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NATIONAL NURSING AUDIT MINISTRY OF HEALTH MALAYSIA ELEMENT

5: CONTINUUM OF CARE

5.1.1
1.

ADMINISTRATION OF MEDICATION VIA INJECTION.

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 medication (oral / injection) 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 / Sept 2012, Bahagian Kejururawatan , Kementerian Kesihatan Malaysia Page 1

Nurses document accurately and completely. Patient does not experience medication errors/ misadventures during hospitalization.2. 3.1 All medication via injection are given according to the 7 R’s of medication use * * * * * * * 3. STANDARD 2.1.3. Bahagian Kejururawatan . Ministry of Health Malaysia : Version 1 / Sept 2012. Right patient Right drug Right dose Right route Right time Right documentation Right to refuse Nurses exhibit the caring component during the administration of medication.2 3. National Nursing Audit. Kementerian Kesihatan Malaysia Page 2 . OBJECTIVES 3.

Administer the medication via injection 9. National Nursing Audit. The nurse is competent in the administration of 5. Identify right patient 2. to be taken when there is an adverse reaction. Take appropriate measure if adverse reaction identified. CRITERIA Structure Process Outcome 1. Monitor patient’s response and document. Listen/ Respond 5 promptly and politely to patient’s /carer‘s questions. Document the medication given or omitted. Operating Procedure (SOP) for administration 4. 1. Medication for injection has knowledge on the effect and adverse drug reaction and the 6. take appropriate nursing measures and document(optional) 3 3. of medication via injection . 11. 8. Ministry of Health Malaysia : Version 1 / Sept 2012. All medications are served according to the 7 R’s of medication use Medication misadventures are detected early and appropriate measures taken timely Documentation is accurate and complete. Each patient has 1. Verify prescription Assess patient. 7. There is a Standard 3. Greet / acknowledge current legal written patient.4. Kementerian Kesihatan Malaysia Page 3 . Prepare the correct 4 medication via injection . 10. prescription / medication profile 2. Bahagian Kejururawatan . Patient receives safe medication during hospital stay 2 Patient is informed of his medication. Explain and inform appropriate measures patient.

5.1. 5. Kementerian Kesihatan Malaysia Page 4 .2.5. DEFINITION OF OPERATIONAL TERMS 6.2.3.1. TIME FRAME One month.1) – one audit form for one observation 5. Ministry of Health Malaysia : Version 1 / Sept 2012. 5. 5.3.1. 6.4 SAMPLE SIZE 30% of Registered Nurses working in in-patient areas 5. Bahagian Kejururawatan . WRITTEN PRESCRIPTION Any legal orders of medication via injection endorsed in the patient’s medication profile / patient’s case notes. Direct observation of nurse giving medication via injection and also gather information from documents 5. AUDIT GUIDE FOR ADMINISTRATION OFMEDICATION VIA INJECTION 5. 6. MEDICATION PROFILE Legal document where the doctor prescribes and the Nurse endorse the administration of medication via injection. Setting: All wards.3. METHODOLOGY 5.1.4 Sample Design: Convenient sampling .3.3. INCLUSION CRITERIA Observation of injection given to all in-patients. INSTRUMENT Audit Form (E5 AF 5. Population: Registered Nurses. 5.3.3.2. 6. IDENTIFY RIGHT PATIENT National Nursing Audit.

3. 6. PREPARATION OF INJECTION ACCURATELY. Kementerian Kesihatan Malaysia Page 5 .2.1. Insulin.2.2. Ministry of Health Malaysia : Version 1 / Sept 2012.5.1 Confirm patient’s identity by 2 identifier 6.6. Nurses when assessing the patient will exhibit the caring component by explaining the intended procedure in a respectful manner 6.2 Verify accuracy of identifier with patient’s medication profile.3. frequency. 6. Initial dose given within a maximum of 1 hour upon prescription / acquisition of medication and subsequent doses according to time as stated in SOP of the unit / ward.5.2. 6. 6.1 With patient’s wrist band for name and registration number.4.4.7. RIGHT TIME 6.1.2. and date ordered 6. signature.1.6.7. Nurses need to determine the patient’s current status prior to administration of selected medication to confirm its continuity.1. Drug – generic name. duration 6.3. dose. National Nursing Audit.2 registration number 6. 6.3. Ask patient to confirm name and cross check : 6.4.2. e. VERIFY WRITTEN PRESCRIPTION BY CHECKING FOR : 6. anti-hypertensive drugs etc.1.1. 6.g.5.3.7. Prescribing doctor – name. Bahagian Kejururawatan . Calculate dosage before giving (right dosage). route.6. An allowance of ± 1 hour 6.6.6. Select required injection (right medication). 6. Read patient’s medication profile (right patient).1 his/ her name 6.3.2.3. ASSESSMENT OF PATIENT PRIOR TO INJECTION : 6.

RATING SYSTEM 7.2. Ministry of Health Malaysia : Version 1 / Sept 2012. Bahagian Kejururawatan .2 Verify written prescription (T3) 7. RIGHT ROUTE Correct method of giving various types of injection.6. For drugs not given. RIGHT DOCUMENTATION Accurate and complete document of the following: 6. example: I. Antibiotic – /m or i/v .9 RIGHT TO REFUSE Patient has the right to refuse the medication prescribed.1. Kementerian Kesihatan Malaysia Page 6 . c) Document on drug refused and explanation given. (T2) 7. b) To inform the doctor.1.1. Insulin .11.11.11. Document explanation of any omitted dose / medication refused in patient’s case notes 7. the following nursing action shall be taken: a) To identify reason for refusal and reinforce explanation on importance of taking that particular drug. Record assessment findings if applicable 6.1 TECHNICAL COMPONENT Medication compliance to technical component include all of the following: 7.11.1. if applicable (T4.5.4.(Follow drug literature) 6.3 Performed assessment.2) 7.11.8.subcutaneous II.4 Read patient’s medication profile (T5.10. Date and time of administration must be indicated in the medication profile 6.3 Signature of nurse who serve medication in the appropriate column 6. 6.1. it should be indicated in the medication profile 6.1 Identify right patient.1) National Nursing Audit. When patient verbalizes refusal.

Ministry of Health Malaysia : Version 1 / Sept 2012.1 Greet / acknowledge patient – verbal / non verbal (S1) 7. time and signature 7.1) 7. Kementerian Kesihatan Malaysia Page 7 .8 Administer injection.3 DOCUMENTATION COMPONENT Accurate and complete documentation compliance included all of the following for D10: 7.2 Explanation prior assessment.3. the nurse need to inform doctor and document omission for refusal.2) 7.3 Document omission for refusal.2.4 Document communication with doctor (if applicable).3.(S6) 7.6 Calculate dosage before preparing the injection (T5.1.3. 7.1) 7.2. if applicable.2) 7.2) 7.5 Select required medication from patient’s drawer of medication cart / treatment room (T5.2.7.1.7 Re-verify identity of right patient (T7.2 SOFT SKILL COMPONENT Conformance is verified by direct observation and listening to the nurse .3) 7. [ if applicable ] (T7. National Nursing Audit. if applicable.1 Document assessment findings (if applicable) 7.3.1.3.1.2 Document injection given / omitted – date. Bahagian Kejururawatan .3) 7.1.9 When patient refuse injection.3 Respond promptly and politely to patient’s / carer‘s questions. (T7. (D7. (S4.

1 1. AUDIT FORM NATIONAL NURSING AUDIT MINISTRY OF HEALTH MALAYSIA VERSION 1/2012 ELEMENT 5 : CONTINUUM OF CARE TOPIC : 5.1 2.3. Auditee : …………………………………… National Nursing Audit..8. Nurses document accurately and completely the injection administered.1. 1/3 Date of Audit: Locality : Auditors: …………………………………. Ministry of Health Malaysia : Version 1 / Sept 2012. All injections are given according to the 7 R’s of medication use Nurses exhibit the caring component during the administration of Injection.. 2. OBJECTIVES 2. Bahagian Kejururawatan . STANDARD : Patient does not experience medication errors/ misadventures during hospitalization. DATE : 1 Sept 2012 PAGE No. Kementerian Kesihatan Malaysia Page 8 .2 2.1.1 ADMINISTRATION OF MEDICATION VIA INJECTION DOCUMENT NO : E5 AF 5.

Calculate the required dosage T5. Identify right patient. Bahagian Kejururawatan . Observe nurse. Verify prescription.B. Explain and inform patient the procedure *S7. SOURCE OF S/N ITEM INFORMATION Listen / Observe nurse. Instructions for Auditors 1. Observe nurse / check for written evidence. Read patient’s medication profile T5.1. Responds promptly and Listen / Observe nurse. 2. Observe nurse. . Greet patient. Kementerian Kesihatan Malaysia Page 9 Observe nurse Observe nurse and countercheck calculation. Listen / Observe nurse. Select required medication from patient’s drawer of medication cart/ floor stock T5. National Nursing Audit. Ministry of Health Malaysia : Version 1 / Sept 2012.3. T2. Observe nurse. S6. politely to patients /career questions. (if required) T5. Item 4 is not rated if no specific nursing measures required. T3. Observe nurse. Assess patient.4 Reconfirm the medication and dosage before dilution/syringing out. YES NO N/A S1. Prepare the correct medication T5.N.2. T4. To tick [√ ] at appropriate column.

Listen/ Observe nurse.3 right dose T8.S/N ITEM SOURCE OF INFORMATION YES NO N/A T8. ii. Momentarily stop the intravenous flow. Bahagian Kejururawatan .5 right route Listen/ Observe nurse. v vi vii viii ix T9B i ii.4 right time T8.1 right patient. (optional) Continue the intravenous flow . Flush the canula with heparinised saline/saline again. Administer the medication according to 7R: T8. Choose the correct site to administer the drug.(optional) For intramuscular medication Choose the correct site to administer the drug Swab the site with an alcohol swab.2 right injection T8. Kementerian Kesihatan Malaysia Page 10 . (optional) Inject the medication slowly via the rubber bung/canula Swab the rubber bung /stopper using alcohol swab again. Swab the rubber bung /stopper using alcohol swab. Listen/ Observe nurse. National Nursing Audit. Listen/ Observe nurse Listen/ Observe nurse T9A. T8. Ministry of Health Malaysia : Version 1 / Sept 2012. iii iv.(optional) Withdraw air from the syringe Flush the canula with heparinised saline /saline. For intravenous medication i.

iii. Withdraw the piston to ensure no blood vi.2 Assessment findings. Observe nurse. Insert needle. ii. Stretch the skin at the site for injection and inject into the muscle at 90° v. i. iii. National Nursing Audit. Administer the drug slowly. Remove the needle and swab the site . Ministry of Health Malaysia : Version 1 / Sept 2012. directly below and outside the prepared injection site iv. vii. Remove the needle and swab the site T9D For intradermal medication i.iii Withdraw air from the syringe iv. vi. Bahagian Kejururawatan . Administer the drug slowly. bevel up. Apply downward pressure.. Pinch the skin at the site for injection and inject into the subcutaneous tissue at 45°. Remove the needle and swab the site with dry swab D10 Document: 10. Choose the correct site to administer the drug Prepare the injection site i. Observe nurse. 10. Administer the drug slowly. Kementerian Kesihatan Malaysia Page 11 . Swab the site with an alcohol swab. iv.1 Medication administered. T9C For subcutaneous medication Choose the correct site to administer the drug ii. iii. just under the skin at an angle of 15 to 20 degrees until the bevel is covered v. Swab the injection site accordingly.

Auditor 2 (name and signature): ………………………………………….………. Ministry of Health Malaysia : Version 1 / Sept 2012. Kementerian Kesihatan Malaysia Page 12 . …………………………………. Bahagian Kejururawatan . ………………………………………….AUDIT REPORT (please [√] the appropriate box) Rating: Conformance Technical Documentation Soft skill REMARKS: Non conformance Auditor 1 (name and signature): …………………………………………. National Nursing Audit..

Ministry of Health Malaysia : Version 1 / Sept 2012. Bahagian Kejururawatan .National Nursing Audit. Kementerian Kesihatan Malaysia Page 13 .