Safety and quality are critical when discussing medication administration. Let's discuss nursing considerations and medication administration.
Hey there, and welcome to nursing with Dr. Hobbick. Today I'm thinking about safety and quality in medication administration. This is a very important topic for nurses as we do a lot of medication administration. And in fact, we are responsible for the medications that we administered to our patients, I always tell my students that they can sort of think of themselves as the last line of defense, in light of any errors that could reach the patient. In fact, in 2000, the Institute of Medicine released a shocking report called To err is human building a safer healthcare system. And in that report, they estimated that 98,000 People die in any given year from medical errors that occur in hospitals. This demonstrates how important it is for nurses to be aware of methods that they can use to prevent this from happening to their patients. The first thing that we need to think about is what's called the rights of medication administration. Now, honestly, I've seen five rights, six rights 11 rights, we're going to go with six rights because I think those are the easiest to remember the rights of medication administration are the right patient, the right drug or medication, the right dose, or amount, the right time, the right route, and the right documentation. My fun way to remember this something that I came up with in nursing school. Okay, I hope you're ready for this. It's actually D, the nurse, you know, D, she's a tramp, tramp D, but we love her breaks a new heart every day. Okay, hopefully I won't get sued for that one. So what are the six rights of medication administration? Well, the six rights of medication administration are the things that you should be looking at before you administer medications, there's actually three checks, which are times where you perform these rights of medication administration. The first check happens when you're initially looking at the patient's chart. So if I was at work, I would get report on my patient because you know, I like to make sure they're still alive and everything before I go off and look in their chart, I pull the chart up and I start to plan my day and and a very essential part of that is looking at their medications to identify what priorities I have, what medications they have. So I look at each of these the right patient, I'm looking at the patient I'm looking at their conditions I'm looking at a does it make sense for them to have this medicine I'm looking at the medication for the same reason I'm looking at the dosage is it in the normal range of what I see doesn't match what my medication guide tells me they should be getting? is the right time some medications should be given in the evening like Aricept is a medication that can come sense sometimes cause drowsiness. And so is typically given in the evening or statin medications. Those are evening medicine. So if you see those in the morning, you might go to the provider and ask for clarification, I want to know that it's the right route. If I have a patient who can't safely swallow, then giving them medicines by mouth doesn't make sense. By the same token, if I have a patient who can swallow, giving them medications, I don't know, rectally might not be appropriate. I like my patients to like me, right. And then the right documentation, we really have to make sure that we do our documentation appropriately, so that everybody knows what's been going on with this patient. The second check is done. While you're pulling your medications, you should have access either to the EMR the electronic medical record while you're pulling your medications, or you make a list. And once you're done, you go and compare against the mar the Medication Administration Record. While you're in there, you're looking for all of these same things. The right patient, the right drug, the right dose, the right time, the right route, the right documentation, the last check the third check, that one is completed at the bedside with the patient right before you go to administer the medications. So let's talk about each of these in a little more detail. Patient. That's where we verify the patient with two forms of identification. We're also making sure that what we're looking at makes sense, the right medication, we during the third check should be scanning the medicines scanning the patient, if that's available, we should be making sure that the order was completed by a licensed provider, making sure that we're looking at the label on the medicine. Is it the medicine that you expect it to be pulling out of the units medication distribution system? Does it make sense that this patient is taking this does their vital signs their health record their allergies, their lab results? We put all that information together to determine if it's safe for us to administer this medication to the patient If you have to do any drug calculations or medical calculations, those need to be verified with another nurse, we should never trust our own mathematical abilities. I personally don't math Well, in my mind, I have to write them down. But we should always get another nurse to verify the dosage. And we also want to know the beginning and end date of the order because sometimes things are only ordered for 24 hours, or they're only ordered for a week. Next, we'll talk about dose, we need to again, make sure that we're verifying dosage, make sure that the patient's weight if the dosage is weight dependent is accurate, and we have the most up to date weight, we want to validate dose of certain medications, these would be your high risk medications like Heparin, or insulin, there are others, but those are the first two that come to mind, make sure that those are all going to be safe for the patient. Right time, we're using health care agency policy, if the policy is that these medications are time sensitive, typically, they should be given within 30 minutes. If they're not time sensitive, we should give them within an hour. That means if they're due at nine o'clock, and they're not time sensitive, you could give them any time between eight and 10. But for example, insulin or some cardiac medications are time sensitive, and they're due at nine they should be given some time between 830 and 930, that 30 minute timeframe, we need to think about food, is that going to effect this medication, can I give this medicine while the patient has food in their stomach? Does it have to be given on an empty stomach? That's going to change the timeframe that I choose to administer the medication? Are they having a procedure? Is that scheduled? Is it okay for them to receive these medications? Are they nothing by mouth or NPO? For that procedure, in that case, I would need to check with the surgeon or the facility policy, I need to make sure that the expiration date is okay that it's not expired. If the patient is on something like an antibiotic, it's very important to keep it within the therapeutic index that we talked about before. We want to make sure that it is given as close to on time as possible. And then anytime a patient is going to have dialysis, we need to think about the medications that they're going to get ahead of time. A big thing to think about there is going to be an antihypertensive that we typically will hold before they get dialysis. Right route as I mentioned earlier is necessary for adequate absorption. We talked about this in pharmacodynamics and pharmacokinetics episode, we want to make sure the patient is able to swallow safely. Remember that we can't crush medication that is extended release or delayed release or sustained release or enteric coated. If it is one of those and the patient needs their medicines crushed, we need to contact the pharmacy to see if there's a liquid or granules or powder that we can use said we want to offer the patient water but not typically juice. Iron can be taken with orange juice because it absorbs better in an acid environment. And we want to make sure that we're using aseptic technique. I know you open those little pills, they fly all over the place it even if it lands on your desk on your table. I don't know how clean that is, do you, we want to make sure we get rid of that we always want to make sure we're using gloves because it could be a medicine that is teratogenic. Meaning if you are a person with a uterus, and maybe don't know that you're pregnant, you could inadvertently harm the baby by handling that medication documentation. This is super important. You've always got to document after you administer the medication. The reason is you'll curse yourself. If you don't if you document your medication prior to actually administering it. Either the medicine will go flying across the room, the patient will not be able to take it for whatever reason. And now you have falsified documentation and remember that the EMR the EHR is admissible in court. This is a court admissible document. It's a legal document. You don't want to be the one to falsify that. So it's simple enough to wait until you have actually administered the medication. Know that the patient has safely been able to take it or receive it, and then document your administration. Another important thing that I want to talk about today is a culture of safety. It's very easy for us to say any nurse who inadvertently causes an error or harm to a patient should immediately be fired should lose her nursing license should not be able to function anymore. There's a couple things that we need to consider before we make a judgement like that. The first thing that we need to consider is the environment. Folks, nurses do not have safe staffing ratios. And it is very difficult to work in healthcare because it has high level of distraction. I usually have my students watch a very interesting video. That's called interrupts. awareness, a nursing minute for patient safety, I highly encourage you to take a look at it on YouTube. It demonstrates how hard it is to concentrate with just a few levels of distraction. And this is where nurses work every day. The more patients you have, the more distracted you are. And I personally, usually work in med search, and we have six patients on average. Now, it's not too bad if they're medically stable like they should be. And people should know that during the COVID pandemic, especially the worst parts of it. For us where I live in July and August, we had eight patients each, and we had patients who were not necessarily medically stable, added on to that we typically have nurses who are assigned patients, we have an extra nurse who doesn't have patients who helps out and we have a charge nurse who doesn't have patients. And here we are running 24 beds with all with patients who aren't necessarily medically stable with three nurses. That's right, our charge nurse even had eight patients, folks, that's not safe. It doesn't matter where you are, or who you are a few steps into that environment, you would see how unsafe that is, it would be very easy for a medication error to happen in that sort of circumstance. And the other reason that we need to have a culture of safety is because it's very difficult to get a nursing license. And I'm here to tell you that anybody who worked so hard to develop a career and who spent however much money on getting that degree, there's a chance that should they make an error like that, they might hide it because they don't want to get in trouble. They don't want to get fired. They don't want to lose their livelihood. Think about it, if you were threatened with losing your entire livelihood, whatever career you've chosen for yourself, you'll never be able to do that, again, was you hide an error? I think to be honest, there's a portion of the public who would do so it's much easier to treat a patient who has experienced a medication error if we know what the error was. And so it's much better, it's far better for us to have a culture of safety, where we can say, how can we stop this from happening again, the really big thing that we want to find is those near misses. If we can identify a near miss and stop that from happening. Stop it from ever reaching a patient. If we can notice that there's a trend, then that would be much better. I think we can all agree. Now on the topic of safety, we want to make sure that we are reconciling the patient's medications. The Joint Commission has identified that the top places where errors happen is during transitions. So the transition might be going from the hospital to home the hospital to long term care, short term rehab to long term care, etc. Making sure that those medications follow through. Patients may not understand when they leave the hospital, what medications they should be starting, what medications they should be stopping. So we need to make sure that we've covered that information, disposal of medications. Typically, you need to find out if your local area has some kind of medicine take back program, we want to discourage patients from disposing of medications down the toilet. This is causing problems where medications, you know could end up in the water supply. We might have them mix the medication in a really yucky or undesirable substance like cat litter. The courts want to remove all their identifying information. And again, if they don't know where to dispose of their medicines, check with law enforcement or local pharmacists, they may have some idea. sharps safety is something that we also need to consider. As nurses. There should be safeties attached to our sharps unless there's some very detailed plans on how to safely dispose of these that's typically reserved for a physician or provider. So when you give an injection, never recap the needle, immediately activate the safety and it goes into the sharps container. I tell my students do not pass go do not collect $200 Straight to the sharps container unless your patient all of a sudden needs CPR. Something that's become a bigger risk lately is buying medicines on the internet and it's very difficult to tell if medications are real or counterfeit. I always encourage my patients to make sure that they are only purchasing their medications from a licensed pharmacy because it is so hard to tell if the medication is counterfeit. That's all I've got for you today. Thanks for hanging out with me here on nursing with Dr. Hobbick. I'll see you next time.