Preventing medication errors.

During every shift of every day, a vast array of medications are administered to what may be hundreds of nursing home residents, most of whom take multiple medications. Add to this the increasing numbers of sicker residents and subacute patients with even more complex pharmaceutical needs, and it's little wonder that many of the lawsuits arising in nursing homes are due to medication errors.

In order to prevent legal actions and other serious problems, licensed nurses need to be cognizant of methods intended to prevent costly mistakes when administering medications. The following tips should help to reduce and eliminate medication errors:

1. Follow the "five rights" in giving medications at all times, i.e., right drug, right dose, right route, right time, right patient.

2. Read the medication label three times prior to administering the medication.

3. Be very careful when responding to emergencies. Many well-meaning nurses have tried to help in an emergency, only to harm the resident because nurses unfamiliar with the resident can make serious mistakes. During an emergency, communicate openly with all nurses, especially if you happen to be the nurse who is unfamiliar with the patient. Write down times and other pertinent information so that the data can be charted as soon as possible, and seek clarification of any unclear order.

4. Be extra cautious when more than one nurse is assigned to give medications to the same group of residents (realizing that the staff nurse may have a routine that does not include others giving medications to her assigned residents). Again, ensure open communication so that such errors will not occur.

Special note for teaching nursing homes: It is easy to make errors when student nurses are administering medications, especially since the staff may not be accustomed to utilizing students and may even forget that they are present.

5. If a medication is to be withheld, write a note to that effect in clear view on the medication record. Ensure that all nurses concerned are aware that the medication is to be withheld.

6. Be sure to refer to the medication record prior to administering any medication. Don't rely on memory, as doctors' orders may -- and often do -- change.

7. Assign reliable licensed nurses to review all doctors' orders daily. This will prevent an error from continuing for several days or even months. Many facilities assign this duty to the licensed nurse on the night shift. In any event, the nurse must be thorough and careful to pay attention to detail.

8. If you are unable to read a doctor's order, seek clarification from the doctor who wrote the order. Anyone else would be second-guessing the prescribing physician.

9. Notify the doctor when a medication is withheld without an order, as can happen when a patient has a bad reaction or develops a swallowing disorder. Some medications cannot be abruptly discontinued. Dilantin, phenobarbital, prednisone, and coumadin are examples of medications that, when withheld without tapering, have the potential to lead to serious consequences.

10. Utilize a standard abbreviation list (i.e., do not make up your own abbreviations). In cases resulting in litigation, lawyers frequently request the "standard abbreviation list." If such a list is not available, write out the information in full rather than using made-up abbreviations. For example, "Sub.q 2 hrs. before surgery" could be interpreted as: "give sub. every two hours before surgery" or "give subq. two hours before surgery." Needless to say, a misunderstanding can lead to serious harm.

10. Know the medications being administered. Know the side effects and know when to withhold medications and notify the physician.

11. Never give medication without an order. Don't be afraid to call a doctor for an order.

12. Be familiar with methods for giving injections. Know the Z-tract method -- pushing back excess skin before giving intramuscular injections to avoid skin trauma -- and when it should be used.

13. Be aware of dangerous drug interactions. Seek information from texts and qualified medical personnel.

14. Administer A.C. medications (before meals) and P.C. medications (after meals) on time.

15. Crush only those medications that can be crushed. Your pharmacy keeps specific lists of these, and the lists should be consulted. Don't mix medication with a vehicle, such as apple sauce, until just prior to administration. Some medications lose their effectiveness when mixed too far ahead of time.

These 15 tips, though not all-inclusive, should help staff nurses to administer medications safely and correctly, and to prevent many common medication errors that compromise the quality of care we provide and the financial well-being of our facilities.