administering medications the right way student manual

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administering medications the right way student manual

The manual incorporates principles that support training for non-licensed staff. The goal of the training is to teach how to administer medications in a mindful, error-free manner. With well defined objectives, key terms to study, scenarios, exercises and examples the manual will help students learn how to administer medications. All the skills are outlined in tables and illustrated for easy learning and for quick reference. The materials are easy to read and full of exercises to validate knowledge and assist in critical thinking. The student manual is. So this website was intended for free download articles fromYou are self-liable for your download.You can learn how to disable cookie here. Please enable scripts and reload this page. The DHS Medication Administration model is managed and operated by the Office of Developmental Programs (ODP). ODP is responsible for delivering the approved Medication Administration curriculum to approved candidates who, in turn, become certified to teach the principles and guidelines for medication administration in facilities licensed under the Chapter 11, 2380, 2390, 2600, 2800, 3800, 6400 and 6600 regulations. The Medication Administration Training program delivers training to candidates from multiple program offices including DHS’s Office of Administration, ODP, the Office of Long Term Living (OLTL), the Office of Children, Youth and Families (OCYF), the Office of Mental Health and Substance Abuse Services (OMHSAS) and DOA. In collaboration with the Pennsylvania State Board of Nurses, ODP developed the Medication Administration Training Program in 1981.All rights reserved. Tubes and Attachments 10.1 Introduction 10.2 Caring for Patients with Tubes and Attachments 10.3 Nasogastric Tubes 10.4 Urinary Catheters 10.5 Tracheostomies 10.6 Chest Tube Drainage Systems 10.7 Ostomy Care 10.

8 Summary Appendix 1: Glossary Appendix 2: Checklists Summary About the Authors Versioning History Safe and accurate medication administration is an important and potentially challenging nursing responsibility. Medication administration requires good decision-making skills and clinical judgment, and the nurse is responsible for ensuring full understanding of medication administration and its implications for patient safety. When preparing and administering medication, and assessing patients after receiving medication, always follow agency policy to ensure safe practice. Review Table 6.1 for guidelines for safe medication administration. Always receive the required training on the use of the medication system for each agency to avoid preventable errors. Always follow agency policy for patient identification. Mistakes are often referred to as attentional behaviours where lack of training or knowledge is the cause of the error. Slips account for most errors in heath care. If possible, follow a standard list of steps for every patient. Answer questions regarding usage, dose, and special considerations. Give the patient an opportunity to ask questions. Include family members if appropriate. For example, a nurse may “borrow” a medication from another patient while waiting for an order to be filled by the pharmacy. These workarounds fail to follow agency policy to ensure safe medication practices. Consult with the pharmacist, charge nurse, or other health care providers and be sure to resolve all questions before proceeding with medication administration. Technology has the potential to help decrease errors. Use technology when administering medications but be aware of technology-induced errors. The most common high-alert medications are anticoagulants, narcotics and opiates, insulins, and sedatives. The types of harm most commonly associated with these medications include hypotension, delirium, bleeding, hypoglycemia, bradycardia, and lethargy.

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. 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). 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 AMDS, the medication and the nurse who accessed the system will be linked to the patient’s electronic record. Different dosages may be indicated for different conditions. Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Show details Hughes RG, editor. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

With the growing reliance on medication therapy as the primary intervention for most illnesses, patients receiving medication interventions are exposed to potential harm as well as benefits. Harm from medications can arise from unintended consequences as well as medication error (wrong medication, wrong time, wrong dose, etc.). With inadequate nursing education about patient safety and quality, excessive workloads, staffing inadequacies, fatigue, illegible provider handwriting, flawed dispensing systems, and problems with the labeling of drugs, nurses are continually challenged to ensure that their patients receive the right medication at the right time. The purpose of this chapter is to review the research regarding medication safety in relation to nursing care. We will show that while we have an adequate and consistent knowledge base of medication error reporting and distribution across phases of the medication process, the knowledge base to inform interventions is very weak. Defining Medication Errors Shared definitions of several key terms are important to understanding this chapter. Drugs are defined as “a substance intended for use in the diagnosis, cure, mitigation, treatment or prevention of disease; a substance (other than food) intended to affect the structure or any function of the body; and a substance intended for use as a component of a medicine but not a device or a component, part or accessory of a device.” 3 Medications include, but are not limited to, any product considered a drug by the Food and Drug Administration (FDA). 3 Given the number and variety of definitions for medication errors, the IOM has recommended that international definitions be adopted for medication error, adverse drug events, and near misses.

2 Medication Errors One commonly used definition for a medication error is: Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Misreading medication names that look similar is a common mistake. These look-alike medication names may also sound alike and can lead to errors associated with verbal prescriptions. Medications with complex dosing regimens and those given in specialty areas (e.g., intensive care units, emergency departments, and diagnostic and interventional areas) are associated with increased risk of ADEs. 6 Phillips and colleagues 7 found that deaths (the most severe ADE) associated with medication errors involved central nervous system agents, antineoplastics, and cardiovascular drugs. Most of the common types of errors resulting in patient death involved the wrong dose (40.9 percent), the wrong drug (16 percent), and the wrong route of administration (9.5 percent). The causes of these deaths were categorized as oral and written miscommunication, name confusion (e.g., names that look or sound alike), similar or misleading container labeling, performance or knowledge deficits, and inappropriate packaging or device design. Adverse Drug Events and Adverse Drug Reactions Adverse drug events are defined as injuries that result from medication use, although the causality of this relationship may not be proven. 8 Some ADEs are caused by preventable errors. An adverse drug reaction is defined as “an undesirable response associated with use of a drug that either compromises therapeutic efficacy, enhances toxicity, or both.” 10 ADRs can be manifested as diarrhea or constipation, rash, headache, or other nonspecific symptoms.

One of the challenges presented by ADRs is that prescribers may attribute the adverse effects to the patient’s underlying condition and fail to recognize the patient’s age or number of medications as a contributing factor. 11 According to Bates and colleagues, 12 more attention needs to be directed to ADEs—including both ADRs and preventable ADEs—which range in severity from insignificant to fatal. Black Box Warnings and High-Alert Medications In 1995, the FDA established the black box warning (BBW) system to alert prescribers to drugs with increased risks for patients. These warnings are intended to be the strongest labeling requirement for drugs or drug products that can have serious adverse reactions or potential safety hazards, especially those that may result in death or serious injury. 13 While the FDA does not issue a comprehensive list of drugs with BBWs, 14 some of the BBW drugs are celecoxib (Celebrex), warfarin, rosiglitazone (Avandia), methylphenidate (Ritalin), estrogen-containing contraceptives, and most antidepressants. 15 One study funded by the Agency for Healthcare Research and Quality found 40 percent of patients were taking a medication with a BBW and that many of those patients did not receive the recommended laboratory monitoring. The authors concluded that BBWs did not prevent the inappropriate use of high-risk medications. 16 Medication errors can be considered a sentinel event when they are associated with high-alert medications. The researchers found that 3.7 percent of hospitalizations involved adverse events that prolonged hospital stay or were manifested as a new disability at the time of discharge. About one in four of these adverse events were judged to be attributable to negligence, and 58 percent were judged to be preventable. It is difficult to reduce or eliminate medication errors when information on their prevalence is absent, inaccurate, or contradictory.

Bates 20 put forth the notion that for every medication error that harms a patient, there are 100, mostly undetected, errors that do not. Most medication errors cause no patient harm or remain undetected by the clinician. 20, 21 The low rate of detected errors makes assessing the effectiveness of strategies to prevent medication errors challenging. Rates of medication errors vary, depending on the detection method used. The impact was less in male patients, younger patients, and patients with less severe illnesses and in certain diagnosis-related groups. Without an infrastructure to capture and assess all medication errors and near misses, the real number is not known. These rates could be expected to be higher once patient safety organizations begin to collect nationwide errors and health care clinicians become more comfortable and skilled in recognizing and reporting all medication errors. The concern raised in To Err Is Human 1 about the potential prevalence and impact of ADEs—2 out of every 100 hospitalized patients—was just the beginning of our understanding of the potential magnitude of the rates of medication errors. In this stage, the wrong drug, dose, or route can be ordered, as can drugs to which the patient has known allergies. Similar results have been found in mandatory adverse event reporting systems. An analysis of 108 reports associated with significant harm or death reported to the State of New York noted that, when the error occurred during the prescribing stage, written prescriptions accounted for 74 percent of the errors, and verbal orders accounted for 15 percent. 6 While the preponderance of the research focuses on physician prescribing, there is a brief discussion about the role of advanced practice nurses in prescribing to ensure safety. One investigation of the occurrence of ADRs in outpatient veterans found no difference in ADR events between physicians and nurse practitioners. 11 Prescribers may make changes in medication therapy (e.g.

, change the dosage or discontinue the medication) in response to ADRs (e.g., constipation, rash) or other indications communicated to them by nurses or patients. Transcribing, dispensing, and delivering In some settings, medication orders are transcribed, dispensed, and then delivered for nurse administration. In certain circumstances and settings, both nurses and pharmacists are involved in transcribing, verifying, dispensing, and delivering medications. Yet errors of these two stages (transcribing and verifying, dispensing and delivering) have been predominately studied for pharmacists. Medication administration Nurses are primarily involved in the administration of medications across settings. Nurses can also be involved in both the dispensing and preparation of medications (in a similar role to pharmacists), such as crushing pills and drawing up a measured amount for injections. Early research on medication administration errors (MAEs) reported an error rate of 60 percent, 34 mainly in the form of wrong time, wrong rate, or wrong dose. In other studies, approximately one out of every three ADEs were attributable to nurses administering medications to patients. 21, 28 In a study of deaths caused by medication errors reported to the FDA from 1993 to 1998, injectable drugs were most often the problem; 7 the most common type of error was a drug overdose, and the second most common type of error was administering the wrong drug to a patient. The 583 causes of the 469 deaths were categorized as miscommunication, name confusion, similar or misleading labeling, human factors (e.g., knowledge or performance deficits), and inappropriate packaging or device design. The most common causes were human factors (65.2 percent), followed by miscommunication (15.8 percent). Nurses are not the only ones to administer medications. Physicians, certified medication technicians, and patients and family members also administer medications.

Part of the challenge in understanding the impact of nursing in medication administration is the need for research that clearly differentiates the administrators of medications. Several studies have reported medication administration errors that have included nonnurses. 37, 38 Among many reasons for the prevalence of nurse involvement in medication errors is that nurses may spend as much as 40 percent of their time in medication administration. 39 A large-scale study by the U.S. National Council of State Boards of Nursing assessed whether there were any identifiable characteristics common to those nurses who committed medication administration errors. The most significant finding was that “the age, educational preparation and employment setting of RNs disciplined for medication administration errors are similar to those of the entire RN population” 40 (p. 12). The “rights” of medication administration include right patient, right drug, right time, right route, and right dose. These rights are critical for nurses. A survey of patients discharged from the hospital found that about 20 percent were concerned about an error with their medications, and 15 percent of them were concerned about being harmed from mistakes by nurses compared to 10 percent who were concerned about mistakes by physicians. 41 However, the complexity of the medication process has led to the formulation of the rights of nurses in the area of medication administration. Of the 130 errors for physicians, the majority were wrong dose, wrong choice of drug, and known allergy. Among the 126 nursing administration errors, the majority were associated with wrong dose, wrong technique, and wrong drug. Each type of error was found to occur at various stages, though some more often during the ordering and administration stages. The categorization approach used determines whether the implication can be targeted to stage, and therefore discipline, or to types of error.

For example, 11 studies reported rates of types of medication errors using institution-specific and national databases, yet not specifying whether the error occurred during the prescribing, dispensing, or administration stage of the medication process or not clearly specifying administration errors associated with nurse administration. One of these studies analyzed deaths associated with medication errors, finding that the majority of deaths were related to overdose and wrong drug 7 —again, not specified by stage. Yet among these, it may be possible to see that wrong dose, dose omission, wrong drug, and wrong time are the most frequent type of medication error. Even then, comparisons and practice implications are challenging due to the lack of standardization among the types of categories used in research. Working Conditions Can Facilitate Medication Errors Following the release of To Err Is Human, 1 the focus on deaths caused by medication errors targeted system issues, such as high noise levels and excessive workloads, 47 and system interventions, such as the need for computerized order entry, unit dose (e.g., single-dose packaging), and 24-hour pharmacy coverage. 48 The IOM’s report, Crossing the Quality Chasm, 49 put forth the concept that poor designs set the workforce up to fail, regardless of how hard they try. Thus, if health care institutions want to ensure safer, higher-quality care, they will need to, among other things, redesign systems of care using information technology to support clinical and administrative processes. Early research in this area found a relationship between characteristics of the work environment for nurses and medication errors. 30, 50, 51 For example, Leape and colleagues 27 found an association between the occurrence of medication errors and the inability to access information and failure to follow policies and guidelines.

Also, research has found that health care clinicians should be aware of the repeated patterns of medication errors and near misses to provide insight on how to avoid future errors. 52 The system approach to safety emphasizes the human condition of fallibility and anticipates that errors will occur, even in the best organizations with the best people working in them. This approach focuses on identifying predisposing factors within the working environment or systems that lead to errors. 53 Reason’s 53 model of accident causation describes three conditions that predicate an error: Latent conditions —Organizational processes, management decisions, and elements in the system, such as staffing shortages, turnover, and medication administration protocols. Threats to medication safety include miscommunication among health care providers, drug information that is not accessible or up to date, confusing directions, poor technique, inadequate patient information, lack of drug knowledge, incomplete patient medication history, lack of redundant safety checks, lack of evidence-based protocols, and staff assuming roles for which they are not prepared. Together these studies indicate that the medication errors that are reported do not represent the actual incidence of medication errors. Without reporting, many errors may not be known. Based on a survey of nurses on barriers to reporting, Wakefield and colleagues 62 suggested several strategies to increase the reporting of MAEs: agreement on the definition of error; supporting and simplifying reporting of errors; institutionalizing a culture that rewards and learns from error reporting (i.e., a culture of safety, where learning is encouraged and blaming discouraged); capitalizing on feedback reports to determine system factors contributing to error; and ensuring positive incentives for MAE reporting. Incident reports, retrospective chart reviews, and direct observation are methods that have been used to detect errors.

There were two studies that compared detection methods. One of these studies of medication administration in 36 hospitals and skilled nursing facilities found 373 errors made on 2,556 doses. 77 The comparison of three detection methods found that chart review detected 7 percent of the observed errors, and incident reports detected only 1 percent. Direct observation was able to detect 80 percent of true administration errors, far more than detected through other means. A second study compared detection methods and found that more administration errors were detected by observation (a 31.1 percent error rate) than were documented in the patients’ medical records (a 23.5 percent error rate). 78 Therefore, no one method will do it all. When automated systems that use triggers are not in place, multiple approaches such as incident reports, observation, patient record reviews, and surveillance by pharmacist may be more successful. 79 The wide variation in reported prevalence and etiology of medication errors is in part attributable to the lack of a national reporting system or systems that collect both errors and near misses. State-based and nationally focused efforts to better determine the incidence of medication errors are also available and expanding (Patient Safety and Quality Improvement Act of 2005). Research reported to date clearly reveals that medication errors are a major threat to patient safety, and that these errors can be attributed to all involved disciplines and to all stages of the medication process. Unfortunately, the research also reveals that we have only weak knowledge of the actual incidence of errors. Our information about ADEs (those detected, reported, and treated) is better, but far from complete. With this knowledge of the strengths and limitations of the research, this chapter will consider the evidence regarding nurses’ medication administration.

Research Evidence—Medication Administration by Nurses The research review targeted studies involving medication administration by nurses. This excluded several studies that assessed medication administration errors without differentiating whether the errors were associated with physicians, assistants, or nurses. None of these studies included interventions. Rates and Types of Medication Administration Errors Thirteen studies explicitly reported types of MAEs associated with nurses. The incidence of MAEs was detected either formally through incident reports, chart reviews, or direct observation, or informally through anonymous surveys. Using chart reviews, Grasso and colleagues 43 found that 4.7 percent of doses were administered incorrectly. Direct observation studies placed the estimate of total incorrect doses between 19 percent and 27 percent, 87 and when an extra review was done to separate the errors into stages of the medication process, between 6 percent and 8 percent of doses were in error because of administration. The majority of types of MAEs reported were wrong dose, wrong rate, wrong time, and omission. All of the studies reviewed here reported wrong drug and dose, but varied across the other types of MAE categories (see Evidence Table 1 ); this was dependent upon the study methodology. Evidence Table 1 Types of Reported and Observed Medication Administration Errors (MAEs) Five studies evaluated self-reported MAEs, involving incident reports and informal reports. 38, 44, 81, 82 The most common types of reported errors were wrong dose, omission, and wrong time. Of the reported contributing factors, 78 percent were due to the inexperience of the nurse. The Beyea and Hicks 81, 82 studies looked at errors associated with the operating room, same-day surgery, and postanesthesia; they found the majority of errors attributable to administration but did not classify them by error type.

The other study reviewed 88 incident reports from a long-term care facility submitted during a 21-month period. It found that the majority of MAEs were associated with errors involving interpreting or updating the medication administration record, delayed dose, wrong dose, or wrong drug. 92 A separate component of this study surveyed administrative and clinical nurses and found that they believed the majority of medication errors occurred at either the administration or dispensing stage. Two other studies assessed the type of MAEs reported by nurses in nationwide surveys. 84, 85 While the majority (57 percent) of errors reported by critical care nurses involved MAEs, an additional 28 percent of reported errors involved near misses. Medication administration errors involving wrong time, omission, and wrong dose accounted for 77.3 percent of errors, while wrong drug and wrong patient accounted for 77.8 percent of near misses. The most frequent types of medication errors were wrong time (33.6 percent), wrong dose (24.1 percent), and wrong drug (17.2 percent), and the three most frequent types of near misses were wrong drug (29.3 percent), wrong dose (21.6 percent), and wrong patient (19.0 percent). 85 Many of the reported MAEs in ICUs involved intravenous medications and fluids. 84 In these surveys, the nurses who reported making errors described between two and five errors during a 14-day period. At the more advanced stage of incident reports, one study reviewed 68 malpractice cases involving MAEs in Sweden. 80 Among the cases reviewed, the majority of MAEs made by nurses involved wrong dose. When the nurses delegated the drug administration to subordinate staff, the majority of MAEs involved wrong drug or wrong concentration of a drug. Errors, which were reported to the immediate supervisor, were also reported to the physician in 65 percent of cases.

The reported causes of MAEs were lack of administration protocols, failure to check orders, ineffective nurse supervision when delegating administration, and inadequate documentation. One study assessed medication errors using 31 medical records of patients discharged from a psychiatric hospital and found a total of 2,194 errors. 43 Of these, 997 were classified as MAEs (4.7 percent of all doses, and 66 percent of all errors). Of these, 61.9 percent were due to scheduled doses not documented as administered, 29.1 percent as drugs administered without an order, 8 percent as missed doses because of late transcription, and 3 percent resulting from orders not being correctly entered in the pharmacy computer. Table 1 Comparison of the Incidence of Medication Administration Errors by Type Categories The number of studies using direct observation of medication administration is increasing in response to the concern about the accuracy of other sources of data. Ten studies were found, only three of which were done in the United States. While we attempt to summarize across these studies, it is difficult to determine consistency across studies as each focused on different sets of errors (some only intravenous errors, some included gastrointestinal tube technique) and were conducted in different settings. In many of the non-U.S. studies, nurses dispensed drugs from ward stock and prepared many of the intravenous solutions for administration. Three observational studies were conducted in pediatric units—one in France, 78 one in Switzerland, 25 and one in the United States. 24 Buckley 24 reported 52 of the 263 doses (19 percent) observed to be in error, but only 15 (6 percent) of those were in the administration stage. Those 15 were nearly evenly divided among wrong dose, wrong time, wrong technique, and extra dose categories. Prot 78 reported nearly 50 percent more MAEs.