Learning Objectives
By the end of this section, you will be able to:
- List safety measures of medication administration
- Verbalize the rights of medication administration
Understanding the safety measures of medication administration and being able to verbalize the rights of medication administration are critical components of nursing practice with profound implications for patient care. These principles serve as fundamental safeguards to protect patients from medication errors and potential harm. It is imperative for nurses to grasp these concepts thoroughly, as medication errors can have severe consequences, including patient injury or even death. By adhering to established safety measures and rights of medication administration, nurses can mitigate risks, ensure accuracy, and promote optimal patient outcomes
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.
Several organizations are dedicated to supporting safety measures for medication administration. The Institute for Safe Medication Practices (ISMP), a nonprofit organization renowned for its efforts in preventing medication errors, has created lists of look-alike and sound-alike drugs, advocated for the use of tall man (uppercase) lettering to distinguish between similar drug names, published recommended abbreviations, compiled lists of high-alert medications, and implemented a medication error reporting program (ISMP, n.d.). The Joint Commission (TJC) evaluates and accredits healthcare organizations nationwide, setting practice standards and issuing safety alerts to address concerns. TJC takes proactive steps to enhance patient safety by setting national patient safety goals, issuing sentinel event alerts, and offering evidence-based practice recommendations. Some of these recommendations include a Do Not Use list of abbreviations and requiring accredited healthcare organizations to provide a written processes for managing high-alert and hazardous medications. Additionally, organizations such as the Centers for Disease Control and Prevention (CDC), Poison Control, the National Institutes of Health (NIH), and the Food and Drug Administration (FDA) play vital roles in promoting medication safety through various programs, research initiatives, and regulatory measures. Ensuring safe medication administration involves collaborative efforts across multiple organizations to establish and enforce evidence-based practices and policies.
Link to Learning
The Institute for Safe Medication Practices (ISMP) develops safe medication standards. Review the ISMP’s current list of drug names with tall man lettering that aims to reduce medication errors related to look-alike and sound-alike medications.
Patient Identification
According to TJC’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 (MAR). 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, most medication orders are prescribed electronically. Using computerized provider order entry (CPOE), a provider submits patient orders by electronic means, 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; notice of incorrect transcription of handwritten orders; and hard stops to ensure the order is complete. Additionally, CPOE reduces the risk of erroneously transcribing handwritten medication orders.
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. When a drug is used for an FDA-approved purpose, it is termed a “labeled” indication, whereas using it for an unapproved purpose is considered “off-label.” 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 acetate (Megace) 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, to question the provider if it is unclear as to why a drug is ordered , and to explain to patients what they are taking and why.
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 on numerical rating scale give ii 200 mg tabs PO Q8 hours” and administer “Percocet PRN pain rated 6–10 on numerical rating scale give ii 2.5/325 mg tabs PO Q8 hours.”
Maintaining a Safe Environment
Maintaining a safe environment is crucial for ensuring the safe administration of medications. Essential practices to maintain a safe environment include the following:
- Secure medications by keeping them in a locked cart or cabinet.
- Avoid leaving medications at the patient’s bedside unless ordered by the provider.
- Store narcotics in a double-locked cabinet or automated dispensing cabinet (Figure 11.3).
- Count narcotics at the beginning and end of each shift and each time they are accessed.
- Restrict access to medications to approved staff only.
- Grant electronic log-on access or keys to medication carts and cabinets only to approved staff.
- Gather medications for one patient at a time.
- Clearly label all prepared medications.
- Immediately administer medications once gathered.
- Return medications to the cabinet if there is a delay in administration.
- Avoid placing patient medications in clothing pockets.
- Minimize distractions and interruptions.
- Label medication preparation zones as “no talking” zones.
Link to Learning
Safeguards must also be in place when administering “high-alert” drugs, which are drugs that can cause significant harm if an error occurs. A complete list of “high-alert” medications is provided by the ISMP. Visual cues such as red text and tall man lettering are used to differentiate similar drug names.
If an actual or potential drug administration error occurs, 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.
Clinical Safety and Procedures (QSEN)
Principles for Maintaining a Safe Medication Administration Environment
Quality and Safety Education for Nurses (QSEN) provides a framework of competencies essential for maintaining a safe environment during medication administration. By integrating these competencies into daily practice, nurses can mitigate the risk of medication errors and promote positive patient outcomes. Here’s how these competencies relate to maintaining a safe environment during medication administration:
- Patient-centered care: Ensure medications are administered with consideration for individual patient needs and preferences. For example, assess patient allergies before administering medications to prevent adverse reactions tailored to patient-specific risks. Collaborate with patients in shared decision-making regarding their medication regimen.
- Teamwork and collaboration: Collaborate with interdisciplinary teams to implement safety protocols. For instance, communicate effectively with pharmacists to clarify medication orders and resolve discrepancies in the medication administration process. Participate in interprofessional rounds to discuss medication plans and ensure coordinated care.
- Evidence-based practice (EBP): Implement evidence-based guidelines and protocols for medication administration. Utilize resources such as the ISMP to stay updated on best practices and recommendations for safe medication administration techniques. Incorporate research findings into practice to enhance medication safety and optimize patient outcomes.
- Quality improvement (QI): Participate in quality improvement initiatives to enhance medication safety practices. For example, engage in root cause analysis following medication errors to identify system weaknesses and implement corrective actions to prevent future errors. Regularly audit medication administration processes and outcomes to identify areas for improvement.
- Safety: Prioritize patient safety by following standardized procedures and safety checks during medication administration. For instance, use barcode scanning technology to verify patient identity and medication accuracy before administering any medications. Implement safety measures such as independent double-checks for high-risk medications to reduce the likelihood of errors.
- Informatics: Utilize informatics tools, such as electronic health records (EHRs), to access patient medication profiles and allergy information promptly. Ensure accurate documentation of medication administration and adverse reactions to facilitate communication among healthcare team members. Utilize data analytics to identify trends in medication errors and implement targeted interventions to improve safety.
Incorporating QSEN principles into medication administration practices empowers nurses to uphold the highest standards of safety and quality in patient care. By prioritizing patient-centered care, fostering teamwork and collaboration, embracing evidence-based practice, engaging in quality improvement initiatives, ensuring safety protocols, and leveraging informatics tools, nurses can mitigate risks associated with medication administration and promote optimal patient outcomes.
Adverse Reactions
An unwanted and undesirable effect related to a drug is called an adverse reaction. Unlike a side effect, which is a predictable undesirable effect 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 (U.S. Food and Drug Administration, 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).
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
Take Action: Intervening When an Allergic Reaction Occurs
Darlene, a 55-year-old female with a history of hypertension and diabetes, was admitted to the hospital for a routine diagnostic procedure involving a computed tomography (CT) scan with contrast dye. She was prepped for the CT scan, and an intravenous (IV) contrast dye was administered to enhance the imaging. Within ten minutes of the dye administration, Darlene started feeling uneasy and reported an unusual sensation on her back. The nurse noticed Darlene scratching her back and asked her about her symptoms. Darlene reported intense itching and a burning sensation that started shortly after the contrast dye was injected.
The nurse performed a physical assessment and found a red, raised rash covering most of Darlene’s back. Recognizing these cues—the timing of the symptom onset, the nature of the itching, and the visible rash—the nurse suspected a possible allergic reaction to the contrast dye. To gather more information, the nurse checked Darlene’s vital signs to monitor for any systemic involvement, such as changes in blood pressure or heart rate. The nurse also asked Darlene when the itching started, if she had any other symptoms such as difficulty breathing or swelling, and if she had any known allergies.
Based on the analysis of the cues—the rapid onset of itching and rash following the administration of the contrast dye—the nurse hypothesized that Darlene was experiencing an allergic reaction to the IV contrast dye. The nurse immediately stopped the infusion of the contrast dye and alerted the provider about the suspected allergic reaction. The provider ordered an antihistamine (diphenhydramine) and a corticosteroid to manage the allergic reaction and reduce inflammation. Darlene was placed under close observation to monitor for any progression of the allergic reaction, particularly signs of anaphylaxis, such as difficulty breathing or swelling of the face or throat.
Toxic Effect
The degree to which a drug can be poisonous or harmful to the body is called drug toxicity. 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 thirty to forty hours and is excreted through the kidneys. Patients with impaired kidney function, such as older adults or those with chronic kidney disease, are at a higher risk of developing a buildup of digoxin, potentially leading to toxicity. Signs of digoxin toxicity may include gastrointestinal upset, dyspnea, syncope, palpitations, and the appearance of yellow halos around lights. Drug toxicity can occur for various reasons, including accidental factors such as a dose being too high or slowed metabolism of the drug, or intentional factors such as a suicide attempt. If drug toxicity is suspected, the nurse should immediately notify the provider. Treatment for toxicity may involve withholding the drug until serum blood levels in the body decrease or performing stomach lavage to remove significant amounts of the ingested medication (Merck & Co., 2023).
Tolerance
A tolerance refers to a decrease in the effectiveness of the drug over time due to repeated use. 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 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, whereas eating leafy greens may decrease the effects of warfarin.
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 are examples of paradoxical effects of medications. 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 11.3).
| Medication Rights | Nursing Actions |
|---|---|
| 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 armband, 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 (e.g., 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. |
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.
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.
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 Code of Ethics for Nurses 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.