Medication administration and medication error prevention

● CNO outlines 3 principles relating to medication administration to promote public safety.

They are authority, competence, and safety.
● Authority
○ Definition: Nurses must have the necessary authority to perform medication
practices, so we have to think about if we have an order in place before initiating
the procedure.
○ When do we need an order? (When do nurses require an order for a medication
practice)
■ If a controlled act is involved
● Acts that could cause harm if performed by those who do not have
the knowledge, skill and judgment to perform them. Some
examples of controlled acts are inserting IVs, performing wound
care below the dermis, and inserting an urinary catheter.
■ If we are administering a prescription medication
■ If it is required by legislation (The example given by the CNO is that for
client treatments and diagnostic procedures, the Public Hospitals Act
requires us to obtain an order from an NP or a physician.)
○ If an order is required, nurses should also make sure that the order is clear (font,
and meaning), complete, and appropriate.
■ How do we know if the order is clear?
● Do I understand the order?
■ How do we know if the order is complete?
● Does the order contain all of the information that I need to
administer or dispense the medication safely?
■ How do we know if the order is appropriate?
● We are considering the client here to see if the medication
practice is appropriate for the client’s current condition, health
history, and so on.
■ What should we do if the order is unclear, incomplete, or inappropriate?
● Nurses should not perform the medication practice and we should
follow up with the prescriber.
● (so we talked about one of the principles–authority, how we should have the authority to
perform medication practices, and when we need an order, and what an order should be
like). The second principle outlined by CNO is competence.
○ What does competence mean?
○ Nurses ensure that we should have the knowledge, skill and judgment to perform
medication practices safely.
○ The practices should be evidence informed, and we should also understand our
limits and get help as needed.
● Safety is the third principle
 ○ Nurses promote safe care, and contribute to a culture of safety within their
practice environments. How can nurses promote safe care during medication
practices?
■ E.g. doing a thorough assessment; inquiring the patients about their
health history; provide education to the patients about their meds; prevent
medication error; engage the patients in the decision making process;
● Okay, so let’s talk about the 12 rights of medication administration.
● What are the 12 rights?
○ Right medication
○ Right dose
○ Right patient: check MAR against the identification bracelet and ask the patient to
state their name.
○ Right route: (what will happen if the med is given in the wrong route?) if the
prescriber’s order does not specify a route or the route is not the recommended
one, we should always consult the prescriber first. We should also be careful
when injecting a liquid, because injecting the liquid which is designed for oral
use, for example, can cause local or fatal systemic complication
○ Right site
○ Right date and time
○ Right frequency: potter and perry pose this question: what is the difference
between q8h and three times a day? The q8h medication is expected to be given
around the clock to maintain therapeutic blood levels. And three times a day
medication is administered during the waking hours. STAT medication? What is
the window that we can administer the medication?
○ Right documentation: (why is right documentation important? It is important
because it is how healthcare providers communicate with each other) we are
also responsible for documenting pre assessment data regarding certain
medications. For example, we assess and document the blood pressure before
giving antihypertensive medication. Same things also apply to blood sugar
lowering medications and pain medications.
○ Right reason: we should know why the medication is given, expected onset of the
medication, contraindications, adverse effects, and so on. So basically the things
we include in our drug card. By having an understanding of the medication, we
will be able to recognize when the prescriber orders a medication that is
contraindicated or maybe the dose is too high
○ Right to refuse: patients are not passive recipients of care, they have the right to
refuse the medication, but at the same time, they should also be informed about
the potential consequences of their refusal.
○ Right patient education: education about their medication and the treatment plan.
Sometimes we also need to educate the patients’ families especially if they are
the ones who manage the medication at home.
○ Right evaluation: this includes monitoring of the effectiveness of the medication,
the adverse effects, or any signs of drug interactions. Sometimes we also need
 to evaluate older adults’ cognitive ability because it can affect their ability to
manage their medications.
● Three checks:
○ 1st: check the ADU against MAR
○ 2nd: take the med out the ADU, check it against MAR and check expiry date
○ 3rd: check the medication against MAR at the bedside.
● So basically summarizing what we have talked about, when we give meds, these are the
steps that we should follow:
○ Do we have a proper authorizing mechanism in place? Like do we have the order
or the directives?
○ Do we have the competence to administer? (knowledge, skill, judgment)
○ Have we assessed environmental supports such as the human and technological
resources if needed to intervene?
○ Have we assessed client factors? (for example, have we identified the patient
using two identifiers? Is the order appropriate for the patient? Did the patient give
consent?)
○ Administer the medication
○ Evaluate the outcomes such as assessing the therapeutic effects of the
medication and watching out for any adverse effects
● Common medication error 781
○ Preparing drugs for multiple patients
■ Organize the medication process by preparing medications for one
patient at a time. When preparing medications for multiple patients, apply
patient labels to medication cups, removable needle caps of syringes,
and IV bags.
○ MAR unavailable or not referenced
■ Prepare medications in accordance only with the original MAR, and take
the MAR to the patient’s bedside for verification before administering
medications.
○ Calculation error
○ Wrong patients (patients with the same name)
■ Identify patients using two identifiers
○ Other activities interrupt the medication administration process
○ Partial drug administration
■ How to prevent forgetting to cut the pills
○ Forget some medication requiring ongoing monitoring
■ Antihypertensive medication requires vital signs monitoring, warfarin
requires lab value monitoring
○ Oral liquids in parenteral syringes