1. Medication Administration in the Perioperative Setting
Presented by: Chesapeake Bay Perioperative Consortium
Updated: April 2017

2. By the end of this presentation, the learner will be able to:
Define Medication error
Review State Regulations
Review AORN Standards
Define Best Practice
Review dispensing to the sterile field
Review TJC Labeling Standards
Identify Correct Medication Labeling
The purpose of this portion of the course is to educate the Perioperative nurse on the risks of medication errors, current state, JC and AORN standards, best practices, and proper dispensing and labeling of medications. It is imperative that the Perioperative nurse have a good understanding of these practices to provide safe and efficient care for each patient.
Objectives

3. Medication Administration Errors
Definition:
Preparation or administration of a drug which IS NOT in accordance with the physician order or manufacturer specification for the use of the drug
Related to:
Inconsistent communication
Confusion in verbal medication order (muffled through masks)
Inaccurate preference cards
Inconsistent labeling on and off the field
Medication preparation without a pharmacist overseeing
Look-alike, sound-alike medications
Extended work hours leading to fatigue
A medication error is defined as the administration of a drug that is not in accordance with the physician order or manufacturer specifications. There are multiple reasons that medication errors can occur. Inconsistent communication between the physician and the nurse regarding the patient’s current and previous medication regimen is a primary cause. In addition, masks worn in the operating room can muffle a verbal order or written orders can be incomplete. It is extremely important that if the nurse is unsure about any part of a medication order, they clarify the order with the ordering physician. Preference cards, which contain medication orders, need to be updated periodically to avoid a medication error. Labeling of medications on and off the field is another big responsibility of the perioperative nurse because inaccurate labeling can lead to major medication errors. Pharmacy should be involved in the medication preparation process because they are trained to detect potential medication errors. The danger of look-alike and sound-alike medications is a reality not only for perioperative nurses, but all nurses. It is especially important to clarify these medications. The perioperative nurse consistently works long hours, which puts us at risk for any kind of error-not just medication. It is imperative to be able to recognize when you have reached your limit and are too fatigued to work safely.
*GSH Guidelines on Preventing Medication Errors, retrieved from

4. Levels of Medication errors
Non medication error, but potential for error
Error caught before medication given to patient
Medication given to the patient, but no harm done
Medication given to the patient, with temporary harm and intervention needed
Medication given to the patient, resulting in permanent harm or death
Levels of Medication errors
There are several levels of medication errors-some are worse than others. The non medication error, but potential for error could be seen as a “good catch.” These types of errors can bring attention to a process issue and prevent future, more detrimental errors. Therefore, it is very important that these “non medication” errors are reported. The next level of errors should also be reported, even though it has been caught before the medication was given to the patient. The third level of errors include those where the medication has been given to the patient, but no harm was done. Again, these need to be reported, so that more harmful errors can be prevented. The fourth level of errors include a medication given to the patient that causes temporary harm and needs intervention. The highest level of medication errors include a medication given to the patient that results in permanent harm or death.
*GSH Guidelines on Preventing Medication Errors, retrieved from

5. Medication Administration
Who may administer medications???
MD Nurse Practice Act clearly identifies this: “Administration of medication is a nursing function and the nurse retains full responsibility.”
May an Unlicensed personnel or Tech administer medications??
The Maryland Nurse Practice Act states the regulatory requirements that identifies qualified personnel who can administer medications
At no time is a nurse allowed to delegate medication administration in the Perioperative setting
A Surgical Technician is not qualified under these regulations to administer medications, including calculation of any medication dose
The Maryland Nurse Practice Act is no longer available in print, but a link can be accessed at The Practice Act is very specific in the tasks that can be delegated to an unlicensed personnel or tech. Medication Administration is taken very seriously by the Maryland Board of Nursing.
The Maryland Nurse Practice Act (2017) clearly states that the nurse MAY NOT delegate, “Calculation of any medication dose, administration of medications by injection route, administration of medications by way of a tube inserted in a cavity of the body, and administration of medication by intravenous route”.
*Maryland Nurse Practice Act, retrieved from
Medication Administration

6. ONLY a RN may dispense medications to the sterile field
AORN Standards
The perioperative RN will retrieve medications for only one patient at a time from the dispensing storage system
The perioperative RN will verify all medications retrieved against the original order or preference cards
The perioperative RN is not to be interrupted or distracted when preparing/ administering medications
ONLY a RN may dispense medications to the sterile field
When the RN is retrieving medications for a surgical procedure, medications should be removed one patient at a time. Each medication needs to be verified with the original order or preference card. The RN should not be interrupted during the process of preparing medications for the surgical procedure. A ST, or other unlicensed personnel is not permitted to dispense medications to the sterile field.
General
*AORN, 2017

7. AORN Standards General
The RN and ST will verbally and visually verify the medication in its original container prior to dispensing. The medication name, strength, dosage, and expiration date should be verified
Aseptic technique (transfer device) should be used when transferring medications to the sterile field to prevent contamination. Receptacle should be placed by the table’s edge or held by the ST.
The medication is to be immediately labeled by the ST, and verified by the RN, upon receipt to the surgical field
Verbal confirmation is required upon handing medications to the surgeon; all medications should be re-verified if there are any personnel changes
The RN must verify the medication name, strength, dosage, and expiration date with the ST prior to dispensing it to the field. Medication vials are not designed to aseptically pour the contents onto the sterile field. Transfer devices should be used, and the medication should be poured slowly to minimize splashing, spilling, and the need to reach over the sterile field. The ST should place the receptacle near the table edge, or hold it. The medication is to be immediately labeled by the ST, and verified by the RN, upon receipt to the sterile field. Verbal confirmation is required upon handing any medication to the surgeon. If there are any personnel changes, the medications need to be verified again with the new personnel.
General
*AORN, 2017

8. AORN Standards Multidose Vials
When a multidose vial is used, it is to be disinfected with alcohol and allowed to dry before entry
When medications are needed from more than one multidose container, separate needles/syringes should be used
A new needle/ syringe should be used every time a multidose vial is accessed
When a new multidose vial is used, an expiration date of 28 days from the date of open and the RN’s initials needs to be labeled on the vial
Multidose vials should be avoided, but if necessary, it is to be properly disinfected, accessed, and labeled.
Multidose Vials
*AORN, 2017

9. Labeling Medications- A TJC Requirement
The joint commission has specific requirements in medication labeling. Each facility must comply with these requirements to receive accreditation.
NPSG states, “Label all medication, medication containers (syringes, medicine cups, and basins) and other solutions on and off the sterile field in perioperative and other procedural settings.
Label medications that are not immediately administered, and as soon as they are prepared.
Include medication name, strength, and concentration at a MINIMUM…follow your facility’s policies.
Verify verbally and visually by two individuals qualified to participate
Medication labeling is a key point in Joint Commission surveys. These standards must be followed in order to receive accreditation.

10. Labeling Medications 4U or 44??? *AORN, 2017
Medications must be labeled to minimize medication errors
Medications are labeled in a standardized manner in accordance with laws, regulations, and standards of practice
AORN recommends avoiding error-prone abbreviations and symbols known to cause confusion or misinterpretation
Retain all original medication containers for medications that have been delivered to the sterile field until the end of the procedure
Your facility may have its own policy and procedures which must be followed, whereas AORN is recommended practices
Safe medication practice, including labeling, is essential for patient safety. Medications are labeled in the standardized fashion discussed previously. While your facility may have their own policy, in order to receive accreditation, Joint Commission standards must be followed.
4U or 44???
*AORN, 2017

11. Labeling Medications 5 or .5???
Decimal points Ensure correct labeling when decimal points are included in the dosage
Correct= 5 mL 0.5 mL
Incorrect= 5.0 mL .5 mL
Do not use abbreviations
“U” for units can be mistaken for a zero (10U of Heparin could look like 100 units)
HS (half strength) can be mistaken for hs (hour of sleep)
Decimal points must be used correctly when labeling medications. Unapproved abbreviations or abbreviations that could be misinterpreted should be avoided.
5 or .5???

12. SEVEN Rights of Medication Safety
1. Right Patient
2. Right Medication
3. Right dose
6. Right time
5. Right route
4. Right indication
7. Right documentation
SEVEN Rights of Medication Safety
The traditional five rights of medication safety have been expanded too include the right indication and the right documentation (AORN, 2017). It is the nurse’s responsibility to verify the patient with the medication order. Once the medication has been retrieved, the medication, dose, time, and route should be verified with the medication order. The nurse is expected to understand the indication and contraindications for a medication’s use. It is also imperative that the proper documentation related to the administration is completed.
“If you didn’t document it, you didn’t do it”
-every RN student instructor ever
*AORN, 2017

13. Best Practices- Medication safety
Always establish dosage limits with the surgeon/ anesthesia
Monitor patients for adverse medication reactions
If no scrub is present, the RN should verify the medication visually and verbally with the surgeon performing the procedure
When in doubt, ALWAYS “do more” and follow your facility policies and procedures
Dosage limits should be verified with the surgeon and/or anesthesia. The RN should monitor the patient for adverse medication reactions. In the event that a scrub is not present, the circulator should verify the medication with the surgeon.
*AORN, 2017

14. References
Association of periOperative Nurses: Guidelines for perioperative practice
(2017 ed.).
ASHP guidelines on preventing medication errors. (1993). Retrieved from
Maryland Nurse Practice Act. (2017). Retrieved from
The Joint Commission Standards Accreditation requirements. (2012). Retrieved
from