Which action is most important for the nurse to implement prior to the administration?

By Michelle Colleran Cook

Below, is testimony provided by MNA Member Michelle Colleran Cook on behalf of the MNA Congress on Nursing Practice at a hearing before the Joint Committee on Health Care, which concerned the issue of prevention of medication errors in health care settings.

My name is Michelle Colleran Cook. I am employed per diem in the Recovery Room of a Boston teaching hospital. I am also an instructor in a LPN School of Nursing and will graduate from Regis College with a Masters Degree in Nursing Administration in May 1999.

Recently, there have been national and local incidences of nurse errors in medication administration that have resulted in negative patient outcomes. Nurses, because they administer the drugs directly to patients, are the last links in the safe medication administration chain. Complicating matters is the increased acuity of the patients they serve, and the decrease in the resources available to nurses to ensure safe practice. Because of the climate of health care today, nurses need to become cognizant of their practice’s vulnerability and vigilant about protecting their practice.

All nurses have been taught the five rights of medication administration. They were drilled into our conscious in nursing school until they became part of our unconscious behavior as practicing nurses. The right patient, the right drug, the right dose, the right route and the right time form the foundation from which nurses practice safely when administrating medications to our patients in all health care settings.

Just as nurses know the five rights of medication administration, they should also know what rights they have when administering medications. These "Six Rights for Nurses Administering Medications" will hopefully guide nurses as they continue to care for patients despite these turbulent times.

1. THE RIGHT TO A COMPLETE AND CLEARLY WRITTEN ORDER
   You, as the nurse, have the right to demand that an order be complete and clearly written. You have the right to require that the drug, dose, route and frequency be written by the physician. All of these components must be present for a physician order to be considered complete.

   It is no longer good practice to accept orders when the dosage is written as "1 tablet." A complete order includes specific numerical dosages. For example, Acetaminophen 2 tablets po prn should now be written as Acetaminophen 650 mg. po prn. It is also no longer safe practice to administer vague orders such as "Laxative of choice." Drugs ordered need to be specific and the dose explicit.

   Verbal orders should never be taken and telephone orders should only be taken if the physician is not physically present. Nurses cognitively know this but often in the interest of saving time may be tempted not to practice it. Nurses who write orders for physicians are placing their license and their patients at risk.

   Orders should be legibly written. The Massachusetts Hospital Coalition recommends physicians use computers to directly order medications. However, such costly systems may take years to implement. Until that occurs, nurses need to remember that it is their duty and right to question physician orders that are illegible. Cefoxitan and Cefotetan may look alike when hand written but confusing one drug for the other results in the patient receiving the wrong medication.

2. THE RIGHT TO HAVE THE CORRECT DRUG ROUTE AND DOSE DISPENSED
   Nurses administer medications but it is the pharmacy’s duty to dispense medications correctly. Pharmacies process and distribute an incredible volume of medications daily. Pharmacists, like nurses, are susceptible to the pressures of time and patient needs and can dispense the incorrect drug or dose. The nurse who discovers the error then notifies the pharmacy of this oversight. If all goes well, pharmacy will deliver the medication promptly to the nursing unit. In this case the system works well.

   Sometimes, the nurse is told there is no one from pharmacy available to deliver the medication. The nurse is given the option of either waiting for her patient’s medication, coming to the pharmacy herself to get the medication, or finding someone else to do so. Such errors of dispensing eat away at nursing time and energy. They pull nurses away from caring for their patients. They place patients in jeopardy of not receiving the drug on time. Additionally, unnecessary stress is placed on the nurse who is struggling just trying to gather the drugs necessary to care for her patient. This hurried atmosphere places the nurse in a position that she may make a medication error in her haste.

   Another recommendation from the Massachusetts Hospital Coalition states that a unit dose system of medication can decrease the number of medication errors. Many hospitals have adopted this system of medication administration. However, scenarios such as the one above coupled with the available technology of automated medication administration systems such as the Pixis has placed nurses in a potentially unsafe situation. First developed to dispense narcotics, these automated systems can be programmed to allow nurses access to many other types of medications. Now, in an attempt to address missing or incorrectly dispensed medications, and decrease the turnaround time of getting the correct drug to the patient, they are being used widely in acute care hospitals as quasi satellite pharmacies.

   At first, they may be seen by the nurse as a welcome relief from the frustration of not having medications readily available to administer. But they must be used with caution. The nurse enters patient data into the automated medication dispenser; the machine opens the correct drawer and directs the nurse to the correct drug compartment where the medication can be found. But in some systems, when the Pixis drawer opens, the nurse has access to many drugs. In this situation, the unit dose safeguard is eliminated and therefore increases the chances of the nurse selecting the incorrect drug or dose and administering it to their patient.
   
   

3. THE RIGHT TO HAVE ACCESS TO INFORMATION
   Nurses have the right to expect updated and easily accessible drug information. This means that the hospital formulary, a Physicians Desk Reference and a current nursing drug reference book need to be available to nurses who administer medications.

   Nurses have the right to ask questions about the drugs that they are to administer to their patients. Pharmacists are the drug experts and nurses should have access to a pharmacist no matter what time of day. Hospitals need to have a pharmacist available on a 24-hour basis. More dialogue between nurses and pharmacists can only improves patient outcomes and decreases the chances of medication errors occurring.

   As pharmacology and technology advances, patients should be able to expect a nurse who is continually updated on new medications and the ways they are delivered. Good nursing practice dictates that nurses are never to administer a drug they are unfamiliar with. If a patient is to receive a drug that is too new to be in the usual reference books, nurses should insist that information be provided to them. And they should not administer that drug until they have enough information to be comfortable doing so.

4. THE RIGHT TO HAVE POLICIES ON MEDICATION ADMINISTRATION
   It is the responsibility of health care administration to provide the structure necessary for nurses to administer medications safely. Nursing practice is governed by the Board of Regulation in Nursing but nursing policies are what guide nursing practice at that health care entity. Policies often protect the nurse from litigation should an error occur. Conversely, not following policy or administrating medication without a policy will put the nurse at risk not only for litigation but can result in license suspension or forfeit.

   New medications enter the market daily. Research discovers new uses and ways to administer old medications. Administrators are not practitioners; they need to be updated by staff on new trends in medication administration. Subsequently, nursing administrators need to initiate and develop systems that promote safe medication administration. Nursing administrators have to insist that nurses of their organization be allowed to deliver patient care in the safest environment possible.

5. THE RIGHT TO ADMINSTER MEDICATIONS SAFELY AND TO IDENTIFY PROBLEMS IN THE SYSTEM
   Nurses are the experts on what impacts safe medication administration. Shaping systems and creating solution for safe medication administration should include those who actually do the work of administering medications.

   Nurses have the right to speak up when they see situations that can potentially result in medication errors. System glitches that place the patient at risk need to be addressed and corrected. Repeated breaks in the system can only be fixed if at first it is identified. Just as you would advocate for a patient, you should advocate for your ability to practice in a safe setting. Your input is of tremendous value to all.
   

6. THE RIGHT TO STOP, THINK, AND BE VIGILANT WHEN ADMINISTERING MEDICATIONS
   Nurses know medication administration is serious business. Often nurses are caught up in the hustle and hassle of a busy work place. With decreases in licensed staff and organizational support and increasing patient acuity, nurses still manage to do it all. But we are human, we are all fallible. There is only so much sensory input a person can handle, only so many questions one can process at a time.

   When we find our minds so overloaded we are unable to think. We have the right to stop and do so. When we see orders that somehow do not make sense even if we can not identify why this order seems odd, we have the right to stop and find out why. When we are about to administer a drug we are unfamiliar with, we have the right to stop and find out about this new drug. If we need to ask other nurses or professionals about this drug or check the policy for giving this drug, we need to stop and do so. Will this take additional time? Yes. Will others think we are stupid? Maybe. Will some people become irritated with us? Probably.

   But, if stopping to think before administering medications to your patient seems like an inconvenience, ask yourself this question: Would I rather be known as the nurse who is slow giving her meds, or the nurse who did her patient harm?

   Unsafe medication administration situations will be lessened as long as nurses continue to recognize problems and steadfastly protect their patients and their practice. Nurses need to take the time to identify and address sloppiness in their work place and in other professionals. Confrontation is not easy for nurses. Nurses would rather fix it themselves. This system only perpetuates others’ poor practice and allows the nurse to assume responsibility for all. This is not our job. Our allegiance is to our patients.