Course Objectives:

Upon completion of this course the student will be able to:

1. List 3 common causes of medication errors

2. State the “7 Rights” of medication administration
3. Give an example of a “Red Flag” medication order
4. Discuss 3 different routes of medication administration and nursing
considerations
5. Explain the importance of understanding the “right reason” before
dispensing medication
6. List 3 ways to assure that medication administration documentation is
clear, concise and easily understood
7. Give 2 examples when it is necessary to use 2 patient identifiers
according to The Joint Commission National Patient Safety Goal # 1.

Common causes of Medication Error’s

Nurses are routinely asked to calculate dosage information and provide data
entry services for medications and intravenous infusions. Assuming the
physician's order and patient information are correct, there are three general
possibilities for mistakes when administering IV medications via a pump: dosage
miscalculation; transcription data entry error; and titration of the wrong
medication.

Miscalculation Error: A miscalculation error can occur for any number of

reasons, including the use of inaccurate parameters such as dose, weight,
height, drug units, or solution volume. A misplaced decimal or missing number in
this complex calculation can result in a calculation error that may not be
immediately apparent to the clinician. While a nurse will immediately recognize
certain miscalculations, some mistakes like using the wrong concentration data in
the calculation, may go unnoticed and may result with a medication error that is
clinically significant, and life threatening.

Data Entry Error: A transcription type data entry error occurs when a nurse
inadvertently inputs the wrong data into the infusion pump. Another type of
transcription error is the inputting of an incorrect decimal point. For example, the
proper infusion rate is calculated, but the rate is incorrectly entered as 54.0 ml/hr
instead of 5.40 ml/hr.

Titration Errors: According to their effect on the patient, many drug delivery
rates are changed while the infusion pump is infusing. This type of rate change is
called titration. Understanding the medication that is being ordered and the
dosage that this drug is routinely given in is key to assuring that the patient is
getting the proper dose of medication.
Transcription Errors: Being able to read a physicians writing is sometimes a
difficult task, get clarity if uncertain about what has actually been written. If taking
a verbal or phone order, a "read-back" system can be instituted in which the
nurse who is taking the order, writes down the verbal order and reads it back to
the prescribing physician. Once it is read back to the physician and both parties
are in agreement, the order can then be processed.

The “Seven Rights” of Medication Administration

Most registered nurses learned about the "5 rights" early in their careers. The 5
rights (right drug, right client, right dose, right time and right route) have been
incorporated in their nursing practice. Registered nurses also recognize they
need to know the reason the drug is given — the right reason. The administration
of medication is not complete until documentation has occurred — the right
documentation.

1. RIGHT drug
2. RIGHT client (Two Identifiers)
3. RIGHT dose
4. RIGHT time
5. RIGHT route
6. RIGHT reason
7. RIGHT documentation

The addition of “Right Reason” to the original “5 Rights” of medication

administration will not only assure that the right medication was ordered, but will
also assist in assuring that it is for the right person. The following examples are
some Red Flags to consider when receiving or preparing to administer a
medication order:

Your patient’s diagnosis is Sub-Dural Hemorrhage > You receive an order for
Digoxin 0.125mg Q Day > In questioning why this patient would need Digoxin,
you go back to the original diagnosis and history and find that the patient has no
cardiac history > You NEED to question this order.

Your patient is admitted status post Carotid Endarderectomy > You see an order
for an Insulin Sliding Scale to be done Q 6 hours > In questioning why this
patient would need Insulin > you go back to the original diagnosis and history
and find that the patient has no history of Diabetes > You NEED to question this
order.

Your patient is admitted with Abdominal Pain/rule out Small Bowel Obstruction >
You receive an order for PO medication > In reviewing your original diagnosis or
Abdominal Pain and probable need for NPO status > You NEED to question this
order.
To assure safe and accurate documentation of Medication Administration, the
“Right Documentation” has been added to the original “5 Rights”. Remember the
W's when documenting medication administration on the patient chart:

• When (time)
• Why (include assessment, symptoms/complaints, lab values)
• What (medication, dose, route)
• Where (site)
• Was (the med tolerated and if known, helpful to the patient)

In addition to using the W’s for safe and effective Medication Administration
Documentation, using the following techniques will assure that your
documentation is clear, concise and easily understood:

• Legible writing or printing.

• Use of specified ink color.
• Correct grammar & spelling
• Correct recording of time.
• Assure patient identification information is on each page.
• No blanks and no spaces between entry and signature.
• Charting promptly after provision of care.
• Use approved abbreviations.
• Subjective data should be in patient's own words.

What is at the “Route” of the problem?

IV Bolus:

• Drug tolerance declines in patients with decreased cardiac output,

diminished urine output, pulmonary congestion, or systemic edema. To
compensate, dilute the prescribed drug more than usual and administer it
at a slower rate.
• Don't give a drug by I.V. bolus injection if you need to dilute it in a large-
volume parenteral solution before it enters the bloodstream.
• Avoid using an I.V. bolus injection whenever the rapid administration of a
drug, could cause life-threatening complications

IVP:

• Injected into the vein

• Provides a rapid, predictable absorption with minimal complications
Subcutaneous:

• Inject directly into the fatty, subcutaneous tissue under the skin that
overlies the muscle
• Absorption from this route is slow, resulting in a delayed onset of action
and prolonged effect

Interocceous:

• Used primarily with pediatric patients

• Inject into the bone marrow
• Medications quickly enter the circulatory system

Inhalation:

• Must be delivered through the respiratory tract

• Inhaled medication may be administered via aerosolized treatments and
inhalers

Enteral:

• Digestive tract
• Oral
• Sublingual
• Rectal

Trans-dermal:

• Placed on the skin

• Absorbed into the circulatory system through the skin
Intramuscular (IM):

• Injected into the muscle tissue

• It is absorbed into the bloodstream
• Administration has a predictable rate of absorption
• Onset of action is considerably slower than intravenous administration

Because wrong patient medication administration errors can occur during all
stages of the diagnosis and treatment of a patient; the intent of The Joint
Commission’s NPSG #1 is actually two-fold. The first goal is to reliably identify
the patient and the second is to assure that the service or treatment intended; is
actually for the correct patient. The following are situations where The Joint
Commission requires that two patient identifiers are used: Administering
medications, blood or blood components. Collection of all blood samples and
other specimens for clinical testing. Providing any other procedure or test. NOTE:
the patient’s room number or physical location is no to be used as a reliable
identifier.

References
The Joint Commission (2009). National patient safety goals. Retrieved on
September 6, 2009 at:
http:
//www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/09_hap_np
sgs.htm

Iyer, Patricia, W., & Camp, Nancy, H., (1999). Nursing Documentation: A nursing
process approach. (3rd ed.). (pp. 18-25). Mosby. St. Louis Mo.

Joint Commission of Hospital Accreditation. (2006). Hospitals National Patient

Safety Goals. Retrieved on December 15, 2006 at:
http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/06_np
sg_cah.htm

Otto, Shirley, E., (2004). Mosby’s Pocket Guide Infusion Therapy. (5th ed).
Elsevier Mosby. St. Louis

Yocum, Faye, (2004). Abbreviations: A shortcut to disaster. Retrieved on

December 13, 2006 at:
www.nso.com/resources/artcls_abbrevs.php