McCuistion: Pharmacology: A Patient-Centered Nursing Process Approach,

9th Edition

Chapter 09: Safety and Quality

Key Points

• The “five-plus-five” rights of medication administration are important goals for

medication safety. The nurse following these guidelines will give (1) the right patient (2)
the right drug in (3) the right dose via (4) the right route at (5) the right time.
• The “plus five” refers to the five additional rights that have been recommended: (1) right
assessment, (2) right documentation, (3) the patient’s right to education, (4) right
evaluation, and (5) the patient’s right to refuse. The right patient determination is
essential.
• The right patient determination is essential. The Joint Commission (TJC) requires two
forms of identification before drug administration.
• The nurse must accurately determine the right drug prior to administration.
o When working with an EHR, once the bar code on the patient’s wristband has
been scanned, the patient’s drug profile will appear on the computer screen.
o The nurse will then scan the patient’s medication label, and it will automatically
validate the time, date, and the nurse administering the patient’s medication.
o If it is not the correct medication, the nurse will receive an alert and will be
unable to proceed in the MAR until the correct medication is scanned.
• It is the nurse’s responsibility to administer the drug as ordered by the provider, and if the
drug order is incomplete, the drug should not be administered. Verification of a
questionable order must be done in a timely manner.
• Nurses are legally liable if they give a prescribed drug and the dosage is incorrect, or if
the drug is contraindicated for the patient’s health status.
• The right dose refers to a verification by the nurse that the dose administered is the
amount ordered and that it is safe for the patient for whom it is prescribed. The right dose
is based on the patient’s physical status.
• The right time is the time the prescribed dose is ordered to be administered. Every drug
cannot be given exactly when ordered; therefore, health care agencies have policies that
specify a range of times within which drugs can be administered before or after the
appointed time.
• The right route is necessary for adequate or appropriate absorption. The right route is
ordered by the health care provider and indicates the mechanism by which the medication
enters the body.
• The nurse determines if the drug is safe to administer according to the drug’s
pharmacodynamics (action) and the patient’s vital signs.
• Renal and hepatic functions are important considerations because many drugs are cleared
through the kidneys and metabolized by the liver.
• Prior to drug administration, it is important that the nurse carefully review the patient’s
 most current lab results.
• The right time refers to the time the prescribed dose is ordered to be administered.
• The right route is necessary for adequate or appropriate absorption. The right route is
ordered by the health care provider and indicates the mechanism by which the medication
enters the body.
• The right assessment requires the collection of appropriate baseline data before
administration of a drug.
• The right documentation requires the nurse to immediately record the appropriate
information about the drug administered. This includes (1) the name of the drug, (2) the
dose, (3) the route, (4) the time and date, and (5) the nurse’s initials or signature.
Documentation of the patient’s response to the medication is required with a variety of
medications.
• The right to education requires that patients receive accurate and thorough information
about the medication and how it relates to their particular condition. Patient teaching also
includes therapeutic purpose, expected result of the drug, possible side effects of the
drug, any dietary restrictions or requirements, skill of administration, and laboratory test
result monitoring.
• The right evaluation determines the effectiveness of the drug based on the patient’s
response to the drug. Evaluation in this context asks whether the medication did for the
patient what it was supposed to do.
• The patient has the right to refuse the medication, and it is the nurse’s responsibility to
determine the reason for the refusal, explain to the patient the risks involved with refusal,
and reinforce the important benefits of and reasons for taking the medication. When a
medication is refused, the refusal must be documented immediately, and follow-up is
always required.
• The nurses’ six rights are (1) the right to a complete and clear order; (2) the right to have
the correct drug, route (form), and dose dispensed; (3) the right to access to information;
(4) the right to policies to guide safe medication administration; (5) the right to
administer medications safely and to identify system problems; and (6) the right to stop,
think, and be vigilant when administering medications.
• In addition, the American Nurses Association (ANA) published a bill of rights for nurses
in 2015 that contains seven premises concerning workplace expectations and
environments that nurses from across the United States recognize as necessary for safe
nursing practice. The Bill of Rights supports nurses in workplace situations and includes
issues such as unsafe staffing, mandatory overtime, and health and safety issues in the
workplace.
• A medication error may be defined as “any preventable event that may cause or lead to
inappropriate medication use or harm to a patient.”
• The ANA supports the concept of Just Culture in its position statement (2010), and it
encourages organizations to avoid using punitive approaches in reporting drug errors
because they focus on punishing individuals for reporting such errors. In a Just Culture,
individuals would be encouraged to report drug errors so the system can be repaired and
the problem fixed. A Just Culture does not hold individual practitioners responsible for a
failing system, although it does not tolerate disregard for a patient or gross misconduct.
• Most organizations have a risk management department staffed with nurse managers and
risk managers who conduct root cause analysis (RCA), a method of problem solving used
to identify potential workplace errors. Such analysis presents opportunities for learning
and focuses on strategies that can be put in place to correct problems.
• If a patient dies as the result of a drug error, it is called a sentinel event.
• The National Patient Safety Goals (NPSGs) focus on problems in health care safety and
how to solve them.
• When a prescription drug is known to be effective for some patients but may cause
serious side effects in others, the FDA will require the drug’s printed materials to carry a
warning about the adverse effects surrounded by a black box.
• Drug reconciliation is an important component of the culture of safety. It is defined as the
process of identifying the most accurate list of all medications that the patient is taking at
transitions in care, which includes admissions and discharges from a hospital to another
health care setting such as long-term care.
• The Secure and Responsible Disposal Act encourages both public and private entities to
develop secure, convenient, and responsible methods for collecting and destroying
medications and controlled substances.
• The Needlestick Safety and Prevention Act (NSPA) requires that employers implement
safer medical devices for their employees, provide a safe and secure workplace
environment with educational opportunities, and develop written policies to help prevent
sharps injuries.
• Every year in the United States, 1.5 million preventable drug errors occur. Data support
that a hospitalized patient is subject to one medication administration error per day.
• The majority of medication errors occur in the transcription stage (56%), followed by the
nurse administration stage (41%), and finally the doctor prescribing stage (39%).
• Counterfeit drugs look like the desired drug but may have no active ingredient, the wrong
active ingredient, or the wrong amount of active ingredient. Improper packaging or
contamination can also be problems.
• Although some drugs can be used crushed, some should not be crushed; do not crush any
extended- or sustained-release drugs because this will change the pharmacokinetic phase
of the drug.
• High-alert drugs can cause significant harm to the patient. If a high-alert medication is
given in error, it can have a major effect on the patient’s organs.
• Nurses should be aware that certain drug names sound alike and are spelled similarly.
• Creating a distraction-free environment is critical to safe administration of medications.
• In 2015, the FDA replaced the lettered pregnancy categories A, B, C, D, and X on
prescription drug labeling. The FDA decided that the previous lettering did not effectively
communicate the risk a drug may have during pregnancy and lactation and in females and
males with reproductive potential.
• The new labeling system provides a broader explanation based on current available
information of the benefits and risks medications can have to the mother, the fetus, and
the breastfeeding child.