Don’t Kill your patient: This is One of the most fearful thoughts, and it should be, and rightly so!!! And it should be these types of fears that keep us as NURSES… UN-COMFORTABLE, Yet Safe!!! Especially if you are a new nurse, or currently a nursing student, or going to be a nursing student.
Even for experienced nurses…after years and years, of sometimes what seems routine, old hat, and robotic…you cannot become comfortable, complacent, or relaxed when it comes to administering medications.
Let’s find out how to be a Safe Nurse and use one of the most basic concepts in Nursing…
The 5 rights of Medication Administration!
I’ve titled this BLOG something a little scary:
Don’t Kill your patient: The 5 rights of Medication Administration!
Which can actually be a reality, and be the end result, if you as a nurse do not do due diligence in following an established safety practice in nursing…following THE 5 RIGHTS OF MEDICATION ADMINISTRATION. The goal is to correctly give patients their medications so that the medications can help them along their healing journey, as part of their overall therapy. And like I mentioned, whether you are an experienced nurse, and especially if you are a new nurse, or currently a nursing student, or going to be a nursing student.
We don’t just want to be going through the motions of medication administration that are a routine, old hat, and robotic…you DON’T want to become comfortable, complacent, or relaxed when it comes to administering medications. Yes, You can have a routine, but let it be a safe and systematic routine.
I will be sharing about the “official” 5 Rights of Medication Administration, but there are actually more than 5, I am going to include 6 more rights, for a total of 11 Rights of medication administration, which I will also be sharing in this BLOG.
So how do we NOT Kill or NOT cause harm to our patients…??? And keep us also safe and licensed.
First, we must take care of ourselves, be adequately rested, and focused, we must be alert. As it is, after working 8 hours of a 12 hour shift, statistics show that a nurses judgement is already compromised, or impaired, but, that’s a topic for another BLOG.
So, let’s add in fatigue, sleep deprivation, the general day to day, or night to night busy-ness and demands of a shift.
Nurses are the last stop, the last check before a medication is given to a patient. Now a medication would have gone through quite a long chain of eyes and hands, and brains, and processes and systems… to finally end up in the hands of a nurse, at the last stop, at the last check.
Let me illustrate what I mean…The medication is ordered by a physician or provider, either electronically or hand written, or maybe even verbally to a nurse (this practice nowadays is highly discouraged), then if given to a nurse, then nurse transcribes it and forwards it to the pharmacy. The pharmacist then receives the order from the nurse or physician, via fax, scan, electronically or physically. Then reads it, interprets it, or sometimes deciphers the hidden message in the handwriting, then processes the medication, entering it onto the patient’s profile, on a computer system, which is then connected and entered into a pyxis system, or whatever medication dispensing system your hospital has, which is loaded with numerous and various medications. Generally, personnel from the pharmacy usually load the medications, into the Pyxis, making it available for dispensing, and retrieval by the nurse.
When the time has come to give the medication, the nurse then accesses the pyxis, enters the patient’s name, drug and removes it to give to the patient. The nurse then takes the medication, to a patient’s room, and gives it to the patient.
Now, at any point this medication could have been heard wrong, written wrong, interpreted wrong, read wrong, stocked wrong, dispensed wrong, labeled wrong, and given to the wrong patient with similar names, rooms numbers etc.
For example… what if Cerebyx was misinterpreted for Celebrex or vice versa. Here is a real life example that can cause an error. Cerebyx (fosphenytoin sodium) is an injectable medication used to treat epilepsy and control seizures.
Celebrex is a nonsteroidal anti-inflammatory drug (NSAID), specifically a COX-2 inhibitor, which relieves pain and swelling and is used to treat arthritis, acute pain, and even menstrual pain.
One is an injection and one is a “pill” or oral medication.
Now let’s add a poor phone connection, a typo, an accent, and a tired nurse, and maybe new nurse, and an on-call doctor not familiar with the patient, a busy pharmacist, etc, etc .
Celebrex could be easily misunderstood for Cerebyx or Cerebyx for Celebrex.
AGAIN…..How do we as nurses, not cause harm to a patient??
Ok so I’m going to share “The Five Rights” in their traditional order, But then share some additional ones to keep you and your patient even more safe!!!
So let’s Start with…
1.The right patient
Ideally, use 2 or more identifiers and ask the patient to identify themselves. Verify the patient’s identification, check their ID band, some places you will scan their arm band if you use an electronic medication administration system, check their name and Date of birth. You can always ask the patient their name, but be aware of their mental status, if the patient is confused or does not have the capacity to answer, or is sedated.
Be careful of patients with the same first names, last name, or both, and especially if these patients are in adjacent rooms to each other.
So, whether you are using a paper system or electronic system, keep focused and make sure you have the RIGHT PATIENT.
Ideally patients with similar names should be separated to opposite sides of the unit (on another unit if possible) and assigned to different nurses. One more thing, do not lead the patient or confirm the patient’s name by asking …
“Hi are you Mrs. Doe?” They might agree, or may have heard you ask “Can I open the door?” To which the answer would be yes to both. Better to ask…”Can you tell me your name and date of birth?”
2. Right medication
When reviewing the medication administration record, and you have received report on the patient, is the drug appropriate for the patient and situation
First, is it the RIGHT DRUG, take a look at the name, is it a medication that can sound similar or is spelled similar. These medications are called SALAD medications or Sound Alike, Look Alike Drugs, and may be even packaged similarly. Remember my example of Cerebyx and Celebrex, although those two are different in the sense that one is an injection and one a pill.
Check the name twice, 3 times or more. Like I mentioned earlier fatigue can set in, and lead to errors.
In the ideal world, a nurse would be able to have total focus, without distraction when obtaining and administering medications to a patient. The Electronic Medication Administration System or MAR, can help, but is only as good as those who entered the information, as well as the end user.
Also check and review the patents allergies. They should be listed, and if all else fails, ask the patient if possible. Ensure they have an allergy band for any allergies.
Check the name of the medication, brand names should be avoided.
3. Right dose
Is it the right dose? Check the order, is the dose appropriate? Check the dose on hand, and the dose ordered, then determine the actual amount to be given to a patient.
Be sure to use calculator if you need to so you can verify doses of a medication. Pay careful attention to decimal points, trailing zeros, or even leading zeros. If it is a high alert medication, have another nurse calculate the dose as well. Many hospitals have policies for high alert medications that need a 2nd check or verification, but just because a medication is not on a list or part of a policy doesn’t mean that you can’t have one double checked if you feel the need to.
With that said…We don’t want to underdose or overdose a patient, we want the therapeutic effect of a medication. So dose and frequency are important.
When in doubt, review the actual order, as doses, and frequency may be incorrect.
4. The Right Route
When reviewing the medication, for correctness, verify the medication with the order and appropriateness of the route prescribed.
Then confirm that it can be given to the patient in the route ordered.
Medications can be given in a numerous amount of ways: Sublingual, topical, subQ, PO, PR, OTIC, IM, IV, Intra-nasally, epidurally and intrathecally. The chosen route is usually the best therapeutic route for absorption, etc.
For example, medications that are to be delivered intravenously will likely have a higher bioavailability, which can potentiate the medication, and provide a faster onset of action, as they are introduced directly into the circulation. Where oral medications must first be digested, and then absorbed to reach the desired effect.
5. “Right time”
Again…We don’t want to underdose or overdose a patient, we want the therapeutic effect of a medication. So timing is crucial to maintain the consistent serum levels in the blood, of a medication.
Even with the busy-ness of a nursing unit, nurses are charged with the task of administering medications on a timely basis. The goal is to continue the bioavailability of a medication in the circulation. Grossly deviating from prescribed times, can alter the therapeutic effect of a medication, decreasing its purpose.
So those are the traditional five rights if medication administration are:
1. Right patient 2. Right medication 3. Right dose
4. Right route 5. Right time
Now, moving past the 5 traditional rights, but even though these are not part of the nursing canon of medication rights, they are also very effective in maintaining an atmosphere of safety for the patient and the nurse.
6. Right documentation
Providing documentation pertaining to the time administered, route administered, allows for continuity of care. An electronic medication administration system provides documentation, and should allow for charting of a patients pain level, or temperature for example, prior to and after administration, of a medication. Or can be charted in the actual patient record. Ensure you have signed for the medication AFTER it has been administered. Although, electronic MARs will have you scan the patient’s armband prior.
7. Right evaluation
This will provide information as to whether a medication’s effect is appropriate…for example, did a patients temperature decrease after administration of an antipyretic; or pain level decrease after giving a certain dose of a pain medication. Or do the doses or medications need to be changed.
8. Right (Patient) education
Discuss with the patient, the name of the medication, and what is it used for, and the desired effect of the medication, and possible side effects. And to have the patient have contact you as the nurse or someone if they are experiencing a reaction or side effect. Now be it understood that you are not going to give a dissertation of a medication at the bedside to a tired, sleepy, sick, altered, and already medicated patient,
but that should not also be an excuse to attempt to explain to the patient about a medication. This practice of explaining medication will make you as a nurse more of an expert on a drug, each time to recite about one.
9. Right Expiration date.
Check the expiration date on the packaging, vial, etc. of the medication to be administered. Ensure that it is not expired so as not to potentiate or decrease the effects of the medication, or provide a toxic environment of bacterial growth, etc.
10. Right Reason or Assessment
What is the reason that the medication is prescribed? Is it appropriate for the patient? Is the medication contraindicated, due to interactions, allergies, physical or psychological conditions? An electronic system should hopefully “catch” possible interactions and allergies, but it will not catch the appropriateness for the patient. For example, if a patient is ordered insulin, but does not have diabetes, does not take “diabetes” medications at home, is not on any medications that would elevate blood glucose levels in the hospital, such as corticosteroids, is not having their blood glucose levels monitored, daily lab-work from a metabolic panel shows a glucose well within normal limits, and is eating a “regular” diet. SO why is the patient being administered Insulin? Maybe it was ordered for reasons that are not apparently clear, so that should prompt more investigation.
Or the example from earlier… the Cerebyx for Celebrex.
If the nurse who is familiar with the patient and their history, has an order for Cerebyx, and anti-seizure medication, it should prompt the nurse to ask…
Why is this medication being ordered for my patient? Did I miss something, I didn’t see a history of seizure, or new onset seizures. And my patient does not have epilepsy…Hmmm? It should prompt further investigation by the nurse. Nurses are there to review, and critically think about these things.
The nurse could then contact the pharmacy / pharmacist, the physician / provider etc. Maybe the order was supposed to be for Celebrex, and the patient does have a history of arthritis. Hmmm!
Last but not least…
11. The Right to refuse
You as the nurse, may go through all these medication rights, checks, verifications, and investigations; and finally, be ready to give it to the patient, but the patient still has the right to refuse, for whatever reason. A patient must consent in order for you to give them their ordered medication. They must also have the mental capacity to refuse. If a patient refuses to take colace (which is a stool softner), due to them having loose stools, then that may be appropriate. If, however, they are refusing all their medications, due to a conspiracy theory… that may need further investigation and intervention. Refusal of medications should be brought to the attention of the provider.
The five traditional rights of:
1. Right patient 2. Right medication 3. Right dose
4. Right route 5. Right time
And the unofficial, but highly beneficial
6. right documentation 7. Right education
8. Right Evaluation 9. Right Expiration date
10 Right Reason / Right Assessment and 11. Right to Refuse
So one last thing that I have to mention…
Medication Errors… SO what if you do make a medication error… It is not the end of the world.
Be sure to tell your charge nurse, manager, physician…and for you students, tell your instructors (although your instructors are usually with you for medication administration).
The reasons are many… such as what if something happens to the patient?
Also…to review systems errors…to determine if there was a breakdown in the system that led to the error… that way it can be corrected.
The more information that can be discovered, can be another way to prevent a medication error. Because chances are,
someone has done it before.
So after learning all this information, instead of the title being:
Don’t to kill your patient? The 5 rights of medication administration.
How about we now change the title to:
“HOW TO KEEP YOUR PATIENTs SAFE!” The Art of the 5 rights of medication administration PLUS 6 more safety rights…
For a total of “THE 11 RIGHTS OF MEDICATION ADMINISTRATION”.
And Don’t forget to ALWAYS KEEP YOUR PATIENTS SAFE by following the 5 rights… or Now 11 Rights of Medication Administration!!!