Patient Safety and Medication Administration
Growing numbers of patients—and drugs—bring increased risk of medication errors. Compounding this risk are the tremendous upsurge in the use of over-the-counter (OTC) drugs and herbal remedies and the overwhelming impact of the Internet and direct-to-consumer advertising in influencing patient compliance and decision making. There have always been checkpoints in ensuring medication safety. There have traditionally been three levels of checks protecting the patient—the prescriber who chooses and orders a drug, the pharmacist who fills the prescription and, finally, the nurse who actually administers the drug to the patient. Each serves as a check within the system to catch errors—the wrong drug, the wrong patient, the wrong dose, the wrong route, or the wrong time.
Back in the 1950s and 1960s, most drugs were given in a hospital or institutional setting and these checks were effective in catching wrong drugs, wrong doses, and so forth. But in today’s world, with skyrocketing health care costs and the push for early discharge, more people are being treated outside the hospital than in the hospital. National studies published in 2008 predicted that, with so many patients managing their own drug regimens at home, over 5 million preventable medication errors can occur each year with an estimated annual cost of $350 billion and untold personal suffering. The usual checks are still in place, but the patient is now responsible for administering the drug and the nurse is the person with the responsibility for discharging patients to home with the knowledge and tools they will need to manage a potentially complicated drug regimen.
The Rights of Medication Administration
In the clinical setting, the monumental task of ensuring medication safety can be managed by consistently using the seven rights of drug administration: right drug, right route, right dose, right time, right patient, right response, and right documentation.
Right Patient
Check the patient’s identification even if you think you know who the patient is. Ask for the patient’s full name, and check the patient’s identification band if available.
Review the patient’s diagnosis, and verify that the drug matches the diagnosis. If a drug does not make sense for the patient’s diagnosis, look it up and, if necessary, consult the prescriber.
Make sure all allergies have been checked before giving a drug. Serious adverse reactions can be avoided if allergies are known.
Ask patients specifically about OTC drugs, vitamin and mineral supplements, herbal remedies, and routine drugs that they may not think to mention, such as oral contraceptives, thyroid hormones, and insulin. Serious overdoses, adverse reactions, and drug interactions can be avoided if this information is acquired early.
Review the patient’s drug regimen to prevent potential interactions between the drug you are about to give and drugs the patient already takes. If you are not sure about potential interactions, consult a drug reference.
The bottom line in avoiding medication errors is simple: “If in doubt, check it out.” A strange abbreviation, a drug or dosage that is new to you, and a confusing name are all examples that signal a need for follow-up. Look up the drug in your drug guide or call the prescriber or the pharmacy to double-check. Never give a drug until you have satisfied yourself that it is the right drug, given by the right route, at the right dose, at the right time, and to the right patient.
Right Drug
Always review a drug order before administering the drug.
Do not assume that a computer system is always right and will protect the patient. Always double-check.
Make sure the drug name is correct. Ask for a brand name and a generic name. Because many drug names look and sound alike (note the Clinical Alerts throughout the monographs), the chance of reading
the name incorrectly is greatly reduced if both generic and brand names are used.
Avoid taking verbal or telephone orders whenever possible. If you must, have a second person listen in to verify and clarify the order.
Abbreviations can be confusing between and even within health care facilities. Do not be afraid or embarrassed to ask the meaning of an abbreviation, even a common one. For instance, many people use “hs” to mean “hour of sleep”; others may read it as “every hour.” As much as possible, spell out abbreviations for clarification.
Consider whether the drug makes sense for the patient’s diagnosis. If you do not know or you have questions, look up the drug and ask the patient what it is being used for.
Right Route
Review the available forms of a drug to make sure the drug can be given according to the order.
Check the routes available and the appropriateness of the route for this patient. Be familiar with the appropriate and safe technique for administration by the ordered route.
Make sure the patient is able to take the drug by the route indicated. If you know that the patient has trouble swallowing, for example, you also know that a liquid form of the drug may be better than a tablet or capsule.
Do not use abbreviations for routes because the danger of confusion is too great. For example, “SC” is often used to mean “subcutaneous,” but it has been misinterpreted to mean “sublingual” among other misinterpretations. Also, “IV” can be misinterpreted to mean “IU,” or international units.
Right Dose
Make sure the dose about to be delivered is the dose the prescriber ordered.
There should always be a 0 to the left of a decimal point, and there should never be a 0 to the right of a decimal point. For example, “0.5” is correct (not “.5,” which can be easily mistaken for “5”) and “5” is correct (not “5.0,” which can be easily mistaken for “50”). If you see an ordered dose that starts with a decimal point, question it. And if a dose seems much too big, question that.
Double-check drug calculations. If a dose has to be calculated for pediatric or other use, always have someone double-check the math, even if a computer did the calculations. This is especially important with drugs that have small margins of safety, such as digoxin and insulin.
Check the measuring devices used for liquid drugs. Advise patients not to use kitchen teaspoons or tablespoons to measure drug doses.
Do not cut tablets in half to get the correct dose without checking the warnings that come with the drug. Many drugs cannot be cut, crushed, or chewed because of the matrix systems that have been developed to prepare the drugs.
Right Time
Increased workloads, decreased nursing staffs, and constant interruptions can interfere with the delivery of medications at the right times. Even at home, patients are busy, have tight schedules, and may fail to follow a precise schedule. Ensure the timely delivery of the patient’s drugs by scheduling dosing with other drugs, meals, or other consistent events to maintain the serum level.
Teach patients the importance of timing critical drugs. Keep in mind that patients tend to take all of their daily drugs at once, in the morning, to reduce the risk of forgetting them. But with critical drugs, such as those with a small margin of safety, those that interact, and those that need meticulous spacing, you will need to stress the importance of accurate timing. As needed, make detailed medication schedules and prepare pill boxes.
Right Response
Monitor the patient’s response to the drug administered to make sure that the response is what is anticipated. A response that is not anticipated could indicate that the wrong drug is being used or that this particular patient has a unique reaction that needs to be addressed.
Right Documentation
Document according to facility policy. Include the drug name, dose, route, and time of administration. Note special circumstances, such as the patient having difficulty swallowing or the site of the injection. Include the patient’s response to the drug and any special nursing interventions that were used. Remember, “if it isn’t written, it didn’t
happen.” Accurate documentation provides continuity of care and helps prevent medication errors.
happen.” Accurate documentation provides continuity of care and helps prevent medication errors.
Preventing Miscommunication
As with so many things in the world, miscommunication can be the source of many safety issues in medicine and nursing. Working to prevent miscommunication is a complicated task for the entire health care team.
Although abbreviations can save time, they also raise the risk of misinterpretation, which can lead to potentially disastrous consequences, especially when dealing with drug administration. To help reduce the risk of being misunderstood, always take the time to write legibly and to spell out anything that could be misread. This caution extends to how you write numbers as well as drug names and other drug-related instructions. The Joint Commission is enforcing a growing list of abbreviations that should not be used in medical records to help alleviate this problem. It is important to be familiar with the abbreviations used in your clinical area and to avoid the use of any other abbreviations. (See Common dangerous abbreviations, page 4).
