Hayes et al. (2015) estimated that nurses spend between 16% and 40% of their time in medication administration, a process that entails reviewing the medication administration record; retrieving, preparing, and administering the medication; monitoring the outcomes; and documenting the intervention (Rodriguez-Gonzalez, 2014). However, errors occur in around 20% of all instances of medication administration leading to patient harm and increased costs of care (Hayes, 2015). Nurses need to be aware of their responsibilities in medication administration, developmental factors that increase the risk of harm, and best practices to prevent medication errors and adverse events.
Responsibilities in Medication Administration
In a systematic review of 91 studies, Keers et al. (2013) found that the most common medication errors detected through direct observation data collection techniques were wrong timing of administration, wrong drug dosage, and omission of medications. In a study of medication administration in a long-term care facility for seniors, the most common errors were wrong administration time, wrong person, and giving a discontinued medication (Szczepura, Wild & Nelson, 2011). It is therefore important to think about actions that enhance patient safety when administering medications.
Best practices in safe medication administration include consideration of the 6 rights each time nurses administer a drug. These rights are right medication, right dose, right patient, right route, right time, and right documentation (Potter et al., 2013). Fulfillment of these rights depends on the performance of certain actions. Nurses are responsible in ensuring that the medication administration record (MAR), as a reference, is complete and accurate. The MAR should have the patient’s first and last names, full name of the drug prescribed, dosage, time of administration, frequency, and route (Potter et al., 2013). The physician’s medication order should be compared to what is indicated in the MAR especially when a drug is prescribed to the patient for the first time and when a patient is handed over from another unit (Potter et al., 2013).
Another nursing responsibility is to verify the appropriateness of the route indicated in the physician’s order and the MAR (Potter et al., 2013). Medication references are useful when making this check. Inappropriateness of route, missing information about the route, and any concerns with medication orders should prompt clarifications with the provider (Potter et al., 2013). Moreover, it is also a nursing responsibility to know the rationale for any preconditions, such as before or after meals, and the times that doses are to be given in order to administer medications in a timely manner (Potter et al., 2013). The correct route and time of administration help ensure treatment effectiveness.
During the preparation of medications, a nursing responsibility is to compare the medication label with the information on the MAR. Performing this action three times, i.e. when retrieving the medication, when preparing the medication dose, and prior to administration, reduces the likelihood of a wrong drug or wrong dose error (Potter et al., 2013). Assuming that two containers hold the same drug and drug dose just because they look alike has resulted in adverse events including patient death (Vanderveen, 2009). Medications should not be drawn from containers without labels or have labels that are difficult to read so as not to cause adverse events (Potter et al., 2013).
Nurses are also responsible in performing correct medication preparation techniques to minimize wrong dose errors. In cases when there is a need to prepare medication from a container that has a different volume than is on the order and MAR, standards require that the calculations made should be corroborated by a qualified colleague (Potter et al., 2013). Measurement accuracy can further be ensured by using standard measuring tools like syringes and graduated medicine cups. However, only enteral syringes should be used to prepare oral medications as the risk of wrong route is high with parenteral syringes. Labels should be placed on syringes, and oral syringe caps removed prior to administration. A medication reference should be used to verify whether a pill is meant to be split if splitting is indicated in the order and MAR (Potter et al., 2013).
Similarly, when orders are to crush the medicine prior to administration, nurses must validate if the drug indeed could be administered in crushed form (Potter et al., 2013). In addition, it is important to clean the pill crushing device to prevent an inadvertent increase in dose or mixture with a different drug not intended for the patient (Potter et al., 2013). Crushed pills should be mixed with liquid or food but in small amounts only and in children, not with their favorite foods.
Schaefer, Shebab and Perz (2010) also highlighted infection control as a nursing responsibility during medication administration. They clarified the differences between single-dose and multi-dose vials of parenteral medications. Single dose vials do not contain antimicrobials or preservatives making it unsafe to use them for multiple patients over a period of time. The CDC (2011) further recommends the aseptic preparation of parenteral medications with handwashing using soap and water or hand sanitizers as the first step. The vial’s rubber septum should be cleaned and a sterile needle and syringe used to draw the contents (CDC, 2011). Preparation should be done in a clean area to prevent contamination. These steps prevent infection as an adverse event related to medication administration.
Nurses are responsible for ensuring that medications are received by the right patient (Potter et al., 2013). This can be achieved by comparing the patient identification information on the MAR with that on the patient’s wristband. Confirmation is reliable when it employs two pieces of information such as the patient’s full name and patient record number (Potter et al., 2013). Relying solely on name can lead to wrong patient errors because of the possibility of patients having the same names. Asking the patient his or her name is also acceptable when the information on the wristband happens to be illegible or whenever there is doubt regarding the patient’s identity (Potter et al., 2013). Documentation should only be done right after medication administration.
Developmental Factors that Influence Pharmacokinetics
Developmental factors have an impact on pharmacokinetics and can increase the risk of harm induced by medications. These factors are the underlying rationale for monitoring patients following medication administration. In older adults, the stomach empties at a slower rate and motility slows down as well (Potter et al., 2013). Compounded with a decline in the ability of cells in the small intestine to absorb and transport, the result is a decline in gastrointestinal absorption (Shi & Klotz, 2011). Moreover, the liver becomes smaller, blood flow to this organ declines, and enzymes become less effective affecting the older adult’s ability to metabolize drugs (Potter et al., 2013). Drug clearance declines as well because of reduced blood circulation in and waste elimination by the kidney (Shi & Klotz, 2011). With a decline in muscle mass and plasma proteins and an increase in fat tissue, the concentration of drugs soluble in water and plasma levels increase substantially (Potter et al., 2013).
In infants, the gastrointestinal mucosa is largely immature, such as in terms of transport systems, as is the secretory mechanism and action of pancreatic juices and bile (Fernandez et al., 2011). The former reduces the rate of absorption while the latter impacts the absorption of vitamins soluble in fat. With a higher volume of body water, water-soluble drugs are more easily distributed compared to fat-soluble ones (Fernandez et al., 2011). Plasma protein binding and the renal excretion are also at lower capacities in general in the pediatric population (Fernandez et al., 2011). Meanwhile, high levels of circulating hormones and emesis reduce the GI absorption of medications while increase in the volume of body water reduces the concentration of drugs (Shaikh & Kulkarni, 2013). Hormones also boost enzymatic activity in the liver thereby increasing the rate of metabolism (Shaikh & Kulkarni, 2013). Because of an increase in the renal blood circulation and filtration rates, renal excretion rates also increase (Shaikh & Kulkarni, 2013).
Nursing Actions in Preventing Medication Errors
A study by Kim and Bates (2013) showed that only 45.6% of nurses in a hospital checked the medication label against the MAR at least once and only 6.5% verified patient identify using the wristband. Medications were administered at the right time in only 41% of cases (Kim & Bates, 2013). Clearly, nurses can prevent medication errors by continually improving their knowledge and skills and strictly adhering to standards of care and facility guidelines or policies. Following the rights of medication administration, infection prevention measures, and correct techniques of preparation and administration as described above can reduce the incidence of medication errors. When technologies such as barcode scanning and electronic medical records (EMRs) are used, it is also best practice to follow related protocols (Potter et al., 2013). Learning can be ensured by participating in learning activities and reflecting on past experiences of errors.
In addition, there are other best practices that nurses can follows for medication error prevention. One is to avoid preparing medications for several patients at the same time, and another step is to check the patient’s allergies to reduce the risk of anaphylaxis (Potter et al., 2013). Interruptions in the medication administration process also an important factor associated with errors (Hayes et al., 2015). As such, medications should be prepared without any interruptions such as needing to answer a phone call. Safety is also enhanced by having a qualified colleague validate the correctness of the preparation and administration of high-risk drugs (Potter et al., 2013).
Fatigue, like in other professions such as airline pilots, increases the likelihood of errors. It is therefore the responsibility of nurses to make sure they have had adequate rest before their shift (Potter et al., 2013). Patient involvement can also help reduce errors. By explaining to the patient what the medications are and how they should be administered, patients can help detect errors such as a medicine that looks different than usual (Kim & Bates, 2013). It is also important to emphasize that any doubts or concerns including unusual doses should be clarified with the provider.
Conclusions
Medication errors and infections are important albeit preventable patient safety issues associated with medication administration. Nurses play an important role in prevention. Knowledge of one’s responsibilities throughout the different steps of medication administration and the potential impact of patient-specific developmental factors on patient safety can help the nurse administer medications safely. Medication error prevention also entails adhering to best practices such as the 6 rights of medication administration.
References
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