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16
Medication Administration
and IV
3. List four possible causes of this childs seizure.
5. What are the possible routes of medication administration for this patient (list in order of your preference and explain).
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Active Learning
Some people are great at math, and then there are
the rest of us. There is a certain amount of common
sense that goes into calculating drug dosages, but
for the most part it is based on simple formulas and
calculations.
1. Equivalents
Before you begin calculating drug dosages, there
are several things that you will need to commit to
memory:
a.
pound(s) (lb) make up 1 kilogram
(kg).
b. 1 kg is equal to
gram(s) (g).
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Chapter 16
c. 1 g is equal to
milligram(s) (mg).
microgram(s)
d. 1 mg is equal to
(mcg).
e. 1 liter (L) is equal to
milliliter(s)
(mL).
f. 1 cubic centimeter (cc) is equal to
mL.
g. 1 teaspoon (tsp) is equal to
mL.
mL.
h. 1 tablespoon (T) is equal to
i. 1 fluid ounce (fl oz) is equal to
mL.
mg.
j. 1 grain (gr) is equal to
k. 1 deciliter (dL) is equal to
L.
l. 1 centimeter (cm) is equal to
meter(s) (m).
m. 1 milligram (mg) is equal to
g.
n. 1 mcg is equal to
g.
2. Calculation Methods
There are several ways to determine how much
of a medication you are supposed to administer
to a patient. No matter what method you choose
to use, if performed properly, they should all
come up with the same answer. Following are
three methods for determining the appropriate
dose based on information that you have available to you.
Method 1
The first method is based on the following formula:
Volume on hand
Volume to be
Ordered (or calculated) dose
administered (X)
Concentration (in units
of mg, mcg, g, etc.)
Example: Medical control orders you to administer 5 mg of morphine sulfate IV to your 84-year-old
female patient who has signs and symptoms of a
hip fracture. The morphine in your formulary
contains 10 mg in 1 mL. How many milliliters of
morphine sulfate do you need to administer to this
patient in order to deliver 5 mg?
You have the following information:
Order:
On hand:
5 mg morphine sulfate IV
10 mg/1 mL
1 mL 5 mg
10 mg
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Cancel any common values (volumes or concentrations) that exist on the top and on the bottom, and
multiply across the top.
X
1mL 5 mg
10 mg
1 5 mL
10
5 mL
10
0.5 mL
You need to administer 0.5 mL of morphine sulfate
to your patient.
Method 2
This second method involves ratio and proportion.
The symbol for proportion is ::, and the symbol for
ratio is : .
Using the same problem as in method 1, start
with the known ratio on the left side of the proportion:
10 mg : 1 mL ::
Place the unknown ratio on the right side of the
proportion in the same sequence as the ratio
on the left side of the proportion. This ratio is
usually the physician order or the dosage that
you are permitted to administer based on standing orders:
10 mg : 1 mL :: 5 mg : X mL
First, multiply the extremes ( the far outside
values: 10 mg and X mL) and place the result
on the left side of the equation. Second, multiply the means (the numbers on either side of
the proportion symbol: 1 mL and 5 mg) and
place this value on the right side of the expression:
10X 1 5
Multiply:
10X 5
Divide both sides by the number in front of
the X:
10X
5
10
10
X 0.5 mL
You need to administer 0.5 mL of morphine sulfate
to your patient.
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Method 3
The third method is referred to as the cross
multiplication method. This method sets the problem up using fractions. The first fraction is the
concentration, and the second fraction is the physicians order over the volume of medication being
administered.
10 mg
5 mg
1 mL
X mL
Cross multiply the fractions by multiplying numerators by the denominator on the opposite side.
Express the results as an algebraic equation the
same as used in the proportion method.
10X 5 1
5
X 0.5 mL
You need to administer 0.5 mL of morphine sulfate
to your patient.
Drip rate
250 mL 60 gtt/ mL
X Time
4. IV Infusions
There are also several methods for determining
IV drip rates for patients receiving IV infusions.
The following methods are examples of how this
can be done.
Formula Method
This method finds the ordered dosage over time
based on the patients weight.
Example: You have a resuscitation patient who
has a return of spontaneous circulation (ROSC)
after you defibrillate her out of ventricular fibrillation. You reassess the patient and discover that
she is in a normal sinus rhythm, but she is hypotensive. Fluid boluses do not affect the patients
blood pressure, so you decide to start the patient
on a dopamine infusion at 10 mcg/kg/min per
your protocols. The patient weighs 132 pounds.
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Chapter 16
X
185
250 mL
10 mcg/kg
60 gtt
200 mg
1 min
1mL
25
6
6 gtt
20
1 min
1
900 gtt
X
20 min
X
90 gtt
2 min
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60
600 mcg
45
gtt/min
15
200 mcg
30
400 mcg
2 mg/min
60 gtt/mL
1g
250 mL
The following formula should be used when calculating these types of problems:
Volume on hand Drip chamber
Ordered dose
Drops per minute
Amount of drug on hand
First, convert grams to milligrams to allow for consistency between the requested dosage and the
concentration of medication on hand:
1g 1,000 mg
4 mg
60
3 mg
45
gtt/min
15
1 mg
30
2 mg
5. Calculation Problems
Using any of the preceding methods, solve the following dosage calculation problems.
a. You have been instructed by medical control to
administer an initial dosage of 0.1 mg/kg of IV
adenosine to your 33-lb pediatric patient followed by a rapid fluid bolus. Based on the available packaging of adenosine (depicted in the
photo at the top of page 187), you will need to
administer
mL.
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Chapter 16
b. You are working up a patient who is in ventricular fibrillation. The patient has been defibrillated
following the administration of 1 mg of epinephrine 1:10,000, CPR is in progress, and the patient
is now ready for her first round of lidocaine at
1.5 mg/kg. The patient weighs 132 lb. Based on
the order and the lidocaine that you carry in your
formulary (depicted below), you will need to
administer
mL of lidocaine.
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FIGURE 16-1
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Chapter 16
Test Yourself
1. You are called to an apartment building by law
enforcement officials who have discovered a man
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10. Although needle-less systems do not require needles, they are compatible with traditional needles.
True
False
11. Your partner has been experiencing chronic bumps
and raised, red areas on her hands. When she went
on vacation for 2 weeks, the symptoms gradually
disappeared, but a week after returning to work,
the symptoms have returned. She is always very
careful to wear gloves when handling medications
and during any patient contact. You should suspect
a. a reaction to handling a medication.
b. contact dermatitis contracted from a patient.
c. a fungal infection.
d. a latex allergy.
12. Which of the following statements regarding injectable medications is true?
a. Most injectable medications should not be frozen.
b. Most injectable medications have a very short
shelf life.
c. Most injectable medications can only be stored
in glass bottles.
d. Most injectable medications cannot be exposed
to light.
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Chapter 16
Need to Know
The following represent the Key Objectives of Chapter 16:
191
effects or complications, precautions, any possible interactions with other medications, and the
expected therapeutic effects, based on their scope
of practice and the formulary of their provider.
Is the paramedic able to administer the medication based on standing orders, or does the medication administration require consultation with
medical control?
Because most medication dosages are based
on a patients weight, the paramedic must be able
to perform drug calculations so that the patient
does not receive an overdose or an underdose of
a medication. Since some medications do not
come packaged as ready to administer, paramedics
need to know how to prepare medications for
administration. For example, glucagon comes in
two vials. One of the vials contains a powder, and
the other vial contains a liquid. The powder needs
to be combined with the liquid and thoroughly
dissolved before it can be administered. Similarly, some medications need to be mixed with
an IV solution in an IV bag before they can be
administered as an IV drip (infusion). If given
such a medication undiluted as an IV bolus, the
patient could experience undesired effects.
Standard medication administration must
follow safe administration techniques via the
appropriate administration route while maintaining asepsis. Contaminated disposable medication
administration equipment needs to be disposed of
in the appropriate disposal container, and reusable
medication administration equipment needs to be
cleaned and maintained per the manufacturers
instructions.
Any preexisting medication administration
device that is used by paramedics must be approved
by the EMS agency and the EMS provider that the
paramedic works for. Any medication administration device that the paramedic is not familiar with
or specifically trained how to use should not be
used by the paramedic.
Other than ensuring that the five rights of
medication administration are followed and the
patient is not allergic to the medication that you
are administering, perhaps the most important
step in medication administration is to reassess
the patient following the administration of a medication to see if it had the desired or any undesired
effects. Make sure that the medication administration is clearly and accurately documented on your
patient care report. This report is a part of the
patients medical record and may be referred to by
medical personnel to direct them in further treatment of the patient.
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Need to Do
The following medication administration skills are explained and illustrated in a step-by-step manner, via skill
sheets and/or Step-by-Steps in this text and on the accompanying DVD:
Skill Name
Step-by-Step Number
and Location
Intravenous Access
43 DVD
43 DVD
Phlebotomy
44 DVD
N/A
46 DVD
N/A
47 DVD
N/A
51 DVD
N/A
54 DVD
N/A
55 DVD
N/A
56 DVD
N/A
57 DVD
N/A
59 DVD
N/A
89 DVD
N/A
91 DVD
N/A
Step-by-Step
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Intravenous Access
Conditions: The candidate should perform this skill on a simulated patient under existing indoor,
ambulance, or outdoor lighting, temperature, and weather conditions. Establish a patent IV line within
6 minutes.
Indications: Patients who require or may potentially require administration of fluids or intravenous
medications.
Red Flags: Prep the site with aseptic or medically clean technique as field conditions permit. Avoid starting
an IV on the same arm as a dialysis shunt. IV infiltration, especially when medications are being administered,
can cause serious and irreversible tissue damage. Avoid using areas of burned skin or heavy vein scarring.
Steps:
1. Use appropriate standard precautions.
2. Select proper fluid and check its expiration date
and clarity.
3. Select proper IV tubing.
4. Close roller clamp.
5. Remove tab from IV bag and cap from spike
end of IV tubing. Insert spike into IV bag
administration port (Figure SBS 42-1).
SBS 42-2
11. Cleanse area with alcohol prep.
12. Control site by pulling skin firmly, taking care to
keep your fingers out of the needle path.
13. Insert needle at less than a 45-degree angle with
the bevel up (Figure SBS 42-3).
SBS 42-1
6. Squeeze the drip chamber until IV solution
reaches fluid line or the drip chamber is half full.
7. Run fluid through the tubing until fluid fills
tubing and air bubbles are removed.
8. Gather equipment (IV needle, tourniquet, tape,
gauze, alcohol prep, etc.).
9. Apply tourniquet proximal to desired site.
10. Select site (Figure SBS 42-2). (Possible sites
include between knuckles, dorsal thumb, back of
hands, forearms, or antecubital fossa.)
SBS 42-3
14. Advance needle in a smooth motion.
Continued
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SBS 42-6
Critical Criteria:
SBS 42-4
20. Remove needle from hub and place in a sharps
container.
21. Connect administration set to catheter hub.
22. Open roller clamp and observe for free flow
through drip chamber (Figure SBS 42-5).
SBS 42-5
Step-by-Step
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45
Red Flags: Long-bone deformity distal to access site on same bone; unable to locate landmarks.
Steps:
1. Use appropriate standard precautions.
SBS 45-1
4. Cleanse site with alcohol and/or iodine.
5. Place IO device against bone.
6. Insert needle straight into bone at a 90-degree
angle (Figure SBS 45-2).
SBS 45-3
12. Inspect site for infiltration. If swollen, remove
needle and apply pressure.
13. Attach administration set, and run fluid wide open.
14. Ensure free flow and no swelling, and adjust to
desired rate.
15. Secure device (Figure SBS 45-4).
SBS 45-2
7. Stop at proper depth or when resistance is no
longer felt (popping sensation).
SBS 45-4
Continued
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Drug Administration
Critical Criteria:
SBS 45-5
Step-by-Step
48
Red Flags:
Steps:
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SBS 48-1
7. Expel air from syringe.
8. Cleanse IV port with alcohol prep.
9. Attach syringe to IV port (Figure SBS 48-2).
SBS 48-4
14. Thoroughly document medication administration.
15. Monitor patient for desired and adverse effects.
Critical Criteria:
SBS 48-2
10. Occlude IV line between port and IV bag, or
close roller clamp.
11. Push medication at the proper rate (Figure
SBS 48-3) while observing for infiltration.
SBS 48-3
Step-by-Step
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49
Steps:
1. Use appropriate standard precautions.
2. Explain procedure to a conscious patient.
3. Ensure patient is not allergic to the medication.
4. Ensure IV flows without infiltration.
5. Ensure that five patient rights of drug
administration are met.
6. Calculate drug dosage in drips per minute
(gtt/min).
SBS 49-3
SBS 49-1
8. Fill drip chamber, and flush tubing (Figure
SBS 49-2).
SBS 49-2
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SBS 49-4
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Chapter 16
Critical Criteria:
Use standard precautions.
Check for patient allergies and medication
reactions.
Step-by-Step
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50
SBS 50-1
SBS 50-2
Continued
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SBS 50-4
15. Thoroughly document medication administration.
16. Monitor for redness and swelling.
17. Monitor patient for desired and adverse effects.
Critical Criteria:
SBS 50-3
12. Slowly inject medication.
13. Withdraw needle from patient, and dispose of
needle and syringe in appropriate sharps
container.
14. Apply sterile gauze and direct pressure to site
(Figure SBS 50-4).
Step-by-Step
52
A patient whose condition requires the administration of a medication through the nebulized
route.
Red Flags: Equipment used to nebulize medications can vary significantly. Practice with your local
systems equipment until you are comfortable with assembly and use.
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Chapter 16
Steps:
1. Use appropriate standard precautions.
2. Explain procedure to a conscious patient.
3. Ensure the patient is not allergic to the medication.
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SBS 52-4
SBS 52-1
6. Screw on chamber cover.
SBS 52-5
SBS 52-2
8. Assemble administration set according to
manufacturers instructions, ensuring nebulizer
chamber remains upright.
SBS 52-6
14. Refill chamber per local protocol.
SBS 52-3
Continued
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Critical Criteria:
Use standard precautions.
Ensure that five rights of medication
administration are met.
Step-by-Step
53
SBS 53-1
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Chapter 16
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SBS 53-4
14. Withdraw needle, and dispose of needle and
syringe in appropriate sharps container.
SBS 53-2
10. Insert needle at a 45-degree angle.
11. Smoothly advance needle into subcutaneous
tissue (Figure SBS 53-3).
Critical Criteria:
SBS 53-3
12. Attempt to aspirate for blood with syringe
(should be difficult). If blood returns, withdraw
and try a different site.
13. Inject the medication (Figure SBS 53-4).
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58
Step-by-Step
Red Flags: Feeding tube or syringe must be inserted deep enough into rectal space in order to deliver
medication. Forceful insertion can perforate the bowel wall. Remove needle prior to insertion of syringe into rectum.
Steps:
1. Use appropriate standard precautions.
2. Explain procedure to a conscious patient or
parents.
3. Ensure patient is not allergic to the medication.
SBS 58-2
10. Advance past both sphincter muscles.
11. Slowly deliver medication.
12. Remove syringe and hold buttocks together
(Figure SBS 58-3).
SBS 58-1
6. Remove and dispose of needle in appropriate
sharps container.
7. Choose administration option:
a. Attach an extension: large-bore IV catheter
without needle or cut 3.0 ET tube.
b. Use a tuberculin (TB) syringe without needle.
c. Insert a suppository with gloved finger.
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SBS 58-3
13. Dispose of syringe in appropriate container.
14. Thoroughly document medication administration.
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Chapter 16
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Critical Criteria:
Use standard precautions.
Check for patient allergies and medication
reactions.
Ensure that five rights of medication
administration have been met.
Lubricate administration device or suppository
and finger before administration.
Pinch buttocks closed after administration.
Immediately dispose of sharps in appropriate
container.
Monitor patient for desired and adverse effects.
SBS 58-4
Connections
Chapter 15, Pharmacology, in the textbook contains additional information on medication
indications, contraindications, precautions, and
special considerations. See Box 15-6 in the textbook for a description of the patient rights
that are identified in the DOT curricula.
Chapter 10, Therapeutic Communications and
History Taking, in the textbook describes techniques that can be helpful in obtaining information from patients.
Chapter 9, Safety and Scene Size-Up, in the
textbook includes additional information on
BSI precautions.
Chapter 17, Documentation and Communication,
in the textbook details information on performing a radio consultation and what elements of
medication administration documentation are
important to capture on the patient care report.
Link to the companion DVD for a chapter-based
quiz, audio glossary, animations, games and
exercises, and, when appropriate, skill sheets
and skill Step-by-Steps.
Street Secrets
Shortcuts Drug dosage calculations can be a
nightmare for many paramedics. The need to perform them in any situationlet alone a situation
in which one is caring for a critical patient who
has a very low blood pressurecan send the most
confident paramedic into a meltdown. The following simple formulas are shortcuts that will give
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Answers
Are You Ready?
1. The patient is critically ill. The infant is seizing and blue
(cyanotic). This alone is evidence of a life-threatening
emergency.
2. Airway, airway, airway! Followed by breathing and circulation.
3. Any four of the following: fever, hypoglycemia, head
injury, ingestion (poisoning), hypoxia, arrhythmia,
epilepsy, hypovolemia, and electrolyte imbalance.
4. You should perform a blood sugar test. If the patient is
hypoglycemic and you stop the seizure with an anticonvulsant, you may not remember to check the patients
blood sugar, and a blood sugar level low enough to cause
seizures can cause significant damage if left untreated.
5. Administration of medications needs to be in compliance with local EMS policies and protocols, but for the
sake of this exercise general guidelines are as follows:
a. The first choice would be IV administration of medications because of the relative ease of establishing
an IV, the relatively minimal invasiveness of the
procedure, and the rapid onset of action of medications administered intravenously. You also have a
route to administer IV fluids in the setting of hypovolemia.
b. The second choice would be based on the type of
medication being administered. If you are delivering
an anticonvulsant such as a benzodiazepine, the rectal
route should be considered next. This route does not
allow for correction of hypovolemia or hypoglycemia.
c. If the patient is hypoglycemic and/or hypovolemic,
another more invasive, yet very effective, means of
delivering medications to a critical patient is via the
intraosseous route (Figure 16-2).
Active Learning
1. a. 2.2 lb; b. 1,000 g; c. 1,000 mg; d. 1,000 mcg; e. 1,000
mL; f. 1 mL; g. 5 mL; h. 15 mL; i. 30 mL; j. 65 mg;
k. 1/10 or 0.1 L; l. 1/100 or 0.01 m; m. 1/1,000 or 0.001 g;
n. 1/1,000,000 or 0.000001 g
5.
a. In order for you to administer 0.1 mg/kg of adenosine to this 33-lb (15 kg) patient, you will need to
administer 0.5 mL.
b. In order to administer 1.5 mg/kg of lidocaine to this
132-lb cardiac arrest patient, you will need to
deliver 4.5 mL.
c. To administer a 0.02-mg/kg dose of atropine to this
22-lb (10 kg) child, you must administer 2 mL of
atropine.
d. In order to deliver 1,120 mL/hour, you will need to
deliver 187 gtt/min.
e. The 500-mL bag of normal saline dripping at a
rate of 120 gtt/min through a 10-gtt/mL administration set will be completed in 41.66 or about
42 minutes.
f. In order to administer 300 mL of fluid over 45 minutes via a 10-gtt/min administration set, you will
need to set your drip rate at 67 gtt/min.
g. Drops per minute = 16.8 gtt/min. Run the infusion
at 17 drops per minute to infuse 3 mcg/kg/min of
dopamine to your patient.
h. For your 165-lb patient to receive 15 mcg/kg/min
of dobutamine from an IV bag that contains 250 mg
of dobutamine in 500 mL of normal saline, using a
60-gtt/min administration set, the patient needs to
get a 135-gtt/min infusion.
i. In order for your 88-lb patient to receive 20 mcg/
kg/min of dopamine (200 mg/250 mL D5W) via a
micro-drip administration set, you will need to
administer 60 gtt/min.
j. In order to deliver 2 mg/min, you will need to set
the IV drip rate of the 60-gtt/mL administration set
at 30 gtt/min.
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Chapter 16
3. Perform complete primary and secondary examinations
including vital signs, ECG, and pulse oximetry; take a
medical history, including medications and allergies to
medications.
4.
Does the patient have any allergies to medications?
Will the patients current hemodynamic status allow
for the administration of the chosen medication?
Will the administration of the chosen medication
negatively impact the patients medical condition(s)?
(For example, if the patient has a history of ulcers,
will the administration of aspirin have a negative
impact on the patient?)
Will the administration of the chosen medication
interact negatively with any of the medications that
the patient takes on a regular basis?
5. Prior to administering any medication, a paramedic
should be aware of its indications, contraindications, precautions, side effects, interactions, and therapeutic effects.
The paramedic should also be familiar with the appropriate route of administration for that particular medication,
as well as the appropriate rate of administration.
6.
The
The
The
The
The
right
right
right
right
right
patient
medication
dosage
route
time
Test Yourself
1. d
The unopened pill bottles in the patients kitchen are a
good indication that he has not been taking his prescribed medication. Medications such as antipsychotics
(which help control delusions) must be taken continually to maintain their effectiveness.
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12. a
When familiarizing yourself with your services formulary, you should read the accompanying literature from
the medication package box (called the package insert)
to determine if there are any special storage or handling
requirements.
13. Extreme heat from steam under pressure (autoclaving),
dry heat, and ethylene oxide gas.
Sterilization kills all biotic material, including bacterial
spores. Human tissue and some equipment cannot be
sterilized.
14. To confirm that the correct medication has been selected
for administration, you can first repeat the drug name
and dosage when received during consultation; then
carefully read the medication name before taking it out
of the box; and finally ask another member of the patient
care team to verify the name on the medication container.
This three-step approach is a good, systematic way to
make sure you are administering the correct medication.
Although it may not always be practical to follow all
three steps in the field, you should always check to confirm that the right medication has been selected for
administration.
15. b
Minimize the possibility of an accidental needle stick
by performing all injections or IVs while the ambulance
is stationary. If patient transport has begun, gather and
prepare the equipment while the ambulance is moving.
When ready, ask the driver to pull over and stop for a