Bulletproof Medication Administration

In nursing school there are a lot of rules, and to be honest, some of them don’t make that much sense to me. Rules about tattoos and the color of your shoes just seem like they add unnecessary stress. But, there are some rules that I absolutely LOVE because they’re designed to keep both you and your patients safe. Very few things in life are absolute, but I have to say I think this one might be. It’s my favorite rule of all of them and I believe in it so much that I’m going to shout it from the rooftops…ready?

IF YOU FOLLOW THE RULES MEDICATION ADMINISTRATION YOU WILL NOT BE ABLE TO MAKE A MEDICATION ERROR. Period.

Did you hear that? Did I shout that loud enough for you guys? Here it is again just to be sure…if you follow the five rights of medication administration you will not (and cannot) make a medication error. How is that possible? Let’s break it down.

The 5 Rights of Medication Administration…what most schools teach

#1 The right patient

This rule ensures you are giving medication to the proper patient. This means checking two unique identifiers, which are typically the patient’s name and their birthdate or medical record number. For an added layer of safety, most hospitals scan their patients’ armbands prior to giving meds. But how do you KNOW the armband is correct? How easy would it be for someone to slap the wrong armband on a patient? TOO EASY! 

So, look at the information on the band and then ASK the patient (or family) to verify the patient’s name and date of birth. Never rely solely on scanning the band if you’ve got someone at the bedside who can also tell you that you’re working with the correct patient. It may seem repetitive to ask them, but most patients appreciate the extra care and level of attention to safety. 

#2 The right medication

It is extremely important that you double-check that you are giving the right medication to the patient. A lot of meds look alike, others sound alike (like dopamine and dobutamine). Some meds come in a different color or different shape, depending on the manufacturer. Or, maybe whoever stocked the Pyxis accidentally put the pill packets in slot 34 when they were supposed to go in slot 35. It happens. 

So, always check the printed name on the medication when you are pulling it from the med room. This is typically supposed to be a “distraction free zone” and it’s your opportunity to slow down and think through your actions. When you get to the bedside, it’s likely you’ll have multiple distractions, so I always relish the brief moment of clarity in the med rooms “zone of silence” before I get back to the hustle-and-bustle at the bedside. 

And, once you are back at the bedside, you’re going to check the med AGAIN just to be doubly sure that you’ve got the right one. It only takes a moment and the peace of mind it provides is well worth it. Besides, most hospitals scan the medications just like they do the patient’s armbands. I, for one, am always grateful for that extra layer of safety.  

#3 The right time

So you’ve got the right med, you’re giving it to the right patient…but are you giving it at the right time? PRN medications are given “as needed” but must be spaced out by a specified amount of time, while scheduled meds are given at set times. Depending on your facility’s policy, you will have a window surrounding that scheduled time in which to safely give the medication. For example, at my facility, that window of time is one hour. So, if a scheduled med is due at 0900, I can give it anytime in the hour before to the hour after. This gives me a range from 0801 to 0959 to give the scheduled medication. When I was a student, however, my clinical professor gave us a 30-minute window, so you’ll always want to check to see what the expectation is so you can plan your day. 

PRN medications are more strict, however. If you’ve got a pain medication that you can give every four hours, it has to be AT LEASTS four hours between doses. No wiggle room on this one!

#4 The right dose

Another thing you want to check is that you are giving the prescribed dose. Are you supposed to give two tablets, half a tablet? If it’s an IV medication, are you sure you’ve got the volume correct? With this step, you need to think through the dosage and ensure you are giving the right amount. 

I would say the biggest mistake that happens is giving a tablet and THEN realizing you were supposed to cut it in half. A while back I was taking care of a patient who was to receive aspirin via a suppository. Giving suppositories to intubated and sedated patients is a group project, because you need someone to hold the patient on their side while you give the medication. So, the mobility tech showed up and I had to be ready to go. I was so focused on the mechanics of moving this patient that I completely forgot to cut the suppository in half. OF COURSE, I remembered it as soon as it was outside of my grasp…isn’t that how mistakes always happen? 

So, I had to go fess up and tell the ordering physician that the patient received a whole 325 mg of aspirin instead of the half dose. She was very nice about it, told me not to stress and absolutely no harm came to the patient. But do you think I’ll ever forget to double check a suppository dose again? I sure hope not! 

Here’s a key tip for you guys. If you are having to open multiple vials or pill packs, I want you to step back and ask yourself if you are sure you have the proper dose. Ask another nurse to check your math, call the pharmacy for an expert consultation. Sure, there may be times when you’ve got to give a patient three or four pills, but always be on high alert anytime there are multiple packages or vials being opened.

#5 The right route

Another very important factor you want to consider is if you giving the medication by the proper route. Some medications are PO liquids and you would NOT want to give that medication IV. For this reason, pharmacies will dispense oral medications in special ORAL syringes that do not connect at all to IV tubing. Sometimes lactulose is given as an enema, other times it’s given PO. Sometimes insulin is given SubQ and other times it’s given IV. Haldol can be given IV or IM. In other words, always know the route. If you’re having to jimmy something together to give a medication, I want you to step back and ask yourself if you’re doing the right thing. 

A classic example of this is the nurse who SOMEHOW hooked up a patient’s tube feeding to their IV. Those two tubing components have absolutely nothing in common, and I cannot figure out how on earth she was able to get the tube feeding connected to an IV. There must have been an awful lot of jimmying going on, and sadly the patient did not survive.

But wait, there’s more! 

What we’ve talked about so far are the basic 5 Rights of Medication Administration. Many schools will actually teach you a few more, and since I love medication rules let’s talk about them here. 

#6 The right indication

It’s important to know WHY you’re giving the medication. For example, your patient has atrial fibrillation and has metoprolol ordered. Metoprolol, a beta-blocker, is commonly used as an antihypertensive agent. You notice the patient’s blood pressure is 110/65 so do they even need an antihypertensive medication? Should you hold the metoprolol dose? 

The answer here is no. And that’s because the patient isn’t getting the beta blocker for blood pressure control. He’s actually getting it for RATE control because patients with a-fib very commonly have an associated tachycardia. By knowing why your patient was prescribed a beta blocker, you ensure you’re giving the medication for the right indication. Also, knowing WHY your patient is getting a particular medication means you can more accurately assess the efficacy of that drug. For example, let’s say you gave the metoprolol, but the patient’s heart rate remained over 110. Has the medication had the desired effect? Probably not, so it’s something you’d want to share with the prescriber.

#7 The right formulation

Make sure the formulation matches what was ordered. For example, nitroglycerin comes in MANY different forms. So make sure that if ointment is ordered, that ointment is what’s given. If it’s an extended release tablet, make sure you get the ER tablet. 

#8 The right documentation

Always chart your medication administration in a timely manner as well as any associated data. For example, if you’re giving your patient an antihypertensive medication for a blood pressure of 188/110 make sure that you have the initial blood pressure documented and then the patient’s response to that medication. 

#9 The right response

This one dovetails into #6. You want to observe your patient to see if they’ve had the response you’ve expected. Going back to our patient with the high blood pressure, let’s say you gave him 10mg of IV hydralazine. You would absolutely expect the patient’s blood pressure to come down (along with a little bit of transient tachycardia that often occurs as well). If your patient does not have the desired effect, you know that his blood pressure will need additional intervention. 

#10 The right compatibility

If you’re hanging an IVPB medication or connecting two IV infusions via a Y-site on the tubing, you always need to check compatibility. A mistake I see often is when the patient has Lactated Ringers running as their primary IV infusion and the IV piggyback medication is not compatible with it due to its calcium component. Ceftriaxone is a great example of this! When combined with lactated ringers, it can form a precipitate in the blood that can injure the patient’s lungs, kidneys and gallbladder. 

If any solution becomes cloudy when combined with another substance, always STOP and double-check compatibility. And, just because lactated ringers is a common IV infusion, do not assume you can piggy back anything and everything with it. When patients have LR running as their primary medication, I always set up a normal saline bag to run with their IV piggyback meds for this very reason. 

#11 The right contraindications

And last, but certainly not least, I want you to be aware of any contraindications that would alert you to NOT giving a patient their medication. A big one here is allergies, so always check a patient’s allergies before giving any medication. It’s always a good idea to be watchful of allergic reactions when giving patients medications for the first time (especially IV antibiotics!). 

Here are a few other examples of contraindications to get you thinking along those lines:

• Metoprolol is typically only given if the HR is greater than 60 and the systolic blood pressure is greater than 90. A contraindication to giving metoprolol would be your patient with a heart rate of 55 or a BP of 88/54.
• Opioids would be contraindicated in a patient with respiratory depression, so if your patient’s respiratory rate is 7 breaths per minute then you’re hopefully going to hold off on more pain medication for a bit.
• Haldol can prolong the QT-interval, putting the patient at risk for deadly cardiac arrhythmias. So, a QT-interval that’s already prolonged would be a contraindication for giving Haldol. 

And lastly, the most important thing you can do when giving your patients medication is to slow down, think through the situation and always ask if you are unsure. I promise you will never regret speaking up for patient safety. 

Get this on audio in Episode 76 on the Straight A Nursing Podcast.

References

Deglin, J. H., & Vallerand, A. H. (2007). Davis’s drug guide for nurses(11th ed.). Philadelphia, PA: F. A. Davis Company.