Medication Administration

by Jennifer Meyering
Objectives:
 Review the six rights of medication administration
 State common causes of medication errors and how to prevent them
 Explain the most commonly used methods of medication administration
 
Medication administration is one the most important skills that a nurse, or any
healthcare professional, will learn.  From legal, ethical, and practical standpoints,
medication administration is a highly complex procedure.  It requires you to have a
wide-range of knowledge, analytical skill, professional judgment, and clinical expertise. 
 

Six Rights of Medication Administration

Any time you administer any medication, you must check the six rights.  Checking the
six rights can help you avoid medication errors.  Each time you administer a medication,
confirm that you have the:
 right drug
 right dose
 right patient
 right time
 right route
 right documentation

Right drug
Before giving a medication, always compare the name of the ordered drug with name
printed on the medication label.  Do this carefully; drugs with similar-sounding and
similar-looking names may have different indications and effects.  The Institute for Safe
Medicine and Practice has issued a list of medications that look and sound alike.  The
Joint Commission has also made it mandatory for hospitals to keep a list of look-alike
sound-alike medications (Joint Commission, 2009).  For example, Celexa (citalopram)
and Celebrex (celecoxib) sound alike, but they have very different functions.  Celexa is a
selective serotonin reuptake inhibitor that is used to treat depression.  Celebrex is a
nonsteroidal anti-inflammatory medication that is used to treat osteoarthritis and
rheumatoid arthritis.
When a medication is individually wrapped in single doses, check the name of the
medications when removing it from the medication dispensing system, and again when
you unwrap and give the drug to the patient. 
Besides carefully checking the ordered medication name against the container label, also
check the patient’s reaction to the drug as attempt to give it to him.  If he states the
medication is different than the medication he usually takes, stop what you’re doing and
recheck the order.  It may be as simple as explaining to the patient that the practitioner
has ordered a different dose of the drug, or that you are administering a different
generic brand than the patient takes at home.  It is also possible that you will discover
that you’re giving the wrong medication.  Either way, you must carefully follow up on
any comment a patient makes about changes in his medications- and you must follow
up before you administer the medication.

Right dose
The use of unit-dose medication (where a single dose of medication is wrapped and
labeled for individual use) has greatly decrease the risk of giving a patient the wrong
drug dose.  Also, the availability of many commercially prepared medications in various
tablet sizes decreases the need for calculations to determine the correct dose.
Whenever you must perform a calculation, double check your answer with another nurse
or a pharmacist.  Many hospitals require a double on certain medications, such as insulin
and heparin, and those that involve children’s medications.

Right patient
To reduce the risk of medication errors, never assume that the patient in a labeled bed
is the patient named on the label.  Instead, always check the patient’s ID bracelet
carefully against the medication administration record before giving any medication
(Joint Commission, 2009).  As an additional check, also ask the patient to tell you his
name.  Don’t say the patient’s name and ask him if that is his name- a confused patient
may answer “Yes”, even though it isn’t his name.
Also, if your facility uses a bar-coding system, scan the patient’s bar code and the
medication administration record.  This helps ensure that you are giving the medication
to the right patient.

Right time
The right administration time may be based on therapeutic or practical considerations,
or both.  For therapeutic purposes, the right time is one that appropriately maintains the
level of the drug in the patient’s bloodstream.  For practical purposes, the right time is
one that is convenient for the staff and the patient.  Therapeutic considerations always
take precedence of practical ones.
To meet therapeutic goals, you may need to space the delivery of some medications
evenly around the clock.  Doing this helps maintain a consistent level of the drug in the
patient’s bloodstream.  If you don’t need to space the drug delivery over 24 hours, you
can space it over the patient’s waking hours so you don’t disrupt his sleep.
Before administering some drugs, you will need to measure the patient’s therapeutic
response before determining if it’s the right to time administer another dose.  For
example, you should check the patient’s apical heart rate before administering digoxin,
and you should check the patient’s pain level and respiratory rate before administering
morphine or other opioids.
Along with maximizing the therapeutic effect, administering medications at specified,
evenly spaced intervals has practical benefits.  One benefit is it allows you to plan
administration times that don’t interfere with patient meals, or a busy time on the floor. 
For example, a medication that is administered twice daily can be given at 9:00 am and
9:00 pm, rather than 7:00 am and 7:00 pm, which are common times for shift change.
Another benefit of standardized administration times is that it establishes a habit in the
patient’s mid.  This makes it easier for him to keep taking the medication at the right
times when he is discharged.
Whatever the reasons behind the administration times that are established for the
patient, you will need to follow those times carefully.  Many facilities consider it a
medication error if you don’t administer a medication with 30 minutes of its scheduled
administration time.

Right route
Always pay close attention to the administration route that is specified on the medication
label and the medication order.  Also, you should always make sure that the ordered
from of the drug is appropriate for the intended route.  Only drugs that are labeled for
injection should be used for any type of injection.
Before you give the drug, consider whether the amount ordered is appropriate to
administer by the route you’re preparing to give it.  For example, while 10 mg of
morphine is appropriate to administer intramuscularly, a more appropriate I.V. dose is 2
to 4 mg.
Remember that the route that you give a drug affects the rate that it is absorbed into
the patient’s bloodstream.  Because certain forms of a drug may be intended for specific
routes, be careful not to interfere with the drug’s action by changing routes or
circumventing the chemical preparation.  You should never crush an enteric-coated
tablet or open a sustained-release capsule.
You can also decrease the rate of absorption and effectiveness of a drug.  If a patient
chews or swallows a sublingual drug, such as nitroglycerin, it will decrease the rate of
absorption and the effectiveness of the medication.

Right documentation
The time and type of medication documentation that is required is defined by each
facility.  Medication documentation includes the time, route, dosage, site of
administration (for parenteral administration), and your initials and signature.  If your
facility using electronic charting, most, if not all, of these requirements can be met by
simply clicking with a mouse.
Specific documentation may be required if you don’t administer a medication as
ordered.  Many facilities require that you circle the time of administration when you
don’t administer a medication for any reason.  If you don’t administer the medication,
you must indicate the reason, such as NPO, or patient refused.  If the reason is complex,
or requires additional explanation, you also need to chart the missed medication in the
nurses notes.
Some medications, such as insulin or heparin, may have a separate flowsheet for
additional information.  Information that may be included on this form includes the
location of each injection, the dose, and a second set of nurse’s initials checking the
dose.
You are also responsible for documenting the therapeutic and adverse effects of the
medication.  For example, when administering pain medication, this includes
documenting the pain relief that the patient obtains, as well as if the patient experiences
constipation, respiratory depression, or other adverse effects.
When documenting medication administration, the most important thing is document
immediately after giving the medication to decrease the risk of errors.
 

Avoiding medication errors

Medication errors are the most common type of errors in hospitals.  One study
showed that adverse drug events are the most common type of medical errors
(Rozich, 2003).  The Institue of Medicine released a study that showed the majority
errors that occur in health care come from flaws in the system, rather than gross
neglect (Institute of Medicine, 1999).  Along with carefully following your facility’s
policies, there are also simple things that you can do to help prevent medication
errors. 

Patient allergies
Any time you administer medication to a patient, take a moment and check his
allergies.  Not only do you need to make sure that the patient isn’t allergic to the
medication you are about to give him, you also need to make sure that his isn’t allergic
to a component of the medication.  For example, a patient who has a peanut allergy
may have an allergic reaction to Atrovent given by metered-dose inhaler.  For this
patient, you will need to administer the intranasal form of Atrovent, which doesn’t
contain soy lecithin which is a peanut allergen.  If you are unsure about the patient’s
allergies and if the medication may cause a problem, contact the pharmacist or
practitioner.

Medication orders
In order to administer a medication correctly, every member of the health care team has
a role that must be correctly performed.  The doctor must take care to write the order
for the medication correctly and in a manner that can be easily read.  The pharmacist
must correctly evaluate the order and determine if it is appropriate for the patient, and
then dispense the medication correctly.  The last part of chain is you- the nurse.  You
must evaluate the order and if the medication is appropriate for the patient, and then
administer it correctly.
If there is a breakdown anywhere along this chain of events, a medication error can
occur. The healthcare team must act together as a team, performing the checks and
double-checks that help prevent errors from occurring.

Route errors
Many medication errors can be traced back to a problem related to the route of
administration.  This is especially true with intravenous medications, and increases even
more when the patient has several I.V. lines for different purposes. 
When a patient has an abdominal tube, such as a PEG tube, prepare all medication to go
into the tube in a syringe that has a tip too big to fit into the I.V. tubing.  This helps
prevent inadvertent intravenous administration of oral medication.  Another technique
that can help prevent a medication error is to never increase a drip rate on an I.V. pump
to clear bubbles or an obstruction from the line.  Always remove the tubing from the
pump, disconnect it from the patient, and use the flow-control clamp to begin the flow.  
This helps prevent an overdose in medication if you forget to reset the correct pump
rate.