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Chapter 2 Medication Administration:
The Joint Commission’s National Patient Safety Goals
NCSBN’s Model Administrative Rules
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Quality and Safety in Health Care
Chapter 2 Medication Administration
The Joint Commission’s National Patient Safety Goals
NCSBN’s Model Administrative Rules
Dr. Julio A. Garcia
Medication Administration
• Ensuring the safe administration of medications within the health
care system is complex and requires a health care professional’s
attention to multiple factors during the process.
• No one professional can prevent all medication errors.
• The nurse is at the sharp end of delivery of medications that may
have started out wrong in the physician’s order, in the drug
packaging, in the pharmacy, or in labeling and packaging similarities.
• The professional who is attentive to these multiple factors increases
the chances for safe medication administration.
Medication Administration
• In order to reliably and safely administer medications, the nurse
needs to determine the patient’s condition and/or stability, the
actions and side effects of the medication to be administered, the
patient’s current medications, the patient’s environment, and the
activities that other health care professionals are carrying out on
behalf of the patient.
• Conscious patients should be enlisted to assist with safe
administration of medication by clearly identifying themselves to the
nurse and being informed of their medications taken at home and in
the hospital.
Medication Administration
• Adverse medication effects can occur even under optimal conditions.
• A medication combined with other medications, substances, and/or
the patient’s physiology has the potential to create life-threatening
reactions within the patient, causing temporary or permanent harm
to the patient.
• Computerized information programs on drug interactions, solubility,
safe routes, dosages, and complications are an indispensable aid in
avoiding delivery of a contraindicated drug to a patient.
• The nurse must learn to use these systems, and hospitals need to
ensure their accessibility to all members of the health care team.
Medication Administration
• Nurses who are knowledgeable about patients’ illnesses and
medications are able to provide competent care as they are alert to
information sources about the known or expected side effects,
medication contraindications, and incompatibilities.
• Nurses are well positioned as the patient’s last line of defense to
protect patients from unsafe medication administration by using all
the available resources pertaining to the particular patient and
medication, double-checking all aspects of medication
appropriateness in terms of correct dosage, route of administration,
timing, purpose, and whether this is the correct patient
Medication Administration
• The IOM report describes an active error as an action of the frontline
operator in which the results are immediately known. For example, a
nurse may convert a latent error to an active error by not recognizing
that a medication with a name similar to ibuprofen was erroneously
dispensed by a pharmacy. As a result, a nurse may accidentally
administer bupropion (Wellbutrin) to the patient instead of
ibuprofen.
Causes leading to medication errors
• Errors associated with the order and administration of medications.
• Inappropriate dosage, overlooked known allergies, and wrong drug or
route of administration.
• Such errors often stem from a confluence of factors including
environmental distractions, miscommunications, and drug-labeling
problems
• Distractions in the form of noise, interruptions, multitasking, and
work overload seriously hamper the nurse’s ability to administer
medications safely.
Causes leading to medication errors
• Health professionals report their perceptions of errors occur
frequently cite interruptions and distractions.
• Relying on memory is dangerous, and the nurse, like all members of
the health care team, needs to avoid reliance on memory related to
drug actions, dosages, interactions, and contraindications.
• The nurse must evaluate and double-check for errors in the
medication order, in misspelled or unclear orders, the manner in
which the order was transcribed, and the route by which the
medication was dispensed.
Causes leading to medication errors
• Lack of automatic alerts to heightened risk medications,
use of dangerous abbreviations, lack of automated
warnings of drug contraindications and dangerous
interactions) place the nurse at unnecessary increased risk
for making medication errors, especially in highly pressured
work environments.
The Joint Commission’s National Patient Safety Goals
Questions most pertinent to ask when reviewing the nurse’s activities
in each error scenario are:
•What information should the nurse have checked but did not?
•What general knowledge about pharmaceutical classes and actions of
drugs was missing?
•Did the nurse properly research and apply the knowledge he/she
checked in relation to the medication being administered?
•What knowledge or pharmaceutical references and medication safety
cross-checks did the nurse not have access to that, if the resource had
been available at the time he/she administered the medication, would
have changed the nurse’s actions?
TERCAP
• The TERCAP (Taxonomy of Error, Root Cause Analysis and Practice
Responsibility) database is designed to collect the practice breakdown
data from boards of Nursing (BONs) to identify the root causes of
nursing practice breakdown from the health care system and
individual perspectives. This approach will facilitate the development
of strategic interventions to ensure the highest safety standards of
nursing practice.
TERCAP
• TERCAP provides a framework to collect, analyze, and disseminate the
factors that comprise and contribute to medication administration errors
by accurately categorizing the behavior of nurses and others, and thoughts
about their activities at the time of the error.
• TERCAP identifies factors that are external to and at the perimeter of the
involved nurse’s professional control, but may have contributed to the
nursing practice breakdown, resulting in a medication error.
• It is important that these factors be identified and discussed in the context
of the health care environment, the nurse-patient situation, and the
resulting error, so that the learning that occurs can be applied to
subsequent nurse-patient situations and similar errors may be prevented.
The NCSBN’s Model Administrative Rules
• Delineate the general requirements of states’ nurse practice acts.
• Include the standard that each registered nurse clarify orders when
needed, especially “phone orders” (first by clarifying on the phone
and second by looking up the safety and reasonableness of the
order).
• Undergraduate nurses have little experience in phoning a doctor for a
provider order. This incident illustrates the need for instruction and at
least simulated practice in obtaining emergency medication for a
rapidly changing or dangerous patient condition.
(Read Historical Case Study 4)
Case Analysis
Read and Analysis the Historical Case Study 1, 2,3, and 4:
• HISTORICAL CASE STUDY #1: The Chemotherapy Protocol. PRACTICE
BREAKDOWN IN MEDICATION ADMINISTRATION
• HISTORICAL CASE STUDY #2: A Groupthink Error. PRACTICE
BREAKDOWN IN MEDICATION ADMINISTRATION
• HISTORICAL CASE STUDIES #3 And #4: The Right Medication, The
Wrong Route
• HISTORICAL CASE STUDY #4
Textbook, Nursing Pathways for Patient Safety Chapter 2, Pages 34 – 44.
References
• Agency for Healthcare Research and Quality: In Medical errors and patient
safety. 2008, Available online
at http://www.ahrq.gov/qual/errorsix.htm, Retrieved October 1, 2008.
• Benner, P., Sutphen, M., Leonard-Kahn, V., Day, L. (In press.) Educating nurses: A
call for radical transformation. San Francisco: Jossey-Bass and Carnegie
Foundation for the Advancement of Teaching.
• D.J. Cullen, B.J. Sweitzer, D.W. Bates, E. Burdick, A. Edmondson, L.L. Leape:
Preventable adverse drug events in hospitalized patients: A
comparative study of intensive care and general care units. Critical
Care Medicine. 25(8), 1997, 1289–1297.
• J. Ely, W. Levinson, N. Elder, A. Mainous, D. Vinson: Perceived causes of family
physicians’ errors. Journal of Family Practice. 40(4), 1995, 337–344.
References
• J. Gladstone: Drug administration errors: a study into the factors underlying
the occurrence and reporting of drug errors in a district general
hospital. Journal of Advanced Nursing. 22(4), 1995, 628–637.
• K. Henriksen, E. Dayton, M.A. Keyes, P. Caravon, R. Hughes: Understanding
adverse events: a human factors framework. In R. Hughes (Ed.): Patient
safety and quality: A handbook for nurses. 2008, Agency for Healthcare
Policy and Research, Rockville, MD, 1–19.
• R. Hughes: In Patient safety and quality: A handbook for nurses. 2008, Agency
for Healthcare Policy and Research, Rockville, MD, Available
online
at http://www.ahrq.gov/qual/nurseshndbk/, Retrieved 8/15/08.
• Institute of Safe Medication Practices (ISMP): Available online
at http://www.ismp.org/Pages/ismp_erract.html, 2008, Retrieved October
30, 2008.
References
• The Joint Commission: Available online at www.JointCommission.org, 2008,
Retrieved October 30, 2008.
• Committee on Quality of Health Care in America, Institute of Medicine: In L.T.
Kohn, J.M. Corrigan, M.S. Donaldson (Eds.): To err is human: Building a safer
health system. 2000, The National Academies Press, Washington, DC.
• P.J. Maddox, M. Wakefield, J. Bull: Patient safety and the need for professional
and educational change. Nursing Outlook. 49(1), 2001, 8–13.
• National Council of State Boards of Nursing (NCSBN): Model nursing
administrative rules. In The NCSVN Model Nursing Practice Act and Model
Nursing Administrative Rules were revised by the 2004 Delegate Assembly.
2004, http://www.ncsbn.org/1455.htm, See.
• Ohioans First: Available online at http://www.ohiopatientsafety.org/meds/,
2004; 2009, Retrieved June 15, 2009.