Administration of medications Jana HeŘmanovÁ ICM II, 24 February 2014

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

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

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

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

ICM II, 24 February 2014

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

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

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

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

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

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

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

Hooray for the apps! ICM II, 24 February 2014

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

Complete ICM II, 24 February 2014

Not so complete ICM II, 24 February 2014

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

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 12-18-24-6 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

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

…and clear ICM II, 24 February 2014

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

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

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

Monitoring the effects ICM II, 24 February 2014

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

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

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

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

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

Label safely ICM II, 24 February 2014

Store safely ICM II, 24 February 2014

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

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

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