Chapter 10

Medication Administration

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 Medication Administration:
Objectives
After reviewing this chapter, you should be able to
1. state the consequences of medication errors
2. identify the causes of medication errors
3. identify the role of the nurse in preventing
medication errors
4. identify the role of the Institute for Safe
Medication Practices (ISMP) and The Joint
Commission (TJC) in preventing medication
errors

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 Medication Administration:
Objectives (Cont.)
5. state the base six “rights” of safe medication
administration
6. identify factors that influence medication
dosages
7. identify the common routes for medication
administration
8. define critical thinking
9. explain the importance of critical thinking in
medication administration

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 Medication Administration:
Objectives (Cont.)
10. identify important critical thinking skills
necessary in medication administration
11. discuss the importance of client teaching
12. identify special considerations relating to the
elderly and medication administration
13. identify home care considerations in relation
to medication administration

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 Medication Errors
 Definition (NCCMERP):

A medication error is any preventable event that may

cause or lead to inappropriate medication use or patient
harm while the medication is in the control of the health
care professional, patient, or consumer.

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 Medication Errors (Cont.)
 Potential consequences:
 Acute or chronic disability
 Death
 Increased hospital stay
 Increased health care cost
 Legal consequences
 Loss of nursing license
 Loss of position
 Most common cause of client injury despite
advances in technology

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 Medication Errors Causes
 Lack of med information  Failure to educate clients
 Lack of client information  Administration of meds without
 (e.g., allergies, home medications,
the reason for the medication being
critical thought
administered)  Failure to comply with the
 Confusing med names required policy or procedure
 Miscalculation of dosages  Shortage of nursing personnel
 Incomplete orders  shift changes, floating staff,
double shifts, and workload
 Failure to observe “rights”
increases
 Failure to identify a client  Distractions and interruptions
 Miscommunication of orders
 poor handwriting, misuse of zeros
and decimal points, confusion of
dosing units, inappropriate
abbreviations and errors in
computer order entry.

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 Medication Errors
 Organizations involved in advancement of client
safety
 Institute for Safe Medication Practices (ISMP)
 United States Pharmacopeia (USP)
 The Joint Commission (TJC)
 United States Food and Drug Administration (FDA)
 Quality and Safety Education for Nurses (QSEN)
 National Quality Forum (NQF)

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 Critical Thinking and
Medication Administration
 Definition: a process of thinking that includes
being reasonable and rational
 Organizational skills
 Autonomy: willingness to challenge incorrect orders
and get clarification
 Distinguish irrelevant from relevant information
 Reasoning: selection of right tools and client
assessment
 The nurse who administers a medication is
legally liable for the medication error regardless
of the reason for the error.
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 Factors Influencing
Medication Dose and Action
 All must be considered
1. Route of administration
2. Time of administration
3. Age of client
4. Nutritional status of client
5. Absorption and excretion of the drug
6. Health status of the client
7. Gender of the client
8. Ethnicity and culture of the client
9. Genetics

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Special Considerations for Elderly
 Two thirds use Rx and OTC meds
 Americans 65 years or older are expected to be
21.7% of the population by 2040.
 Physiological changes
 slow function
 cause unexpected medication reactions
 make the elderly person more sensitive to the effects of
many medications
 Physiological changes include:
 Changes in circulation, absorption, metabolism, excretion,
and stress response
 Lowered body weight, change in mental status

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Special Considerations for Elderly
(Cont.)
 Require lower doses as a rule
 May need
 Special delivery devices
 Visual aid to read labels
 Easy-open lids
 Allow extra time for teaching
 Clients of every age should demonstrate back
what you taught them

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Figure 10-1 A, Container that holds a week’s medications. B, The Pill Timer beeps, flashes, and
automatically resets every time it is closed. (From Perry AG, Potter PA, Elkin MK, Ostendorf WR: Nursing
interventions and clinical skills, ed 6, St Louis, 2016, Mosby.)

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 Six “Rights” of Medication
Administration
1. Right client
 Two unique identifiers (e.g., name and DOB)
 NOT room number
2. Right medication
 Compare medication administration record
(MAR) with order
 Check 3 times before administration
3. Right dose
 Check calculations and labels

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 Six “Rights” of Medication
Administration (Cont.)
4. Right route
 How medication is administered (by mouth, injection, etc.)
 Check orders and drug guides
 Special considerations with feeding tubes
5. Right time
 Time of day and frequency SAFETY ALERT!
 “30-minute rule” When a client questions a
6. Right documentation med, STOP and LISTEN.
 This may be an
No documentation leads opportunity to identify an
to double-dosing error before a client is
 Avoid “Do Not Use” abbreviations harmed
 Outcomes of medications

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 Other “Rights”
 The right indication
 Understands the reason for a medication to know when to hold
 The right to know
 Educate clients regarding medications
 Right to refuse
 Document and notify caregiver
 Exception: Kendra’s Law
• Potentially dangerous mentally ill
• Court-ordered assisted outpatient treatment (AOT)
 Exception: Emergency court orders
• May give forcibly
• Requires judge’s order
 The right response
 ensuring the medication has the intended effect

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 Case Study 3
Mr. Ross is a 62-year-old male who is s/p palliative
colostomy with mucous fistula. He has a history of
advanced metastatic rectal cancer. Before he is
transferred to the unit from the post-anesthesia
care unit (PACU), you must confirm PCA morphine
settings with the PACU nurse. What are the six
rights you will verbalize to reduce medication
errors?

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 Case Study 3 (Cont.)
ANS:

1. Right medication
2. Right dosage
3. Right client
4. Right route
5. Right time
6. Right documentation

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 Medication Reconciliation
 Process of comparing medications the client has
been taking before admission with the
medications the organization will provide
 On admission, nurses need to get a thorough
history of medications being taken by a client to
prevent medication interactions that may cause
harm or death
 Avoids errors of
 Transcription, omission, duplication of therapy, and
medication interaction

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 Patient/Client Education
 Imperative for preventing errors
 Helps prevent adverse reactions
 Improves adherence
 Include the following:
 Brand and generic names, explanation of amount,
explanation of timing for dose, measuring devices,
and route
 Follow up on teaching

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 Case Study 3
Mr. Ross is transferred to the unit in stable
condition. He has an NGT to low intermittent
suction draining brownish red fluid. Surgical
dressing is clean, dry, and intact, with minimal
bloody drainage to colostomy and mucous fistula
bags. Mrs. Ross is very involved in her husband’s
care and you ask her to confirm the medication
reconciliation form. How do you respond when
she asks, “What is medication reconciliation?”

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 Case Study 3 (Cont.)
ANS:

Medication reconciliation compares medications

Mr. Ross takes at home with the medications that
we will administer during his stay. This helps to
prevent medication interactions.

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 Home Care Considerations
 Home health care is increasing with increased
population and early discharges
 Special considerations for “home” setting
 Practice requires more autonomy
 Use the six rights as guidelines
 Teaching focuses on devices from local
pharmacies and calibrated home devices
 Communication is critical!

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Nurse’s Role in Med Error Prevention
 Open communication between nurses and
clients may prevent med errors
 This involves teaching AND listening
 “Errors have been prevented by observant and
informed patients and families” (Cohen, 2010)
 When med errors occur, report them per your
organization’s policy
 Always adhere to safety standards and use
technology to help you prevent med errors and
identify safety risks

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 Routes of Administration
 Oral (p.o.)  Parenteral
 Swallowed tablets,  IV, IM, Subcut, or ID
capsules, or liquid
solutions
 Insertion
 Placed into body
 Sublingual (SL)
 Placed under tongue cavity such as rectal or
vaginal suppositories
 Buccal
 Placed in mouth against
 Instillation
cheek  Placed in the eye,
 Enteric coated nose, or ear
 dissolves in the small
intestine
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 Routes of Administration (Cont.)
 Inhalation (INH)  Topical
 Administered into  Applied to skin
respiratory track such (lotions, ointments,
as metered-dose pastes)
inhalers, nebulizers,  Percutaneous
spacers  Applied to skin or
 Intranasal mucous membranes
 Solution instilled into  Transdermal
the nostrils  Topically applied
medicated patches or
discs
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 Case Study 3
Mr. Ross is to receive 2 L of Dextrose 5% in ½
normal saline through a 20-gauge peripheral IV
located on the right forearm. The IV fluid will run at
a rate of 125 mL/hr. Which route of administration
will be used?

a. Instillation
b. Percutaneous
c. Transdermal
d. Parenteral
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 Case Study 3 (Cont.)
ANS: D

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Equipment for Med Administration
 Medicine cup (30 mL/1 oz/2 Tbs)
 Used for liquid medication 5–30 mL
 Soufflé cup
 Used for solids such as tablets or capsules
 Calibrated dropper
 Used to administer small amounts of liquid
medication

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Equipment for Med Administration (Cont.)
 Nipple
 Adapted for some infant meds
 Oral syringe
 To administer liquid medications orally
 Parenteral syringe
 Used for IM, Subcut, ID, IV meds
 Barrel marked in mL or units
 Needle attached to tip
 Plunger pushes medication through needle

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Figure 10-2 A, Plastic medicine cup. B, Soufflé cup. (Courtesy
of Chuck Dresner. From Clayton BD, Willihnganz M: Basic
pharmacology for nurses, ed 17, St Louis, 2017, Mosby.)

Figure 10-3 Medicine droppers.

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 Figure 10-4 Nipple. (Modified from Clayton BD, Willihnganz M: Basic pharmacology for nurses, ed 17, St Louis, 2017,
Mosby.)

Figure 10-6 Parts of a syringe. (From Potter PA, Perry AG, Stockert P, Hall A:
Fundamentals of nursing, ed 9, St Louis, 2016, Mosby.)
Figure 10-5 Oral syringes. (Courtesy of Chuck
Dresner. From Clayton BD, Willihnganz M: Basic
pharmacology for nurses, ed 17, St Louis, 2017,
Mosby.)

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Figure 10-7 Types of syringes. A, Luer-Lok syringe marked in 0.1 (tenths). B, Tuberculin syringe marked in
0.01 (hundredths) for dosages of less than 1 mL. C, Insulin syringe marked in units (100). D, Insulin syringe
marked in units (50). (From Potter PA, Perry AG, Stockert P, Hall A: Fundamentals of nursing, ed 9, St Louis,
2016, Mosby.)

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Figure 10-8 A, Acceptable devices for measuring and administering oral medication to children (clockwise):
measuring spoon, plastic syringes, calibrated nipple, plastic medicine cup, calibrated dropper, hollow-
handled medicine spoon. B, Medibottle used to deliver oral medication via a syringe. (A, From Hockenberry
MJ, Wilson D: Wong’s nursing care of infants and children, ed 9, St Louis, 2011, Mosby. B, Courtesy Paul
Vincent Kuntz, Texas Children’s Hospital, Houston.)

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 Practice Problems
1. Which device can you use to administer 1.5 mL
of an oral medication?
2. How many tablespoons can one medicine cup
hold?
3. Differentiate between the sublingual and buccal
routes of administration.
4. What should you do if you make a med error?
5. Discuss some special considerations for the
elderly.

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