Medication: PR Ac T Ice Standar D

PR AC T ICE STAndAR d
Medication
Revised 2014
Table of Contents
Introduction 3
Nursing education 3
Standard Statements 4
1. Assessment 4
2. Planning 5
3. Implementation
4. E!aluation
Dispensing Medication 7
Repac"aging #rugs Alread$ #ispensed %
Enhancing Client Safety 8
Sa&e medication practices '
(edication reconciliation )
Institute &or Sa&e (edication Practices Canada )
Ad!erse drug reactions )
lossary !"
Medication Terms !!
Continued on next page
Table of Contents continued
#dditional Information !3
Administration o& medication *$ an unregulated care pro!ider +,CP- 13
Decision Tree$ Deciding #bout Medication #dministration !4
%eferences !&
Suggested %eadings !'
#ppendi( #$ )egislation o*erning +ursing ,ractice !7
*ision
.eading in regulator$ e/cellence
mission
Regulating nursing in t0e pu*lic interest
Medication (Revised 2014) Pu*. No. 4111%
IS2N )%'313%%113 11%3 1
Cop$rig0t 4 College o& Nurses o& 5ntario6 2114.
Commercial or &or3pro&it redistri*ution o& t0is document in part or in 70ole is pro0i*ited e/cept 7it0 t0e 7ritten consent o& CN5. T0is
document ma$ *e reproduced in part or in 70ole &or personal or educational use 7it0out permission6 pro!ided t0at8
9 #ue diligence is e/ercised in ensuring t0e accurac$ o& t0e materials reproduced:
9 CN5 is identi&ied as t0e source: and
9 T0e reproduction is not represented as an o&&icial !ersion o& t0e materials reproduced6 nor as 0a!ing *een made in a&&iliation 7it06
or 7it0 t0e endorsement o&6 CN5.
;irst pu*lis0ed No!em*er 1)) as Medication Administration Standards
Reprinted <anuar$ 21116 5cto*er 21116 5cto*er 2112
Re!ised <une 2113 as Medication Standards (2003) +IS2N 13')455%3333-6 Reprinted as Medication <anuar$ 21146 #ecem*er 2115.
Re!ised <une 211' as Medication, Revised 2008, ,pdated <une 211) +IS2N 13')%31'3 43)-. ,pdated No!em*er 2111 &or 2ill 1%) c0anges.
Re!ised <anuar$ 16 2114 &or #ispensing
Additional copies o& t0is *oo"let ma$ *e o*tained *$ contacting CN5=s Customer Ser!ice Centre at 41 )2'3 1)11
or toll3&ree in 5ntario at 1 '11 3'%3552.
College o& Nurses o& 5ntario
111 #a!enport Rd.
Toronto6 5N (5R 3P1
77 7 .c n o . o rg
Ce &ascicule e/iste en &ran>ais sous le titre 8 !administration de m"dicaments (revis"e 2014)6 n
o
5111%
3
Pr ac t ice Standar d
#ursing standards are expectations t$at contri%ute to
pu%&ic protection' ($e) in*orm nurses o* t$eir
accounta%i&ities and t$e pu%&ic o* +$at to expect o*
nurses' Standards app&) to a&& nurses regard&ess o* t$eir
ro&e, ,o% description or area o* practice'
College of Nurses of Ontario
Introduction
Sa&e6 e&&ecti!e and et0ical medication practice is
an important component o& client care. As 7it0
an$ nursing procedure6 administering6
recommending and?or prescri*ing1 a medication
re@uires "no7ledge6 tec0nical s"ills and Audgment.
Nurses2
need t0e competence to assess t0e appropriateness
o& a medication &or a client6 manage ad!erse
reactions6 understand issues related to consent and
ma"e et0ical decisions a*out t0e use o&
medications.
As 7ell6 client care en!ironments need
s$stems and structures t0at support and
&acilitate sa&e medication practice.
T0e College o& Nurses o& 5ntario=s +t0e College=s-
practice standards appl$ to all nurses regardless o&
t0eir role or practice area. Nursing practice
standards are e/pectations t0at contri*ute to pu*lic
protection. T0e$ in&orm nurses o& t0eir
accounta*ilities and t0e pu*lic o& 70at to e/pect o&
nurses.
College practice standards6 along 7it0 t0e Regu&ated
-ea&t$ .ro*essions Act, 1//1 +RBPA- and #ursing
Act,
1//1, pro!ides a &rame7or" &or nursing practice.3
T0is practice document includes &our standard
statements 7it0 indicators t0at descri*e nurses=
accounta*ilities &or medication practice.
Administering a medication is one component
o& a continual process t0at goes *e$ond t0e
tas" o& gi!ing a medication to a client. Nurses
must appl$ t0eir "no7ledge a*out t0e client
and t0e
medication 70en assessing6 planning6
implementing and e!aluating t0e process. T0e
College ad!ocates
&or t0e same nurse per&orming all administration
steps to minimiCe t0e c0ance o& error and
clari&$ indi!idual accounta*ilit$. T0is
document applies to prescription drugs as 7ell as
ot0er su*stances6
including o!er3t0e3counter medications and 0er*al
preparations. T0e decision tree on page 14 can
0elp nurses decide a*out medication administration
and determine i& administering a speci&ic drug is
7it0in t0eir indi!idual nursing role.
+ursing education
As a result o& di&&erences in *asic nursing education6
t0e &oundational "no7ledge o& RNs and RPNs is
di&&erent. 2ot0 categories stud$ &rom t0e same *od$
o& nursing "no7ledge6 70ic0 includes
p0armacolog$. Bo7e!er6 RNs stud$ &or a longer
period o& time6 allo7ing &or a greater dept0 and
*readt0 o& "no7ledge. T0ose 70o appl$ &or College
registration must meet *asic RN and RPN
competencies &or
medication administration. Nurse Practitioners
+NPs- demonstrate additional competencies
associated 7it0 t0eir aut0orit$ to prescri*e a drug.4
To determine
t0e categor$ o& nurse most appropriate to
administer a medication in a particular conte/t6 t0e
needs o&
t0e client6 t0e "no7ledge6 s"ill and Audgment o&
t0e nurse6 and t0e &eatures o& t0e practice
en!ironment need to *e re!ie7ed.5
In practice6 nurses ma$ need to administer
medications *$ routes and met0ods t0at 7ere
not included in t0e e/periences o& t0eir *asic
educational program. D0ile nurses 7ill 0a!e
learned t0e competencies associated 7it0 sa&e
medication practices6 t0e$ ma$ need
additional "no7ledge to competentl$ assume
t0ese
responsi*ilities. Eou can ac@uire suc0 "no7ledge
and s"ill in continuing education courses or
in3ser!ice education. As 7ell6 $ou need to *ecome
&amiliar 7it0 t0e policies and procedures
pro!ided
*$ an emplo$er. Nurses are accounta*le &or
assessing t0eir competencies and related s"ills in
pro!iding
1
Nurse Practitioners 0a!e t0e additional aut0orit$ to prescri*e a drug.
2
In t0is document6 nurse re&ers to a Registered Practical Nurse +RPN-6 Registered Nurse +RN- and Nurse Practitioner +NP-.
3
;or more in&ormation on t0e legislation go!erning nursing practice6 see Appendi/ A on page 1%.
4
;or more in&ormation6 re&er to t0e College=s #urse .ractitioner practice document at 77 7 .c n o. o rg ?d o c s .
5
;or more in&ormation6 re&er to t0e College=s 0ti&i1ation o* R#s and R.#s practice document at 77 7 .c n o. o rg ?d o c s .
College o& Nurses o& 5ntario .ractice Standard2 Medication
4
care related to medications. E!en nurses 70o do
not administer medications must still understand
t0e actions +&or e/ample6 purposes6 ris"s and
potential side e&&ects- 70en caring &or clients 70o
recei!e medications as part o& t0eir treatment plan.
Standard Statements
T0ere are &our standard statements6 eac0 7it0
accompan$ing indicators6 t0at descri*e a nurse=s
accounta*ilities related to medication practice.
T0e
standard statements descri*e *road principles t0at
guide nursing practice and are listed in a manner
t0at re& lects t0e steps o& t0e nursing process. T0e
standard statements 0a!e *een organiCed &or
clarit$: 0o7e!er6 t0e process is not a linear
progression. ;or e/ample6 it is e/pected t0at
assessment 7ill occur t0roug0out all p0ases o&
medication administration and not solel$ as t0e
&irst step in t0e process. T0e indicators are *road
statements t0at nurses can
appl$ to t0eir particular practice en!ironment.
!- #ssessment
Nurses use their knowledge, skill and judgment in
the assessment of the client, the medication
and the practice supports prior to administering
medication.
Indicators
T0e nurse meets t0e standard *$8
a- accepting authori.ing mechanisms onl$ &rom
prescri*ers 7it0 ordering aut0orit$ +&or
e/ample6 p0$sicians6 NPs6 dentists6 c0iropodists
and mid7i!es-:
*- accepting a medication order t0at is complete
and includes t0e order date6 client name6
medication name6 dose in units6 route6 &re@uenc$6
purpose
+&or e/ample6 a researc0 or PRN medication-6
and prescri*er=s name6 signature and designation
+t0e prescription la*el is t0e order-:
c- accepting an outpatient or communit$ order%
&or medication t0at includes all o& t0e a*o!e
in&ormation as 7ell as t0e amount to *e
dispensed6 t0e duration o& t0erap$ and t0e
num*er o& repeats or re&ills:
d- 7it00olding t0e medication and &ollo7ing up
7it0 a prescri*er in a timel$ manner in t0e
e!ent t0at a medication order is incomplete6
unclear6 inappropriate or misunderstood:'
e- re@uesting 7ritten orders 70en t0e prescri*er is
present6 or onl$ accepting electronic orders 70en
t0ere is a secure s$stem in place +&or e/ample6
!ia a secure &a/ or e3mail-:
& - accepting a *erbal order onl$ in an emergenc$
situation or 70en t0e prescri*er cannot
document 0er or 0is orders +&or e/ample6 in t0e
operating room or during a code-:
g- recogniCing t0at telephone orders s0ould *e
limited to situations re@uiring direction &or
client care 70en t0e prescri*er is not present:
0- ensuring t0at !er*al and telep0one orders
are repeated in t0eir entiret$ &or accurac$:
i- documenting !er*al and telep0one orders as 7ell
as t0e prescri*er=s name and designation in t0e
client=s record +t0e nurse is not responsi*le &or
ensuring t0at suc0 orders 0a!e *een signed *$ t0e
prescri*er-:)
A- assessing 0er or 0is o7n "no7ledge6 s"ill and
Audgment to competentl$ carr$ out
medication administration6 use medication
e@uipment and inter!ene during an ad*erse
reaction:

2olded 7ords are de&ined in t0e glossar$ on page ).
%
Clients in t0e communit$ ma$ not *e regularl$ assessed *$ a 0ealt0 care pro!ider or 0a!e p0armaceutical supports in place to promote
client sa&et$. .imiting t0e amount o& medication and t0e time t0e medication is a!aila*le 0elps ensure t0at clients recei!e an appropriate
course o& t0erap$.
'
;or more in&ormation6 re&er to t0e College=s 3isagreeing 4it$ t$e .&an o* Care practice document at
77 7 .c n o. o rg ?d o c s .
)
;or more in&ormation6 re&er to t0e College=s 3ocumentation, Revised 2008 practice document at 77 7 .c n o. o rg ?d o c s .
11
;or more in&ormation6 re&er to t0e College=s Consent practice document at 77 7 .c n o. o rg ?d o c s .
&
"- !eri&$ing t0at in&ormed consent11 0as *een
o*tained &rom t0e client or t0e client=s
su*stitute decision3ma"er:
l- assessing t0e appropriateness o& t0e
prescri*ed medication &or t0e client *$
considering t0e8

client=s age6 7eig0t6 pat0op0$siolog$6
la*orator$ results6 !ital signs6 medication
"no7ledge6 and c0oice or pre&erence6

e/pected *ene&its and potential ris"s?side
e&&ects6 t0e possi*le interaction 7it0 ot0er
medications6 and an$ &oods t0at are
contraindicated or decrease a*sorption6

client=s allergies6 sensiti!ities and pre!ious
ad!erse reactions6 and

appropriate use o& t0e medication as
prescri*ed &or t0e client in t0e particular
situation +&or e/ample6 a PRN medication-:
m- ensuring and?or ad!ocating &or appropriate
resources to monitor and inter!ene to
manage potential ad!erse drug reactions
+&or e/ample6 0a!ing t0e prescri*er on3site
*e&ore administration-:
n- per&orming all o& t0e administration steps to
minimiCe t0e c0ance o& error and clari&$
indi!idual accounta*ilit$ +&or e/ample6
e/ercising Audgment in deciding 70et0er to
in!ol!e ot0er nurses in preparing t0e !accine in a
mass3 immuniCing campaign-: and
o- identi&$ing and ad!ocating &or s$stems and
resources t0at support nurses in maintaining
competenc$ in medication practice.
/- ,lanning
Nurses are accountable for ensuring the
accuracy, appropriateness and completeness of a
clients plan of care in regards to medication
order(s,
and for communicating concerns about the
treatment plan to other members of the
health care team.
Indicators
a- transcri*ing medication orders as 7ritten6 or
!alidating t0e accurac$ and completeness o& t0e
transcription 70en ot0ers 0a!e completed t0e
transcri*ing:
*- sc0eduling dosing times &or a medication6
ta"ing into consideration t0e e&&ect o& &ood
inta"e
on medication a*sorption6 contraindications6
re@uired inter!entions *e&ore6 during and a&ter
administration +&or e/ample6 *lood pressure-6
and client c0oice or pre&erence:
c- re&raining &rom accepting medication order
in&ormation &rom t0ose 70o do not 0a!e
p0armacolog$ "no7ledge +&or e/ample6 a unit
cler"-:
d- communicating orders 7it0 indi!iduals 7it0in
t0e circle o& care +&or e/ample6 t0e 0ealt0 care
team or client or6 7it0 consent6 t0e &amil$-:
e- demonstrating clear6 e!idence3*ased rationale &or
decisions and ta"ing appropriate steps11 to resol!e
issues relating to medication administration: and
& - ad!ocating &or s$stems t0at pro!ide a
mec0anism &or resolution 70en t0ere is
disagreement among mem*ers o& t0e 0ealt0 care
team regarding a medication order.
11
;or more in&ormation6 re&er to t0e College=s 3isagreeing 4it$ t$e .&an o* Care practice document at 77 7 .c n o. o rg ?d o c s .
'
3- Implementation
Nurses prepare and administer medication(s to
clients in a safe, effecti!e and ethical manner.
Indicators
a- ensuring t0at t0e client recei!es appropriate
education a*out t0e treatment plan and
current medication:
*- ensuring t0at t0e client or t0e client=s su*stitute
decision3ma"er 0as gi!en consent12 to administer
t0e medication:
c- preparing and administering t0e
medication according to an e!idence3*ased
rationale:
d- o*taining a ne7 suppl$ o& medication i& t0ere
are concerns a*out 0o7 t0e medication 0as
*een maintained:
e- appl$ing principles o& in&ection pre!ention
and control13 70en administering medication:
& - !eri&$ing8
t0e rig0t client6
t0e rig0t medication6
t0e rig0t reason6
t0e rig0t dose6
t0e rig0t &re@uenc$6
t0e rig0t route6
t0e rig0t site6 and
t0e rig0t time:14
g- ensuring t0at t0e client recei!es appropriate
monitoring during and a&ter administering
t0e medication6 and inter!ening i& necessar$:
0- documenting6 during and?or a&ter medication
administration6 in t0e client=s record according
to documentation standards:15 and
i- ad!ocating &or appropriate en!ironmental
supports to ensure clients recei!e sa&e6 e&&ecti!e
and et0ical care.
4- E*aluation
Nurses e!aluate client outcomes following
medication administration and take appropriate
steps for follow"up.
Indicators
a- recogniCing client outcomes &ollo7ing
medication administration6 including
e&&ecti!eness6 side e&&ects6 signs o& ad!erse
reactions and?or drug interactions:
*- &ollo7ing up 7it0 t0e prescri*er regarding
an$ concerns or @uestions a*out t0e
medication:
c- re&erring clients to t0e appropriate care
pro!ider &or &urt0er assessment and &ollo73up
70en necessar$ +&or e/ample6 70en t0e
underl$ing pro*lem persists despite PRN
medication-:
d- documenting actions ta"en or ad!ice gi!en and
client outcomes according to documentation
standards:
e- documenting6 70en appropriate6 i& t0e client
is capa*le o& sel&3administering t0e
medication6 including t0e t$pe o& assistance
t0e client re@uires6 i& an$6 and t0e ongoing
nursing assessment o& t0e client=s capacit$ to
continue sel&3administration: and
& - ad!ocating &or ade@uate resources and
s$stems t0at &acilitate sa&e6 e&&ecti!e
administration according to standards.
12
;or more in&ormation6 re&er to t0e College=s Consent practice document at 77 7 .c n o. o rg ?d o c s .
13
;or more in&ormation6 re&er to t0e College=s 5n*ection .revention and Contro& practice document at 77 7 .c n o. o rg ?d o c s .
14
T0is is "no7n as t0e rig0ts o& medication administration.
15
;or more in&ormation6 re&er to t0e College=s 3ocumentation, Revised 2008 practice document at 77 7 .c n o. o rg ?d o c s .
7
Dispensing Medication
#ispensing is a controlled act t0at aut0oriCes a
nurse to select6 prepare and trans&er stoc"
medication &or one or more prescri*ed
medication doses to a client or 0is or 0er
representati!e &or administration at a later time.
All nurses 0a!e access to t0e controlled act o&
dispensing *ut t0e$ cannot delegate dispensing.
T0e &ollo7ing in&ormation on dispensing
medication applies to RNs and RPNs. ;or
&urt0er in&ormation on NP dispensing6 see t0e
#urse .ractitioner practice document at
00 0 -c n o- o r g.
RNs and RPNs dispense medication in a sa&e
and et0ical manner *$8

accepting an order to dispense onl$ &rom
prescri*ers 7it0 prescri*ing aut0orit$

ensuring t0e medication order is appropriate
&or t0e client

accepting an order to dispense t0at is complete
and includes t0e order date6 client name6
medication name6 dose in units6 route6
&re@uenc$6 purpose6 @uantit$ to dispense6 and
prescri*er=s name6 signature and designation

dispensing medication &or t0erapeutic
purposes onl$

preparing t0e medication according to e!idence3
*ased practice

pac"aging medication in a container t0at is
appropriate &or t0e client and maintains
t0e integrit$ o& t0e medication

ensuring t0e medication 7ill not e/pire *e&ore t0e
client is e/pected to ta"e t0e last dose

7it00olding t0e medication 70en t0ere are
concerns a*out 0o7 t0e medication 0as *een
maintained and &ollo7ing up as is
appropriate

la*elling t0e medication container or
pac"aging 7it0 t0e &ollo7ing re@uired
in&ormation8
t0e drug identi&ication num*er6 i& applica*le
t0e client=s name
t0e date t0e medication is dispensed
t0e name and6 i& applica*le6 strengt0 o&
t0e medication
t0e dose6 route o& administration6 &re@uenc$6
and i& applica*le6 duration
@uantit$ or amount o& medication dispensed
an$ special instructions t0at ma$ appl$ to
t0e medication
t0e e/pir$ date o& t0e medication
t0e name and designation o& t0e prescri*er
t0e name6 address6 and telep0one num*er o&
t0e organiCation &rom 70ic0 t0e medication
is dispensed

educating t0e client or client=s representati!e
a*out t0e purpose o& t0e medication6 dosage6
instructions6 e/pected *ene&its6 common side3
e&&ects6 and storage re@uirements

0anding t0e medication directl$ to t0e client6 or
t0e client=s representati!e

documenting in t0e 0ealt0 record t0e speci&ics
o& t0e medication dispensed6 including all o&
t0e in&ormation contained on t0e la*el t0at is
not alread$ part o& t0e client=s 0ealt0 record

dispensing according to all applica*le &ederal and
pro!incial legislation

a!oiding dispensing medication &or an$ direct or
indirect *ene&it6 suc0 as monetar$ gain6
incenti!e6 or re7ard

discussing t0is practice in t0e course o& pro!iding
care6 70en rele!ant to t0e client=s care *ut
ot0er7ise re&raining &rom ad!ertising t0e &act t0at
t0e nurse dispenses medication

ad!ocating &or s$stems t0at support sa&e and
et0ical dispensing o& medication.
%epac1aging Drugs #lready Dispensed
It is not a controlled act to repac"age medication
t0at 0as alread$ *een dispensed. D0en
pro!iding clients 7it0 t0eir repac"aged
medications6 nurses
are accounta*le &or ensuring t0at t0e medication
0as *een repac"aged sa&el$. Nurses are also
accounta*le &or ensuring t0at t0e la*el includes
in&ormation clients need to administer t0eir o7n
medication sa&el$.
8
Enhancing Client Safety
Nurses and emplo$ers 0a!e a s0ared responsi*ilit$ to
create sa&e practice en!ironments. Fualit$ practice
settings include appropriate sta&&6 medication
s$stems +&or e/ample6 deli!er$6 administration6
policies6 procedures- and en!ironments to
&acilitate sa&e6 e&&ecti!e and et0ical care. T0e
&ollo7ing section pro!ides in&ormation and
resources to 0elp nurses and emplo$ers 7or"
toget0er to pre!ent and resol!e medication issues.
Safe medication practices
To support sa&e medication practice6 s$stems
need to *e in place to trac"6 address and learn
&rom
an$ medication errors t0at occur in t0e
practice en!ironment.
Medication errors
A medication error is de&ined as an$ pre!enta*le
e!ent t0at ma$ cause or lead to inappropriate
medication use or client 0arm 70ile t0e
medication is in t0e control o& t0e 0ealt0 care
pro&essional6 client or consumer. Suc0 e!ents ma$
*e related
to pro&essional practice6 0ealt0 care products6
procedures and s$stems6 including prescri*ing:
order communication: product la*elling6
pac"aging and nomenclature: compounding:
dispensing: distri*ution: administration: education:
monitoring and use.1
(edication errors can *e &urt0er classi&ied into
errors o& commission +&or e/ample6 gi!ing t0e
7rong medication- and errors o& omission +&or
e/ample6
not administering an ordered medication-6 70ic0
can result in an ad!erse drug e!ent resulting in
0arm6 inAur$ or deat0. 5r6 it could result in a
Gnear miss.H In t0is situation6 an error does not
reac0
t0e client6 *ut 0ad it6 t0e client could 0a!e *een
0armed. +;or e/ample6 a 7rong dose is
prescri*ed *ut is intercepted *e&ore
administration.-
Pre!enting and reducing errors in!ol!es
colla*oration *et7een t0e nurse6 ot0er 0ealt0
care pro&essionals and t0e &acilit$. Nurses can
o&ten
identi&$ and correct errors *e&ore t0e$ occur.
Addressing indi!idual accounta*ilit$ and using a
s$stems3*ased approac0 to anal$Ce errors ensures
t0at errors are identi&ied6 and t0at sta&& participate
in an interpro&essional process t0at identi&ies root
causes and results in correcti!e actions. D0en an
error is made6 t0e nurse must ensure t0e 7ell3
*eing o& t0e client and limit t0e client=s e/posure
to an$ potential 0arm. T0e plan o& action 7ill
depend on t0e pro*lem+s- identi&ied. Some
strategies to address pro*lems are s$stem
modi&ications6 in3ser!ice education6 indi!idual
assistance and potential per&ormance management.
Safe medication practice includes$

ad!ocating &or setting3speci&ic6 accessi*le6
current medication information6 suc0 as drug
&ormularies:

e!aluating t0e need &or a colleague to conduct
an independent double2chec1 on a prepared
medication:

meeting and *eing a7are o& t0e &acilit$=s
e/pectations on independentl$ dou*le3c0ec"ing
preparations:

ad!ocating &or 7ritten policies and supporting
processes 70en t0e practice setting re@uires
independentl$ dou*le3c0ec"ing preparations:

0a!ing "no7ledge o& high alert
medications &or t0e practice setting +&or
e/ample6 c0emot0erapeutic agents-:

a!oiding t0e use o& error3prone a**re!iations6
dose designations and s$m*ols6 and ad!ocating &or
a polic$ on t0e use o& accepta*le a**re!iations:

reporting all errors and near misses using
&ormal practice3setting communication
mec0anisms:

ad!ocating &or organiCational s$stems and policies
t0at promote continuit$ and sa&et$ o& client
medication administration during trans&er o& care
and at transition points:

ensuring t0at t0e client or t0e client=s su*stitute
decision3ma"er 0as t0e most complete and
accurate list possi*le o& all medications
currentl$ *eing ta"en:

communicating to t0e client and appropriate
1
+National Coordinating Council &or (edication Error Reporting and Pre!ention6 211'-
3
caregi!ers t0e current list o& medications during
transfer of accountability:

addressing s$stem issues t0at contri*ute to
medication errors:

ad!ocating &or and?or participating in
interdisciplinar$ error3reporting and root cause
s$stem anal$sis:

ad!ocating &or &acilit$ policies and?or procedures
regarding disclosure o& ad!erse e!ents: and

&ollo7ing legislation and?or ad!ocating &or
practice setting policies and procedures regarding
t0e storage6 counting6 administration and disposal
o& medication.
Medication reconciliation
T0is process is intended to pre!ent
medication errors 70en a client=s care is
trans&erred. (edication reconciliation assists
in reducing t0e ris" o& pre!enta*le ad!erse
e!ents and is an
important client sa&et$ initiati!e. T0e
medication reconciliation process ma$ in!ol!e
all mem*ers o& t0e 0ealt0 care team.
The process in*ol*es$

creating t0e most complete6 accurate list o& all
medications a client is currentl$ ta"ing and t0e
time t0e last medication 7as gi!en +&or e/ample6
a *est possi*le medication 0istor$-:

using t0is list 70en 7riting admission
medication orders:

comparing t0e list and t0e admission
medication orders:

identi&$ing an$ discrepancies and6 i& an$ are
&ound6 *ringing t0em to t0e attention o& t0e
prescri*er and ma"ing appropriate c0anges to
t0e orders:

communicating t0e current list o& medications to
t0e client and appropriate caregi!ers:1% and

comparing t0e medication 0istor$ to trans&er?
disc0arge orders to ensure t0at t0e client=s
medications are reconciled at
trans&er?disc0arge.1'
Institute for Safe Medication ,ractices
Canada
T0e Institute &or Sa&e (edication Practices
+IS(P- Canada is an independent6 national6
non3 pro&it agenc$ committed to t0e
ad!ancement
o& medication sa&et$ in all 0ealt0 care settings. It
7or"s colla*orati!el$ 7it0 t0e 0ealt0 care
communit$: regulator$ agencies and polic$3
ma"ers: pro!incial6 national and international
client sa&et$ organiCations: t0e p0armaceutical
industr$ and t0e pu*lic. IS(P Canada is a
resource &or in&ormation on 0o7 to pre!ent errors
and identi&$ 0ig0 alert medications. It also 0as a
list o& industr$ accepted a**re!iations. ;or more
in&ormation6 contact IS(P Canada at8
Toll3&ree8 1 ' 5443%%2
E3mail8 i n &o I i s m p 3 c a n a d a .o r g
De*site8 77 7 .i s m p 3 c a na da .o r g
#d*erse drug reactions
A serious ad!erse drug reaction +A#R- is
de&ined as a no/ious and unintended response to
a drug t0at occurs at an$ dose and re@uires in3
patient
or e/tended 0ospitaliCation: causes congenital
mal&ormation: results in persistent or signi&icant
disa*ilit$?incapacit$: is li&e3t0reatening or results in
deat0.1) A nurse 70o assesses a serious A#R
s0ould report it or ad!ocate &or reporting it to t0e
Canada Jigilance Program8
Toll3&ree8 1 ' 23432345
De*site8 77 7 .0 c3s c .g c .c a ?d 0 p 3m p s ?m e d e & & ?
inde/Ke.0tml
1%
+Institute &or Sa&e (edication Practices Canada6 211-
1'
+Sa&er Bealt0care No76 211%-
1)
+Bealt0 Canada6 211%-
!"
lossary
#d*erse reaction- ,ndesira*le p0$sical reactions
to 0ealt0 products6 including drugs6 medical
de!ices and natural 0ealt0 products. #rugs
include prescription and non3prescription
p0armaceuticals: *iologicall$ deri!ed products
suc0 as !accines6 serums and *lood deri!ed
products: cells6 tissues and organs: disin&ectants and
radiop0armaceuticals.21
#uthori.ing mechanism- An order6 initiation6
directi!e21 or delegation. A means speci&ied in
legislation or descri*ed in a practice standard or
guideline t0roug0 70ic0 nurses o*tain t0e
aut0orit$ to per&orm a procedure or ma"e t0e
decision to per&orm a procedure.22
4igh alert medications- #rugs t0at *ear a
0eig0tened ris" o& causing signi&icant client
0arm 70en t0e$ are used in error.23
Independent double2chec1- A process t0at ensures
t0at a second practitioner conducts a !eri&ication6
eit0er in t0e presence or a*sence o& t0e &irst
practitioner. ;or e/ample6 a nurse ma$ use t0is
process to !eri&$ a dosage calculation. T0e most
critical aspect is to ensure t0at t0e &irst 0ealt0 care
pro!ider does not communicate 70at 0e or s0e
e/pects t0e second practitioner to &ind: t0is 7ould
reduce t0e !isi*ilit$ o& a mista"e.24
Medication information- In&ormation a*out
a speci&ic drug suc0 as indications6 appropriate
dose6 precautions6 contraindications6 drug?&ood
interactions6 e/pected outcomes6 potential ad!erse
reactions6 side e&&ects and 0o7 to minimiCe
and treat t0em6 0ig0 alert medications6
special consideration6 storage and
administration.
Telephone order- An order communicated !ia
telep0one *$ an aut0oriCer 70o is not p0$sicall$
present to 7rite t0e order. T0e person accepting
t0e order must 0a!e "no7ledge o& t0e client6
including 0is or 0er 0ealt0 0istor$ and
treatment plan. ,ltimatel$6 t0e person
implementing t0e order is accounta*le &or
ensuring t0at t0e order
is appropriate. Practice settings s0ould esta*lis0
procedures &or timel$ sign3o&& *$ t0e aut0oriCer
o& t0e telep0one order.
Transfer of accountability- An interacti!e
process o& trans&erring client3speci&ic in&ormation
&rom
one caregi!er to anot0er or &rom one team o&
caregi!ers to anot0er &or t0e purpose o& ensuring
t0e continuit$ o& care and t0e sa&et$ o& t0e client.25
5erbal order- An order t0at is communicated *$
an aut0oriCer 70o is present in t0e practice
en!ironment *ut is una*le to document t0e order.
Jer*al orders must onl$ *e used in emergenc$
situations or 70en t0e prescri*er is una*le to
document t0e order6 suc0 as in t0e operating
room.
21
+Bealt0 Canada6 211%-
21
;or more in&ormation6 re&er to t0e College=s 3irectives practice document at 77 7 .c n o. o rg ?d o c s .
22
;or more in&ormation6 re&er to t0e College=s Aut$ori1ing Mec$anisms practice document at 77 7 .c n o. o rg ?d o c s .
23
+Institute &or Sa&e (edication Practices Canada6 211'-
24
+Institute &or Sa&e (edication Practices Canada6 211'-
25
+Patton6 211%-
!!
Medication Terms
#llergy challenge testing- T0e administration o&
an allergen *$ oral6 in0aled or ot0er route in
70ic0 a positi!e test is a signi&icant allergic
response +&or e/ample6 anap0$lactic s0oc"-. ,nless
delegated6 nurses cannot per&orm allerg$ c0allenge
testing.
#llergy testing and desensiti.ing in6ections-
An allerg$ test is a pric"?puncture procedure to
determine allergies6 i& an$. A positi!e test results
in a 70eal and area o& er$t0ema. A desensitiCing
inAection is an intracutaneous inAection to
desensitiCe to an allergen. 2ecause allerg$ testing
and desensitiCing inAections carr$ a ris" o& ad!erse
reactions6 nurses must *e a*le to recogniCe side
e&&ects6 inter!ene in t0e e!ent o& complications +&or
e/ample6 di&&icult$ *reat0ing6 ras0 or anap0$lactic
s0oc"- and manage outcomes. I& t0e nurse cannot
manage ad!erse outcomes6 a competent 0ealt0 care
practitioner and appropriate en!ironmental
supports and medications must *e readil$ a!aila*le.
Controlled substance- An$ t$pe o& drug t0at t0e
&ederal go!ernment 0as categoriCed as 0a!ing a
0ig0er3t0an3a!erage potential &or a*use or
addiction. Suc0 drugs are di!ided into categories
*ased on
t0eir potential &or a*use or addiction.
Controlled su*stances range &rom illegal street
drugs to prescription medications.2
T0e 5&&ice o& Controlled Su*stances o& Bealt0
Canada regulates t0e distri*ution o& controlled
su*stances in Canada6 including t0ose su*stances
used *$ indi!iduals and 0ealt0 care &acilities
&or legitimate scienti&ic or 0ealt0 reasons. T0e
go!erning &ederal legislation includes t0e Contro&&ed
3rugs and Su%stances Act6 t0e #arcotic Contro&
Regu&ations6 Part L +Controlled #rugs- o& t0e 6ood
and 3rug Regu&ations and 7en1odia1epines and
8t$er (argeted Su%stances Regu&ations.
,nder t0e legislation6 all licensed 0ealt0 care
&acilities in 5ntario6 suc0 as pu*lic 0ospitals6
pri!ate 0ospitals and long3term care &acilities as
de&ined *$
t0e #ursing -omes Act6 are re@uired to maintain a
count o& controlled su*stances. ;acilities t0at are
not pro!inciall$ licensed as de&ined *$ t0e -omes
*or t$e Aged and Rest -omes Act are not *ound *$
t0e Contro&&ed 3rugs and Su%stances Act and
related regulations.
Immuni.ing agent7s8- A !accine. T0e s"ill
re@uired to administer immuniCing agents is t0e
same as
t0at &or ot0er inAections. ;or more in&ormation6
re&er to t0e College=s 5n*&uen1a 9accinations
practice guideline.
9*er2the2counter 79TC8 medication 0ithout
an order- (edications and preparations t0at do
not re@uire a prescription: &or e/ample6 0er*al
t0erapies and acetaminop0en. 5TC medications
are not part o& t0e act o& prescri*ing. In some
situations6 0o7e!er6 t0e nurse=s role ma$
include
administering or recommending 5TC medications
to clients. Nurses are solel$ accounta*le &or
recommending 5TC medications to clients and
&or an$ outcomes o& t0ose recommendations.
2e&ore recommending an 5TC medication6 nurses
must 0a!e t0e "no7ledge6 s"ill and Audgment
a*out
t0e client=s situation: t0e client=s condition and
medication pro&ile: and t0e medication. .egislation
or organiCational policies ma$ re@uire an order
&rom an aut0oriCed prescri*er. ;or more
in&ormation6
re&er to t0e College=s Comp&ementar) ($erapies
practice document.
,lacebo- A p0armacologicall$ inert su*stance t0at
0as no p0$siological e&&ect. Administering place*os
to clients 7it0out t0eir "no7ledge and in&ormed
consent is inappropriate and unaccepta*le.
Place*os ma$ *e administered8

70en prescri*ed 7it0 client consent *ecause
t0e client e/periences a place*o e&&ect: and?or

as part o& a dou*le3*lind researc0 stud$ in
70ic0 t0e client 0as *een in&ormed6 as part o&
t0e consent process6 t0at 0e or s0e ma$ recei!e a
place*o.
2
+Bealt0 Canada6 211'-
!/
,%+ medication7s8- (edications t0at are
prescri*ed and administered as needed. T0e order
includes t0e &re@uenc$6 suc0 as F4B6 and t0e
purpose +&or e/ample6 sleep6 pain or nausea-.
Nurses must 0a!e current "no7ledge o& t0e use and
action o& PRNs6 as 7ell as t0e competence to assess
t0e need &or PRNs and 70et0er to administer t0em
to
a client.
%ange doses- #osages6 &re@uencies or routes t0at
are prescri*ed in ranges +&or e/ample6 Lra!ol
51M111 mg &or nausea-. (ost medications are not
prescri*ed in range doses: 0o7e!er6 range doses are
used in situations in 70ic0 t0e need &or t0e
amount o& a drug !aries &rom da$ to da$ or 7it0in
t0e
same da$. Range doses gi!e nurses t0e & le/i*ilit$ to
administer t0e dose t0at *est suits t0e assessment o&
t0e client.
Self2administration- Administrating one=s o7n
medication. Clients ma$ sel&3administer t0eir
medications at 0ome and in some agencies to
de!elop or maintain an optimal le!el o&
&unctioning and independence. Clients 70o sel&3
administer
ma$ *e completel$ independent6 or ma$ re@uire
some assistance6 suc0 as reminders6 0elp opening
containers or assisti!e de!ices +&or e/ample6
dosettes-6 or 0elp in &illing assisti!e de!ices. Nurses
must ensure t0at medications are securel$ stored.
:hen using in*estigational and emergency
release medications 7off label8- D0en p0$sicians
prescri*e t0ese medications6 t0e p0$sician or
p0armacist must gi!e t0e nurse a drug
monograp0? in&ormation. Alt0oug0 t0e nurse is
not accounta*le &or an$ outcomes produced *$
t0e medications6 t0e nurse is accounta*le &or
correctl$ administering
t0e drug6 and is re@uired to inter!ene and possi*l$
7it00old medications i& se!ere side e&&ects occur.
A&ter administration6 t0e nurse monitors t0e
client &or ad!erse side e&&ects.
:hen using medication brought from home- In
some settings6 suc0 as geriatric da$care centres and
c0ildren=s camps6 clients *ring t0eir medications
&rom 0ome. Nurses ma$ administer t0ese
medications i& t0e$ are in t0eir original dispensing
containers +t0at is6 not in an en!elope or assisti!e
de!ice &or sel&3administration-. I& t0e in&ormation
pro!ided *$ t0e client or t0e client=s representati!e
is di&&erent &rom t0at on t0e dispensing la*el6 t0e
nurse needs to use 0er or 0is Audgment a*out t0e
appropriateness o& &ollo7ing t0e directions and
&ollo7 up 7it0 t0e prescri*er 70en re@uired. T0e
nurse s0ould document t0e discrepanc$ and 0er or
0is rationale &or &ollo7ing t0e c0osen directions.
!3
#dditional Information
#dministration of medication by an
unregulated care pro*ider 7;C,8
Tec0nological ad!ances6 s0orter 0ospital sta$s6 &iscal
constraints and a general s0i&t to communit$3*ased
care 0a!e contri*uted to t0e increased use o& ,CPs
to assist 7it0 or per&orm aspects o& care6 including
medication administration6 t0at 7ere &ormerl$
pro!ided *$ regulated care pro!iders. Nurses ma$
teac0 ,CPs medication administration6 including
t0e process o& administration and documentation6 as
re@uired. Alt0oug0 administering *$ some routes is
not a controlled act and doesn=t re@uire delegation6
t0ere is still a ris" o& 0arm 70en per&orming an$
procedure i& it is not done competentl$. T0e nurse
remains responsi*le &or t0e8

ongoing assessment o& t0e client=s needs:

plan o& care in conAunction 7it0 t0e 0ealt0
care team:

e!aluation o& t0e client=s 0ealt0 status: and

e&&ecti!eness o& t0e medication+s-.
,CPs do not 0a!e t0e "no7ledge to pro!ide t0is
component o& t0e plan o& care. I& t0e nurse decides
it is appropriate &or t0e ,CP to administer
medication+s-6 t0e nurse is accounta*le to ensure
criteria are de!eloped and communicated to t0e
,CP t0at clearl$ de&ine 70en t0e ,CP needs to
contact
t0e nurse. T0e nurse must ma"e pro!isions to
ensure an ongoing assessment o& t0e client=s
condition.2%
2%
;or more in&ormation6 re&er to t0e College=s 0ti&i1ation o* 0nregu&ated Care .roviders (0C.s)6 4or:ing 4it$ 0nregu&ated Care .roviders
and Aut$ori1ing Mec$anisms practice documents at 77 7 .c n o. o rg ?d o c s .
!4
Decision Tree$ Deciding #bout Medication #dministration
,se t0is tool to 0elp $ou determine 70et0er or not to administer a medication. 2e sure to consider all o&
t0e components o& medication administration in t0is document.
,roper authori.ing mechanism in place<
;or e/ample6 order or medical directi!e
+9
=ES
Do not administer
medication
Ta"e appropriate action
to sa&eguard client
interest and ensure
continued care: &or
e/ample6 &ollo7 up 7it0
prescri*er
#ssessed client factors<
;or e/ample6 identi&$ client6 !eri&$
consent
+9 =ES
#ssessed your abilities<
;or e/ample6 $our "no7ledge o& medication6 s"ills to
reconstitute and administer6 Audgment to identi&$
and respond to outcomes
+9 =ES
#ssessed en*ironmental supports<
;or e/ample6 0uman and tec0nological resources to
monitor and inter!ene i& needed6 s$stems in place to
support sa&e medication administration
+9 =ES
#dminister medication
E*aluate outcomes
I& an ad!erse reaction occurs6 ta"e appropriate action
+ote$ 3ocument during and;or a*ter administering medication, according to documentation standards'
!&
%eferences
Bealt0 Canada. +211%-. D0at is an ad!erse
reactionN Retrie!ed ;e*ruar$ 2)6 211'6 &rom
77 7 .0 c3s c .g c .c a ?d 0 p 3m p s ?m e d e & & ?a d ! e r s 3
r e a c t3 neg?inde/Ke.0tmlO1.
Bealt0 Canada. +211'-. Controlled su*stances
and precursor c0emicals. Retrie!ed
;e*ruar$
156 211'6 &rom 77 7 .0 c 3s c .g c .c a ?d 0 p 3m p s ?
su*stancontrol?inde/Ke.0tml.
Institute &or Sa&e (edication Practices Canada.
+211-. (edication reconciliation M In t0e
0ospital and *e$ond. Retrie!ed <anuar$ 2)6
211'6 &rom 77 7 .i s m p 3 c a n a d a .o r g.
Institute &or Sa&e (edication Practices
Canada. +211'-. #e&inition o& terms.
Retrie!ed
(arc0 %6 211'6 &rom 77 7 .i s m p 3 c a n a d a .o r g ?
de&initions.0tm: IS(P=s .ist o& 0ig0 alert
medications is a!aila*le at
77 7 .i s m p .o r g ?to o l s ? 0ig0alertmedications.pd&.
National Coordinating Council &or (edication
Error Reporting and Pre!ention. +211'-.
A*out medication errors. Retrie!ed <anuar$
146 211'6 &rom 77 7 .n c c m e r p .o r g.
Patton6 P. +211%-. -ando** communication
g&o%a& edition2 Sa*e transitions in patient care'
(ar*le0ead6 (A8 Aut0or.
Sa&er Bealt0care No7Q +211%-. Letting started
"it8 (edication reconciliation6 pre!ention o&
ad!erse drug e!ents. Retrie!ed (arc0 6 211'6
&rom 77 7 . s a &e r0 e a lt 0 c a re n o 7 .c a ?d e & a u lt .
asp/N&olderIdR'2ScontentIdR124.
!'
Suggested %eadings
Armitage6 L.6 S Pnapman6 B. +2113-. Ad!erse
e!ents in drug administration8 A literature
re!ie7. <ourna& o* #ursing Management6 11+2-6
1313141.
2arnsteiner6 <.B. +21156 (arc0-. (edication
reconciliation8 Trans&er o& medication
in&ormation across settings T "eeping it &ree
&rom error. American <ourna& o* #ursing6 +Suppl.-6
3133.
2ennett6 <.6 Barper3;emson6 ..A.6 Tone6 <.6 S
RaAmo0amed6 E. +211-. Impro!ing
medication administration s$stems8 An
e!aluation stud$. Canadian #urse6 112+'-6 353
3).
2ur"e6 P.L. +21156 (arc0-. E/ecuti!e summar$8
T0e state o& t0e science on sa&e medication
administration s$mposium. American <ourna&
o* #ursing6 +Suppl.-6 43).
C0e!alier6 2.A.(.6 Par"er6 #.S.6 (acPinnon6
N.<.6 S S"etris6 I. +211-. Nurses= perceptions o&
medication sa&et$ and medication reconciliation
practices. Canadian <ourna& o* #ursing eaders$ip6
1)+3-6 13
%2.
#a!id0iCar6 R.6 S .onser6 L. +2113-. Strategies to
decrease medication errors. -ea&t$ Care
Manager6
22+3-6 2113
21'.
Eisen0auer6 ..A.6 Burle$6 A.C.6 S #olan6 N.
+211%-. Nurses= reported t0in"ing during
medication administration. <ourna& o* #ursing
Sc$o&ars$ip6 3)+1-6 '23'%.
Bug0es6 R.6 S 5ritC6 E. +21156 (arc0-.
(edication errors8 D0$ t0e$ 0appen6 and 0o7
t0e$ can *e pre!ented. American <ourna& o*
#ursing6 +Suppl.-6
14324.
Po0n6 ..T.6 Corrigan6 <.(.6 S #onaldson6
(.S. +Eds.-. +2111-. (o err is $uman2 7ui&ding
a sa*er $ea&t$ s)stem. Das0ington6 #.C.8
National Academ$ Press.
(cInt$re6 ..<.6 S Coure$6 T.<. +211%-. Sa&e
medication administration. <ourna& o* #ursing
Care =uarter&)6 22+1-6 41342.
5ntario. 5&&ice o& t0e Auditor Leneral. +211%-.
.ong term care 0ome M (edication
management. In 200> Annua& Report6 232325.
Retrie!ed <anuar$ 246 211'6 &rom
77 7 .au d ito r.o n .c a ?e n ?
reportsKen?en1%?enK211%AR.pd&.
Rein0ard6 S.C.6 Eoung6 B.(.6 Pane6 R.A.6 S
Fuinn6 D.J. +211-. Nurse delegation o&
medication administration &or older adults in
assisted li!ing. #ursing 8ut&oo:6 54+2-6 %43
'1.
Tang6 ;.6 S0eu6 S.6 Eu6 S.6 Dei6 ..6 C0en6 C.
+211%-. Nurses relate t0e contri*uting &actors
in!ol!ed
in medication errors. <ourna& o* C&inica& #ursing6
1+3-6 44%345%.
!7
#ppendi( #$ )egislation o*erning
+ursing ,ractice
T0e Regu&ated -ea&t$ .ro*essions Act, 1//1
+RBPA-2' and #ursing Act, 1//1 set and guide t0e
practice
o& nursing. ,nder t0ese acts6 nurses are gi!en
t0e aut0orit$ to per&orm controlled acts and
pro!ide client care. T0e scope o& practice
statement &or nursing is8
($e practice o* nursing is t$e promotion o* $ea&t$
and t$e assessment o*, t$e provision o*, care *or, and
t$e treatment o*, $ea&t$ conditions %) supportive,
preventive, t$erapeutic, pa&&iative and re$a%i&itative
means in order to attain or maintain optima&
*unction'2)
Controlled acts are de&ined as acts t0at could
cause 0arm i& per&ormed *$ t0ose 70o do not 0a!e
t0e "no7ledge6 s"ill and Audgment to per&orm
t0em.
A regulated 0ealt0 pro&essional is aut0oriCed to
per&orm a portion or all o& t0e speci&ic controlled
acts t0at are appropriate &or 0is or 0er pro&ession=s
scope o& practice. 2ecause some scopes o& practice
o!erlap6 certain pro&essionals are aut0oriCed to
per&orm t0e same6 or parts o& t0e same6
controlled acts.
Nurses are aut0oriCed to per&orm &our
controlled acts 70en ordered or permitted *$
regulations under t0e #ursing Act8

per&orming a prescri*ed procedure *elo7 t0e
dermis

administering a su*stance *$ inAection or
in0alation

putting an instrument6 0and or &inger *e$ond a
*od$ ori&ice or arti&icial opening to t0e *od$
and

dispensing a drug.
NPs can per&orm t0e controlled acts aut0oriCed
to all nurses as 7ell as additional controlled
acts.31
Alt0oug0 administering medications *$ some
routes is not a controlled act +&or e/ample6 orall$
or topicall$-6 t0ere is a ris" o& 0arm in per&orming
an$ procedure i& it is not done competentl$.
Per&orming controlled acts represents onl$ a small
portion o& nursing practice. It is important to note
t0at8

controlled acts are not t0e onl$ procedures
t0at can cause 0arm:

0a!ing t0e aut0orit$ to per&orm a procedure does
not automaticall$ mean it is appropriate to do so:
and

eac0 nurse is accounta*le &or 0er or 0is decisions
and actions.
2'
;or more in&ormation6 re&er to t0e College=s R-.A2 Scope o* .ractice, Contro&&ed Acts Mode& re&erence document at
77 7 .c n o. o rg ?d o c s .
2)
;rom t0e #ursing Act, 1//1.
31
;or more in&ormation6 re&er to t0e College=s #urse .ractitioner practice document at 77 7 .c n o. o rg ?d o c s .
!8
+otes$
!3
+otes$
111 #a!enport Rd.
Toronto6 5N
(5R 3P1
77 7 .c n o. o rg
Tel.8 41 )2'31)11
Toll3&ree in 5ntario8 1 '11 3'%3552
;a/8 41 )2'351%
E3mail8 cn o I cn o m a il.o rg
<AN 2114
4111%
21133')

Medication: PR Ac T Ice Standar D

Diunggah oleh

Informasi Dokumen

Judul Asli

Hak Cipta

Format Tersedia

Bagikan dokumen Ini

Bagikan atau Tanam Dokumen

Opsi Berbagi

Apakah menurut Anda dokumen ini bermanfaat?

Apakah konten ini tidak pantas?

Hak Cipta:

Format Tersedia

Medication: PR Ac T Ice Standar D

Diunggah oleh

Hak Cipta:

Format Tersedia

PR AC T ICE STAndAR d

Anda mungkin juga menyukai