NATIONAL NURSING AUDIT MINISTRY OF HEALTH MALAYSIA ELEMENT

5: CONTINUUM OF CARE

5.1 ADMINISTRATION OF ORAL MEDICATION
1. INTRODUCTION
“First, do no harm” is the ethical imperative for every patient safety effort. In working to reduce the frequency of medication errors, first priority must be to prevent those errors with the greatest potential for harm. The leading cause of patient harm is medication errors, which account for almost 20 percent of medical injuries.

The definition of a medication error as approved by the National Coordinating Council for Medication Error and Prevention 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. Such events may be related to professional practice, health care products, procedures, and systems including: prescribing, order communication, product labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use." Administering oral medications is a core function of nurses. Their responsibility is to comply with safe medication use processes and practices in order to prevent occurrence of medication errors / misadventures.

National Nursing Audit, Ministry of Health Malaysia : Version 1 / September 2008, Bahagian Kejururawatan , Kementerian Kesihatan Malaysia Page 1

2.

OBJECTIVES 2.1. 2.2. To prevent occurrence of oral medication errors / misadventures To ensure nurses serve medications according to the 6 R’s of Medication use. * * * * * * 2.3. Right patient Right drug Right dose Right route Right time Right documentation

To ensure that nurses exhibit the caring component when administering oral medication.

3.

STANDARD 3.1.
3.2.

Nurses serve oral medications according to the 6 R’s of medication use. Nurses exhibit the caring component during the administration of oral medication. Nurses document accurately and completely the medication administered.

3.3.

National Nursing Audit, Ministry of Health Malaysia : Version 1 / September 2008, Bahagian Kejururawatan , Kementerian Kesihatan Malaysia Page 2

4.

CRITERIA Structure Process
Greet patient. Identify right patient Verify prescription Assess patient, take appropriate nursing measures and document 5. 6. Dish out the correct 3. Medication misadventures are Explain and inform detected early and appropriate patients. measures taken timely Listen/Responds promptly medication and politely to patient’s /carer questions. 8. Administer and ensure patient takes oral medication. 9. Document medication served / omitted. 10. Monitor patient’s response and document. 11. Take appropriate measure if adverse reaction identified. 4. Patient is informed of his medication. 5. Documentation is accurate and complete. 2. 3. 4.

Outcome
1. All medications are served according to the 6 R’s of medication use 2. Patient receives safe medication during hospital stay

1. Each patient has current legal 1. written prescription / medication profile 2. There is a Nursing Operating Procedure (NOP) for administration of Medication. 3. The nurse is competent in the serving of medication, has knowledge on the effect and adverse drug reaction and the appropriate measures to be taken when there is an adverse reaction.

7.

TECHNICAL

DOCUMENTATION

SOFT SKILL

National Nursing Audit, Ministry of Health Malaysia : Version 1 / September 2008, Bahagian Kejururawatan , Kementerian Kesihatan Malaysia Page 3

identify patient accordingly verify prescription.

document assessment findings document medication served / omitted – date, time and signature


• •

greet patient explain and inform patient listen,respond promptly and politely to patient’s questions.


assess patient prior to • administration of selected medication

dish out medication accurately – right drug and right dose. • •

exhibit caring component when assessing patient

document adverse reactions identified document appropriate measures taken if adverse reactions identified

administer and ensure patient takes the medication

6.

AUDIT GUIDE FOR ADMINISTRATION OF ORAL MEDICATION 6.1. INCLUSION CRITERIA All patients in the ward who are on oral medication

6.2.

INSTRUMENT Audit Form (E5 AF 5.1) – one audit form for one observation

6.3 .

Methodology 6.3.1. Direct observation of nurse administering oral medication and also gather information from documents 6.3.2. Setting : All wards
6.3.3. Population: Staff Nurses

6.3.4 Sample Design: Convenient sampling

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6.4. Sample Size - 200 of staff nurses from each activity / program, equally divided among the wards for Hospital with Specialist and 100 staff nurses for non-specialist hospital 6.5. Time Frame -One month. 7. DEFINITION OF OPERATIONAL TERMS 7.1. Written prescription 7.1.1. Any legal orders of oral medication endorsed in the patient’s medication profile / patient’s case notes 7.2. Medication profile 7.2.1. Legal document where the doctor prescribes and the nurses endorse the administration of the medication 7.3. Patient’s response 7.3.1. Refers to favorable / adverse reactions of medication administered. E.g. favorable - pain relieved; adverse – develop rashes. 7.4. Dish out medication accurately 7.4.1. Read patient’s medication profile 7.4.2. Select required medication from patient’s drawer of medication cart 7.4.3. Calculate dosage before dishing out 7.4.4. Reconfirm the medication and dosage before putting back the balance. 7.5. Identify right patient 7.5.1. Confirm patient’s identity by 2 identifier 7.5.1.1. 7.5.1.2. His/ her name Registration number

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7.5.2. Ask patient to confirm name. 7.5.2.1. Cross check with patient’s wrist band for name and registration number. 7.5.2.2. Verify accuracy of identifier with patient’s medication profile. 7.6. Verify prescription by checking for 7.6.1. Prescribing doctor – name, signature, and date ordered 7.5.2. Drug – generic name, dose, frequency, route, duration 7.7. Assessment of Patient for Administration of Selected

Medication: 7.7.1. Nurses need to determine the patient’s current status prior to administration of selected medication to confirm its continuity. E.g. Anti-hypertensive, oral hypoglycemic agents, digitalis, analgesics, antipyretics, betablockers. 7.7.2. Nurses when assessing the patient will exhibit the caring component: 7.7.2.1. 7.7.2.2. Communicating well in a respectful manner Giving the patient the privacy, dignity and modesty 7.8. 6 R’s of Medication Use 7.8.1 Right patient 7.8.2 Right medication 7.8.3 Right dose 7.8.4 Right route

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7.8.4.1. Correct method of taking medication according to type: i. Tab. Magnesium Trisilicate - chewable ii. Tab. Glycerl Trinitrate - sublingual iii. Lugol’s Iodine – straw 7.8.5. Right time: 7.8.5.1. An allowance of ± 30 minutes 7.8.5.2. Initial dose served immediately or within a maximum of 30 minutes upon prescription /acquisition of medication and subsequent doses according to time as stated in SOP of the unit / ward. 7.8.6. Right documentation - implies accuracy and completeness 7.8.6.1.
7.8.6.2.

Record assessment findings signature of nurse who serve medication in the appropriate column for drugs not served, it should be indicated in medication profile document explanation of any omitted doses in patient’s case notes

7.8.6.3.

7.8.6.4.

7.8.6.5.

Document the evaluation of the patient response to the medication, when appropriate. document any identified adverse reaction to the medications administered. date and time of administration must be indicated in the medication profile

7.8.6.6.

7.8.6.7.

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7.9

Compliance of Medication Safety Audit 7.9.1. Technical - Every step in the process must be performed.
i. ii.

Identify patient accordingly, verify prescription. Assess patient prior to administration of selected medication Dish out medications accurately – right drug and right dose. Administer and ensure patient takes the medication

iii.

iv.

7.9.2. Essence of Care (Soft Skills): –

i.
ii. iii.

Greet patient Explain and inform patient Responds promptly and politely to patient’s questions. Exhibit caring component when assessing patient

iv.

7.9.3. Documentation - Every step in the process must be

performed. i. ii. iii.
v.

document assessment findings document medication served / omitted – date, time and signature document adverse reactions identified

document appropriate measures taken if adverse reactions identified

8.

Audit Form

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NATIONAL NURSING AUDIT MINISTRY OF HEALTH MALAYSIA ELEMENT 5 : CONTINUUM OF CARE TOPIC : 5.1 ADMINISTRATION OF ORAL MEDICATION DOCUMENT NO : E5 AF 5.1 Standard: 1. 2. All medication are served according to the 6 Rights of medication use. All nurses will exhibit the caring component during the administration of oral medication. Objectives:
1. 2.

VERSION 2/04

DATE : 8.5.08

PAGE No. 1/3

To prevent occurrence of medication errors / misadventures To ensure nurses serve medications according to the 6 R’s of medication use. To ensure that nurses exhibit the caring component when administering oral medications

3.

Date of Audit: Locality: Auditors: 1. …………………………………...
2.

……………………………………

N.B. Instructions for Auditors
1. To tick [√] at appropriate column.
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2. Item 4 is not rated if no specific nursing measures required. S/N ITEM SOURCE OF INFORMATION *1. Greet patient. 2. 3. Identify right patient. Verify prescription. Listen / Observe nurse. Listen / Observe nurse. Observe nurse. Observe nurse / check for written evidence. YES NO N/A

*4. Assess patient. 5. Dish out correct medication : 5.1. Read patient’s medication profile 5.2. Select required medication from patient’s drawer of medication cart. 5.3. Calculate dosage before dishing out 5.4 Reconfirm the medication and dosage before putting back the

Observe nurse.

Observe nurse.

Observe nurse and countercheck calculation. Observe nurse.

balance *6. Explain and inform patient Observe nurse *7. Responds promptly and
politely to patient’s /carer questions.

Listen / Observe nurse.

S/N 8.

ITEM Administer and ensure patients take oral

SOURCE OF INFORMATION

YES

NO

N/A

National Nursing Audit, Ministry of Health Malaysia : Version 1 / September 2008, Bahagian Kejururawatan , Kementerian Kesihatan Malaysia Page 10

medication: 8.1 right patient. 8.2 right medication 8.3 right dose 8.4 right time 8.5 right route 8.6 9 Document: 9..1 Medication administered. 9.2 Assessment findings. 9.3 9.4 Observe nurse. Observe nurse. Listen / Observe nurse. Listen / Observe nurse. Listen / Observe nurse. Listen / Observe nurse Listen / Observe nurse

AUDIT REPORT (Please [√] the appropriate box) Conformance Non-Conformance

REMARKS Auditor 1[Name and Signature]: …………………………… Auditor 2 [Name and Signature]: ……………………………

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