Pharmacology Chapter 3: Medication Safety

The 1st nursing right
The right to a complete and clear order

2nd nursing right
The right to have the correct drug, route, and dose dispensed

3rd nursing right
the right to access to information

4th nursing right
the right to policies to guide safe medication administration

5th nursing right
the right to administer medications safely and to identify system problems

6th nursing right
the right to stop, think, and be vigilant when administering medications

Experience indicates that 5 additional rights are essential to professional nursing practice:
1) right assessment
2) right documentation
3) client’s right to education
4) right evaluation
5) client’s right to refuse

A telephone order (TO) or verbal order (VO) for medication must be cosigned by the prescribing health care provider within how many hours?
24 hours

Components of a drug order:
1) date and time the order is written
2) drug name (generic preferred)
3) drug dosage
4) Route of administration
5) frequency and duration of administration
6) any special instructions for withholding or adjusting dosage based on nursing assessment, drug effectiveness, or laboratory results
7) physical or other health care provider’s signature or name if TO or VO
8) signatures of licensed practitioners taking TO or VO

What should the nurse do if any part of the drug order is incomplete?
Do not administer the drug and clarification must be done in a timely manner

To avoid drug error, when should the drug label be read before administration?
1) at the time of contact with the drug bottle/container or the prepacked drug unit
2) before measuring the drug
3) after measuring the drug

Nursing interventions related to drug order included the following:
1) the nurse should be well versed int he client’s health history and previously performed assessments.
2) check that the mediation order is complete and legible
3) know the client’s allergies
4) know the reason the client is to receive the medication
5) Check the drug label 3 times before administration of the medication
6) know the date the medication was ordered and any ending date

Two most frequently used methods of drug distribution:
1) stock drug method
2) unit dose method

Drugs that are stored on u it and dispensed to all clients from the same container
Stock drug method

Drugs that are packaged in doses for 24 h by the pharmacy
Unit dose method

Advantages of stock drug method
– Always available
– cost-efficiency of large quantities

Advantaged of unit dose method
– Saves time for nurse b/c no dose calculation is required
– Billed for specific doses
– More accountability
– Less chance for contamination and error

Disadvantages of stock drug method
– Drug errors are more prevalent with multiple “pourers”
– More risk of abuse by health care workers
– Less accountability for amount used; unable to track usage
– Increased opportunity for contamination

Disadvantages of unit dose method
– Potential delay in receiving drug
– Not immediately replaceable if contaminated
– More expensive

This technology improves client care by promoting accurate and quick access to medications, locked storage for all medications, and electronic tracking for controlled substances.
Automated Dispensing Cabinets (ADCs)

Nursing interventions related to the right dose include:
– Calculate the drug dose correctly; when in doubt, recalculate
– Check the Physician’s Desk Reference (PDR), drug package insert, or other drug references for the recommended range of specific drug doses

Nursing interventions related to the right time include:
– Administer drugs at the specified times
– Administer drugs that are affected by foods before meals
– Administer drugs that can irritate the stomach with food
– Adjust the medication schedule to fit the client’s lifestyle, activities, tolerances, or preferences, as appropriate and if possible
– Check whether or not the client is scheduled for any diagnostic procedures that contraindicate the administration of medications
– Check the expiration date
– Administer antibiotics at even intervals

Nursing interventions related to the right route:
– Assess the client’s ability to swallow before administering oral meds
– Do not crush or mix meds in other substances before consultation with a pharmacist
– Use aseptic technique when administering drugs. (Sterile technique is required for parenteral routes)
– Administer drugs at the appropriate sites for the route
– Stay with the client until oral drugs have been swallowed
– If medication must be mixed with another substance, explain it to the client

Right documentation includes:
– Name of drug
– dose
– route (injection site of applicable)
– time and date
– nurse’s initials or signature

Documentation of the client’s response to the medication is required with a variety of medications:
– Narcotics (how effective was pain relief?)
– nonnarcotic analgesics
– sedatives
– antiemetics
– unexpected reactions to the medication

Why do you not sign off medications prior to administration?
Patient may refuse the medication or it may not be given for some reason.

Client teaching of medication includes:
– therapeutic purpose
– expected result of drug
– possible side effects of drug
– any dietary restrictions or requirements
– skill of administration
– laboratory test result monitoring

The right of client teaching that is based on the individual having the knowledge necessary to make a decision is a principle called ______.
informed consent

Any preventable event that may cause or lead to inappropriate medication use or harm to a patient best defines ______.
Medication error

What does CPOE stand for?
computerized prescriber order entry

5 Goals related to medication safety:
1) Improve the accuracy of patient identification
2) improve the effectiveness of communication among caregivers
3) improve safety of using medications
4)Reduce the risk of health care-associated infections
5) Accurately and completely reconcile medications across the continuum of care

How can you improve the accuracy of patient identification?
Use at least 2 patient identifiers when providing care, treatment, or services.

How can you improve the effectiveness of communication among caregivers?
Timely reporting of critical tests and critical results

How can you help to improve the safety of medications?
1) Labeling medications
2) Reducing harm from anticoagulation therapy

How can you help to reduce the risk of health care-associated infections?
1) Meeting hand hygiene guidelines
2) Preventing multidrug-resistant organism infections
3) Preventing central line-associated blood stream infections
4) Preventing surgical site infections

In what ways can you accurately and completely reconcile medications across the continuum of care?
1) comparing current and newly ordered medications
2) communicating medications to the next provider
3) providing a reconciled medication list to the patient
4) Settings in which medications are minimally used

What does ONDCP stand for?
White House Office of National Drug Control Policy

What does ONDCP do?
Issues guidelines for appropriate disposal of prescription drugs

General guidelines for drug disposal:
1) Follow specific information on the drug label or drug insert
2) Unless specifically instructed, do not flush medications down the toilet
3) Recommended that your remove the drug from it’s original container and dispose of it in a sealed bag with an undesirable substance such as cat litter or coffee grounds

How should you properly dispose of medication containers?
Remove all identifying information

Actions to create safe medication administration:
1) use drug reference
2) When in doubt, contact the prescribing health care provider and document any clarification
3) double-check all calculated doses
4) use a leading zero (0.5), never a following zero (5.0)
5) Avoid verbal orders; if you must take them, repeat the order out loud to confirm
6) Scan the bar code at the point of care
7) Include the pharmacist on client rounds
8) Avoid easily confused abbreviations
9) consistently think critically

What is Pathways for Medication Safety?
A set of tools designed to assist hospitals through a system based approach to reduce mediation errors

What does the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) do?
Specializes in medication errors from an interdisciplinary persepctive

What is pregnancy category A?
No risk to fetus. Studies have not shown evidence of fetal harm

Pregnancy category B
No risk in animal studies, and well-controlled studies in pregnant women are not available. It is assumed there is little to no risk in pregnant women.

Pregnancy category C
Animal studies indicate a risk to the fetus. Controlled studies on pregnant women are not available. Risk versus benefit of the drug must be determined.

Pregnancy category D
A risk to the human fetus has been proved. Risk versus benefit of the drug must be determined. It would be used in life-threatening conditions.

Pregnancy category X
A risk to the human fetus has been proved. Risk outweighs the benefit, and drug should be avoided during pregnancy.

Factors that modify drug responses:
– Absorption
– Distribution
– Metabolism (Biotransformation)
– Toxicity
– Pharmacogenetics
– Route of administration
– Time of administration
– Emotional factors
– Preexisting disease state
– Drug history
– Tolerance
– Cumulative effect

What factors affected drug absorption?
Route of administration and any GI disturbances

What factors affect distribution of a medication?
– protein binding
– blood brain barrier
– placental barrier

What is the blood-brain barrier?
Allows only lipid-soluble drugs to enter into the brain and cerebrospinal fluid

What is the placental barrier?
A membrane that keeps the blood of the mother and fetus separate; However, both lipid-soluble and lipid insoluble drugs can diffuse across the placenta

What factors influence metabolism of a medication?
– Excretion
– Age
– Body weight

How does excretion influence drug metabolism?
Immature liver and kidney function result in decreased excretion of drugs.

What are the routes of drug excretion?
– Bile
– Feces
– respiration
– saliva
– sweat

How does age influence drug metabolism?
Infants and older persons are more sensitive to drugs; elderly people have decreased liver function due to normal aging

How does body weight influence drug metabolism?
Heavier people may need an increased dose than normal weight individuals, and people with lower weight may need a smaller dose than normal people.

How does toxicity modify drug response?
Toxicity can be affected by the same factors that affect metabolism;
Toxicity is more prevalent in persons with liver or renal impairment or very young/old clients

The study of interrelation of heredity on drug response is referred to as __________.
Pharmacogenetics

How can the route of administration modify drug response?
Drugs administered by IV act more rapidly than those administered by mouth.

How can emotional factors modify drug response?
Suggestive comments about the drug and it’s side effects may influence it’s effects on the client.

How can drug history modify drug response?
Past use of the same or different drugs may reduce or intensify the current effects of the drug.

The ability of a client to response to a particular dose of a certain drug that may diminish after days or weeks of repeated administration is called ___________.
Tolerance

THIS occurs when the drug is metabolized or excreted more slowly than the rate at which the drug is being administered.
Cumulative Effect

What are the two interactions that may cause cumulative effect?
– Drug-drug interaction
– Food-drug interation

Describe drug-drug interaction.
– The effects of a combination of drugs may be greater than, equal to, or less than the effects of a single drug;
– Some drugs may compete for the same receptor sites;
– An adverse reaction may lead to toxicity or complications.

Describe food-drug interaction.
The effects of selected foods may speed, delay, or prevent absorption of specific drugs.

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