Rights of Medication Administration

1. Right patient

 Check the name on the order and the patient.

 Use 2 identifiers.
 Ask patient to identify himself/herself.
 When available, use technology (for example, bar-code system).
2. Right medication

 Check the medication label.

 Check the order.
3. Right dose

 Check the order.

 Confirm appropriateness of the dose using a current drug reference.
 If necessary, calculate the dose and have another nurse calculate the dose as well.
4. Right route

 Again, check the order and appropriateness of the route ordered.

 Confirm that the patient can take or receive the medication by the ordered route.
5. Right time

 Check the frequency of the ordered medication.

 Double-check that you are giving the ordered dose at the correct time.
 Confirm when the last dose was given.
6. Right documentation

 Document administration AFTER giving the ordered medication.

 Chart the time, route, and any other specific information as necessary. For example, the site of an
injection or any laboratory value or vital sign that needed to be checked before giving the drug.
7. Right reason

 Confirm the rationale for the ordered medication. What is the patient’s history? Why is he/she taking
this medication?
 Revisit the reasons for long-term medication use.
8. Right response

 Make sure that the drug led to the desired effect. If an antihypertensive was given, has his/her blood
pressure improved? Does the patient verbalize improvement in depression while on an antidepressant?
 Be sure to document your monitoring of the patient and any other nursing interventions that are
applicable.
Reference: Nursing2012 Drug Handbook. (2012). Lippincott Williams & Wilkins: Philadelphia, Pennsylvania.

The “five rights” of drug administration

Nurses are legally responsible for applying and ensuring the “five rights”ofdrug
administration.To helpachieve these goals,use the followingstrategies:

●Right patient. Always confirm thepatient’s identity before administeringa

drug.Check his ID bracelet and ask him to state his name;then confirm
hisname,age,and allergies.The JointCommissionrequires the use
oftwoidentifiers,such as the patient number,his telephone number,or his Social
Security number.Ideally,match the ordered treatment to the patient usinghis name
bracelet and ID number,comparing it to the drug order tran-scribed in the
medication administra-tion record (MAR).Be especially cau-tious ifyour patient is
confused,becausehe may answer to the wrong name.

● Right drug. Giving the wrong drug isthe most common type
ofmedicationerror.It typically results from such fac-tors as look-alike and sound-
alikedrug names,similar drug labels andpackaging,and poor communication.Never
try to decipher an illegible drugorder,and never give a drug ifyou’renot sure why it
was prescribed.To make sure you give the right drug,match the drug label against
the orderin the MAR three times—once when you remove the container from the
patient’s drug drawer,again before youremove the dose from the container
and,finally,before you return the containerto the drawer or discard it.Never give
adrug from a container that is unlabeledor has an unreadable label,and
neverborrow a drug from another patient.In an effort to reduce “wrong-drug”and
other medication errors,many hospitals have adopted newer technolo-gies,such as
bar-code point-of-caredrug administration systems.When using such a system,keep
in mind thatit must be monitored regularly forproblems and that staffmembers
mustreceive adequate training in its use.

● Right dosage. Check the dosageagainst the order in the MAR.Deter-mine ifit’s
appropriate based on thepatient’s age,size,vital signs,and condition.Ifthe dose
needs to bemeasured,use appropriate equip-ment—for instance,an oral
syringerather than a parenteral syringe tomeasure an oral liquid drug.Be on
thelookout for misinterpretation of orders,incorrect calculation ofvol-umes and
infusion rates,misreading of decimal points,and labeling errors.When
administering a drug that cancause serious harm ifgiven incorrectly (such as
I.V.insulin or heparin) orwhen giving an infusion to a pediatricpatient,always
double-check thedosage and pump settings;then verify these with a colleague.

● Right time.The most common vio-lation ofthe five rights ofdrug admin-istration
is giving a drug at the wrongtime.For as long as many nurses can remember,the
right time
has been defined as up to 30 minutes before orafter the scheduled
administrationtime.In 2008,the Centers for Medicare& Medicaid Services (CMS)
made this30-minute rule part oftheir Regula-tions and Interpretive Guidance for
Hospitals,which spells out the condi-tions ofparticipation for receivingMedicare
and Medicaid payments.In a 2010 survey by the Institute forSafe Medication
Practices (ISMP),nurses described the CMS rule as unsafe,impossible to
follow,andlargely unnecessary.The shortcuts and workaroundsnurses used in their
attempts to com-ply were eye-opening,and in Novem-ber of2011,recognizing the
rule wasno longer the standard ofpractice,theCMS removed it.The CMS now
requires hospitals to develop their owndrug administration policies and procedures
based on established stan-dards ofpractice and directs hospitalsto consider the
nature ofeach pre-scribed drug and the relevant patientand clinical
considerations.In responseto this new direction,we have included Guidelines for
Timely Administration of Medication in the “Safe Drug Adminis-
tration”insert,page S-8.

● Right route. Many drugs can be given by multiple routes.The pre-scriber chooses
the route based onsuch factors as the patient’s conditionand the desired onset
ofaction.In turn,the prescribed dosage is based on theadministration
route.Generally,oraldosages ofa given drug are greater thaninjected dosages,so a
serious overdosemay occur ifa dose intended for oraladministration is given by
injection instead.Also,keep in mind that most seriouserror outcomes occur when
the I.V.route is used.(Only a few high-risk drugs,such as
warfarin,somechemotherapy drugs,and a few seda-tives,are given orally.)Finally,be
aware that some drugs ordrug forms (for instance,sustained-release tablets or
capsules) should neverbe crushed.Crushing can alter thedosage delivered,causing
the patient toreceive a bolus ofa drug that’s meant tobe released slowly over
several hours.

Additional nursing responsibilities

Ofcourse,nursing responsibilitiesdon’t stop with these five rights.Docu-

mentation,monitoring,and patientteaching are also crucial.After giving the
drug,always docu-ment that it was administered.Docu-ment the dose as soon as it
is given—never before.When documenting,use only accepted abbreviations
andavoid those that are used rarely or thatcould be misread or misinterpreted.
Ifthe patient refuses a medication,report this to the prescriber immedi-ately.Then
record his refusal on boththe MAR and the patient’s record;include your
initials,full name,andcredentials on both records.During the course ofdrug
therapy,monitor the patient to determine drugefficacy and detect signs and
symptomsofan adverse reaction or interaction.Teach the patient the name ofthe
pre-scribed drug,its dosage,administra-tion route,dosing frequency and times,and
duration oftherapy.Make sure heknows how to recognize the drug’stherapeutic
effects,adverse reactions,and interactions with other drugs,foods,herbs,and
behaviors.Be aware that the Joint Commis-sion’s 2009 National Patient Safety
Goals mandate that health care facilities(and by extension,nurses)
implementapplicable practices that will improveor bring about the following:

● better communication among caregivers

● creation of a standardized list of abbreviations,symbols,and dose designations

not to be used

● improved safety of drug use

● verification ofall labels both verbally and visually by two qualified individu-
als,ifthe person preparing the drug isnot the same person who will adminis-ter it

● accurate and complete medicationreconciliation across the continuum of care

● reduction ofthe risk ofpatient harm stemming from falls caused by medications

● active involvement ofpatients intheir own care (including teachingthem about

their drugs)
Nursing Drug Handbook., 2013. McGraw Hill Education LLC.
INTRAVENOUS SOLUTION BAGS ARE DESIGNED FOR SINGLE USE ONLY

Health professionals are reminded that intravenous (IV) solution bags are designed
for single use only and there are no circumstances where they should be
reconnected (re-spiked) after first use.

Re-spiking is the process of inserting a giving set into an already used or

previously spiked IV bag.

IV fluids are administered via a plastic IV solution bag which collapses on itself as
it empties.

When a bag is disconnected by removing the giving set spike, air can enter the bag.
If it is then reconnected to an IV line, air can potentially enter the patient’s vein
and cause an air embolism. For this reason, partially used IV bags must never be
re-spiked.

All IV bags are designed for single use only - for use in one patient and on one
occasion only. All registered large volume injections, including IV bags, are
required to have this warning (or words to the same effect) clearly displayed on the
labelling.

The TGA has received one report of air embolism associated with an IV bag being
re-spiked, which resulted in the death of a child. While this is the only report the
TGA has received, the risks to patients are extremely serious and it is possible this
issue has been under-reported.

In addition to the potential risk of introducing an air embolus, re-spiking can also
result in contamination of the fluid, which may lead to infection and bacteraemia.

Additional safety considerations

In addition to never re-spiking IV bags, health professionals are reminded of the

risks of pressurising IV bags to increase flow rates in emergency situations.

If residual air in the bag or infusion set is not removed first, pressurised
administration can force the air into the patient’s vein and result in an air
embolism.
Always ensure that the administration set/line is correctly primed and void of all
air before connecting to the patient.

As with any therapeutic product, IV bags should always be used in strict

accordance with the instructions for using the products.

'Use in one patient on one occasion only.'

Medicine Shortages Information

The Medicine Shortages Information Initiative provides information about a

temporary or permanent disruption to the supply of a prescription medicine. Health
professionals and consumers are invited to subscribe to the Medicine Shortages
email list to receive an alert when there is new or updated medicine shortage
information reported to the TGA.

IMPROVED LABELLING FOR ALLERGENS

Health professionals are advised that the TGA is implementing new rules for
medicine labels to include improved information about potential allergens.

While certain allergens, such as peanuts and gluten, were already required on
medicine labels, the new rules include a longer list of substances that must be
declared. The additional substances include crustacea, fish, eggs, soya, milk and
tree nuts.

Additionally, for the first time prescription medicines are also required to declare
potential allergens on their labels, or include a statement directing consumers to the
Consumer Medicine Information leaflet for further information.

In some circumstances, allergens do not need to be declared on the medicine label.

For example, some substances may only cause a reaction if they are administered
orally and therefore don't have to be declared if the medicine is only for topical
use, and some substances are only declared if there is a certain amount in the
product. Further details can be found in Schedule 1 to Therapeutic Goods Order
No. 91 - Standard for labels of prescription and related medicines (link is external)
and Therapeutic Goods Order No. 92 - Standard for labels of non-prescription
medicines (link is external)

Medicines Safety Update, Volume 8 Number 3, June 2017. Austrailain

Government. Department of Health