How Can a Nurse Become Negligent With Medication Administration?

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Long-Term Care Nursing

Providing Care to Patients in Demand of Extended Care

Long-term nursing is not an like shooting fish in a barrel field, merely it comes with many rewards as well as challenges. Long-term care nurses care for patients in need of extended care, including geriatric, wound care, chronic diseases, and disabilities. Nurses must be dedicated to patient care because the aforementioned patients are seen day in and twenty-four hours out. Although most residents are elderly, many are younger.

A long-term care nurse must accept a passion for working with special residents in a long- term care facility. The work can exist hard at times but tin exist then rewarding. Allow'due south explore the duties of a long-term intendance nurse.

Duties Are Varied: Assessments, Medication Assistants, & Wound Care

Long-term care nurses focus on providing care to patients in need of extended care. This care may entail routine care, wound care, dementia, including Alzheimer'south illness, cancer, and aftercare post-obit surgery or strokes. The chief focus is assessing and monitoring the residents' functional status and maintaining or restoring physical health. Due to physiological changes, especially in hepatic metabolism and renal elimination, dosing in the elderly population can be challenging. The elderly may experience an increase in side effects or toxicity more easily. Sensation of side effects in the elderly is particularly of import as near elderly patients are on more than than ane drug. Bully care should be taken when combining drugs.

Routine care involves nursing assessments, medication administration, wound intendance, and collaboration with the team including physicians, families, pharmacy, and therapy. As well included would exist daily care with Activities of Daily Living (A.D.L.s) as needed and proper documentation.

Responsibilities may include:

Consults and coordinates with healthcare team members to assess, plan, implement, and evaluate patient intendance plans.
Prepares, administers, and records given prescribed medications. Reports adverse reactions to medications or treatments.
Records residents' medical information and vital signs.
Assesses resident's ability to perform routine A.D.L.s.
Assists residents with basic needs such every bit dressing, eating, and bathing and encourages patients to do things for themselves to retain feelings of independence and cocky-worth.
Recognizes and manages geriatric syndromes common to older adults, including cardiovascular, respiratory, gastrointestinal, urinary, musculoskeletal, neurological, integumentary, sensory, and pain issues.
Prepares equipment and assists the medico during examination and treatment of a patient.
Facilitates older adults' agile participation in all aspects of their healthcare.
Involves, educates, and, when appropriate, supervises family unit/pregnant others in implementing all-time practices for older adults.

These responsibilities audio overwhelming, particularly for a new nurse, but it does go easier with fourth dimension and experience. A solid orientation is of the utmost importance and the nurse must feel comfortable asking questions.

Medication Pass

The medication laissez passer takes upwards the most hours of the 24-hour interval and evening shifts. The medication pass is the most intimidating task to new nurses. They volition need assistance when beginning starting off. Having the responsibility of giving 30 patients their medications can be frightening and overwhelming for new nurses and fifty-fifty for seasoned nurses.

Medication errors are serious and can cause resident damage or even decease. It is human nature to want to simplify things when there is much to be done. In an attempt to do this, sometimes shortcuts are fabricated. All the same, this is not skilful practice. Particularly when it comes to medications. Exercise not accept shortcuts. More specifically, practise Non, under any circumstances, try to pre-pour medications to relieve time. Pre-pouring medications are confronting regulations. In improver, it increases the run a risk of making mistakes.

Ten Rights of Medication Pass

Outset and foremost, nurses must remember the 10 Rights of Medication Pass:

Correct Patient:

Use two identifiers. The room number is not an identifier. Ask the patient to identify themself, check the name on gild, and the patient. If bachelor, utilise engineering science such equally barcoding. For patients not wearing I.D. bands or those who cannot identify themselves, actress circumspection is necessary. A arrangement should be in identify to place patients without name bands or who are incompetent.

Right Drug:

Every drug administered must have an lodge from the provider. Compare the lodge with the medication administration record (Grand.A.R.) for accuracy. Compare the label on the drug to the data on the K.A.R. three times:
1. Before removing the container from the drawer
2. Every bit the drug is removed from the container and
3. At the bedside before administering it to the patient
Exercise not prepare unmarked drug containers or illegible containers. Be sure to verify drugs at the patients' bedside with the Thou.A.R. and two patient identifiers (Potter et al., 2017).

Correct Dose:

Have a 2nd nurse check whatsoever calculations that demand to be washed. Utilize standard measuring devices such as syringes, graduated cups, or scaled droppers. See if the pharmacists can carve up any required pills for safety (Potter et al., 2017).
If drugs need to be crushed, be certain to clean the devices used before and after. Nurses should access information on therapeutic doses, therapeutic serum levels if applicable, and laboratory results when needed. If there is any dubiety almost the dose on the MAR or if at that place is a question on the drug, stop and verify all information before administering.

Right Route:

Drug errors involving the wrong route of drug administration are mutual. Exist sure to verify if there is any question as to the drug road. The nurse must know the advisable route for the drug. Giving drugs via the wrong route tin cause serious harm to patients. If possible, when using a syringe or other device, label the appropriate route so that there is no confusion.

Correct Fourth dimension:

Nurses need to sympathize why drugs are given at certain times. Although some drugs require clinical judgment as to when to administrate, such as an equally-needed sleeping drug, other drugs are labeled fourth dimension-critical (Vaismoradi et al., 2018). Studies bear witness that giving drugs at incorrect times results in 30-40% of all drug errors (Tariq & Scherbak, 2019; Gorgich et al., 2016). Giving drugs at an incorrect time tin can impact the bioavailability and efficacy of the drug. Doing this results in the drug non working for the patient as it should. Likewise, drugs should not be prepared or mixed in advance for the same reason.

Correct Documentation:

Write downwardly the drug after you give the dose. Note injection sites.

Right Patient Education:

Educate the patient on what to wait regarding side effects, benefits, reactions, and when to seek medical help.

Correct to Reject:

Patients have a right to refuse any drug. Document refusal of the drug.

Right Assessment:

Assess the patient. Notation the patient's history and whatsoever perimeters around drug administration.

Right Evaluation:

Cheque for drug allergies and interactions.

Case Report #1: Nurse Jane

Jane, a new graduate, was doing her first med pass alone subsequently one calendar week of training on the cart. She was passing the morning meds, the heaviest med pass of her solar day, when ane of her residents began to become upset. Afterwards trying to calm her down, to no avail, Jane went to her cart to look at the M.A.R. to run across what med she could give her. She institute the order for Lorazepam 1 mg to be given I.M. every 12 hours and verified it had not been given for near 36 hours. After Jane retrieved the Lorazepam from the refrigerator, she drew up the unabridged 2 ml of the drug, thinking that the concentration was 1 mg/two ml. The actual concentration was 1 mg equals 1 ml. She gave the resident the injection and the resident finally calmed downwardly and fell asleep. At the stop of the shift, during study and narcotic counting, the ongoing nurse asked Jane where the other half of the Lorazepam was equally she did not run across that it was wasted. When Jane realized what happened, she went to the shift supervisor to written report the error. The resident was monitored throughout the night. There were no adverse reactions and the resident slept well. Jane learned a valuable lesson and will e'er recollect her first med fault.

Rules of the Medication Pass

Before beginning a med pass, take a wait at the MAR. NEVER go by memory. Check documentation for patient allergies. Do non bring the cart into the dining room. Do not perform claret saccharide checks or administer medications in the common areas of the facility. This can be considered a alienation of resident confidentiality.

If another nurse asks yous to give a medication she has already poured, you should decline. Only administer medications you have prepared yourself. Yous may not be sure the medication is correct and it may not be the correct patient. Do not borrow medications from another resident's drug drawer. If a drug is missing, employ the Emergency Drug Kit and follow the specific procedure for your facility.

Look for expiration dates on all medications, including over-the-counter drugs. Most insulins expire afterwards 28 days after opening the vial. Metered-dose inhalers (MDIs) expire 1 month after opening.

Official "Practice Non Employ" Abbreviations

Some of the abbreviations we employ for medication passes are not utilized anymore, as they tin crusade defoliation and increase the risk of medication errors. Per The Joint Committee (T.J.C.) (2020), here is the well-nigh recent list of abbreviations to avoid:

Official "Do Not Use" List (T.J.C., 2020)
Do Not Apply	Potential Trouble	Use Instead
U, u (unit of measurement)	Mistaken for "0" (nil), the number "four" (four) or "cc"	Write "unit"
I.U. (International Unit)	Mistaken for IV (intravenous) or the number x (x)	Write "International Unit of measurement"
Q.D., Q.D., q.d., qd (daily) Q.O.D., Q.O.D., q.o.d, qod(every other mean solar day)	Mistaken for each other Period later on the Q mistaken for "I" and the "O" mistaken for "I"	Write "daily" Write "every other day."
Trailing zero (X.0 mg)* Lack of leading nix (.X mg)	Decimal point is missed	Write X mg Write 0.X mg
MS MSO4 and MgSO₄	Can mean morphine sulfate or magnesium sulfate Confused for one some other	Write "morphine sulfate" Write "magnesium sulfate"

The rules regarding not using these abbreviations applies to all orders and medication-related documentation that is handwritten (including free-text reckoner entry) or on pre-printed forms.

*Exception: A "trailing zero" may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report the size of lesions, or catheter/tube sizes. It may non be used in medication orders or other medication-related documentation (T.J.C., 2020). Considering there are many medication errors involving Morphine Sulfate, information technology is very important to never use the abridgement!

Steps of the Medication Pass Process

Wash your easily with soap and h2o earlier and later on med laissez passer.
Ensure med cart is locked when not in use.
Make sure that the med room is ever locked.
Go along your cart make clean and organized without whatever personal items.
Make sure whatever applesauce and/or ice cream that yous will be using to mix medications in, also as the make clean water bullpen, are dated.
It is permissible to use alcohol-based hand sanitizer between patients if easily not visibly soiled.
Make sure to wash hands again afterward 3 uses of hand sanitizer.
Monitor and tape vital signs that are required prior to medication administration.
Use apical pulse for sure medications such as Digoxin and antihypertensive drugs.
Bank check and make sure the order is correct.
Always check the resident's name, drug, dosage, strength, and road using the MAR for reference.
Enter resident's room after knocking and identify yourself.
Make sure the resident is sitting upwardly before giving the medications.
Administer the medications via the correct road.
Document the assistants of the medications.

Important Things to Call up During Medication Pass

Never leave the room until you are sure the resident has taken medications.
Never go out the meds in the room for the resident to take later.
If there always is a difference between the MAR and the medication, STOP!
- Accept Activity:
  - Review the guild in the chart.
  - Check with your supervisor.
  - Telephone call the chemist's if needed.
  - Exercise not give the medication until you know the order is correct and the society has been corrected on the MAR.

Administering High-Alert Medications

Many patients require loftier-take chances/high-alert medications. Loftier-take a chance medications are drugs that bear an increased risk of causing significant patient injury when they are used incorrectly. If is upward to you to identify high-alert medications based on your facility's approved listing. Examples of high-alert medications are anticoagulants, antidiabetic agents, sedatives, and chemotherapeutic drugs. Information technology is peculiarly of import to monitor medication dosing carefully, particularly if dosing adjustments are necessary because of narrow therapeutic windows. Likewise, make sure to obtain and review any laboratory values required for dosing adjustments, interact with the practitioner if values are out of the therapeutic range, and lookout for adverse furnishings.

The nurse is expected to know the action of each medication, so a medication reference book must be kept on each cart. Be sure to look upwardly all medications you are not familiar with!

Loftier-alert medications can be unsafe to your residents. Familiarize yourself with your facility'due south list of high-hazard medications, check and recheck doctor'due south orders, ask for help when you are unsure if an gild is correct or if the resident is showing signs/symptoms of an agin reaction.

Listing of High-Warning Medications (Institute for Safe Medication Practices [ISMP], 2021)

Anticoagulants:
- Heparin is the most common anticoagulant used in long-term care. Monitor for bleeding, breast pain, rapid breathing, and fast heart rate. Vital signs are taken before administration. Vitamin K is to be given for critical level International Normalized Ratio (INR) per md's orders.
Hypoglycemics:
- These are used to control blood sugar. Perform blood sugar tests before giving Insulin or if you doubtable low blood sugar. The most common signs/symptoms of low blood sugar include sweating, confusion, weakness, headache, and dizziness. Ever take a tube of Glucagon on your cart to assist reverse these symptoms.
Opioids:
- The drug that nurses have trouble with is liquid morphine. Exist sure to check and recheck the concentration. All forms of opioids are considered high-gamble. Pay attention to the frequencies and dose. Be sure to watch the resident swallow the narcotic and if is timed release, ensure the resident does not chew the pill.
Digoxin:
- Vital signs must exist taken earlier dose, pay attention to the pulse! If the pulse is below lx or above 100, practise non give and document findings.
Chemotherapy Agents:
- Chemotherapy is only given in oral doses in long-term care. Follow instructions carefully and do not touch the drug.

Residents' Rights and the Med Pass (Centers for Medicare and Medicaid [CMS], 2021)

Earlier nosotros go on with the med pass, let's review residents' rights regarding medications:

Residents take the correct to exist treated with dignity and respect.
Residents have the right to privacy.
Residents (and families) have the right to refuse medication.

Keeping these rights in mind while passing medications helps the residents keep their dignity.

How to Prepare/Administer Medications

Preparing Oral Doses

When preparing oral doses, be sure to follow facility guidelines as well as CMS and chemist's shop guidelines:

If you lot must touch a pill, use gloves.
Ever pop pills from chimera pack over the cart.
If you drib a pill, throw it away. If it is a narcotic, have another nurse waste it with you. You lot always demand a witness when wasting narcotics.
Be certain to split just pills that are allowed to be carve up, no pills that are not scored!
Not all medications that are scored can be crushed [e.thousand., Toprol XL (metoprolol succinate)].
If you have an order to trounce medications, use a pill crusher or mortar and pestle. Crush the medications into a fine powder, mix in applesauce or other items (water for enteral tubes).
Be certain to shake liquids earlier pouring, pour at centre level, wipe any drips from the bottle afterward, and ensure resident swallows the entire dose.

Medications with Agency for Health Care Assistants (AHCA)/CMS Guidelines

Metered-Dose Inhalers (MDIs):
- They are used to treat asthma and chronic obstructive pulmonary disease (COPD).
- Expect one infinitesimal between puffs.
- Accept resident rinse their mouth afterwards doses are administered.
Fentanyl Patches:
- Used for astringent hurting and is fourth dimension-released.
- CMS has adamant that some drugs remain on the pad after removal and can lead to potential diversion and corruption.
- Exist sure to document the time the patch is removed and waste product with another nurse (depending on the rules of your facility). To properly dispose of it, fold it in one-half with the glutinous sides touching and affluent it down the toilet (U.S. Food & Drug Administration [FDA], 2018). Practise non place it in a garbage can where others might become exposed upon touching it (FDA, 2018).
Medication Administration via Feeding Tube: Most time-consuming! Always check placement earlier administering the drug, give each medication separately, and flush tube between each medication (American Association of Postal service-Acute Intendance Nursing [AAPACN], 2021).

Middle Drop Assistants

E'er use a tissue, put on gloves, and enquire the resident to look up. Practice not bear upon the eye with the dropper. Count the drops being administered. Have the resident close their eyes to assistance launder the medication drop over the unabridged eye. Wait at least five minutes earlier administering some other drop.

Ear Drop Assistants

Ever use gloves when administering ear drops. Have the resident lie downwards with the afflicted ear upwardly, pull upward and back on the ear lobe, and instill drops without touching the dropper to the skin, ear lobe, etc.

Common Medication Errors

Every new nurse volition think that it volition not be them to take a medication error, but they will. Especially with the time constraints for med pass in long-term care. Remember the phrase "to err is homo." Slowing downwards, ensuring the correct medication is being given, and remembering the ten rights of medication pass tin can help reduce medication errors.

"A medication fault is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health intendance professional." (National Analogous Council for Medication Error Reporting and Prevention [NCCMERP], 2021).

Antipsychotics, antidepressants, sedatives/hypnotics, and anticoagulants are the most common drugs for errors. The most common errors are giving medications at the correct time, the right dose, and the right route. Sound familiar? Remember the ten rights of medication assistants!

Documentation for Medication Laissez passer

The correct documentation during and after a med pass is of the utmost importance. Remember, if information technology is not documented, it is not washed! Always document the meds given Later on they accept been given. If you document before and the resident refuses or spits out the medication, you lot will have more steps to do in lodge to consummate your paperwork properly.

Remember to utilize the Nursing Procedure (nursing 101): Assessment, Diagnosis, Planning, Implementation, and Evaluation. The cess includes vital signs, lung sounds, abdominal sounds, and adverse reactions to medications. Your documentation is your proof of care provided to each resident.

The nurse has ii hours to consummate the medication pass. Ask the flooring staff to get to the supervisor with questions as med nurses should not exist interrupted during the pass. Check the MAR for the times medications are due. Afterwards each patient, enter the drugs given. If y'all have a missed dose, look until the end of the pass to get the med. If a PRN is given, mark the time, dose, reason, and then get back after one hour to recheck the effectiveness. For hurting medications, don't forget to certificate the pain level before it is given and then after i hour. The nurse must be sure to make full in every space. Remember: If it is not charted, it is not done!

Case Report #two: Nurse Judy

Judy, a new Registered Nurse (RN) on the unit, has been previously "instructed" past the other nurses to pre-pour medications to stay inside the time-limit boundaries of 1 60 minutes before and 1 hour afterward for timely medication administration. She felt pressured to follow the other nurses' routines, afraid she would not get more aid if needed if she did non. Unfortunately, soon after Judy finished pre-pouring the medications, Betty walked in. She took her cart into the med room, emptied all the filled cups into her pockets, and dumped them in an appropriate receptacle. This activity slowed her time down, and now she has to commencement med pass over over again. When she asked the unit manager why the nurses were immune to pre-pour medications, the manager answered, "that is actually non allowed." Judy learned a valuable lesson that day: Practise Non pre-pour meds! If Betty had not constitute all those prefilled med cups, they would accept been fined, and the nurse may take been fired. Pre-pouring medications is unsafe and the biggest reason for medication fault.

Determination

Long-term care nursing is a rewarding and challenging career. A Long-term intendance nurse must have a passion for working with special residents in long-term care. The nurse wears many hats and the days are hectic. When the medication pass is thrown into the mix, the new nurse may become frantic and worried about getting the pass done in a timely fashion. This does sound overwhelming, especially for a new nurse, but it does get easier with fourth dimension and experience. A solid orientation is of the utmost importance and the nurse must experience comfy request questions. Following the rules and regulations of the facility helps the new nurse with all the duties and responsibilities of the twenty-four hours, including an error-free medication pass.

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References

American Association of Post-Acute Care Nursing. (AAPACN). (2021). Medication administration and pharmacy guidelines. Visit Source.
Centers for Medicare & Medicaid Services. (CMS). (2021). Residents' rights & quality of intendance. Visit Source.
Gorgich, Eastward., Barfroshan, S., & Ghoreishi, G. (2016). Investigating the causes of drug errors and strategies to prevention of them from nurses and nursing student viewpoint. 8(eight). Visit Source.
Found for Safe Medication Practices. (ISMP). (2021). High-alert medications in long-term care (Fifty.T.C.) Settings. Visit Source.
The Joint Commission. (TJC). (2020). Official "Practice Non Use" Fact Canvass. Visit Source.
National Coordinating Council for Medication Mistake Reporting and Prevention. (NCCMERP). (2021). Nigh medication errors. Visit Source.
Potter, P., Perry, A., Stockert, & Hall, A. (2017). Fundamentals of Nursing (ninth ed.). Visit Source.
Tariq, R., & Scherbak, Y. (2019). Drug errors. StatPearls. Visit Source.
U.Due south. Nutrient & Drug Administration. (FDA). (2018). FDA drug prophylactic communication: FDA requiring colour changes to Duragesic (fentanyl) hurting patches to assistance safety-- emphasizing that accidental exposure to used patches can cause death. Retrieved August 31, 2021. Visit Source.
Vaismoradi, M., Amaniyan, Due south., & Hashemite kingdom of jordan, S. (2018). Patient safety and pro re nata prescription and administration: A systematic review. Pharmacy (Basel), 6(3), 95. Visit Source.

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