Medications are the most common treatment intervention used in healthcare around the world. When used safely and appropriately, they contribute to significant improvements in the health and well-being of patients. Medicines are generally safe when used as prescribed or directed on the label, but there are risks with the administration and ingestion of any medicine.
Ten Key Elements of Medication Use
Many factors can lead to medication errors. The Institute for Safe Medication Practices (ISMP) has identified 10 key elements with the greatest influence on medication use, noting that weaknesses in these can lead to medication errors.
- patient information
- drug information
- adequate communication
- drug packaging, labeling, and nomenclature
- medication storage, stock, standardization, and distribution
- drug-device acquisition, use, and monitoring
- environmental factors
- staff education and competency
- patient education
- quality processes and risk management.
Accurate demographic information (the “right patient”) is the first of the “five rights” of medication administration. Required patient information includes name, age, birth date, weight, allergies, diagnosis, current lab results, and vital signs.
Accurate and current drug information must be readily available to all caregivers. This information can come from protocols, text references, order sets, computerized drug information systems, medication administration records, and patient profiles. All medications should have labels and should be checked for expiration. All potential side effects and allergic reactions should be noted.
Many medication errors stem from miscommunication among physicians, pharmacists, and nurses. Communication barriers should be eliminated, and drug information should always be verified. One way to promote effective communication among team members is to use the “SBAR” method (situation, background, assessment, and recommendations). Poor communication accounts for more than 60% of the root causes of sentinel events reported to the Joint Commission (JC).
Drug Packaging, Labeling, and Nomenclature
Healthcare organizations should ensure that all medications are provided in clearly labeled unit-dose packages for institutional use. Packaging for many drugs looks similar. Look-alike or sound-alike medications—products that can be confused because their names look alike or sound alike—also are a source of errors. The JC requires healthcare institutions to identify look-alike and sound-alike drugs each year and have a process to help ensure related errors don’t occur.
Medication Storage, Stock, Standardization, and Distribution
Potentially, many errors could be prevented by decreasing floor-stock medications’ availability, restricting access to high-alert drugs, and distributing new medications from the pharmacy in a timely manner.
Drug-Device Acquisition, Use, and Monitoring
Improper acquisition, use, and monitoring of drug delivery devices may lead to medication errors. Some delivery systems have inherent flaws that increase the error risk.
Environmental factors that can promote medication errors include inadequate lighting, cluttered work environments, increased patient acuity, distractions during drug preparation or administration, and caregiver fatigue. Distractions and interruptions can disrupt the clinician’s focus, leading to serious mistakes. To reduce interruptions, Sentara Leigh Hospital in Norfolk, Virginia, has instituted a “no interruption” zone around the automated medication dispensing machines; coworkers know not to interrupt a nurse who’s obtaining medication from the machine. Heavier workloads also are associated with medication errors. The nursing shortage has increased workloads by increasing the number of patients for which a nurse is responsible. Also, nurses perform many tasks that take them away from the patient’s bedside, such as answering the telephone, cleaning patients’ rooms, and delivering meal trays. The absence of nurses from the bedside is directly linked to compromised patient care.
Staff Education and Competency
Continuing education of the nursing staff can help reduce medication errors. Medications that are new to the facility should receive high teaching priority. Staff should receive updates on both internal and external medication errors, as an error that has occurred at one facility is likely to occur at another. As medication-related policies, procedures, and protocols are updated, this information should be made readily available to staff members.
Caregivers should teach patients the name of each medication they’re taking, how to take it, the dosage, potential adverse effects, interactions, what it looks like, and it’s being used to treat.
Quality Processes and Risk Management
A final strategy for reducing medication errors is to establish adequate quality processes and risk management strategies. Every facility should have a culture of safety that encourages discussion of medication errors and near-misses (errors that don’t reach a patient) in a nonpunitive fashion.
Beyond these, there are other areas where medication errors can be an issue. Nurses are routinely asked to calculate dosage information and provide data entry services for medications and intravenous infusions. More than one-third of reported incidents in long-term psychiatric care hospitals involved the wrong drug administration type. Drug identity-checking errors and wrong dose errors were reported as among the most frequent type of errors.
Firstly, there were identification incidents caused by confusing patients with the same or a similar name. This occurred more often when more than two patients with the same name were residents in the same unit. In addition, the similarity of a name also increased the risk. The similarity of drug names is also a risk factor for errors.
Follow this link for a list of sound-alike drugs to be watchful for.
Assuming the physician’s order and patient information are correct, there are three general possibilities for mistakes when administering IV medications via a pump: dosage miscalculation, transcription data entry error, and titration of the wrong medication.
Miscalculation Error: A miscalculation error can occur for many reasons, including the use of inaccurate parameters such as dose, weight, height, drug units, or solution volume. A misplaced decimal or missing number in this complex calculation can result in a calculation error that may not be immediately apparent to the clinician. While a nurse will immediately recognize certain miscalculations, some mistakes like using the wrong concentration data in the calculation may go unnoticed and may result in a medication error that is clinically significant and life-threatening.
Data Entry Error: A transcription type data entry error occurs when a nurse inadvertently inputs the wrong data into the infusion pump. Another type of transcription error is the inputting of an incorrect decimal point. For example, the proper infusion rate is calculated, but the rate is incorrectly entered as 54.0 ml/hr instead of 5.40 ml/hr.
Titration Errors: According to their effect on the patient, many drug delivery rates are changed while the infusion pump is infusing. This type of rate change is called titration. Understanding the medication that is being ordered and the dosage that this drug is routinely given in is key to assuring that the patient is getting the proper medication dose.
Transcription Errors: Reading a physician’s writing is sometimes a difficult task; get clarity if uncertain about what has actually been written. If taking a verbal or phone order, a “read-back” system can be instituted in which the nurse who is taking the order writes down the verbal order and reads it back to the prescribing physician. Once it is read back to the physician and both parties agree, the order can then be processed.
The “Seven Rights” of Medication Administration
Most registered nurses learned about the “5 rights” early in their careers. The 5 rights (right drug, right client, right dose, right time, and right route) have been incorporated into their nursing practice. Registered nurses also recognize they need to know the reason the drug is given — the right reason. The administration of medication is not complete until documentation has occurred — the right documentation.
- RIGHT drug
- RIGHT client (Two Identifiers)
- RIGHT dose
- RIGHT time
- RIGHT route
- RIGHT reason
- RIGHT documentation
The addition of “Right Reason” to the original “5 Rights” of medication administration will assure that the right medication was ordered and assist in assuring that it is for the right person. To assure safe and accurate documentation of Medication Administration, the “Right Documentation” has been added to the original “5 Rights”. Remember the W’s when documenting medication administration on the patient chart:
- When (time)
- Why (include assessment, symptoms/complaints, lab values)
- What (medication, dose, route)
- Where (site)
- Was (the med tolerated and, if known, helpful to the patient)
In addition to using the W’s for safe and effective Medication Administration Documentation, using the following techniques will assure that your documentation is clear, concise, and easily understood:
- Legible writing or printing.
- Use of specified ink color.
- Correct grammar & spelling
- Correct recording of time.
- Assure patient identification information is on each page.
- No blanks and no spaces between entry and signature.
- Charting promptly after the provision of care.
- Use approved abbreviations.
- Subjective data should be in a patient’s own words.
Common Abbreviations and Latin Terms
- t.i.d.: “ter in die” three times a day. The abbreviation t.i.d. is sometimes written without a period either in lower-case letters as “tid” or in capital letters as “TID.”
- q.d. (qd or QD) is once a day; q.d. stands for “quaque die” (which means, in Latin, once a day).
- b.i.d. (or bid or BID) is two times a day; b.i.d. stands for “bis in die” (in Latin, twice a day).
- q.i.d. (or qid or QID) is four times a day; q.i.d. stands for “quater in die” (in Latin, 4 times a day).
- q_h: If a medicine is to be taken every so-many hours, it is written “q_h”; the “q” standing for “quaque” and the “h” indicating the number of hours. So, for example, “2 caps q4h” means “Take 2 capsules every 4 hours.”
- a.c: Before meals
- po: (PO or p.o.): “per os,” meaning “by mouth.”
- prn: as needed.
What is at the “Route” of the Problem?
- Drug tolerance declines in patients with decreased cardiac output, diminished urine output, pulmonary congestion, or systemic edema. To compensate, dilute the prescribed drug more than usual and administer it at a slower rate.
- Don’t give a drug by I.V. bolus injection if you need to dilute it in a large-volume parenteral solution before it enters the bloodstream.
- Avoid using an I.V. bolus injection whenever the rapid administration of a drug could cause life-threatening complications.
- Injected into the vein
- Provides a rapid, predictable absorption with minimal complications
- Inject directly into the fatty, subcutaneous tissue under the skin that overlies the muscle
- Absorption from this route is slow, resulting in a delayed onset of action and prolonged effect
- Used primarily with pediatric patients
- Inject into the bone marrow
- Medications quickly enter the circulatory system
- Must be delivered through the respiratory tract
- Inhaled medication may be administered via aerosolized treatments and inhalers
- Digestive tract
- Placed on the skin
- Absorbed into the circulatory system through the skin
- Injected into the muscle tissue
- It is absorbed into the bloodstream
- Administration has a predictable rate of absorption
- Onset of action is considerably slower than intravenous administration
Avoiding Medication Errors
How can you safeguard your practice from medication errors? For starters, be conscientious about performing the “five rights” of medication administration every time—
right patient (using two identifiers), right drug, right dosage, right time, and right route.
Some experts have expanded this list to include:
- right reason for the drug
- right documentation
- right to refuse medication
- right evaluation and monitoring.
Be sure to use the safety resources available at your facility. Don’t use workarounds to bypass safety systems. Additional steps you can take to promote safe medication use include:
- reading back and verifying medication orders given verbally or over the phone. (See Reading back medication orders.)
- asking a colleague to double-check your medications when giving high-alert drugs
- using an oral syringe to administer oral or NG medications
- assessing patients for drug allergies before giving new medications
- becoming familiar with your facility’s “do not use” list of abbreviations.
Eliminating Medication Errors
Avoiding medication errors requires vigilance and the use of appropriate technology to help ensure proper procedures are followed. Computerized physician order entry reduces errors by identifying and alerting physicians to patient allergies or drug interactions, eliminating poorly handwritten prescriptions, and giving decision support regarding standardized dosing regimens. Be sure to use the safety practices already in place in your facility. Eliminate distractions while preparing and administering medications.
Reading Medication Labels
Before we can even begin to calculate how much medicine to give a patient, we must read a medication label correctly. There are several important pieces of information we should look for whenever we look at a medication label:
Name of the medication
There are actually at least two names on every medication label:
The trade name is the name assigned to the manufacturer’s drug, and it varies from one company to another. A single drug may have many different trade names if manufactured and sold by many different companies. The trade name of a drug is usually capitalized.
For example, you may be familiar with the over-the-counter pain relievers Advil and Motrin. These are actually two different brand names for the same drug that two different companies manufacture.
The generic name is the name assigned to the drug officially in the United States. There is only one generic name for each drug, and all drug labels must list the drug’s generic name in addition to any trade names so that its official name can identify the drug. The generic name of a drug is generally written in lower case letters.
So, Motrin and Advil are trade names that refer to the same drug, and its official generic name is ibuprofen. If you look closely at a bottle of Advil or Motrin, you will see that each bottle’s labels state that they contain ibuprofen.
A drug may be ordered by its brand name or by its generic name, so it is essential to pay attention to both kinds of drug names so that you can identify a drug by either one when it is ordered.
These are units used to measure the drug’s weight or action and are the units used whenever an order is written for the drug.
The most common dosage units are milligrams, grams, micrograms, grains, Units, and milliequivalents.
These are units that are used to measure the drug for actual administration to the patient.
Because it would be challenging to measure a drug by its weight or action, we usually measure drugs by their volume or by counting a number of tablets or capsules when we actually want to take out the exact amount we want to give the patient.
The most common administration units are tablets, capsules, teaspoons, tablespoons, ounces, drops, liters, and milliliters.
Concentration or Dosage strength
This tells us what the relationship is between the dosage units and the administration units.
Because almost all drugs are ordered in dosage units but administered in administration units, we must have a way to convert from one set of units to the other; this is what the concentration of a drug allows us to do.
Total amount of the drug contained in the package
This is exactly what it sounds like: the total number of dosage units or administration units in a particular package of the drug.
All drugs have an expiration date on them, usually prefaced by the abbreviation EXP.; you should always check that the current date is before the drug’s expiration date before giving a drug to a patient.
- Always be careful that the directions are in the same dosage as the medication. For example, “take 2 tabs (50mg)” is equivalent to “take 1 tab (100mg).
Blood pressure is measured by using a sphygmomanometer.
- There are three types of sphygmomanometers used to measure blood pressure: mercury, aneroid, and digital.
- Reading blood pressure by auscultation is considered the gold standard.
Position: supine, seated, standing.
In a seated position, the subject’s arm should be flexed.
The flexed elbow should be at the level of the heart.
If the subject is anxious, wait a few minutes before taking the pressure.
- To begin blood pressure measurement, use a properly sized blood pressure cuff. The length of the cuff’s bladder should be at least equal to 80% of the upper arm’s circumference.
- Wrap the cuff around the upper arm with the cuff’s lower edge one inch above the antecubital fossa.
- Lightly press the stethoscope’s bell over the brachial artery just below the cuff’s edge. Some health care workers have difficulty using the bell in the antecubital fossa, so we suggest using the bell or the diaphragm to measure the blood pressure.
- Rapidly inflate the cuff to 180mmHg. Release air from the cuff at a moderate rate (3mm/sec).
- Listen with the stethoscope and simultaneously observe the sphygmomanometer. The first knocking sound (Korotkoff) is the subject’s systolic pressure. When the knocking sound disappears, that is the diastolic pressure (such as 120/80).
- Record the pressure in both arms and note the difference; also record the subject’s position (supine), which arm was used, and the cuff size (small, standard or large adult cuff).
- If the subject’s pressure is elevated, measure blood pressure two additional times, waiting a few minutes between measurements.
- A BLOOD PRESSURE OF 180/120mmHg OR MORE REQUIRES IMMEDIATE ATTENTION!
- Aneroid and digital manometers may require periodic calibration.
- Use a larger cuff on obese or heavily muscled subjects.
- Use a smaller cuff for pediatric patients.
- For pediatric patients, lower blood pressure may indicate the presence of hypertension.
- Don’t place the cuff over clothing.
- Flex and support the patient’s arm.
- In some patients, the Korotkoff sounds will disappear as the systolic pressure is bled down. After an interval, the Korotkoff sounds reappear. This interval is referred to as the “auscultatory gap.” This pathophysiologic occurrence can lead to a marked underestimation of systolic pressure if the cuff pressure is not elevated enough. For this reason, the rapid inflation of the blood pressure cuff to 180mmHg was recommended above. The “auscultatory gap” is felt to be associated with carotid atherosclerosis and a decrease in arterial compliance in patients with increased blood pressure.
For pediatric patients, use an appropriate table that uses age, sex, and height to interpret blood pressure findings.
How To Dispose of Needles, Lancets, and Blood Strips Properly
Improper disposal of lancets, insulin syringes, infusion set cannulas, and other medical sharps can cause needlestick injuries, especially for garbage collectors. Please throw your used sharps away safely. Keep in mind that anything sharp should not be simply thrown in the trash.
Use a sharps container for all sharp objects like lancets and needles. Use a red biohazard bag for any items that could have bodily fluid on them. Always use universal precautions such as gloves.
General Guidelines for Sharps Disposal
Use a sharps box if one is available.
Remember never to re-cap your syringes before you dispose of them.
If you do not have a regular sharps box, use a hard (puncture-proof) non-clear container for disposing of used clipped or un-clipped syringes and lancets.
If you choose to clip the syringes, use a device that traps the clipped points in a puncture-proof compartment.
Do not drop your used syringes or lancets into the regular trash.
Do not cut off syringe needles with scissors or break off the needles. The needle could break off as you are cutting it and could hurt you or someone else.
Do not use clear plastic bottles for syringe disposal. Children of drug users may see the syringes and try to open the bottle.
Do not put plastic bottles filled with syringes/lancets in recycling bins.