BOX 1-3
First Check
• Read the medication administration record (MAR) and remove the medication(s) from the patient’s drawer. Verify that the patient’s name and hospital number match the MAR.
• Compare the label of the medication against the MAR.
• If the dosage does not match the MAR, determine if you need to do a math calculation.
• Check the expiration date of the medication.
Second Check
• While preparing the medication (e.g., pouring, draw- ing up, or placing unopened package in a medication cup), look at the medication label and check against the MAR.
Third Check
• Recheck the label on the container (e.g., vial, bottle, or unused unit-dose medications) before returning it to its storage place.
or
• Check the label on the medication against the MAR before opening the package at the bedside.
From Przybycien, P. (2005). Safe meds. St. Louis, MO: Mosby. Adapted with permission.
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and then check the patient’s identification band to con- firm the patient’s name, identification number, age, and allergies. With children, the parents or legal guardians are often the ones who identify the patient for the pur- poses of giving prescribed medications. With newborns and labour and delivery situations, the mother and baby have identification bracelets with matching num- bers that should be checked before giving medications. With the older adult or patients with altered sensorium or level of consciousness, asking them for their name or having them state their name is not realistic, nor is it safe. Thus checking identification bands against the medication profile or medication order is important to avoid errors.
Right Documentation
The nurse is responsible for accurate documentation in electronic form, narrative form, SOAP (subjective, object- ive, assessment, planning) notes format, or other form. The nurse should document medication administration during or after (not before) administration in the patient’s record according to documentation standards. Documen- tation consists of clear, concise, abbreviation-free charting related to the meeting of goals and outcome criteria as well as noting of therapeutic effects versus adverse effects and toxic effects of anything related to the medication process. If the time of administration varies from the prescribed time, the time should be noted on the patient’s record with the reason for the altered time. Appropri- ate follow-through activities should also be documented (e.g., pharmacy states medication will be available in 2 hours). Medications should be observed being swal- lowed and not left at the bedside. If a medication is not given or taken, the nurse must follow the agency’s policy for documenting the reason for this. Adult patients have the right to refuse a medication. The nurse’s role is to inform the patient of the potential consequences of refusal and to inform the appropriate health care provider.
Many provinces are moving to implement electronic health records. The electronic health record (EHR) is a health record of an individual that is accessible online from many separate, interoperable automated systems within an electronic network. It provides an online profile of a patient’s drug prescription history. The system also notifies of drug interactions.
Right Reason
The nurse must ensure that the drug is being given for the right reason. If the nurse administers an unfamiliar drug and remains unknowledgeable about its action and intended effect, the drug may cause harm, although unintended, to the patient. Sometimes a medication may be administered for a reason that is not obvious, as the classification is not the reason for the administration. For example, lactulose, although classified as a laxative, is also used for the treatment of hepatic encephalopathy to bind with ammonia to reduce toxic levels.
Other factors must be considered in determining the right time. These include multiple-drug therapy, drug−drug or drug−food compatibility, scheduling of diagnostic tests, bioavailability of the drug (e.g., the need for consistent timing of doses around the clock to maintain blood levels), drug actions, and any biorhythm effects such as those that occur with steroids. It is also critical to patient safety to avoid using abbreviations for any component of a drug order (i.e., dose, time, route). The nurse should always be careful to spell out all terms (e.g., “three times daily” instead of “tid”) because the possibility of miscommunication or misinterpretation poses a risk to the patient.
Right Route
As previously stated, the nurse must know the particu- lars about each medication before administering it to ensure that the right drug, dose, and route are being used. A complete medication order includes the route for administration. If a medication order does not include the route, the nurse must ask the physician to clarify it. The nurse must never assume the route of administration.
Right Patient
Checking the patient’s identity before giving each medi- cation dose is critical to the patient’s safety. The nurse should ask the patient to state the patient’s own name
TABLE
1-1
Conversion of Standard Time to Military Time
Standard Time Military Time
1 AM 0100 2 AM 0200 3 AM 0300 4 AM 0400 5 AM 0500 6 AM 0600 7 AM 0700 8 AM 0800 9 AM 0900 10 AM 1000 11 AM 1100 12 PM (noon) 1200 1 PM 1300 2 PM 1400 3 PM 1500 4 PM 1600 5 PM 1700 6 PM 1800 7 PM 1900 8 PM 2000 9 PM 2100 10 PM 2200 11 PM 2300 12 AM (midnight) 2400
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PART ONE Pharmacology Basicsnurses also have to check the actions of other health care providers (such as UCPs), never assume that all is cor- rect and appropriate, and be responsible for their own actions. For further discussion of medication errors and their prevention, see Chapter 5.
E V A L U A T I O N
Evaluation occurs after the collaborative plan of care has been implemented. It is a systematic, ongoing, and dynamic part of the nursing process as related to drug therapy. It includes monitoring the patient’s therapeutic response to the drug and its adverse effects and toxic effects. Documentation is also an important component of evaluation and should include charting related to the medication administration process (see Legal and Ethical Principles). Charting should be done at the time of an event or as close to it as is prudently possible. Charting should also be consistent with and follow the existing written policy on charting of your current employer (see Box 1-4).
Evaluation also includes the process of monitoring the standards for nursing practice. Several standards of care are in place to help in the evaluation of outcomes of care, such as those standards established by nursing provincial governing bodies and the Canadian Council on Health Services Accreditation (CCHSA). Within the CCHSA, guidelines are established for nursing services,
Medication Errors
When the “rights” of drug administration are discussed, medication errors must be considered. Medication errors are a major problem in health care, regardless of the set- ting. The National Coordinating Council for Medication Error Reporting and Prevention (2008) defines medication error as “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 provider, patient, or consumer. Such events may be related to professional practice, health-care products, procedures, and systems including prescribing; order communica- tion; product labelling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use” (http://www.nccmerp. org/aboutMedErrors.html).
It is important for the nurse to understand the defin- ition of medication errors because it emphasizes that, in evaluating contributors to a medication error, the nurse must look at all the “rights” of medication adminis- tration and at the systems (i.e., ordering, dispensing, preparing, administering, and documenting) involved in the medication administration process, which may include health care providers and ancillary personnel, as well as unit stocking, transcription of orders, and how the medication order is verified and interpreted. Indeed, pharmacists are responsible for their own actions, but
Charting “Don’ts”
Charting is a critical component of the nursing process. The following is a list of charting don’ts:
• Don’t record staffing problems (don’t mention them in a patient’s chart but instead talk to the appropriate nurse manager).
• Don’t record a peer’s conflicts such as charting pos- sible disputes between a patient and a nurse. • Don’t mention incident reports in charting because
they are confidential and are filed separately and not in the patient’s chart. The facts of an incident may be documented, but don’t mention the terms (e.g., that it was an error).
• Don’t use the following terms: “by mistake,” “by accident,” “accidentally,” “unintentional,” or “miscalculated.”
• Don’t chart other patients’ names because this is a violation of confidentiality.
• Don’t chart anything but facts.
• Don’t chart casual conversations with peers, phys- icians, or other members of the health care team. • Don’t use abbreviations, as a general rule of thumb.
Some agencies or facilities may still use a list of approved abbreviations, but overall they are discouraged.
Note: Although this is taken from an American reference, institu- tions in Canada follow similar rules.
Data from the Institute for Safe Medication Practices. (2003, Feb- ruary 20). ISMP medication safety alert, available at http://www. ismp.org/Newsletters/acutecare/archives.asp; and Nursing (2000, revised 2004). Incredibly easy!: Charting “don’ts”. Retrieved July 23, 2009, from http://findarticles.com/p/articles/mi_qa3689/ is_200007/ai_n8911410/.
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the nurse gathers, analyzes, organizes, provides, and acts on data about the patient within the context of prudent nursing care and standards of care. The nurse’s ability to make astute assessments, formulate sound nursing diagnoses, establish goals and outcome criteria, correctly administer drugs, and continually evaluate the patients’ responses to drugs increases with additional experience and knowledge.
policies, and procedures. The CNA Code of Ethics (Can- adian Nurses Association, 2008) and specific medication practice standards regarding nurses’ accountability for medication administration were established to protect both the patient and the nurse.
In summary, the nursing process is an ongoing and constantly evolving process (see Box 1-1). The nursing process, as it relates to drug therapy, is the way in which
1 Record the facts—what you can see, hear, smell, and touch.
2 Record information as closely as possible to the time you deliver care. Don’t document in advance, and don’t leave important notes until the end of the shift.
3 Chart in chronological order, writing on every line so that the chronology cannot be altered.
4 Eliminate bias from your notes. Labelling a patient can alter patient care: In one situation, nurses caring for a patient in labour labelled her a “complainer” and missed the clues to her abdominal obstruction.
5 Use flow sheets to record routine care. Keep them in the patient’s room, if possible, so you can chart immediately after giving a treatment.
6 Consider using a problem-oriented approach. Identify and describe the problem, how it was resolved, and the patient’s response.
7 Ensure continuity. Note problems as they occur and the interventions that followed.
8 Document all medical visits and consultations, whether in person or by phone. Note the discussion of the patient’s condition, any abnormal findings, directions
the physician gave, and the actions you took. Also note the time and date of the visit or consultation.
9 Document discussions about concerns with medical orders and directions the physician gave confirm- ing, cancelling, or modifying the orders. Include the time and date of the discussion and your actions as a result of the orders—for example: 5/12 1930— Discussed morphine dose order and pt.’s pain level ratings over the past 24 hr with Dr. Donhauser. PCA doses changed and pain control improved (see pain- flow sheet). B. Haldeman, RN
10 Prepare a discharge plan that lists instructions for the patient and follow-up. Send a copy of the plan home with the patient and keep a copy in the record. Good charting takes time and effort, but in return it offers protection for you and your patient.
Source: Philpott, M. (1985). Legal liability and the nursing pro-
cess. Toronto, ON: Saunders. Adapted and updated with the
permission of the publisher. 10 rules for good charting obtained from Nursing 2008 (1998 May), 28(5): 27. Reprinted with permis- sion of Wolters Kluwer Health.
BOX 1-4
Ten Rules for Good Charting
❖ Nurses are responsible for safe and prudent decision making in the nursing care of their patients, includ- ing the provision of drug therapy and use of the Ten Rights, and must always adhere to legal and ethical standards related to medication administration and documentation.
❖ Nurses need to document in clear, concise language and avoid the use of abbreviations.
❖ Nurses are entrusted with confidential information and with the lives of their patients during all facets of patient care, including drug therapy.
❖ Safe, therapeutic, and effective medication admin- istration is a major responsibility of professional nurses in the care of patients of all ages and in a wide variety of facilities.
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PART ONE Pharmacology Basics1 An 86-year-old patient is being discharged home on digitalis therapy and has little information regarding the medication. Which of the following statements best reflects a realistic goal or outcome of patient teaching activities?
a. The patient will call the physician if adverse effects occur.
b. The patient will state all the symptoms of digitalis toxicity.
c. The nurse will provide teaching about the drug’s adverse effects.
d. The patient and patient’s daughter will state the cor- rect dosing and administration of the drug.
2 What is the most appropriate response to a patient who informs the nurse that she does not want to share infor- mation about the drugs she takes at home?
a. “We’re just asking to make sure that you do not have any drug allergies.”
b. “It sounds like something you are taking is some- thing that you do not want us to know about.” c. “This information will not become part of your
medical record, but we need to know so that we can monitor your responses to therapy while you are here.”
d. “Information about the drugs that you take at home, including any natural health products, is important for safe administration of drugs while you are here and will be kept confidential.”
3 A patient’s chart includes an order that reads as follows: Lanoxin 0.025 mcg once daily at 0900. Which of the fol- lowing statements regarding the dosage route for this drug is correct?
a. The drug should only be given orally. b. The drug should be given intravenously.
c. The drug should be given via the transdermal route. d. The dosage route should never be assumed when an
order does not specify a route.
4 Which of the following questions is most effective in compiling a drug history for a patient?
a. “What childhood diseases did you have?” b. “Do you have a family history of heart disease?” c. “Do you depend on sleeping pills to get to sleep?” d. “When you take your pain medicine, does it relieve
the pain?”
5 A 77-year-old male who has been diagnosed with an upper respiratory infection tells the nurse that he is allergic to penicillin. Which of the following would be the nurse’s most appropriate response?
a. “That is to be expected—lots of people are allergic to penicillin.”
b. “What type of reaction did you have when you took penicillin?”
c. “This allergy is not of major concern because the drug is given so commonly.”
d. “Drug allergies don’t usually occur in older individ- uals because they have built up resistance.”
For answers see http://evolve.elsevier.com/Canada/Lilley/pharmacology/.
1 What are the crucial responsibilities of the nurse when implementing drug therapy?
2 When medications were administered during the night shift, a patient refused to take his 0200 dose of an anti- biotic, claiming that he had just taken it. What actions by the nurse would ensure sound decision making and maintain patient safety?
3 During a busy shift, you note that the chart of your newly admitted patient has few orders for medications and diagnostic tests, taken by telephone by another nurse. You were on the way to the patient’s room to do your assessment when the unit secretary tells you that one of the orders reads as follows: “Lasix, 20 mg, stat.” What should you do first? How do you go about giving this drug? Explain.
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Glossary
Additive effects Drug interactions in which the effect of a combination of two or more drugs with similar actions is equivalent to the sum of the individual effects of the same drugs given alone (compare with synergistic effects). (p. 37)
Adverse drug event (ADE) Any undesirable occurrence related to administering or failing to administer a pre- scribed drug. (p. 38)
Adverse drug reaction (ADR) Any unexpected, unintended, undesired, or excessive response to a medi- cation given at therapeutic dosages; one type of ADE. (p. 38)
Adverse effects Any undesirable bodily effects that are a direct response to one or more drugs. (p. 22)
Agonist A drug that binds to and stimulates the activity of one or more biochemical receptor types in the body. (p. 34)
Allergic reaction An immunological hypersensitivity reaction resulting from the unusual sensitivity of a patient to a particular medication; a type of ADE. (p. 38)
Antagonist A drug that binds to and inhibits the activity of one or more biochemical receptor types in the body, resulting in inhibitory or antagonistic drug effects; also called inhibitors. (p. 34)
Antagonistic effects Drug interactions in which the effect of a combination of two or more drugs is less than the sum of the individual effects of the same drugs given alone. (p. 37)
Bioavailability A measure of the extent of drug absorption for a given drug and route (can vary from 0% to 100%). (p. 23)
Biotransformation One or more biochemical reactions involving a parent drug. (p. 30)