MEDICATION SAFETYAdministration of Medications

Meeting HFAP Accreditation Standards for Pharmacy Services and

Medication Use

Part Three

MEDICATION SAFETYAdministration of Medications

• HFAP Chapter 25 keeps you in compliance with the Medicare Conditions of Participation

Medication Safety Series1. Using CPOE: Challenges and Solutions to

Address HFAP Standards2. Procurement, Preparation and Dispensing3. Administration of medications – timing, unit

dose, bedside medication verification4. Monitoring of therapy, Medication Use

Evaluations5. TBD

The 6 rightsCollaborative Process (nurses, RT, pharmacists, physicians)Routes of administrationBMV

Advantages Disadvantages What to do if you see medication errors (wrong patient, wrong

drug, wrong time)Patient process

Hand hygiene Identification Education of the patient Verification of the medication (double verification) Medications at the bedside and self-administration Observe for reactions

Outline

Oral: sublingual, buccalParenteral: intradermal, subcutaneous,

intramuscular, intravenousTopicalInhalationIntraocular

Routes of Administration

MetricApothecary (grains)Household

Systems of Measurement

Grams (g), milligrams (mg), kilograms (kg)Liters (L), milliliters (ml)

Metric System

TablespoonsTeaspoonsOuncesCupsPintsQuarts

Household Measurements

Conversions within systemsConversions between systems

Clinical Calculations

Six rightsTriple-check before administrationPatient assessment

Role of the Nurse, and others who administer medications

Right medicationRight doseRight patientRight routeRight timeRight documentation

Six Rights

InformationRefusalCareful assessmentInformed consentSafe administrationSupportive therapyNo unnecessary medications

Patient’s Rights

Collaborative processNursesPharmacistsRespiratory TherapistsPsychiatric TechniciansPhysicians

MEDICATION ADMINISTRATION

Infants and childrenOlder adults

PolypharmacySelf-prescribingOver-the-counter medicationsMisuseNoncompliance

Special Considerations

Patient response to medicationsPatient and family ability to administer

medications

Evaluation

Presence of GI alterationsAbility to swallowUse of gastric suctionPositioning

Oral Administration

Skin applicationsUse of gloves or applicatorsPreparation of skinThickness of application

Topical Administration

Assessment of naresPatient instruction and self-administrationPositioning

Nasal Instillation

Drops, ointments, disksAssessment of eyesAsepsisPositioning

Eye Instillation

Assessment of ear canalWarming of solutionStraightening of canal for children and adultsPositioning

Ear Instillation

Metered-dose inhalers (MDIs) and dry powder inhalers (DPIs)

Patient assessment and instructionUse of spacerDetermination of doses in canister

Inhalation

Medications used to wash out a body cavity delivered with a stream of solution (sterile water, saline, or antiseptic)

Asepsis

Irrigation

EquipmentSyringes: sizes (volume), typesNeedles: length, gaugeDisposable units: Tubex, CarpujectAmpulesVials

Parenteral Administration

Mixing medicationsDetermine compatibility of the medicationsDo not contaminate one medication with

anotherEnsure the final dose is accurateMaintain aseptic technique

Parenteral Administration (cont’d)

InsulinSyringes and needle sizesTypes of insulinMixing of insulinsRotation of vials before withdrawal of solution

Parenteral Administration (cont’d)

Minimize discomfortUse smallest suitable needlePosition client comfortablySelect proper siteDivert client’s attentionInsert the needle quickly and smoothlyHold the syringe steadyInject the medication slowly and steadily

Administration of Injections

Subcutaneous injectionsSites: condition of area, rotation of useAmount of solutionLength and gauge of needlePinch or spread skinAngle of insertion

Administration of Injections (cont’d)

Intramuscular injectionsSites: landmarks, condition of areaAmount of solutionLength and gauge of needleAngle of insertionAspirationAir-lock methodZ-track technique

Administration of Injections (cont’d)

SitesVentroglutealVastus lateralisDeltoid

Administration of Injections (cont’d)

Intradermal injectionsSkin testingSitesLength and gauge of needleAngle of insertionFormation of small bleb

Administration of Injections (cont’d)

Needleless devicesSharps disposalOne-handed recapping technique

Prevention of Needle Sticks

Large volume infusionsBolus injectionVolume-controlled infusions Piggyback

TandemVolume-control setMini-infusor pump

Intravenous Administration

Hand hygieneIdentificationEducation of the patientVerification of the medication (double

verification)Medications at the bedside and self-

administrationObserve for reactions

MEDICATION ADMINISTRATION PROCESS

Wash hands with soap and water or with waterless hand sanitizer before and after patient contact

Gloves

HAND HYGIENE

Must use at least two patient identifiers whenever administering medications.

Acceptable identifiers may be the person’s name, an assigned identification number, a telephone number, a photograph, or another personal identifier.

If bar code scanning is available, scan the patient’s armband

IDENTIFICATION OF PATIENT

Scan barcodeVerify that this is the correct medicationVerify doseDouble verify

High risk medications (heparin, insulin)Controlled substances

VERIFICATION OF THE MEDICATION

More people die in a given year as a result of

medical errors than from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516).

Kohn, Corrigan & Donaldson, “To Err is Human”, Institute of Medicine, 1999

Why barcode medications?

Where do medication errors occur?

Transcripti

on6%

Bates, Cullen, Laird, et al. “Incidence of Adverse Drug Events and Potential Adverse Drug Events.” JAMA, 1995, 274, 29-34.

Nationally 2 of every 100 admissions experienced a preventable adverse drug event, resulting in increased hospital costs of $4,700 per admission.

This is $2.8 million annually for a 700-bed teaching hospital.

Kohn, Corrigan & Donaldson, “To Err is Human”, Institute of Medicine, 1999

Why barcode medications?

Right drug 75% improvementRight dose 62% improvementRight patient 93% improvementRight time 87% improvementMissed meds 70% improvement

*Johnson, Carlson, Tucker, & Willette Using BCMA in VA Medical CentersJournal of Healthcare Information Management-Vol 16, No.1

Effect of BCMA*Barcode Medication Administration (BCMA) in VA Medical Centers*:

8,000,000 doses dispensed 549,000 errors prevented 0 documented errors

*Eastern Kansas Health Care System (VA) 1994-2001*:Why barcode medications?

Physician order received Order faxed to Pharmacy Pharmacists edit and verify electronic orders

into patient profile Pharmacy dispenses ordered medications in Bar-

Coded packages Nurse accesses BMCA software on computer

via log on Nurse scans unique patient bar-coded ID band

BCMA Steps

Nurse utilizes two unique patient identifiers to verify armband

Nurse verifies patient profile medications as per order

Nurse scans bar-code on medications Nurse administers medications

BCMA Steps (cont)

•Reduction in medication errors•The FDA estimated that over a 20 year period the number of medication errors would be reduced by 50% and up to 500,000 adverse events would be avoided by utilizing BCMA

(Food and Drug Administration, 2004).•Ease of checking the five rights of medication administration•Automatic MAR creation•Lab results can be displayed at the point of care•Alerts for missed medications

BCMA Advantages:

BCMA Disadvantages:

Estimated to cost $1,799 per bed to implement BCMA, with an additional $1,000 yearly for maintenance

No universally accepted bar codesBar codes that are unable to be scannedEquipment malfunctionOver reliance on BCMA to catch errorsStat medication turnaround time

(ZIH, 2006)

BCMA Workarounds

Over 15 types have been identified that could potentially lead to errors

For example: Nurses override alerts for 4.2 % of patients cared for and for 10.3% of

meds charted

(Karsh, Koppel, Telles, & Wetterneck, 2008)

Require special order from physicianMust be stored in a secure mannerAvoid using home medications unless they are

unavailable from the hospital pharmacyIf using home medications, they must be stored

in and dispensed from the hospital pharmacy only upon positive identification

Patient education on self-administrationExample: inhalers

MEDICATIONS AT THE BEDSIDE

AssessmentVital signsBlood glucosePain level

EducationWhat drug is forSide effects

BEFORE GIVING THE DRUG

Reassessment

AFTER MEDICATION IS GIVEN

Types of errors:OmissionsDrug administration without a physician’s

orderWrong drugWrong doseWrong timeFailure to follow manufacturer specifications

Do not crushShake wellInadequate fluids

DIRECT OBSERVATION OF MEDICATION ADMINISTRATION

Administration without adequate fluidsAdministration through enteral feeding tube:

Example: phenytoinAdministration of eye drops

Contact time with eyeInhalersAdministration with regard to meal times

DIRECT OBSERVATION OF MEDICATION ADMINISTRATION

Monitoring of TherapyMedication Use EvaluationsTrending of medication errors

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