Chapter 6. Non-Parenteral Medication Administration
Safe and accurate medication administration is an important and potentially challenging nursing responsibility. Medication administration not only requires understanding medications, how they work, side effects, and significant nursing considerations, it also involves good decision-making skills and clinical judgment. Nurses must understand why patients take particular medications, anticipate potential med-med interactions, and assess individual patient response.
Nurses are human, so naturally medication errors do happen. The Joint Commission (TJC), a non profit organization that accredits health care organizations and programs, defines medication errors as any preventable event that may cause inappropriate medication use or jeopardize patient safety (TJC, 2012).
Medication errors have a substantial impact on health care in Canada (Butt, 2010) and are the number-one error in health care (Centers for Disease Control [CDC], 2018).
In one study looking at drug related hospital admissions and emergency department (ED) visits, Zed et al. (2008) found that adverse drug reactions are estimated to account for more than 25% of drug-related hospital admissions and ED visits (as cited in CIHI, 2013). Of these, 68% are considered preventable. Of the patients whose ER visits were drug related, their hospital admission rates were higher and their length of stay longer when compared to patients who presented for other reasons. Studies by other researchers reveal similar and equally concerning findings about negative medication related effects on people (Baker et al., 2004; Bell et al., 2011). The cost to patients and families, as well as to the healthcare system, points to the importance of safety in relation to all phases of the medication administration process.
Review Table 6.1 for principles for safer medication administration.
|Be vigilant when preparing medications.||Avoid distractions. Some agencies have a no-interruption zone where healthcare providers can prepare medications without interruptions.|
|Perform hand hygiene before preparing meds and after administration.||Reduces risk of transmitting microorganisms.|
|Check for allergies. Ask about type of allergy and severity.||Always ask patient about allergies, types of reactions, and severity of reactions.|
|Prepare medications for ONE patient at a time.||Reduces risk of error during preparation.|
|Use two patient identifiers at all times. Always follow agency policy for patient identification.||Use at least two patient identifiers before administration AND compare against the medication administration record (MAR). Whenever possible, MARs and eMARs should be taken to the bedside. Confirm patient ID using two patient identifiers (i.e., name and date of birth) and check against MAR.|
|For all medications being administered, review purpose, normal dose, route, common side effects, onset, peak, contraindications, and nursing considerations.||Knowledge is key to safer medication administration.|
|Label all meds prepared away from the bedside.||Label should include two patient identifiers, drug, dose, time prepared, and initials of the nurse who prepared it. Labeling clearly identifies the drug, dose, patient, and person preparing the medication. Be confident that you know what you are administering.|
|Assessment comes before, during, and after medication administration.||Complete necessary focused assessment depending on what medication is to be administered (i.e., heart rate for beta blockers and calcium channel blockers; BP for diuretics, ACE inhibitors, and calcium channel blockers; INR for warfarin; blood glucose for antidiabetic agents; etc.).
Assessment after medication administration helps to determine if the medication is having its intended effect and/or to determine possible adverse reactions.
|Be diligent in all medication calculations.||Errors in medication calculations have contributed to dosage errors, especially when adjusting or titrating dosages. If in doubt, ask a colleague for an independent double check.|
|Avoid reliance on memory; use checklists and memory aids.||Slips in memory are caused by lack of attention, fatigue, and distractions. Mistakes are often referred to as attentional behaviours, and they account for most errors in healthcare. If possible, follow a standard list of steps for every patient.|
|Communicate with your patient before, during, and after administration.||Provides opportunities for patient education and continued assessment by the nurse.|
|Avoid work-arounds.||A work-around is a process that bypasses a procedure, policy, or problem in a system. For example, nurses may “borrow” a medication from another patient while waiting for an order to be filled by the pharmacy. These work-arounds fail to follow agency policies that ensure safe medication practices.|
|Ensure medication has not expired.||Medication may be inactive if expired.|
|Always clarify an order or procedure that is unclear.||Always ask for help whenever you are uncertain or unclear about an order. Consult with the pharmacist, charge nurse, or other healthcare providers, and be sure to resolve all questions before proceeding with medication administration.|
|Use available technology to administer medications.||Technology has the potential to help decrease errors. Use technology that is available to you when administering medications, but be aware of technology-induced errors.|
|Report all near misses, errors, and adverse reactions.||Reporting through patient safety learning systems (PSLS) allows characteristics of each near miss, error, and adverse reaction to be tracked. Analysis of this information is intended to find root causes and solutions toward safer medication administration practices.|
|Be alert to error-prone situations and high-alert medications.||High-alert medications are those that are most likely to cause significant harm, even when used as intended. The most common high-alert medications are anticoagulants, narcotics and opiates, insulin, and sedatives. The types of harm most commonly associated with these medications include hypotension, respiratory depression, delirium, bleeding, hypoglycemia, bradycardia, and lethargy.
High-alert situations include: frequent dosing to the same patient (i.e., q4h insulin sliding scale; q1h morphine IV), multiple meds (i.e., having to administer meds to multiple patients and each have multiple medications), high stress environments, noisy environments, and multiple distractions during medication preparation.
|Independent double checks. High-alert meds require a second person verifier (insulin, anticoagulants, chemo, etc.—check agency policy).||Two clinicians independently check each high-alert medication in relation to prescribing, dispensing, and administration (i.e., insulin, anticoagulants, IV direct medications).|
|When possible take MARs to the bedside, open medication packages at the bedside, and label medications prepared away from the bedside.||Two identifiers and having MARs and comparing these with the wrist band reduces risk of administering medications to the wrong patient. Having MARs at the bedside provides a quick reference to assist with informing the patient. It gives the nurse time to think about the rights of safe medications within each patient context and allows the patient an opportunity to ask questions.|
|Use a system to help you keep track of which meds you’ve prepared. Some nurses use a “dot” on the MAR; others circle the medication on the MAR.||Having a method to organize and keep track of medication preparation reduces risk of omission errors.|
|Follow the SEVEN rights of medication preparation (right patient, medication, dose, route, time, reason, documentation).||Fundamental principles of safe medication administration intended to reduce risk of error.|
|Complete three checks before administration of medications. Labels on the medication must be checked for name, dose, and route, and compared with the MAR at three different times:
1. when the medication is taken out of the drawer / dispensing system;
2. when the medication is being poured;
3. after the medication is poured and PRIOR to the medication being administered.
|Fundamental principles of safe medication administration intended to reduce risk of error.|
|If a patient questions or expresses concern regarding a medication, stop and do not administer it.||If a patient questions a medication, stop and explore the patient’s concerns, review the physician’s order, and, if necessary, notify the prescriber.|
|Provide patient education.||Provide information to patient about the medication before administering it. Patients should known what medications they are receiving and what the intended purpose is, any significant side effects, and special considerations. Give the patient the opportunity to ask questions. Include family members if appropriate.|
|Strive to give medications on time.||Consult agency guidelines for medication administration “windows”. The historic 30 minute window on either side of the medication administration time is debatable for some medications. See Table 6.2.|
|Sign the MAR AFTER the medication has been administered.||Ensures right documentation.|
|Check MAR to guide you to which medications you are preparing. Follow agency policy to ensure MARs are accurate and verified appropriately.||An MAR that is checked by more than one healthcare professional provides a very reliable record for administering medications. Agencies may vary in relation to MAR verification processes.|
|Data sources: Agency for Healthcare Research and Quality, 2014; Canadian Patient Safety Institute, 2012; Debono et al., 2013; Institute for Healthcare Improvement, 2015; Institute for Safe Medication Practices, 2018; Lilley et al., 2016; Lynn, 2011; National Patient Safety Agency, 2009; National Priority Partnership, 2010; Perry et al., 2018; Prakash et al., 2014.|
Administering medications in a timely fashion and according to the prescribed frequency is considered an important part of safe medication administration in terms of maintaining therapeutic drug levels and, therefore, therapeutic drug effectiveness. Traditionally, a 30 minute window on either side of a medication administration time was considered responsible practice. In a study involving acute care nurses, ISMP (2011) found that increasing patient acuity, polypharmacy, and increasing nursing workloads made it difficult for nurses to administer medications within this time frame. The resulting work-arounds done by nurses to try and avoid medication errors due to being “late” led to other, sometimes serious, errors. In response, the ISMP has challenged this 30 minute tradition and has developed guidelines for timely medication administration. The ISMP does not dictate to institutions what they must do, rather they encourage all institutions to create their own list of time critical medications.
Table 6.2 reflects these new recommendations.
Table 6.2 Acute Care Guidelines for Timely Administration of Schedule Medications (ISMP)
Disclaimer: Always check your agency’s policy and guidelines.
Time-Critical Scheduled Medications
|Type of Scheduled Med||Goals of Timely Administration|
|Hospital defined time critical medications:
Delayed or early administration (more than 30 minutes) can cause harm or sub-therapeutic effect. Example:
Medications with a dosing schedule more frequent than every 4 hours. Example:
|Administer at the exact time indicated as necessary, or within the 30 minutes before and after the window of the scheduled time.|
Non-Time-Critical Scheduled Medications
|Type of Scheduled Med||Goals of Timely Administration|
|Daily, weekly, monthly. Examples:
||Within 2 hours before or after the scheduled time|
|Medications prescribed more frequently than daily but no more frequently than every 4 hours. Examples:
||Within 1 hour before or after the scheduled time|
|Data source: ISMP, 2011|
Technological Advances that Help Mitigate Medication Errors
Computerized physician order entry (CPOE) is a system that allows prescribers to electronically enter orders for medications, thus eliminating the need for written orders. CPOE increases the accuracy and legibility of medication orders; the potential for the integration of clinical decision support; and the optimization of prescriber, nurse, and pharmacist time (Agrawal, 2009). Decision support software integrated into a CPOE system can allow for the automatic checking of drug allergies, dosage indications, baseline laboratory results, and potential drug interactions. When a prescriber enters an order through CPOE, the information about the order will then transmit to the pharmacy and ultimately to the MAR.
The use of electronic bar codes on medication labels and packaging has the potential to improve patient safety in a number of ways. A patient’s MAR is entered into the hospital’s information system and encoded into the patient’s wristband, which is accessible to the nurse through a handheld device. When administering a medication, the nurse scans the patient’s medical record number on the wristband, and the bar code on the drug. The computer processes the scanned information, charts it, and updates the patient’s MAR record appropriately (Poon et al., 2010).
Automated medication dispensing systems provide electronic automated control of all medications, including narcotics. Each nurse accessing the system has a unique access code. The nurse will enter the patient’s name, the medication, the dosage, and the route of administration. The system will then open either the patient’s individual drawer or the narcotic drawer to dispense the specific medication. If the patient’s electronic health record is linked to the automated medication dispensing system, the medication and the nurse who accessed the system will be linked to the patient’s electronic record.
Medication safety is an important component of healthcare delivery. Evidence to support this is provided by the Canadian Patient Safety Institute and the Institute for Safe Medication Practices (ISMP) Canada. The later is an independent, national, not-for-profit agency committed to the advancement of medication safety in all healthcare settings. Safer Healthcare Now! is an initiative to improve patient safety and prevent medication errors in the Medication Reconciliation process.
Critical Thinking Exercises
- What does the Canadian Patient Safety Institute mean by medication reconciliation?
- Name four things within the medication reconciliation process that a nurse can do to reduce the risk of an adverse drug event (ADE).
- View the Canadian Patient Safety Institute’s (2017) List of Error-Prone Abbreviations to see what abbreviations have the potential to compromise medication safety.
- As a nurse you must be aware that some medications have the potential to cause great harm to patients. Lists of high-alert medications are meant to draw the nurse’s attention and result in heightened awareness. Depending on your interest view one or both of the following sites:
- ISMP (2018) High-Alert Medications in Acute Care Settings
- ISMP (2017) High-Alert Medications in Long-Term Care (LTC) Settings
- Have you seen any of these in practice yet?
Figure 6.1. Sample label by author is licensed under a Creative Commons Attribution 4.0 International License.