Safe Medication Administration
Documenting Medication Administration
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- » Ensuring The Six Rights of Medication Administration
- » Administering Oral Medications
- » Documenting Medication Administration
- » Handling Medication Variations
- » Preventing Medication Errors
- » Using Automated Medication Dispensing Systems
Take the Review Test:
Safety
- Comply with the standardized list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout your organization, and at least once a year review your agency’s list of look-alike/sound-alike drugs.
- Use Tall Man lettering to help emphasize dissimilarities in drug names.
- Use practice standards when transcribing medications ordered in fractions. For example, never use a trailing zero after a whole number (e.g., 1.0 mg) and always include a zero preceding a decimal value of less than 1 (e.g., 0.1 mL).
- Document administration after and not before giving to the patient.
- Document the location of all injections.
- Document only medications you yourself have given, or have watched the patient self-administer.
- Follow your institution’s policy for witnessed wasting of narcotic medications.
Equipment
(Roll cursor over items to see labels)
Medication cart or tray containing prescribed medication
Medication administration supplies
Medication administration supplies
Medication administration record (MAR)
PrintableDelegation
The skill of documenting medication administration may not be delegated to nursing assistive personnel (NAP). Before delegating related skills, be sure to inform NAP of the following:
- Instruct NAP to watch for potential side effects and report their occurrence to you.
- Instruct NAP to notify you if the patient’s symptoms (such as pain or nausea) continue or worsen after a PRN medication is given.
Preparation
- Make sure that the information on the medication administration record (MAR) corresponds exactly with the prescriber’s written order and with the medication container label. Do not try to interpret illegible handwriting; clarify the order with the prescriber.
- Review any preadministration assessments (e.g., vital signs, laboratory results).
- Review the MAR before giving any PRN medication. Make sure the ordered time interval has passed before administrating the PRN medication.
Follow-up
- Perform follow-up assessments to determine the patient's response to the medication, as required.
- Notify the prescriber if adverse effects occur or if a medication is not given.
Documentation
- Document the findings of pre and post administration assessments, and note patient’s response to PRN medications.
- Document the site location of all injections.
- Record the reason given for any refused or held medications. Indicate time at which health care provider was notified, if indicated.
- Document any calls to the health care provider for medication clarification or request for change in medication.
- Record administration of medication immediately after delivered, and not before. Include medication name, dose, route, time and site location if appropriate. Note pre-assessments such as BP or pulse on MAR.
Review Questions
1. Which example reflects effective documentation of medication administration by a nurse?
Comparing the written order with the medication administration record (MAR) three times- Providing patient education regarding a medication
- Obtaining a BP before giving a blood pressure medication
Including the location of an injection site on the medication administration record
INCORRECT. Comparing the written order with the MAR helps the nurse ensure that the medication order has been correctly transcribed into the dispensing system; however, this activity occurs before the documentation of medication administration.
INCORRECT. Although offering patient education is appropriate and should be included in patient documentation, this activity does not specifically address documentation of medication administration.
INCORRECT. Obtaining preassessments is important, but the nurse would do so before documenting medication administration.
CORRECT. Including the location of an injection is required when documenting the administration of injected medication.
2. What is the best way for the nurse to ensure that a patient receives the correct dose of a medication?
- Compare the prescriber’s order with the medication administration record before dispensing the medication
- Ask the patient if he would like a larger dose of pain medication
- Assess the patient's ability to swallow oral medications without difficulty
- Check the name of the medication three times against the medication administration record
CORRECT. Reconciling the order with the MAR at the point of delivery ensures that the correct dose is selected.
INCORRECT. Assessing the effectiveness of pain medication is important, but the patient cannot increase the amount of medication he receives.
INCORRECT. Although it is appropriate to assess swallowing ability, doing so does not ensure the correct medication dose is given.
INCORRECT. Checking the name of the medication is required, but will not ensure that the dose is correct. Medications come in a variety of strengths, and name and dose must be checked three times.
3. Which statement best illustrates the nurse’s understanding of the role of nursing assistive personnel (NAP) in documenting medication administration?
- “Make a note that the patient just received her pm dose of pain medication.”
- “Let me know if she says her nausea is getting worse."
- “Can you check the MAR and see when this patient had her pain med last?"
- “Ask the patient if I need to get another order from the provider."
INCORRECT. Documentation of medication administration may not be delegated to NAP.
CORRECT. The nurse may delegate to NAP the task of reporting a patient’s symptoms.
INCORRECT. Reviewing medication documentation cannot be delegated to the NAP.
INCORRECT. Neither the patient nor the NAP is responsible for making this clinical judgment. The skill of patient assessment is a nursing responsibility.
4. The patient refuses the scheduled dose of an antibiotic, saying that the medication makes him feel nauseated. What it the nurse’s best response?
- Informing the patient why the medication is necessary
- Notifying the prescriber of the patient's reason for refusing the medication
- Offering to administer the medication with the patient's favorite snack food
- Noting the patient’s refusal in the medication administration record (MAR)
INCORRECT. Informing the patient that the medication is necessary does not alleviate the nausea he feels when he takes it.
CORRECT. The provider must treat the infectious process for which the antibiotic was ordered. The provider may, for example, offer the patient an agent to alleviate the nausea associated with the medication or order a different agent that produces less nausea, such as an extended-release antibiotic.
INCORRECT. Offering to administer the medication with the patient's favorite snack food might not alleviate the patient’s nausea, in which case the patient is unlikely to be persuaded by this offer a second time. In addition, some antibiotics must be taken on an empty stomach.
INCORRECT. Noting the patient’s refusal in the MAR is appropriate, but the provider must also be notified so that the infectious process for which the antibiotic was ordered can be treated.
5. While reviewing a new medication order, the nurse notes that the frequency of administration has been omitted. What is the nurse’s best response?
- Immediately contacting the prescriber to complete the order
- Referring to a current drug book for the most commonly prescribed dosage
- Calling the pharmacy to determine the frequency
- Asking a registered nurse who is familiar with the prescriber to identify the usual frequency ordered
CORRECT. The prescriber is required to include all pertinent information on the prescription.
INCORRECT. Referring to a current drug book is not an appropriate means of addressing an omission in a medication order.
INCORRECT. Calling the pharmacy to determine the frequency is not an appropriate means of addressing an omission in a medication order.
INCORRECT. Asking another nurse is not an appropriate means of addressing an omission in a medication order.
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