February 5, 2022 • 16 mins
Safety and quality are critical when discussing medication administration. Let's discuss nursing considerations and medication administration.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Unknown (00:00):
Hey there, and welcome to nursing with Dr. Hobbick.
(00:03):
Today I'm thinking about safetyand quality in medication
administration. This is a veryimportant topic for nurses as we
do a lot of medicationadministration. And in fact, we
are responsible for themedications that we administered
to our patients, I always tellmy students that they can sort
of think of themselves as thelast line of defense, in light
(00:26):
of any errors that could reachthe patient. In fact, in 2000,
the Institute of Medicinereleased a shocking report
called To err is human buildinga safer healthcare system. And
in that report, they estimatedthat 98,000 People die in any
given year from medical errorsthat occur in hospitals. This
(00:49):
demonstrates how important it isfor nurses to be aware of
methods that they can use toprevent this from happening to
their patients. The first thingthat we need to think about is
what's called the rights ofmedication administration. Now,
honestly, I've seen five rights,six rights 11 rights, we're
going to go with six rightsbecause I think those are the
(01:11):
easiest to remember the rightsof medication administration are
the right patient, the rightdrug or medication, the right
dose, or amount, the right time,the right route, and the right
documentation. My fun way toremember this something that I
came up with in nursing school.
Okay, I hope you're ready forthis. It's actually D, the
nurse, you know, D, she's atramp, tramp D, but we love her
(01:36):
breaks a new heart every day.
Okay, hopefully I won't get suedfor that one.
So what are the six rights ofmedication administration? Well,
the six rights of medicationadministration are the things
that you should be looking atbefore you administer
medications, there's actuallythree checks, which are times
(01:58):
where you perform these rightsof medication administration.
The first check happens whenyou're initially looking at the
patient's chart. So if I was atwork, I would get report on my
patient because you know, I liketo make sure they're still alive
and everything before I go offand look in their chart, I pull
the chart up and I start to planmy day and and a very essential
(02:18):
part of that is looking at theirmedications to identify what
priorities I have, whatmedications they have. So I look
at each of these the rightpatient, I'm looking at the
patient I'm looking at theirconditions I'm looking at a does
it make sense for them to havethis medicine I'm looking at the
medication for the same reasonI'm looking at the dosage is it
(02:41):
in the normal range of what Isee doesn't match what my
medication guide tells me theyshould be getting? is the right
time some medications should begiven in the evening like
Aricept is a medication that cancome sense sometimes cause
drowsiness. And so is typicallygiven in the evening or statin
medications. Those are eveningmedicine. So if you see those in
(03:01):
the morning, you might go to theprovider and ask for
clarification, I want to knowthat it's the right route. If I
have a patient who can't safelyswallow, then giving them
medicines by mouth doesn't makesense. By the same token, if I
have a patient who can swallow,giving them medications, I don't
know, rectally might not beappropriate. I like my patients
(03:22):
to like me, right. And then theright documentation, we really
have to make sure that we do ourdocumentation appropriately, so
that everybody knows what's beengoing on with this patient. The
second check is done. Whileyou're pulling your medications,
you should have access either tothe EMR the electronic medical
record while you're pulling yourmedications, or you make a list.
(03:45):
And once you're done, you go andcompare against the mar the
Medication AdministrationRecord. While you're in there,
you're looking for all of thesesame things. The right patient,
the right drug, the right dose,the right time, the right route,
the right documentation, thelast check the third check, that
one is completed at the bedsidewith the patient right before
(04:07):
you go to administer themedications. So let's talk about
each of these in a little moredetail. Patient. That's where we
verify the patient with twoforms of identification. We're
also making sure that what we'relooking at makes sense, the
right medication, we during thethird check should be scanning
the medicines scanning thepatient, if that's available, we
(04:31):
should be making sure that theorder was completed by a
licensed provider, making surethat we're looking at the label
on the medicine. Is it themedicine that you expect it to
be pulling out of the unitsmedication distribution system?
Does it make sense that thispatient is taking this does
their vital signs their healthrecord their allergies, their
(04:52):
lab results? We put all thatinformation together to
determine if it's safe for us toadminister this medication to
the patient If you have to doany drug calculations or medical
calculations, those need to beverified with another nurse, we
should never trust our ownmathematical abilities. I
personally don't math Well, inmy mind, I have to write them
(05:13):
down. But we should always getanother nurse to verify the
dosage. And we also want to knowthe beginning and end date of
the order because sometimesthings are only ordered for 24
hours, or they're only orderedfor a week. Next, we'll talk
about dose, we need to again,make sure that we're verifying
dosage, make sure that thepatient's weight if the dosage
(05:35):
is weight dependent is accurate,and we have the most up to date
weight, we want to validate doseof certain medications, these
would be your high riskmedications like Heparin, or
insulin, there are others, butthose are the first two that
come to mind, make sure thatthose are all going to be safe
for the patient. Right time,we're using health care agency
(05:57):
policy, if the policy is thatthese medications are time
sensitive, typically, theyshould be given within 30
minutes. If they're not timesensitive, we should give them
within an hour. That means ifthey're due at nine o'clock, and
they're not time sensitive, youcould give them any time between
eight and 10. But for example,insulin or some cardiac
(06:18):
medications are time sensitive,and they're due at nine they
should be given some timebetween 830 and 930, that 30
minute timeframe, we need tothink about food, is that going
to effect this medication, can Igive this medicine while the
patient has food in theirstomach? Does it have to be
given on an empty stomach?
That's going to change thetimeframe that I choose to
administer the medication? Arethey having a procedure? Is that
(06:41):
scheduled? Is it okay for themto receive these medications?
Are they nothing by mouth orNPO? For that procedure, in that
case, I would need to check withthe surgeon or the facility
policy, I need to make sure thatthe expiration date is okay that
it's not expired. If the patientis on something like an
antibiotic, it's very importantto keep it within the
(07:02):
therapeutic index that we talkedabout before. We want to make
sure that it is given as closeto on time as possible. And then
anytime a patient is going tohave dialysis, we need to think
about the medications thatthey're going to get ahead of
time. A big thing to think aboutthere is going to be an
antihypertensive that wetypically will hold before they
get dialysis. Right route as Imentioned earlier is necessary
(07:25):
for adequate absorption. Wetalked about this in
pharmacodynamics andpharmacokinetics episode, we
want to make sure the patient isable to swallow safely. Remember
that we can't crush medicationthat is extended release or
delayed release or sustainedrelease or enteric coated. If it
is one of those and the patientneeds their medicines crushed,
(07:48):
we need to contact the pharmacyto see if there's a liquid or
granules or powder that we canuse said we want to offer the
patient water but not typicallyjuice. Iron can be taken with
orange juice because it absorbsbetter in an acid environment.
And we want to make sure thatwe're using aseptic technique. I
know you open those littlepills, they fly all over the
(08:11):
place it even if it lands onyour 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 makesure we're using gloves because
it could be a medicine that isteratogenic. Meaning if you are
a person with a uterus, andmaybe don't know that you're
pregnant, you couldinadvertently harm the baby by
handling that medicationdocumentation. This is super
(08:34):
important. You've always got todocument after you administer
the medication. The reason isyou'll curse yourself. If you
don't if you document yourmedication prior to actually
administering it. Either themedicine will go flying across
the room, the patient will notbe able to take it for whatever
reason. And now you havefalsified documentation and
(08:55):
remember that the EMR the EHR isadmissible in court. This is a
court admissible document. It'sa legal document. You don't want
to be the one to falsify that.
So it's simple enough to waituntil you have actually
administered the medication.
Know that the patient has safelybeen able to take it or receive
it, and then document youradministration. Another
(09:17):
important thing that I want totalk about today is a culture of
safety. It's very easy for us tosay any nurse who inadvertently
causes an error or harm to apatient should immediately be
fired should lose her nursinglicense should not be able to
function anymore. There's acouple things that we need to
consider before we make ajudgement like that. The first
(09:39):
thing that we need to consideris the environment. Folks,
nurses do not have safe staffingratios. And it is very difficult
to work in healthcare because ithas high level of distraction. I
usually have my students watch avery interesting video. That's
called interrupts. awareness, anursing minute for patient
(10:01):
safety, I highly encourage youto take a look at it on YouTube.
It demonstrates how hard it isto concentrate with just a few
levels of distraction. And thisis where nurses work every day.
The more patients you have, themore distracted you are. And I
personally, usually work in medsearch, and we have six patients
(10:21):
on average. Now, it's not toobad if they're medically stable
like they should be. And peopleshould know that during the
COVID pandemic, especially theworst parts of it. For us where
I live in July and August, wehad eight patients each, and we
had patients who were notnecessarily medically stable,
(10:42):
added on to that we typicallyhave nurses who are assigned
patients, we have an extra nursewho doesn't have patients who
helps out and we have a chargenurse who doesn't have patients.
And here we are running 24 bedswith all with patients who
aren't necessarily medicallystable with three nurses. That's
right, our charge nurse even hadeight patients, folks, that's
not safe. It doesn't matterwhere you are, or who you are a
(11:05):
few steps into that environment,you would see how unsafe that
is, it would be very easy for amedication error to happen in
that sort of circumstance. Andthe other reason that we need to
have a culture of safety isbecause it's very difficult to
get a nursing license. And I'mhere to tell you that anybody
who worked so hard to develop acareer and who spent however
(11:28):
much money on getting thatdegree, there's a chance that
should they make an error likethat, they might hide it because
they don't want to get introuble. They don't want to get
fired. They don't want to losetheir livelihood. Think about
it, if you were threatened withlosing your entire livelihood,
whatever career you've chosenfor yourself, you'll never be
able to do that, again, was youhide an error? I think to be
(11:50):
honest, there's a portion of thepublic who would do so it's much
easier to treat a patient whohas experienced a medication
errorif we know what the error was.
And so it's much better, it'sfar better for us to have a
culture of safety, where we cansay, how can we stop this from
happening again, the really bigthing that we want to find is
(12:13):
those near misses. If we canidentify a near miss and stop
that from happening. Stop itfrom ever reaching a patient. If
we can notice that there's atrend, then that would be much
better. I think we can allagree. Now on the topic of
safety, we want to make surethat we are reconciling the
patient's medications. The JointCommission has identified that
(12:34):
the top places where errorshappen is during transitions. So
the transition might be goingfrom the hospital to home the
hospital to long term care,short term rehab to long term
care, etc. Making sure thatthose medications follow
through. Patients may notunderstand when they leave the
(12:55):
hospital, what medications theyshould be starting, what
medications they should bestopping. So we need to make
sure that we've covered thatinformation, disposal of
medications. Typically, you needto find out if your local area
has some kind of medicine takeback program, we want to
discourage patients fromdisposing of medications down
(13:16):
the toilet. This is causingproblems where medications, you
know could end up in the watersupply. We might have them mix
the medication in a really yuckyor undesirable substance like
cat litter. The courts want toremove all their identifying
information. And again, if theydon't know where to dispose of
(13:36):
their medicines, check with lawenforcement or local
pharmacists, they may have someidea. sharps safety is something
that we also need to consider.
As nurses. There should besafeties attached to our sharps
unless there's some verydetailed plans on how to safely
dispose of these that'stypically reserved for a
(13:57):
physician or provider. So whenyou give an injection, never
recap the needle, immediatelyactivate the safety and it goes
into the sharps container. Itell my students do not pass go
do not collect $200 Straight tothe sharps container unless your
patient all of a sudden needsCPR. Something that's become a
bigger risk lately is buyingmedicines on the internet and
(14:20):
it's very difficult to tell ifmedications are real or
counterfeit. I always encouragemy patients to make sure that
they are only purchasing theirmedications from a licensed
pharmacy because it is so hardto tell if the medication is
counterfeit. That's all I've gotfor you today. Thanks for
hanging out with me here onnursing with Dr. Hobbick. I'll
(14:42):
see you next time.
Hey there, and welcome to nursing with Dr. Hobbick.
(00:03):
Today I'm thinking about safetyand quality in medication
administration. This is a veryimportant topic for nurses as we
do a lot of medicationadministration. And in fact, we
are responsible for themedications that we administered
to our patients, I always tellmy students that they can sort
of think of themselves as thelast line of defense, in light
(00:26):
of any errors that could reachthe patient. In fact, in 2000,
the Institute of Medicinereleased a shocking report
called To err is human buildinga safer healthcare system. And
in that report, they estimatedthat 98,000 People die in any
given year from medical errorsthat occur in hospitals. This
(00:49):
demonstrates how important it isfor nurses to be aware of
methods that they can use toprevent this from happening to
their patients. The first thingthat we need to think about is
what's called the rights ofmedication administration. Now,
honestly, I've seen five rights,six rights 11 rights, we're
going to go with six rightsbecause I think those are the
(01:11):
easiest to remember the rightsof medication administration are
the right patient, the rightdrug or medication, the right
dose, or amount, the right time,the right route, and the right
documentation. My fun way toremember this something that I
came up with in nursing school.
Okay, I hope you're ready forthis. It's actually D, the
nurse, you know, D, she's atramp, tramp D, but we love her
(01:36):
breaks a new heart every day.
Okay, hopefully I won't get suedfor that one.
So what are the six rights ofmedication administration? Well,
the six rights of medicationadministration are the things
that you should be looking atbefore you administer
medications, there's actuallythree checks, which are times
(01:58):
where you perform these rightsof medication administration.
The first check happens whenyou're initially looking at the
patient's chart. So if I was atwork, I would get report on my
patient because you know, I liketo make sure they're still alive
and everything before I go offand look in their chart, I pull
the chart up and I start to planmy day and and a very essential
(02:18):
part of that is looking at theirmedications to identify what
priorities I have, whatmedications they have. So I look
at each of these the rightpatient, I'm looking at the
patient I'm looking at theirconditions I'm looking at a does
it make sense for them to havethis medicine I'm looking at the
medication for the same reasonI'm looking at the dosage is it
(02:41):
in the normal range of what Isee doesn't match what my
medication guide tells me theyshould be getting? is the right
time some medications should begiven in the evening like
Aricept is a medication that cancome sense sometimes cause
drowsiness. And so is typicallygiven in the evening or statin
medications. Those are eveningmedicine. So if you see those in
(03:01):
the morning, you might go to theprovider and ask for
clarification, I want to knowthat it's the right route. If I
have a patient who can't safelyswallow, then giving them
medicines by mouth doesn't makesense. By the same token, if I
have a patient who can swallow,giving them medications, I don't
know, rectally might not beappropriate. I like my patients
(03:22):
to like me, right. And then theright documentation, we really
have to make sure that we do ourdocumentation appropriately, so
that everybody knows what's beengoing on with this patient. The
second check is done. Whileyou're pulling your medications,
you should have access either tothe EMR the electronic medical
record while you're pulling yourmedications, or you make a list.
(03:45):
And once you're done, you go andcompare against the mar the
Medication AdministrationRecord. While you're in there,
you're looking for all of thesesame things. The right patient,
the right drug, the right dose,the right time, the right route,
the right documentation, thelast check the third check, that
one is completed at the bedsidewith the patient right before
(04:07):
you go to administer themedications. So let's talk about
each of these in a little moredetail. Patient. That's where we
verify the patient with twoforms of identification. We're
also making sure that what we'relooking at makes sense, the
right medication, we during thethird check should be scanning
the medicines scanning thepatient, if that's available, we
(04:31):
should be making sure that theorder was completed by a
licensed provider, making surethat we're looking at the label
on the medicine. Is it themedicine that you expect it to
be pulling out of the unitsmedication distribution system?
Does it make sense that thispatient is taking this does
their vital signs their healthrecord their allergies, their
(04:52):
lab results? We put all thatinformation together to
determine if it's safe for us toadminister this medication to
the patient If you have to doany drug calculations or medical
calculations, those need to beverified with another nurse, we
should never trust our ownmathematical abilities. I
personally don't math Well, inmy mind, I have to write them
(05:13):
down. But we should always getanother nurse to verify the
dosage. And we also want to knowthe beginning and end date of
the order because sometimesthings are only ordered for 24
hours, or they're only orderedfor a week. Next, we'll talk
about dose, we need to again,make sure that we're verifying
dosage, make sure that thepatient's weight if the dosage
(05:35):
is weight dependent is accurate,and we have the most up to date
weight, we want to validate doseof certain medications, these
would be your high riskmedications like Heparin, or
insulin, there are others, butthose are the first two that
come to mind, make sure thatthose are all going to be safe
for the patient. Right time,we're using health care agency
(05:57):
policy, if the policy is thatthese medications are time
sensitive, typically, theyshould be given within 30
minutes. If they're not timesensitive, we should give them
within an hour. That means ifthey're due at nine o'clock, and
they're not time sensitive, youcould give them any time between
eight and 10. But for example,insulin or some cardiac
(06:18):
medications are time sensitive,and they're due at nine they
should be given some timebetween 830 and 930, that 30
minute timeframe, we need tothink about food, is that going
to effect this medication, can Igive this medicine while the
patient has food in theirstomach? Does it have to be
given on an empty stomach?
That's going to change thetimeframe that I choose to
administer the medication? Arethey having a procedure? Is that
(06:41):
scheduled? Is it okay for themto receive these medications?
Are they nothing by mouth orNPO? For that procedure, in that
case, I would need to check withthe surgeon or the facility
policy, I need to make sure thatthe expiration date is okay that
it's not expired. If the patientis on something like an
antibiotic, it's very importantto keep it within the
(07:02):
therapeutic index that we talkedabout before. We want to make
sure that it is given as closeto on time as possible. And then
anytime a patient is going tohave dialysis, we need to think
about the medications thatthey're going to get ahead of
time. A big thing to think aboutthere is going to be an
antihypertensive that wetypically will hold before they
get dialysis. Right route as Imentioned earlier is necessary
(07:25):
for adequate absorption. Wetalked about this in
pharmacodynamics andpharmacokinetics episode, we
want to make sure the patient isable to swallow safely. Remember
that we can't crush medicationthat is extended release or
delayed release or sustainedrelease or enteric coated. If it
is one of those and the patientneeds their medicines crushed,
(07:48):
we need to contact the pharmacyto see if there's a liquid or
granules or powder that we canuse said we want to offer the
patient water but not typicallyjuice. Iron can be taken with
orange juice because it absorbsbetter in an acid environment.
And we want to make sure thatwe're using aseptic technique. I
know you open those littlepills, they fly all over the
(08:11):
place it even if it lands onyour 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 makesure we're using gloves because
it could be a medicine that isteratogenic. Meaning if you are
a person with a uterus, andmaybe don't know that you're
pregnant, you couldinadvertently harm the baby by
handling that medicationdocumentation. This is super
(08:34):
important. You've always got todocument after you administer
the medication. The reason isyou'll curse yourself. If you
don't if you document yourmedication prior to actually
administering it. Either themedicine will go flying across
the room, the patient will notbe able to take it for whatever
reason. And now you havefalsified documentation and
(08:55):
remember that the EMR the EHR isadmissible in court. This is a
court admissible document. It'sa legal document. You don't want
to be the one to falsify that.
So it's simple enough to waituntil you have actually
administered the medication.
Know that the patient has safelybeen able to take it or receive
it, and then document youradministration. Another
(09:17):
important thing that I want totalk about today is a culture of
safety. It's very easy for us tosay any nurse who inadvertently
causes an error or harm to apatient should immediately be
fired should lose her nursinglicense should not be able to
function anymore. There's acouple things that we need to
consider before we make ajudgement like that. The first
(09:39):
thing that we need to consideris the environment. Folks,
nurses do not have safe staffingratios. And it is very difficult
to work in healthcare because ithas high level of distraction. I
usually have my students watch avery interesting video. That's
called interrupts. awareness, anursing minute for patient
(10:01):
safety, I highly encourage youto take a look at it on YouTube.
It demonstrates how hard it isto concentrate with just a few
levels of distraction. And thisis where nurses work every day.
The more patients you have, themore distracted you are. And I
personally, usually work in medsearch, and we have six patients
(10:21):
on average. Now, it's not toobad if they're medically stable
like they should be. And peopleshould know that during the
COVID pandemic, especially theworst parts of it. For us where
I live in July and August, wehad eight patients each, and we
had patients who were notnecessarily medically stable,
(10:42):
added on to that we typicallyhave nurses who are assigned
patients, we have an extra nursewho doesn't have patients who
helps out and we have a chargenurse who doesn't have patients.
And here we are running 24 bedswith all with patients who
aren't necessarily medicallystable with three nurses. That's
right, our charge nurse even hadeight patients, folks, that's
not safe. It doesn't matterwhere you are, or who you are a
(11:05):
few steps into that environment,you would see how unsafe that
is, it would be very easy for amedication error to happen in
that sort of circumstance. Andthe other reason that we need to
have a culture of safety isbecause it's very difficult to
get a nursing license. And I'mhere to tell you that anybody
who worked so hard to develop acareer and who spent however
(11:28):
much money on getting thatdegree, there's a chance that
should they make an error likethat, they might hide it because
they don't want to get introuble. They don't want to get
fired. They don't want to losetheir livelihood. Think about
it, if you were threatened withlosing your entire livelihood,
whatever career you've chosenfor yourself, you'll never be
able to do that, again, was youhide an error? I think to be
(11:50):
honest, there's a portion of thepublic who would do so it's much
easier to treat a patient whohas experienced a medication
errorif we know what the error was.
And so it's much better, it'sfar better for us to have a
culture of safety, where we cansay, how can we stop this from
happening again, the really bigthing that we want to find is
(12:13):
those near misses. If we canidentify a near miss and stop
that from happening. Stop itfrom ever reaching a patient. If
we can notice that there's atrend, then that would be much
better. I think we can allagree. Now on the topic of
safety, we want to make surethat we are reconciling the
patient's medications. The JointCommission has identified that
(12:34):
the top places where errorshappen is during transitions. So
the transition might be goingfrom the hospital to home the
hospital to long term care,short term rehab to long term
care, etc. Making sure thatthose medications follow
through. Patients may notunderstand when they leave the
(12:55):
hospital, what medications theyshould be starting, what
medications they should bestopping. So we need to make
sure that we've covered thatinformation, disposal of
medications. Typically, you needto find out if your local area
has some kind of medicine takeback program, we want to
discourage patients fromdisposing of medications down
(13:16):
the toilet. This is causingproblems where medications, you
know could end up in the watersupply. We might have them mix
the medication in a really yuckyor undesirable substance like
cat litter. The courts want toremove all their identifying
information. And again, if theydon't know where to dispose of
(13:36):
their medicines, check with lawenforcement or local
pharmacists, they may have someidea. sharps safety is something
that we also need to consider.
As nurses. There should besafeties attached to our sharps
unless there's some verydetailed plans on how to safely
dispose of these that'stypically reserved for a
(13:57):
physician or provider. So whenyou give an injection, never
recap the needle, immediatelyactivate the safety and it goes
into the sharps container. Itell my students do not pass go
do not collect $200 Straight tothe sharps container unless your
patient all of a sudden needsCPR. Something that's become a
bigger risk lately is buyingmedicines on the internet and
(14:20):
it's very difficult to tell ifmedications are real or
counterfeit. I always encouragemy patients to make sure that
they are only purchasing theirmedications from a licensed
pharmacy because it is so hardto tell if the medication is
counterfeit. That's all I've gotfor you today. Thanks for
hanging out with me here onnursing with Dr. Hobbick. I'll
(14:42):
see you next time.
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On Purpose with Jay Shetty
I’m Jay Shetty host of On Purpose the worlds #1 Mental Health podcast and I’m so grateful you found us. I started this podcast 5 years ago to invite you into conversations and workshops that are designed to help make you happier, healthier and more healed. I believe that when you (yes you) feel seen, heard and understood you’re able to deal with relationship struggles, work challenges and life’s ups and downs with more ease and grace. I interview experts, celebrities, thought leaders and athletes so that we can grow our mindset, build better habits and uncover a side of them we’ve never seen before. New episodes every Monday and Friday. Your support means the world to me and I don’t take it for granted — click the follow button and leave a review to help us spread the love with On Purpose. I can’t wait for you to listen to your first or 500th episode!