Right drug

Right dose

Right patient

Right time

Right route

Right documentation.

Always compare the name of an ordered drug with the name printed on the container label. Take your time and do it carefully; drugs with similar-sounding and similar-looking names may have very different indications and effects.

For example, Celexa (citalopram hydrobromide) and Celebrex (celecoxib) sound quite similar. But Celexa is a selective serotonin reuptake inhibitor used to treat depression. Celebrex is a nonsteroidal anti-inflammatory drug used to treat osteoarthritis and rheumatoid arthritis. Other similar-sounding drugs may raise a similar risk of mix-ups.

When a medication is individually wrapped in single doses, check the name when removing it from the drawer and again when unwrapping and giving the drug to the patient. Always mention the drug name and the reason you’re giving it before actually giving it to the patient.

Besides carefully checking the ordered drug name against the container label, also check the patient’s reaction to the drug as you try to administer it. If he says, “I usually take one pink pill, but you’ve given me two yellow pills,” stop what you’re doing and recheck the order. Perhaps you’ll simply explain to the patient that the pink pill contains 10 mg of the drug and the yellow ones contain 5 mg each. Or perhaps, you’ll discover that you’re giving the patient the wrong medication. Either way, you must carefully follow up on any comment a patient makes about changes in a medication before you administer it.

The growing use of unit-dose medications (in which a single dose of medication is wrapped and labeled for individual use) has greatly reduced the risk of giving a patient the wrong drug dose. Also, many commercially prepared medications are available in various tablet sizes, decreasing the number of calculations you have to do to determine the dosage.

Even so, you still need to know how and when to perform the appropriate dose calculations.

Whenever possible, double-check all your calculations with another nurse or with a pharmacist. Many hospitals require these double checks when your dosage calculations involve children’s medications or drugs with narrow safety margins, such as heparin and insulin.

No matter what, never take it upon yourself to alter the drug dosage specified in a prescriber’s order. Say, for example, that a doctor orders 75 mg of meperidine for postoperative pain. You give the medication after the patient’s surgery, but he says he still has intense pain. Your conclusion may be that 75 mg of meperidine isn’t enough and that 100 mg would probably do the trick. But that doesn’t give you the authority to change the dose.

Instead, consult with the doctor and obtain a new standard order. However, if the prescriber’s original medication order specifies a range of dosages, then you must determine the most appropriate dose for the patient—within that range.

To reduce the risk of medication errors, never assume that the patient in a labeled bed is indeed the patient named on the label. Instead, always use two patient identifiers (neither of which should be the patient’s room number) before giving any medication. One new identifier used by some hospitals is the bar code medication administration method. The nurse scans their identification badge, the patient’s bracelet, and the medication bar code on the drug that is to be administered to the patient. (Follow agency policy for patient identification.)

As an additional check, also ask the patient to tell you his name and birthdate. (Don’t say something like, “You’re John, right?” because the patient could misunderstand you, could be confused, or could be a different John than the one scheduled for a medication.)

The considerations that make an administration time the “right” time may be therapeutic, practical, or both. For therapeutic purposes, the right time is one that appropriately maintains the level of drug in the patient’s bloodstream. For practical purposes, the right time is one that’s convenient for the staff and the patient. Naturally, therapeutic goals take precedence over practical ones.

To meet therapeutic goals, you may need to space the delivery of some medications evenly around the clock. Doing so helps to maintain a consistent level of the drug in the patient’s bloodstream. If you don’t have a particular need to space the drug delivery over 24 hours, you can space it over the patient’s waking hours to avoid disrupting his sleep.

For some drugs, you may need to measure the patient’s therapeutic response before determining whether it’s the right time to give another dose. For example, you should check the patient’s apical pulse rate (determined by cardiac auscultation for 1 minute) before giving digoxin, and you should assess the patient’s respiratory rate before giving morphine.

Besides maximizing the therapeutic effect, giving medications at specified, evenly spaced intervals provides some practical benefits. For one thing, it allows you to plan administration times that don’t interfere with meals or especially busy times on the nursing unit. For example, instead of scheduling twice-daily administration times at 8 a.m. and 6 p.m., which are common times for shift changes, schedule them at 9 a.m. and 7 p.m. instead.

Another practical benefit of standardized administration times is that they establish a habit in the patient’s mind. This may make it easier for him to keep taking the medication appropriately when he gets home.

Regardless of the reasons behind the administration times you establish for the patient, you’ll need to follow those times carefully. In fact, many facilities consider it a medication error if you fail to give a medication within 30 minutes before or after its scheduled administration time.

Always pay careful attention to the administration route specified in the medication order, on the product’s label, and in the drug guide. Also, make sure the ordered form of the drug is appropriate for the intended route. Only drugs labeled “for injection” should be used for injections of any kind.

Before you give the drug, consider whether the amount ordered is appropriate for the route by which you’re preparing to give it. For example, 10 mg is an appropriate amount of morphine sulfate to give by the I.M. route to relieve pain in an adult. If the patient will be receiving it by the I.V. route, however, the equivalent dose would be more like 2 to 4 mg. If they are taking the drug orally, they will need more than 10 mg to achieve the same effect.

Remember that the route by which you give a drug affects the rate at which it gets absorbed into the patient’s bloodstream. Because certain forms of a drug may be intended for specific routes, be careful not to interfere with a drug’s action by changing routes or circumventing the chemical preparation. For example, you wouldn’t want to crush an enteric-coated tablet or open a sustained-release capsule.

A growing number of drugs are being formulated to exert an effect over many hours. The components of each drug dose dissolve at different rates, thus releasing the drug gradually but continuously into the patient’s bloodstream. Convenient for staff and patients, sustained-release drugs require fewer doses per day and provide steadier control over symptoms.

You can also help increase the speed at which topical nitroglycerin enters a patient’s bloodstream by spreading it over a larger skin area and covering it with plastic wrap.

On the other hand, you can decrease the rate of absorption and effectiveness of a drug. For example, if a patient chews or swallows a sublingual drug, such as sublingual nitroglycerin, the rate of absorption and effectiveness will be decreased.

After administering the medication with the 5 rights completed, your 6th right is to document the administration correctly on the right patient following your facilities policy on documenting medications. There are many ways to document for example: paper charts, computerized charting, finger printing and bar-code scanning.

The 6 rights of medication administration afford you a basic level of protection against medication errors. However, most experts consider them the minimum requirement. Here are some additional measures you should take to help avoid medication errors.

Follow these guidelines when storing and preparing drugs:

• Store and handle drugs carefully to maintain their stability and potency. Remember that some drugs can be altered by temperature, air, light, and moisture; make sure you follow all drug-specific precautions. Some drugs may need to be kept in brown bottles. Some I.V. bags may need to be covered with foil to block the light during infusion.

• Always keep drugs in the containers in which the pharmacy dispensed them. Cap all containers tightly. If you see small cylinders in a container, they probably serve to absorb moisture and keep the product fresh; don’t remove them.

• Store drugs at room temperature unless you’re instructed to refrigerate them. Refrigeration causes moisture to form and could alter some drugs through condensation.

• As required by law, keep opioids and controlled substances under double lock.

• Always note a drug’s expiration date—the date after which it loses some amount of potency. Never administer an outdated drug or one that looks or smells unusual.

• If the original package looks like someone may have tampered with it, don’t give the drug; instead, return it in its package to the pharmacy for an investigation.

• Check the medication label three times—when you take it from the shelf or drawer, before putting it into the medication cup, and before returning the container to the shelf or drawer—to make sure you’re giving the prescribed medication. For a unit-dose medication, check the label just after obtaining the medication and again before discarding the wrapper.

• You may need to reconstitute a drug dispensed as a powder just before you administer it. If medication is left over after you remove your dose, label the container with the date, time, strength, and your initials or signature.

• Never administer a drug that wasn’t labeled properly after reconstitution.

• Discard any drug that will reach its expiration date before another dose is scheduled.

• If you find an unlabeled syringe with medication inside, discard it.

• Let a refrigerated drug reach room temperature before administering it, unless you’re instructed otherwise.

Follow these guidelines when administering drugs:

• Before administering a medication based on new orders, review the patient’s medication history for known allergies or other problems. Always ask the patient if they have any allergies to medications including over-the-counter medications.

• If you know a patient has a drug allergy, make sure the chart clearly displays the allergy.

• Never administer a drug to you patient that you haven’t given before if you haven’t first looked it up in the drug guide.

• When you deliver drugs to a patient’s room, stay with the medication cart. Never leave without locking the cart and taking it back to the medication room or its usual storage place.

• Assess the patient’s physiologic and psychological condition before administering any medication.

• Stay with the patient until they take the medication to verify that they took it as directed.

• Never leave medication doses at a patient’s bedside unless you have a specific order to do so.

• Administer only medications you’ve prepared personally or that the pharmacist prepared.

• Never administer a drug that another nurse asks you to give to their patient.

• Don’t open individually prepared doses (unit-dose medications) until you’re at the bedside and you’ve confirmed the patient’s identity.

• When administering an oral drug, urge the patient to drink a full glass of water, if appropriate. Doing so helps move the medication out of the esophagus and into the stomach. It also dilutes the drug, thus reducing the chance of gastric irritation.

If a medication order specifies that you should leave a drug at the patient’s bedside for self-administration, label the drug with:

• Patient’s name

• Drug name

• Dosage

• Instructions the patient needs.

Drugs commonly left at the patient’s bedside include antacids and nitroglycerin tablets.

• Document drugs immediately after you administer them. Delayed charting, especially of p.r.n. medications, can result in repeated doses. Documenting before giving a medication can lead to missed doses.

• Record your observations of the patient’s positive and negative responses to the medication. For example, if you give an antibiotic to a patient with pneumonia, chart such positive responses as decreased sputum, reduced fever, and easier breathing to confirm the drug’s effectiveness. Also, chart such adverse reactions as skin eruptions or gastric upset. Severe adverse reactions may prompt the prescriber to substitute another drug.

Yet another area of medication administration that you’ll need to master is the drug delivery system. Your facility may use one of several systems by which you can obtain ordered drugs from the pharmacy. In each one, you serve a vital coordinating function between the prescriber and the pharmacist.

Regardless of the delivery system used by your facility, the doctors, nurses, and pharmacists must collaborate to make it work effectively. Common drug delivery systems include:

• Unit-dose system

• Automated systems

• Individual prescriptions.

In a unit-dose system, the pharmacist dispenses a supply of wrapped, labeled individual doses of all forms of drugs: oral, injectable, and I.V. solutions with additives. The pharmacist usually dispenses sufficient drugs and I.V. solutions to last 24 hours; he may also prepare trays of medications for you to administer at specified hours.

The pharmacist may prepare unit doses or purchase them commercially. They usually place each patient’s drugs in an individual drawer of a portable medication cart. Keep the drugs in their labeled wrappers until you actually administer them. The unit-dose system reduces the likelihood of drug administration errors.

In essence, an automated drug delivery system is a computerized version of the unit-dose system. A pharmacist fills an electronic drug-dispensing unit and keeps it locked. The unit then delivers individually wrapped and labeled medications when you request them. A computer records all drug transactions on electronic tape and furnishes requested printouts.

To avoid the possibly disastrous effects from computer downtime, facilities that use automated dispensing systems must have a backup plan for dispensing medications and documenting their delivery.

An automated system greatly simplifies record keeping because the computer can monitor and track drugs from the original inventory to patient billing. It saves staff time and may allow you to spend more time teaching and consulting with patients.

An automated drug delivery system may free you from doing some of what you currently do by hand. For example, you may no longer have to transcribe medication orders or procure and store drugs.

In an individual prescription system, a pharmacist fills a prescription using a container that has been labeled for a particular patient. You then administer the drug to the patient directly from the container. Because the drug is designated for a particular person, this system reduces the risk that you’ll give a drug to the wrong patient. However, the system is cumbersome and slow because the medication order must travel from you to the pharmacy and back to you again.

Common Medication Errors

In addition to following your facility’s policies faithfully, you can help prevent medication errors by studying common ones and avoiding the slip-ups that allowed them to happen.

As you read earlier, drugs with similar-sounding names can be easy to confuse. Keep in mind, however, that even different-sounding names can look similar when written out rapidly by hand on a medication order: Soriatane and Loxitane, for example, both of which are capsules. Any time a patient’s drug order doesn’t seem right for the diagnosis, call the doctor to clarify the order.

Stay on the Ball

Many nurses have confused an order for morphine with one for hydromorphone (Dilaudid). Both drugs come in 4-mg prefilled syringes. If you give morphine when the doctor really ordered hydromorphone, the patient could develop respiratory depression or even arrest.

Consider posting a prominent notice in your medication room that warns the staff about this common mix-up. Or try attaching a fluorescent sticker printed with “not morphine” to each hydromorphone syringe and a sticker of a different color printed with “not hydromorphone” to each morphine syringe.

Drug names aren’t the only kinds of words you can confuse. Patient names can cause trouble as well if you fail to verify each person’s identity. This problem can be especially troublesome if two patients have the same first name.

Consider this clinical scenario: Robert Brewer, age 5, was hospitalized for measles. Robert Brinson, also age 5, was admitted after a severe asthma attack. The boys were assigned to adjacent rooms on a small pediatric unit. Each had a nonproductive cough. When Robert Brewer’s nurse came to give him an expectorant, the child’s mother told the nurse that Robert had already inhaled a medication through a mask.

The nurse quickly figured out that another nurse, new to the unit, had given Robert Brinson’s medication (acetylcysteine, a mucolytic) to Robert Brewer in error. Fortunately, no harmful adverse effects ensued. Had the nurse checked the patient’s identity more carefully, however, no error would have occurred in the first place.

Always check each patient’s full name and birthdate. Also, teach each patient (or parent) to offer an identification bracelet for inspection and to state a full name and birthdate when anyone enters the room with the intention of giving a medication. In addition, urge patients to tell you if an identification bracelet falls off, is removed, or gets lost. Replace it right away.

Teacher’S Lounge

Reducing medication errors through patient teaching

You aren’t the only one who’s at risk for making medication errors. Patients are at an even greater risk because they know so much less about medications than you do.

Clearly, patient teaching is a crucial aspect of your responsibility in minimizing medication errors and their consequences—especially as more patients receive outpatient rather than inpatient care.

After you’ve verified your patient’s full name, take time to check whether he has drug allergies—even if they are in distress. If the patient has an allergy, immediately document the allergy in the appropriate places such as the chart, MAR, wristband, and the pharmacy and report to the doctor.

Consider this real-life example: A doctor issued a stat order for chlorpromazine (Thorazine) for a distressed patient. By the time the nurse arrived with it, the patient had grown more distressed and was demanding relief. Unnerved by the patient’s demeanor, the nurse gave the drug without checking the patient’s MAR or documenting the order—and the patient had an allergic reaction to it.

Any time you’re in a tense situation with a patient who needs or wants medication fast, resist the temptation to act first and document later. Skipping that crucial assessment step could easily lead to a medication error.

Stay on the Ball

A patient who’s severely allergic to peanuts could have an anaphylactic reaction to Atrovent aerosol given by metered-dose inhaler. Ask the patient or the parents whether they are allergic to peanuts before you administer this drug.

If you find that they have such an allergy, you’ll need to use the nasal spray and inhalation solution form of Atrovent. Because it doesn’t contain soy lecithin, this form of the drug is safe for patients who are allergic to peanuts.

Many medication errors stem from compound problems—a mistake that could have been caught at any of several steps along the way. For a medication to be administered correctly, each member of the health care team must fulfill the appropriate role. The doctor must write the order correctly and legibly. The pharmacist must evaluate whether the order is appropriate and then fill it correctly. In addition, the nurse must evaluate whether the order is appropriate and then administer it correctly.

A breakdown anywhere along this chain of events can lead to a medication error. That’s why it’s so important for members of the health care team to act as a real team, checking each other and catching any problems that arise before those problems affect the patient’s health. Do your best to foster an environment in which professionals can double-check each other.

For example, the pharmacist can help clarify the number of times a drug should be given each day, help you label drugs in the most appropriate way, and remind you to always return unused or discontinued medications to the pharmacy.

You must clarify any doctor’s order that doesn’t seem clear or correct. You must also correctly handle and store any multi-dose vials obtained from the pharmacist. Additionally, store drugs in their original containers to avoid errors.

Stay on the Ball

Even a confusing container can cause a medication error if you aren’t careful. For example, it’s easy to mistake eyedrops for the developers used for the Hemoccult test. Some patients have sustained permanent eye damage as a result. The best way to avoid this mistake is to keep Hemoccult developers in an appropriate room (such as the utility room). Never keep them in a patient’s room.

Only administer drugs that you’ve prepared personally. Never give a drug that has an ambiguous label or no label at all. Here’s an actual example of what could happen if you do: A nurse placed an unlabeled cup of phenol (used in neurolytic procedures) next to a cup of guanethidine (a postganglionic-blocking agent). The doctor accidentally injected the phenol instead of the guanethidine, causing severe tissue damage to a patient’s arm. The patient needed emergency surgery and developed neurologic complications.

Obviously, this was a compound problem. The nurse should have labeled each cup clearly, and the doctor shouldn’t have given an unlabeled substance to a patient.

Many medication errors stem at least in part from problems related to the route of administration. The risk of error increases when a patient has several lines running for different purposes.

Consider this example: A nurse prepared a dose of digoxin elixir for a patient who had a central I.V. line and a jejunostomy tube—and she mistakenly administered the drug into the central I.V. line. Fortunately, the patient had no adverse reaction. To help prevent such mix-ups in administration route, prepare all oral medications in a syringe that has a tip small enough to fit an abdominal tube but too big to fit a central line.

Here’s another error that could have been avoided: To clear air bubbles from a 9-year-old patient’s insulin drip, a nurse disconnected the tubing and raised the pump rate to 200 ml/hour to flush the bubbles through quickly. The nurse then reconnected the tubing and restarted the drip, but she forgot to reset the rate back to 2 units/hour. The child received 50 units of insulin before the error was detected. To prevent this kind of error, never increase a drip rate to clear bubbles from a line. Instead, remove the tubing from the pump, disconnect it from the patient, and use the flow-control clamp to establish gravity flow.

You carry a great deal of responsibility for making sure that patients get the right drugs in the right concentrations at the right times and by the right routes. By diligently applying the guidelines offered here, you can minimize your risk of medication errors and maximize the therapeutic effects of your patients’ drug regimens.

References

Berman, A., & Snyder, S. J. (2012). Skills in clinical nursing (7th ed.). Upper Saddle River, NJ: Pearson Education.

Berman, A., Snyder, S. J., & McKinney, D. S. (2011). Nursing basics for clinical practice. Upper Saddle River, NJ: Pearson Education.

Hogan, M., Bolten, S., Ricci, M., & Taliaferro, D. (2008). Nursing fundamentals (2nd ed.). Upper Saddle River, NJ: Pearson Prentice Hall.

Treas, L. S., & Wilkinson, J. M. (2014). Basic nursing concepts, skills & reasoning. Philadelphia, PA: F.A. Davis.

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