Chapter 6. Non-Parenteral Medication Administration
6.2 Safe 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.
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.