.
Right documentation Following administration, document the name of the drug, dose, route, time administered, and patient’s response to the drug administered.
Right response Assess if drug resulted in the desired effect.
Table 11.5 The Rights of Medication Administration

Bar Code Medication Administration (BCMA) is an electronic scanning system used to decrease the risk of medication administration errors and confirm the “rights” of medication administration (Figure 11.5). By scanning barcodes on the patient’s armband and medication labels, the electronic system can confirm that the right patient receives the right dose of the right medication according to the right frequency. BCMA also provides additional alerts, such as when vital signs need to be assessed prior to administering a medication, allergies are present, or a second nurse needs to verify the medication.

Image of patient in hospital bed and nurse scanning patient’s hospital bracelet.
Figure 11.5 Nurses use Bar Code Medication Administration to assist with confirming the “rights” of medication administration. (credit: “20130306-OC-RBN-3904 (8575102671).jpg” by Bob Nichols/U.S. Department of Agriculture, Public Domain)

The five core “rights” of medication administration (right patient, right drug, right route, right time, and right dose) should be confirmed at three different checkpoints during the medication administration process. These three checkpoints are when obtaining the medication, when preparing the medication, and when administering the medications at the bedside. At each of the checkpoints, the medication label should be compared to the medication order to confirm the right patient, right drug, right route, right time, and right dose.

In addition to checking the basic rights of medication administration and documenting the administration, it is important for nurses to verify the following information to prevent medication errors:

  • Right history and assessment. The nurse should be aware of the patient’s allergies as well as any history of any drug interactions. Additionally, nurses collect appropriate assessment data regarding the patient’s history, current status, and recent laboratory results to identify any contraindications for the patients to receive the prescribed medication.
  • Right drug interactions. The patient’s history should be reviewed for any potential interactions with medications previously given or with the patient’s diet. It is also important to verify the medication’s expiration date before administration.
  • Right education and information. Information should be provided to the patient about the medication, including the expected therapeutic effects as well as the potential adverse effects. The patient should be encouraged to report suspected side effects to the nurse and/or prescribing provider. If the patient is a minor, the parent may also have a right to know about the medication in many states, depending on the circumstances.
  • Right of refusal. After providing education about the medication, the patient has the right to refuse to take medication in accordance with the Nurses Code of Ethics and respect for individual patient autonomy. If a patient refuses to take the medication after proper education has been performed, the event should be documented in the patient chart and the prescribing provider notified.

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