Administration of Medications--Preparing to Administer Medications
Objectives
Identify ways in which drugs are supplied to the nursing home.
Describe unit dose and multiple dose packaging of drugs.
Explain proper storage of medicines in the medication room, medication cart and resident's bedroom.
Describe proper storage of controlled drugs.
Identify proper methods to store equipment and supplies related to the administration of medications.
Describe a method to verify medications orders.
Explain the responsibility of the medication aide in questioning medication orders, including what to do if the order is not clear or legible.
Discuss methods for ordering drugs from the pharmacy.
Identify the basic components of a medication order.
Transcribe orders from the ordering practitioner for medications/treatments under the supervision of a licensed nurse.
List times on the clock using "military time."
Communicate medications administered and the resident's responses to medications to the licensed nurse.
Explain how a Kardex, medication cards, and a Medication Administration Record (MAR) are used to communicate medication orders. Demonstrate how to document administration of a medication.
Explain how controlled substances can be accounted for at the beginning of each shift and why this is done. Note: this is subject to each facility's own policy and procedure for controlled substances.
Identify and demonstrate specific techniques to administer medications using the "Five Rights" of medication administration including techniques for specific forms of medications.
Identify and demonstrate ways to prevent the transfer of infection.
List three ways to identify the resident.
Identify potential sources for errors.
Identify drugs which may require special controls or record keeping, and name the controls which are used.
Medication Supply
Please review chapter 5 in your textbook
Medications may be supplied in several ways. All medications must be clearly labeled. If labels are loose or illegible the pharmacist should be notified.
Prescription medications are supplied to the facility by a licensed pharmacy. Over the counter medications (OTC) can be brought to the facility and used as long as the requirements are followed:
KAR 28-39-156(b)(3)
KAR 28-39-282(e)(3)
KAR 28-39-247(e)(3)
KAR 28-39-436(e)(3)
Click the link to read KDADS regulations Click Here
The container must be unopened and in the original package. A licensed nurse or pharmacist shall place the resident's full name on the package.
Drug packaging
Single Unit dose-each dose is individually packaged and labeled.
Each single-dose package contains the proper dose for one administration.
Each dose is labeled with the drug name, strength, expiration date, and in some instances, the resident's name.
Requires little handling and usually there is no special preparation before administering the drug to the resident.
This method of unit dose is usually found in hospital-based units. It is seldom used in other long term care settings, except for emergency drugs.
Multiple Unit Dose-each dose is individually packaged on a card which can contain the doses of a specific drug or drugs for a week or a month. The term commonly used for this method of packaging is bubble pack.
Multiple doses of a medication are placed in plastic "bubbles" affixed in a cardboard container.
The label on each bubble pack card must contain the following information:
Resident's full name
Name of prescribing practitioner
Prescription number
Date prescription was filled
Directions for administration including dosage and time frame for administration for each drug
Brand name or generic name of drug(s)
Any precautions or special instruction
The label on the bubble pack should match the physician's order and the information on the Medication Administration Record (MAR).
Unused doses still in the packaging may be returned to the pharmacy for credit. Unused doses of controlled drugs cannot be returned to a pharmacy. This is a Drug Enforcement Agency (DEA) requirement.
This type of packaging decreases opportunity for error in administration.
Multiple dose packaging-this system is used when an individual purchases a prescription at a pharmacy or drugs are provided by the Veteran's Administration. The container or tube must be labeled with the same information listed above for multiple unit dose packaging.
These drugs require more handling.
More chance for error.
Unused doses cannot be returned to the pharmacy for credit.
Stock Supply-bottles of over the counter medications. See KAR 28-39156(b)(3) for proper handling of these medications.
The proper bottle and dose must be selected by the person administering the medications.
Has the greatest potential for error.
Nursing facilities which participate in the Medicaid program are required to provide selected stock medications to Medicaid recipients
Medication Storage-medications can be stored in several ways
Medication cart
Frequently used for storage of unit dose medications.
Doors or drawers must be kept locked when the nurse or medication aide is not within eyesight of cart.
Cart can be wheeled from room to room.
Sections in the drawers may be divided to hold routine doses and PRN medications.
A special locked drawer holds the controlled drugs-Schedule II, ill, IV. It is re-Iocked immediately after taking a dose out of the drawer.
When controlled drugs are removed from the controlled drug locker, the nurse or medication aide administering the drug must complete the documentation required by the facility. Each facility must have a system for accounting for the receipt and disposition of controlled drugs. It is the responsibility of each nurse or medication aide to report any misuse of controlled drugs to the facility administrator or operator.
Some controlled drugs can be placed in multiple unit dose systems. This is usually done with drugs such as Tylenol #3 and Valium. The number of drugs is limited and doses administered can be accounted for. Controlled drugs such as Lortabs, Dilaudid and Morphine are usually stored in the locked controlled drug drawer in a cart or in the medication room. A documentation system must be used to account for the number of drugs received from the pharmacy for each resident. A record is maintained of when the drugs are removed for administration to the resident. These records should correlate with the Medication Administration Record.
A folder or notebook on top of the cart holds the Medication Administration Records (MAR) for each resident
Medication room
Storage for stock drugs and supplies.
Only personnel who are authorized to administer medications may have access to the keys to the medication room, medication cart or medication storage areas. In nursing facilities, the licensed administrator may have access to the medication room keys.
This room is usually located near the nurse's station in nursing facilities. Assisted living and other residential-type facilities and adult day care are required to have an area where drugs can be safely stored. See regulations for the type of facility.
Medication rooms contain a sink, a refrigerator, and cabinets for storage of medications.
The medication room in a nursing facility must contain a locked cabinet for controlled substances.
Stock drugs-shared by many patients-are stored in a specific drawer of the medicine cart or in a specific cabinet in a nursing facility. Stock supply drugs can be in bottles for individual residents or in bottles from which doses are dispensed for several different residents. Aspirin, Tylenol, milk of magnesia and stool softeners are examples of stock medications.
An emergency drug kit may be maintained in all types of adult care homes.
The emergency drug kit must be in compliance with pharmacy regulations found at KAR 68-7-IO(d). Medication aides must have permission from a licensed nurse to administer medications from the emergency drug kit. The facility should have a written policy and procedure for use of the emergency drug kit.
All topical medication must be in a separate cabinet, box or drawer from the oral medications.
Drugs commonly stored in a refrigerator include insulin, suspension of antibiotics and suppositories. Only food used for administration of medications or tube feeding formulas may be stored in the medication refrigerator.
The temperature in the medication room must not exceed 85° F. Heat can destroy the effectiveness of drugs.
Cabinets in the medicine room should be closed when not in use. Many drugs break down chemically when exposed to light. These drugs are usually packaged in brown or colored bottles.
To prevent medication errors, keep the medication room clean and tidy at all times.
Medication tray
A way to carry medications about the facility.
May be flat, with medicine cups placed next to small med cards.
May be molded with recesses for holding cups and cards.
If the medication tray is placed on a surface other than in the medication room, the tray must be washed with soap and water and dried before returning it to the medication room.
All medications must be identified to point of administration. Medications removed from a package or container with the prescription label, a medication card must be used which contains the resident's name, the name of the drug, the route of administration, special instructions for administration and time of administration. This card must be checked against the MAR before administering the medication to a resident.
Disposing of unused drugs
Unused doses of medications are never returned to the stock supply bottles or multiple dose containers when refused by the resident.
Each facility is required to have policies and procedures for disposal of discontinued medications or medications not used by a resident following discharge. Follow facility regulations.
Leftover drugs in bottles or cards of unused unit dose medications must be placed in a safe area until they are disposed or returned to a pharmacy according to facility policy. In nursing facilities, disposal of unused medications is performed by a pharmacist. In other facilities, disposal of unused medications is performed according to facility policy.
Disposal of controlled substances must be witnessed and co-signed by nurse or a pharmacist and one other person. The second person could be a medication aide.
Checking the medication order
Medication orders are recorded on the resident's chart by an ordering practitioner who may be a physician, advanced registered nurse practitioner (ARNP), a physician's assistant (PA), or dentist.
A licensed nurse may receive a verbal order from a physician, ARNP or PA. The verbal order must be recorded by the nurse receiving the order in duplicate. The duplicate copy is placed on the resident's clinical record. The original copy of the verbal order is sent to the ordering practitioner for signature, returned to the facility and placed on the resident's clinical record. The duplicate copy of the verbal order is then removed from the record.
A medication aide may not take a verbal order from a physician, ARNP or PA. In facilities without a licensed nurse on duty 24 hours a day, seven days a week, the medication aide must contact the licensed nurse on call. The licensed nurse will contact the physician, ARNP or PA, obtain the order, record the order and give the medication aide verbal or written instructions for administration of the medication. The medication aide must record the phone call to the nurse and the directions provided by the nurse in the resident's clinical record. The nurse must also record the directions given to the medication aide in the resident's clinical record on the next visit to the facility.
Verbal orders must be signed by the ordering practitioner and returned to the facility within seven days of the date of the order.
Follow regulations:
KAR 28-39-156(b)(4)
KAR 28-39-436(e)(4)
KAR 28-39-247(e)(4)
KAR 28-39-282(e)(4)
Medication orders should -
Be recorded on resident's clinical record by the ordering practitioner, or recorded on a prescription form, or on a verbal order form.
Include date of the order-including time of the order. Some physicians and facilities use "military time."
Name of the drug. May state that a generic equivalent may be used.
Identify the dosage-including the amount of the drug and the strength, when and how often, if the order is for a limited number of doses or to be used as a PRN (whenever necessary) basis.
Identify the route of administration.
Reflect the Physician's, ARNP's, PA's, or dentist's, signature, or the nurse's signature who took the verbal order.
Specify the number of refills--especially important if a controlled drug.
Describe administration instructions.
Quantify the number oftablets, etc. to dispense.
Contain the ordering practitioner's DEA number if a controlled substance.
Specify the time of day for administration of a drug.
Antibiotics are usually ordered for a specific number of doses.
Automatic stop orders. Nursing facilities are required to have a stop order policy
for drugs. Drugs can be given for a period of time without a renewal order from the
ordering practitioner. A licensed nurse should contact the practitioner a few days
before a stop order on a medication would be implemented to ensure that the
practitioner wants the drug discontinued. The purpose of automatic stop orders is
to require facility staff to review a resident's drug regimen periodically. Automatic
stop orders are usually for more than 60 days up to 6 months. Other licensed
facilities are not required to have an automatic stop order policy.
Standing orders may be used for over the counter medications and treatments given
for specific situations. Regulation Interpretation 93-18 provides guidance for the
use of standing orders. See appendix. Standing orders must be signed by the
resident's attending physician before a medication can be administered. A copy of
the signed standing order must be on the resident's clinical record. A licensed nurse
must be involved in the decision to implement a standing order. A medication aide
cannot make the decision to implement a standing order.
PRN-to be given whenever necessary. Ordering practitioners may write a PRN
order for a medication or treatment. The order must contain specific parameters for
implementing the order. The order must include the name of the drug, the dosage
and specific reasons for administration. An example would be: "Tylenol #3 every 6
hours for pain at incision site." If the resident requests medication for a headache,
the Tylenol #3 should not be administered as the site of the pain is not covered by
the order. Medication aides may not administer PRN medications which require an
assessment. For example, a medication aide could not administer a PRN drug order
for Ativan PRN for agitation. Standard of practice is for a nurse to assess the
resident and decide the best method for reducing the resident's agitation. The
medication aide would need to call a nurse for instructions.
STATorders-medication is to be administered as soon as possible. Stat orders must be implemented under the direction of a licensed nurse. Source of medications for stat orders is usually the emergency drug kit.
Questioning a medication order
It is your right and your duty to check any order with a nurse when the prescription label is unreadable or you are unsure of the order.
Never administer a drug when the directions on the MAR and/or medication package are not clear. Ask a licensed nurse for assistance.
Ordering drugs from the pharmacy
Each facility will have a policy and procedure for ordering medications from a pharmacy.
If the drug order is sent directly to the facility, a licensed nurse must review the order and transmit the order to the pharmacy.
Medication aides may reorder medications if the facility allows.
The licensed nurse is responsible for notifying a pharmacy of a new order.
Some facilities prefer to fax the original physician/ARNP/PA/dentist order to the pharmacy. Re-faxing a faxed order from a physician can be problematic, as the order may not be legible. Decimal points may fade. This can cause a major error in dispensing and administration of some medications. The safest method is to send the pharmacy a carbon copy of the physician's original written order. There is no recopying and less chance for error.
Pharmacy delivery schedules will vary. Be aware of the delivery policies of the pharmacies serving the facility. Out of town pharmacies will have difficulty delivering stat medications. Usually an arrangement is made with a local pharmacy or hospital to provide stat or other drugs needed before the next scheduled delivery. The licensed nurse managing the drug order should be aware of the policy.
Routine refills are done about every two weeks or monthly in nursing homes which use a unit dose system.
The facility should have a policy and procedure for reordering medications. Most facilities keep a record of pharmacy reorders to avoid duplication of orders.
Medication documentation system
The facility is required to ensure that each drug and treatment is recorded when administered according to the physician/ARNP/PA/dentist's order. Most facilities use a document called a Medication Administration Record. A procedure for completing the MAR should be available. It is the responsibility of the medication aide to review this policy and ask for assistance from a licensed nurse.
The MAR is a legal document and must be completed accurately. All medications and treatments must be recorded during the medication aide's time on duty. If the medication aide fails to record a medication or treatment, a late entry must be entered in the resident's clinical record.
Medication cards-used less often today because of the unit dose system. Medications cards may be needed when stock medications or medications in multiple dose packaging are used.
Orders must be copied from the physician's order sheet and MAR onto small cards for each medication.
Cards must be checked for accuracy before each dose, by comparing them to the Kardex or the MAR.
Medication cards must be legible. If a card is damaged so that it is difficult to read, the card must be recopied. The person recopying the card must use the original ordering practitioner's order and MAR as the source for the information recorded on the medication card. A medication aide may perform this function.
Medication Administration Record (MAR) The MAR provides a method for
recording the administration of medications to residents by facility by licensed nurses
and medication aides. Review pages 119 – 120 in your textbook. See the picture of a MAR.
The MAR must contain the name of the resident and other information, such as room, as defined by facility policy.
Each medication order is recorded as written by the physician, ARNP or PA.
The name of the medication, dose, time medication is to be administered, and any specific instructions related to administration.
The pharmacist may add additional information to the label for the medication container. An example would be the brand name along with the generic name of the drug dispensed. There may be precautions such as administering the drug with food, before meals, avoiding dairy products, etc. This information should be recorded on the MAR.
A licensed nurse may add nursing instructions, when appropriate.
The MAR will have space to record all medications administered for a week, two weeks, or a month.
Medications given on a routine schedule are usually listed first on the MAR with PRN medications below. Each facility should have a written policy for recording information on the MAR.
There are three acceptable methods for recording the administration of medications on a MAR when a unit dose system is used.
First method:
Remove the unit dose package or card from the storage unit, check the information on the package or card with the information on the MAR.
Place the unit dose package(s) in a medication cup or punch out each medication from the unit dose card and place in a medication cup. Several medications maybe placed in the medication cup which are to be administered at the same time.
Take the medication to the resident and administer as ordered. The medication aide must observe the resident swallow the medication or apply the medication as ordered. Never, under any circumstances, leave a medication cup with a resident without observing the resident taking or applying the medication.
Return to the location of the MAR and place an identifying initial in the boxes related to the drugs administered and time administered.
Second method:
Same as the first, except the medication aide sets up the medications for one resident and initials the MAR before administration. If the resident does not take the medication, the medication aide circles their initial and records on the back of the MAR or in the interdisciplinary notes the reason the resident did not take the medication.
Third method:
The medication aide sets up the medications for a group of residents. Medication cards are available for each different medication. Medication is placed in a medication cup and the appropriate medication cards are placed on the tray in a slot or under the cup. Administration of the medications is recorded after the medications are administered, using the medication cards as the resource for recording.
MARs for the current time period are usually kept in a notebook on top of the medication cart or in the medication room or area. The MAR contains confidential clinical information. Staff who do not administer medications should not have access to the MAR.
Medications to be administered for a limited time or subject to automatic stop orders should be identified on the MAR according to a written facility policy.
After administering a PRN medication, the medication aide will record the dose on the MAR. The medication aide will also record the reason the medication was administered and later record the resident's response to the medication. In some facilities this documentation will be placed on the back of the MAR, and in other facilities the documentation will be placed in interdisciplinary progress notes. Follow documentation policies for the facility.
Medication preparation or "set up"- general guidelines
The medication aide must know the expected effect of each medication before administration. Each facility should have a nursing drug manual available to staff. If the medication aide is unfamiliar with the medication and cannot find it in a resource, he or she should contact a licensed nurse for that information. The nurse may contact the pharmacist or physician for information. A Physician's Desk Reference does not include all the information necessary for safe administration of medications.
Clear your mind of all distractions, concentrate, do not allow people to talk with you while you are setting up medications.
Prevent transfer of infection.
Wash your hands before setting up drugs. If, during administration of medications, you touch a resident's mucous membrane or an area which contains infected material, the medication aide must immediately wash his/her hands again. It is not necessary to wash hands between each resident.
Avoid touching the medication. Medications can be punched out of unit dose systems into a medication cup without touching. When applying topical medications, handwashing should be done before and after administration. In some facilities, disposable gloves will be used when administering topical medications. Hands must be washed after the removal of gloves. For example, if two residents are to have eye drops administered, the medication aide should wash hands and don gloves before instilling eye drops in the first resident's eyes. The gloves would be removed and placed in a waste basket or container and hands washed again. A second pair of gloves should then be donned, eye drops instilled in the second resident's eye, gloves removed and hands washed.
Clean the medication tray and the top of the medication cart after each use.
Keep the medication tray in a clean area while passing medication.
Do not leave medications on the top of an unattended medication cart.
The environment should promote safety.
There should be plenty of lighting so that labels can be read accurately.
It should be free of distractions and interruptions. The medication aide must concentrate on accuracy.
The area should be kept neat, orderly and clean.
Safety checks help prevent errors.
Medication errors are among the most common medical errors, harming at least 1.5 million people every year, says a new report from the Institute of Medicine of the National Academies. The extra medical costs of treating drug-related injuries occurring in hospitals alone conservatively amount to $3.5 billion a year, and this estimate does not take into account lost wages and productivity or additional health care costs, the report says.
What kinds of errors are most common?
In a study by the FDA that evaluated reports of fatal medication errors from 1993 to 1998, the most common error involving medications was related to administration of an improper dose of medicine, accounting for 41% of fatal medication errors. Giving the wrong drug and using the wrong route of administration each accounted for 16% of the errors. Almost half of the fatal medication errors occurred in people over the age of 60. Older people may be at greatest risk for medication errors because they often take multiple prescription medications.
Read the label three times.
When removing the medication package from a drawer, shelf or tray.
When pouring the medication or removing it from the unit dose container.
When returning the container to the shelf, drawer or tray.
Never administer a medication that has fallen on the floor. Discard the medication. Check to see if there are enough doses available until a new supply is delivered by the pharmacy. Many facilities require another person to witness the discarding of medications.
Check the expiration date. Note if there is a change in color, smell or texture of the medication. Report any irregularities to licensed nurse.
To cut a tablet in half, place it on a clean paper towel and use a clean knife edge or a pill cutter to cut it along the scored line. Instructions to cut a tablet in half should be recorded on the MAR. Only tablets which are scored may be halved.
If taking a pill or capsule from a stock bottle, pour it first into the cap of the bottle, then into the medicine cup.
Always follow the "5 Rights" of Medication Administration.
Review pages 124-126 in textbook. Your textbook gives 7 rights but KDADS curriculum goes by the original 5 rights. On the KDADS state test, please refer to the 5 rights listed below for any questions regarding this issue.
1. Right resident--always make a positive identification of the resident.
Read the identification wristband.
Ask resident to state his or her name.
Ask a family member or another staff member for a positive identification.
Compare the picture of the resident on the MAR with the resident.
2. Right medication
Give medications only from correctly labeled containers.
Keep drugs in unit dose packages until ready to use.
Give only drugs that you have set up. Never give drugs prepared by someone else.
Read the label three times.
Make sure label on medication container matches exactly with the physician's order recorded on the MAR.
Never leave the medicine tray or medication cart unattended.
Watch carefully for drugs with names that are similar, for example, Omade and Orinase.
Graciously recheck any medication that the resident thinks is wrong or shows hesitancy, puzzlement, or questions the medication.
3. Right dose
Read the label carefully and compare it to the physician's order recorded on the MAR.
Know correct abbreviations and have an understanding of various units of measurement.
Medication aides must never calculate the correct dosage of a medication. If the dosage requires calculation, contact a licensed nurse. The dosage information on the MAR should provide specific information related to the dose to be administered.
Use the correct device for measuring doses.
Stay with the resident until all the medication is ingested or applied.
Help resident take the full dose by being patient while they are taking the medications. Offering water before offering oral medications may assist the resident in swallowing.
A licensed nurse or a pharmacist must make the decision to crush a medication, open a capsule or cut a tablet to assist resident's in swallowing medications. This information must be recorded on the MAR.
4. Right route
As ordered by the physician.
Know correct abbreviations for routes.
Notify the licensed nurse when a resident has difficulty swallowing a medication. The nurse should contact the pharmacist and the resident's physician concerning alternative forms of the ordered medication.
5. Right time
Know correct abbreviations for when medication is to be given.
Drugs to be given on empty stomach should be given I hour before, or 2 hours after meals.
Drugs may be ordered to be given before meals (ac), with food or after meals (pc). Medications ordered ac and pc can be given within 30 minutes of the scheduled time.
Routine medications are to be administered within a hour before or an hour after the scheduled time unless there are specific instructions ordered by the physician. Medication for treating Parkinson's disease must be administered in very specific time frames. Effort must be made to administer these drugs as close to the ordered time frame as possible and not more than 30 minutes before or after the scheduled times. This is very important to maintain needed blood levels of the drug.
Techniques specific to medications-settingup methods.
Liquid medications
Pour away from the label. Do not allow spills or drips to obscure the label.
View the medication cup at eye level.
Read the level of the medication from the bottom of the meniscus or curve of the liquid surface.
Recap all bottles tightly after wiping off the neck with clean wet paper towel.
Crushing medications
Enteric coated and sustained-release forms of medications cannot be crushed or removed from capsules for administration.
The decision as to whether a medication can be crushed is made by a licensed nurse or pharmacist.
Use a mortar and pestle or pill-crusher.
Make sure that equipment is not damp and it is free of residue from other medications.
Capsules can simply be opened and poured out.
Mix with food or liquid only if indicated and it is appropriate for that medication.
Mix only with food appropriate to resident's diet. Mix with minimum amount of food to assure that resident consumes all of medication. Mix with food right before administering.
Applesauce, cottage cheese, pudding, yogurt, pureed food are commonly used because they are easy to swallow. Be aware of food-drug interactions, such as dairy products should never be used with tetracycline. A licensed nurse should indicate on the MAR, the food product to be used with the medication.
Controlled drugs
Narcotics, stimulants and depressant drugs require special record-keeping.
The medication aide must follow the policy and procedure of the facility in recording the use of controlled drugs.
Administration of Medications--Preparing to Administer Medications
Unused doses still in the packaging may be returned to the pharmacy for credit. Unused doses of controlled drugs cannot be returned to a pharmacy. This is a Drug Enforcement Agency (DEA) requirement.
Checking the medication order
reason the medication was administered and later record the resident's response to the medication. In some facilities this documentation will be placed on the back of the MAR, and in other facilities the documentation will be placed in interdisciplinary progress notes. Follow documentation policies for the facility.
example, if two residents are to have eye drops administered, the medication aide should wash hands and don gloves before instilling eye drops in the first resident's eyes. The gloves would be removed and placed in a waste basket or container and hands washed again. A second pair of gloves should then be donned, eye drops instilled in the second resident's eye, gloves removed and hands washed.
