1. Administration of medications
Jana HeŘmanovÁ
ICM II, 24 February 2014

2. What does it involve?
Prescribing – MD, nurse practitioner, medical student
Administering – RN, health care assistant, NA, radiology assistant, MD
Taking – the patient
What’s missing? Who’s missing?
Dispensing – clinical pharmacist, pharmacology assistant
ICM II, 24 February 2014

3. What is a medication?
a substance given to a person (or animal) with the aim to cure disease, relieve symptoms, prevent disease or help with diagnosis
ICM II, 24 February 2014

4. What’s in the picture?
ICM II, 24 February 2014

5. Forms of medications Solid
Powder, tablets, capsules, coated tablets, lozenges
Semisolid
Suppositories, creams, ointments, gels, patches
Liquid
Solutions, suspensions, syrups, elixirs, drops, mouth wash
Inhalants/sprays
ICM II, 24 February 2014

6. ICM II, 24 February 2014

7. Routes of administration
Enteral
By mouth p.o.
Rectal p.r.
Parenteral
Intradermal i.d.
Subcutaneous s.c.
Intramuscular i.m.
Intravenous i.v.
Intraarticular i.a.
Intraosseal i.o.
Intrathecal i.t.
Topical
Skin
Nose
Ear
Vaginal
Intrauterine
Inhalation – sprays, inhalers, nebulization
ICM II, 24 February 2014

8. Let’s play a game!
Can you name the forms and methods of administration?
ICM II, 24 February 2014

9. What are the roles of the persons involved?MD
Know the patient – medical history, other drugs taken, allergies, weight, height, dietary habits, activities
Know the drug – recent developments, references, dosing, available products (positive list)
Write legibly, follow the prescription guidelines
Inform/educate the patient
Monitor the effects of medications
ICM II, 24 February 2014

10. Pharmacist Check the order Consult with doctor if in doubt
Check for possible incompabilities
Inform the patient
Educate the medical and nursing staff
ICM II, 24 February 2014

11. Nursing staff Read the order carefully Consult with MD when in doubt
Know the medication, consult when giving new drugs
Identify the patient!
Follow the administration guidelines
Document
ICM II, 24 February 2014

12. The patient
Compliance – to what extent does the patient follows the doctor’s orders, recommendations, treatment regime
Compliance is influenced by many factors – age, level of patient information, side effects, food interference, doctor – patient communication, patient’s expectations, impact on ADL, leisure activities
Communication – honest, open
ICM II, 24 February 2014

13. Increase the compliance - For the little ones
ICM II, 24 February 2014

14. Hooray for the apps!
ICM II, 24 February 2014

15. Prescription guidelines – be complete!
Name of the drug
Form of the drug
Strength of the drug
Route of administration
Dose
Time/frequency
Ibalgin tbl. 400 mg p.o. 1 – 1 - 1
ICM II, 24 February 2014

16. Complete
ICM II, 24 February 2014

17. Not so complete
ICM II, 24 February 2014

18. Specifics Antibiotics – use exact times for timed adm
Chemotherapy – dose prescribed by BSA (body surface area)
Infusions – define the drip rate or length of administration
PRN orders – define criteria for adm., the maximal daily dose
Define measurable goals/target effect in specific meds such as insulin, hypertensives, etc.
ICM II, 24 February 2014

19. Examples of prescription
Wrong
Right
Paralen 1 – 1 – 1
Unasyn 1,5 g a 6h i.v.
Novalgin 1 amp i.m. prn
Actrapid 50U/50ml FR 1-10ml/hr
Paralen 500 mg tbl. 1–1–1 p.o.
Unasyn 1,5g/100 ml FR i.v. give over 30 min at
Novalgin 1amp (5ml) i.m. by VAS over 3, max a 6 hours
Actrapid 50U/50ml FR continuously 1 – 10ml/hr according to glycemia (goal 3,5 – 6,5mmol/l)
ICM II, 24 February 2014

20. Prescription guidelines – be legible!
ICM II, 24 February 2014

21. …and clear
ICM II, 24 February 2014

22. Administration guidelines
According to doctor’s order
Do not transcribe orders (might differ within countries)
Prepare at bedside
From original container (might be problematic with patient’s meds brought to the hospital)
Avoid giving all daily doses at one time
Use protective equipment when giving chemotherapy
Do not give when exspiration over
Follow the “5 Rights” rule
ICM II, 24 February 2014

23. The 5 Rights of Medication Administration
Right patient
Right drug
Right time and frequency administration
Right dose
Right route of administration
ICM II, 24 February 2014

24. The 6th Right - documentation
ICM II, 24 February 2014

25. Monitoring the effects
ICM II, 24 February 2014

26. Medication errors
“A preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient or consumer”
“Any error in the prescribing, dispensing, or administration of a drug whether there are adverse consequences or not”
National Coordination Council for Medication Error Reporting and Prescription
ICM II, 24 February 2014

27. The most common causes of medication errors
Missing patient information
Missing drug information
Illegible, incomplete, misheard order
Look alike/sound alike, faulty drug identification
Drug storage or delivery problems
Drug delivery device problems
Environmental, staffing, workflow
Lack of staff education, patient education, physician’s knowledge
Failure to monitor closely
ICM II, 24 February 2014

28. Sentinel events related to medication errors
Medication not given
Medication given to wrong patient
Wrong rate of administration
Wrong dose/concentration/form
Wrong time of administration
Wrong route of administration
Wrong medication
ICM II, 24 February 2014

29. Prevention of medication errors
Prescription related
Good patient history
Be legible, type or print orders
Use computerized prescription systems
Know the drugs
Avoid abbreviations (PRN, AZT, FeSO4)
Always use zero, e.g. 0.5 mg, never .5 mg
Be aware of LASA (Lasix - furosemide, Losec – omeprazol, Amiloride, Amlodipine)
Follow guidelines for verbal orders (only in emergency, always follow with written order, read back the order to the physician, document immediately, never use verbal orders for chemotherapy or high alert drugs)
ICM II, 24 February 2014

30. Prevention of medication errors
Administration related
Identify the patient!
Check for allergies
Double-check dosage calculation of high alert drugs by another staff member (insulin, KCl, chemotherapy)
Store LASA separately
Store high alert drugs separately, label properly
Prepare medication at bedside
Minimize interruptions
ICM II, 24 February 2014

31. Label safely
ICM II, 24 February 2014

32. Store safely
ICM II, 24 February 2014

33. Real life clinical stories
1. Warfarin order 11/2 – 11/2 – 0 (What was the meant dose? What dose was given?)
2. Verbal order of 500ml 10% G to run at 100ml/hr for the patient with critical hypoglycemia (Doctor fell asleep, did not follow with written order. Dose too low, what could have happened?)
3. Wrong rate of insulin infusion (10 x faster) due to mistake with managing the i.v. lines, poor work organization (What are the risks? What should change?)
ICM II, 24 February 2014

34. Summary…let’s go to the movies 
Administering oral medications
ICM II, 24 February 2014

35. Safety of the patient first!
Assess..Diagnose…Treat…Monitor…Communicate
ICM II, 24 February 2014