THE SIX RIGHTS OF DRUG ADMINISTRATION Right Drug Many drugs have similar spellings and variable concentrations. Before the administration of the medication, it is imperative to compare the exact spelling and concentration of the prescribed drug with the medication card or drug profile and the medication container. Regardless of the drug distribution system used, the drug label should be read at least three times: 1. Before removing the drug from the shelf or unit dose cart. 2. Before preparing or measuring the actual prescribed dose 3.
Before replacing the drug on the shelf or before opening a unit dose container (just prior to administering the drug to the patient) Right Time When scheduling the administration time of a medication, factors such as timing abbreviations, standardized times, consistency of blood levels, absorption, diagnostic testing, and the use of p. r. n. medications must be considered. 1. Standard Abbreviations—The drug order specifies the frequency of drug administration. Standard abbreviations used as part of the drug order specify the times of administrati0n.
The nurse should also check institutional policy concerning administration of medications. Hospitals often have standardized interpretations for abbreviations. The nurse must memorize and utilize standard abbreviations in interpreting, transcribing, and administering medications accurately. 2. Standardized Administration Times—For patient safety, certain medications are administered at specific times. This allows laboratory work or ECGs to be completed first, in order to determine the size of the next dose to be administered. 3.
Maintenance of Consistent Blood Levels—The schedule for the administration of a drug should be planned to maintain consistent blood levels of the drug in order to maximize the therapeutic effectiveness. 4. Maximum Drug Absorption—The schedule for oral administration of drugs must be planned to prevent incompatibilities and maximize absorption. Certain drugs require administration on an empty stomach. Thus, they are given 1hour before or 2 hours after meals. Other medications should be given with foods to enhance absorption or reduce irritations.
Still other drugs are not given with diary products or antacids. It is important to maintain the recommended schedule of administration for maximum therapeutic effectiveness. 5. Diagnostic Testing—Determine whether any diagnostic tests have been ordered for completion prior to initiating or continuing therapy. Before beginning antimicrobial therapy, assure that all culture specimens (such as blood, urine, or wound) have been collected. If a physician has ordered serum levels of the drug, coordinate the administration time of the medication with the time the phlebotomist is going to draw the blood sample.
When completing the requisition for a serum level of a medication, always make a notation of the date and time that the drug was at last administered. Timing is important; if tests are not conducted at the same time intervals in the same patient, the data gained are of little value. 6. P. R. N. Medications—Before the administration of any p. r. n. medication, the patient’s chart should be checked to ensure that the drug has not been administered by someone else, or that the specified time interval has passed since the medication was last administered. When a p. rn. medication is given, it should be charted immediately.
Record the response to the medication. Right Dose Check the drug dosage ordered against the range specified in the reference books available at the nurses’ station. 1. Abnormal Hepatic or Renal Function—Always consider the hepatic and renal function of the specific patient who will receive the drug. Depending on the rate of drug metabolism and route of excretion from the body, certain drugs require a reduction in dosage to prevent toxicity. Conversely, patients being dialyzed may require higher than normal doses. Whenever a dosage is outside the normal range for that drug, it should be verified before administration.
Once verification has been obtained, a brief explanation should be recorded in the nurses’ notes and on the Kardex 9or drug profile) so that others administering the medication will not be repeatedly contacted with the same questions. The following laboratory tests are used to monitor liver function: aspartame aminotransferase (AST), alanine aminotransferase (ALT), gamma glutamyl transferase (GGT), alkaline phosphatase and lactic dehydrogenase (LDH). The blood urea nitrogen (BUN), serum creatinine (Crs), and creatinine clearance (Ccr) are used to monitor renal function. 2.
Pediatric and Geriatric Patients—Specific doses for some drugs are not yet firmly established for the elderly and for the pediatric patient. The nurse should question any order outside the normal range before administration. For pediatric patients, the most reliable method is by proportional amount of body surface area or body weight. 3. Nausea and Vomiting—If a patient is vomiting, oral medications should be withheld and the physician contacted for alternate medication orders, as the parenteral or rectal route may be preferred. Investigate the onset of the nausea and vomiting.
If itbegan after the start of the medication regimen, consideration should be given to rescheduling the oral medication. Administration with food usually decreases gastric irritation. Consult with a physician for changes in orders. Right Patient When using the medication card system, compare the name of the patient on the medication card with the patient’s identification bracelet. With the unit dose system, compare the name on the drug profile with the individual’s identification bracelet. When checking the bracelet under either system, always check for allergies, as well.
Some institutional policies require that the individual be called by name as a means of identification. This practice must take into consideration the patient’s mental alertness and orientation. It is much safer ALWAYS to check the identification bracelet. 1. Pediatric Patients—Never ask children their names as a means of positive identification. Children may change beds, try to avoid you, or seek attention by identifying themselves as someone else. Check identification bracelets EVERY TIME. 2. Geriatric Patients—It is a wise policy to check identification bracelets, in addition to confirming names verbally.
In a long-term care setting, residents usually do not wear identification bracelets. In these instances, only a person who is familiar with the residents should administer medications. Many errors may be voided by carefully following the practices just presented. Make it a habit to check the identification bracelet EVERY TIME a medication is administered. The adverse effects of administration to the wrong medication to the wrong patient and the potential for a lawsuit can thus be avoided. Right Route The drug order should specify the route to be used for the administration of the medication.
Never substitute one dosage form of medication for another unless the physician is specifically consulted and an order for the change is obtained. There can be a great variation in the absorption rate of the medication through various routes of administration. The intravenous route delivers the drug directly into the bloodstream. This route provides the fastest onset, but also the greatest danger of potential adverse effects such as tachycardia and hypotension. The intramuscular route provides the next fastest absorption rate, based upon availability of blood supply.
This route can be quite painful, as is the case with many antibiotics. The subcutaneous route is next fastest, based on blood supply. In some instances the oral route may be as fast as the intramuscular route, depending on the medication being given, the dosage form (liquids are absorbed faster than tablets), and whether there is food in the stomach. The oral route is usually safe if the patient is conscious and able to swallow. The rectal route should be avoided, if possible, due to irritation of mucosal tissues and erratic absorption rates.
In case of error, the oral and rectal routes have the advantage of recoverability for a short time after administration. Right Drug Preparation and Administration Maintain the higher standards of drug preparation and administration. Focus your entire attention on the calculation, preparation, and administration of the ordered medication. A drug reconstituted by a nurse should be clearly labeled with the patient’s name, the dose or strength per unit of volume, the date and time the drug was reconstituted, the amount and type of diluent used, the expiration date/ or time, and the initials or name of the nurse who prepared it.
Once reconstituted, the drug should be stored according to the manufacturer’s recommendation. • CHECK the label of the container for the drug name, concentration, and route of appropriate administration. • CHECK the patient’s chart, Kardex, medication administration record, or identification bracelet for allergies. If no information is found, ask the patient, prior to the administration of the administration of the medication, if he or she has any allergies. • CHECK the patient’s chart, Kardex, medication administration record for rotation schedules of injectable or topically applied medications. CHECK medications to be mixed in one syringe with a list approved by the hospital or the pharmacy for compatibility. Normally, all drugs mixed in a single syringe should be administered within 15 minutes after mixing. Immediately prior to administration, ALWAYS CHECK the contents of syringe for clarity and the absence of any precipitate; if either is present, do not administer the contents of the syringe. • CHECK the patient’s identity EVERY TIME a medication is administered. • DO approach the patient in a firm but kind manner that conveys the feeling that cooperation is expected. DO adjust the patient to the most appropriate position for the route of administration (for example for oral medications, sit the patient upright to facilitate swallowing). Have appropriate fluids ready before administration. • DO remain with the patient to be certain that all medications have been swallowed. • DO use every opportunity to teach the patient and family about the drug being administered. • DO give simple and honest answers or explanations to the patient regarding the medication and treatment. DO use a plastic container, medicine cup, medicine dropper, oral syringe, or nipple to administer oral medications to an infant or small child. • DO reward the child who has been cooperative by giving praise; comfort and hold the uncooperative child after completing the medication administration. • DO NOT prepare or administer a drug from a container that is not properly labeled or from a container where the label is not fully legible. • DO NOT give any medication prepared by an individual other than the pharmacist. ALWAYS check the drug name, dosage, frequency, and route ofadministration against the order.
Student nurses must know the practice limitations instituted by the hospital or school and which medications can be administered under what level of supervision. • DO NOT return an unused portion or dose of medication to a stock supply bottle. • DO NOT attempt to administer any drug orally to a comatose patient. • DO NOT leave a medication at the patient’s bedside to be taken “later”; remain with the individual until the drug is taken and swallowed. • DO NOT dilute a liquid medication form unless there are specific written orders to do so. BEFORE DISCHARGE: (1) Explain the proper method of taking prescribed medications to the patient. (2)Stress the need for punctuality in the administration of medications, and what to do if a dosage is missed. (3)Teach the patient to store medications separately from other containers and personal hygiene items. (4)Provide the patient with written instructions reiterating the medication names, schedules, and how to obtain refills. Write the instructions in a language understood by the patient, and use LARGE BOLD LETTERS when necessary. (5) Identify anticipated therapeutic response. 6)Instruct the patient, family member(s), or significant others on how to collect and record data for use by the physician to monitor the patient’s response to drug and other treatment modalities. (7)Give the patient, or another responsible individual, a list of signs and symptoms that should be reported to the physician. (8)Stress measures that can be initiated to minimize or prevent anticipated side effects to the prescribed medication. It is important to do this further encourage the patient to be complaint with the prescribed regimen.
Right Documentation Documentation of nursing actions and patient observations has always been an important ethical responsibility, but now it is becoming a major medicolegal consideration as well. Indeed, it is becoming known as the sixth right. Always chart the following information: date and time of administration, name of medication, dosage, route, and site of administration. Documentation of drug action should be made in the regularly scheduled assessments for changes in the disease symptoms the patient is exhibiting.
Promptly record and report adverse symptoms observe. Document health teaching performed and evaluate and record the degree of understanding exhibited by the patient. • DO record when a drug is not administered and why. • DO NOT record a medication until after it has been given. • DO NOT record in the nurses’ notes that an incident report has been completed when a medication error has occurred. However, data regarding clinical observations of the patient related to the occurrence should be charted to serve as a baseline for future comparisons.
Whenever a medication error does occur, an incident report is completed to describe the circumstances of the event. An incident report related to a medication error should include the following data: date, time the drug was ordered, drug name, dose, and route of administration. Information regarding the date, time, drug administered, and dose and route of administration should be given, and the therapeutic response or adverse clinical observations present should be noted. Finally, record the date, time, and physician’s ordered given. Be FACTUAL; do not state opinions on the incident report.