Constant System Analysis
Ensuring a "Double Check" |
Involves the physician, nurse, nursing unit, and pharmacy department |
Requires educating the patient |
Includes the entire "system" of medication administration |
System: Ordering, Dispensing, Preparing, Administering, Documenting |
Medication Administration 7 Rights
The Right... |
Dosage |
Confirm that the dose is appropriate for the patient's age, size, lab results, vitals, and check the prescribed dose against what it is stock. Recheck all math calculations and be mindful of decimal points and zeros (ex. 2.0mg can be seem as 20mg, so 2mg is more acceptable). |
Drug |
Nurses are responsible for checking all medication orders and prescriptions. Do not pre-pour medications or sign off for other nurses. Check the medication label against the order three times. Check the right drug, drug name, and drug expiry date |
Time |
30 minute rule. Also consider the drug dose schedule, is it acceptable for the patient to adhere to? The standard is to use military time. Avoid using abbreviations (ex.prn) |
Route |
Never assume the route, a drug order must contain the route. Ask. |
Patient |
Always ask the patient for their name, check the wristband. Babies and mothers have wristbands with identical numbers. The patient's room number is not an acceptable identifier. |
Reason |
self explanatory |
Documentation |
date and time of medication administration, name of medication, dose, route, and site of administration. Documentation must also reflect any improvement in the patient's condition, symptoms, or disease process as well as whether there has been no change or a lack of improvement. Report also if drug is not administered and why and what actions have been taken. |
Med.Administration 6 Elements of Drug Order
Patient's Name |
Name, Address, Personal Health Number or ID |
Date order is written |
. |
Name of Medication |
. |
Dosage |
Amount, Frequency, Number of doses |
Route of Administration |
Signature of prescriber |
. |
♦ Other essential components
- Rx Symbol
- Dispensing instructions for the pharmacist
- Directions for administration to be given to the patient
- Number of refills
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