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Dos and DOSES.

Techniques to prevent medication errors and inappropriate use

Much attention during the past few years has been focused on problems related to prescribing, administering, and managing medications, especially in the elderly population. Examples of errors and inappropriate medication use are numerous. These include confusing one medication for a similar-sounding one that has very different actions and contraindications; misreading hastily scrawled physician handwriting; and misplacing decimal points when writing dosages. These errors can happen because of staff workload and fatigue, which result in disruptions while passing medications; lack of follow-through with the five rights of administration (patient, medication, time, drug, route); incorrect technique; and inappropriate, missing, or untimely documentation. (See "Prescription for quality care," page 41.) Staff members find it difficult to keep up with the proliferation of new medications and may not be aware of potential or actual side effects, or may recognize but not report or document them adequately or promptly. Often residents are on multiple medications, many of which are without time-limitation. Some interact with each other or result in adverse reactions requiring treatment with other medications.

There is reason for concern about medication-related problems. Errors or inappropriate use have a dramatic impact on quality of life. Adverse reactions range from annoying nuisance events to death. According to studies, such as one cited in the Ohio State University Extension Bulletin SS-128-97, "Medication Misuse Among Older Adults," as many as 50 percent of prescriptions are not taken properly. [1] It has been estimated that almost 20 percent of hospital admissions of elderly are because of medication side effects and that approximately one fourth of nursing home admissions are related to the inability to manage medications properly. It has been projected that, for every dollar spent on medications within nursing facilities, another $1.33 is spent to treat associated morbidity and mortality factors. [2] (See "Control Rx costs," page 42.)

Directors of nursing in long term care facilities should be aware of changes in the survey process, effective July 1, 1999, related to medications. These changes revised the medication error definition by increasing the focus on appropriate drug delivery technique; assessing medication use through 5 of 24 quality indicators; and expanding the list of medications considered potentially inappropriate for the elderly resident.

This article will focus on the medication administration process as well as surveyor observation of that process.

Because the goal is for all residents to receive optimal drug therapy, the surveyor's objective is to validate the appropriateness of the facility's drug delivery system, specifically the technique used.

The appropriate techniques they look for are not necessarily new. What is new is that the survey guidelines consider a medication error to have occurred if manufacturer specifications, accepted professional standards, or physician orders are not followed.

Surveyors observe medication administered to residents in a selected sample, or to residents representative of the sample's care needs. They observe as many staff members as possible to get a broad picture of facility practices. They look at a wide variety of routes of administration. And they look at the time the medication is given in relationship to the designated schedule or meals.

Techniques assessed during administration include:

* proper mixing of liquid forms;

* giving adequate fluids with medications;

* giving medications with foods;

* following appropriate procedures when giving medications through a feeding tube;

* not crushing medications when precluded; and

* appropriate administration of ophthalmic solutions, breathing inhalers, and sublinguals.

Licensed staff members learn accepted professional standards of medication administration in their basic nursing classes. However, your nurses must constantly update their knowledge and skills by conscientiously checking medication reference books and package inserts, or consulting the pharmacist. (See "Dispensing good advice," page 42.) Additionally, while a physician's medication order must be followed, if the nurse is aware that an order does not match standards of practice or manufacturer specifications, there must be discussion and clarification with the physician followed by documentation of the discussion. Let's go back and review the medication administration techniques:

* Knowing when to crush. Sustained-release and enteric-coated medications should not be crushed. A sustained-release medication contains small particles of a drug coated with materials requiring varying amounts of time to dissolve. Some of the particles dissolve and are absorbed almost immediately while others dissolve during a period of 2 to 12 hours.

Enteric-coated medications are formulated to resist gastric-juice action and thereby delay disintegration until reaching the intestine.

Consequently, crushing either of these forms can lead to increased side effects, toxicity, gastric irritation, or drug inactivation.

Ask your pharmacist to provide a list of other drugs which, although neither sustained-release nor enteric-coated, should not be crushed because they may irritate the oral mucosa, are extremely bitter, or contain dyes or substances that stain the teeth or mucosa.

* Mixing and shaking medications property. Liquid suspensions and emulsions should be shaken well before being measured to ensure distribution of the dosage throughout the solution. Inadequate mixing may result in an inaccurate dose being delivered, erratic blood levels, and a poorly controlled resident condition. An example is breakthrough seizuring when Dilantin is not mixed sufficiently.

Easy does it: You must know which suspensions to shake vigorously and which gently. For instance, insulin must be agitated gently to distribute the suspension throughout the bottle. Roll the vial between the palms of your hands; repeatedly invert it or swirl it gently. Vigorous shaking generates air bubbles in the vial and syringe. Important: Don't use the insulin if it is clumped or granular.

* Giving adequate liquids with medication. Providing the right amount of fluids with certain medications is imperative to enhance drug effectiveness and prevent complications. Some drugs, such as potassium and arthritis preparations, may irritate the stomach if not given with an appropriate amount of fluids-usually 4 to 8 ounces-according to manufacturer specifications.

Follow manufacturer or pharmacist instructions when giving fiber laxatives, which generally require 8 ounces of fluid.

* Giving medications with food. Manufacturer instructions and physician orders will advise if a medication should be given at mealtime. Food, especially that with fat and protein, affects how quickly a medication is absorbed and how much enters the system. The presence of food also delays emptying of stomach contents and allows more time for a medication to dissolve before entering the small intestine for absorption.

Some medications, such as nonsteroidal anti-inflammatories, can irritate the stomach lining, so administering with or immediately after a meal or with an antacid minimizes the possibility of irritation. However, some medications must be given on an empty stomach because they are poorly absorbed if food is present. These medications should be given an hour before or two hours after a meal.

* Administering ophthalmic solutions. To be effective, ophthalmic medications must be instilled into the "pouch" of the lower lid and not onto the eyeball itself. To accomplish this, have the resident assume a sitting or lying position and look upward. Then use a gauze to pull down the lower eyelid. Place a hand against the resident's forehead for stability and instill the required number of drops inside the lower eyelid, close to the outer corner. The dropper must not touch any part of the eye during the procedure. If the drug flows toward the tear duct, systemic absorption through nasal mucosa can occur. Reduce this possibility by gently pressing your thumb on the inner canthus after instillation.

Closing the eye gently and slowly for one or two minutes after the procedure allows for even distribution over the eye surface and avoids forcing out the medication. An interval of three to five minutes is necessary before administering another ophthalmic solution.

* Spacing and sequencing of inhalers. The inhaler delivers topical drugs to the respiratory tract, where it produces both local and systemic effects. The respiratory tract's mucosal lining absorbs the medication almost immediately. A bronchodilator improves airway patency and facilitates mucous drainage while a mucolytic liquifies tenacious bronchial secretions. When both a bronchodilator and mucolytic are ordered, the bronchodilator should be administered first to open the air passages.

Most handheld inhalers are of the metered-dose variety. They must be shaken well before administration. Have the resident tilt his or her head back slightly, then exhale. Place the inhaler about one inch in front of the resident's open mouth. Push the bottle down against the mouthpiece, then have the resident inhale slowly, over a period of three to five seconds, through the mouth, and continue inhaling until the lungs feel full. Direct the resident to hold his or her breath for 10 seconds, then exhale slowly through pursed lips to keep distal bronchioles open. There should be an interval of one minute between puffs for better lung penetration.

* Giving medications through a feeding tube. A physician's order is required before administering a medication through a feeding tube. Most oral medications with the exception of those that are enteric-coated, sustained release, or enzyme-specific can be administered through a tube. Crush tablets and open capsules, then mix with 30 ml of water or other diluent. liquid dosage forms are preferred but, if viscous, need to be diluted in at least 30 ml of water. Calculate the water used in dilution of medications in the free water allotment.

Do not mix medications together and do not add medications to the enteral feeding. Tube placement must always be checked before administration. The tube must be flushed with at least 30 ml of water both before and after administration to ensure that medications are washed into the gastrointestinal system.

* Administration of sublinguals. Drugs given sublingually are placed under the tongue to be absorbed by the blood supply immediately. The drug is not to be chewed, swallowed, or crushed; swallowing destroys or reduces the intended action while crushing may make much of the drug ineffective or inoperative. Caution the resident not to smoke before the drug has dissolved because vasoconstrictive effects of nicotine slow absorption.

The DON must ensure that nursing staff is being supported to achieve a safe and effective medication administration program. It is also important to avoid a "survey mentality," whereby one practices these standards to please primarily a surveyor. The real reason is to achieve quality outcomes for the resident by optimal medication delivery at all times.

Janice K. Olson is a regular contributor to CLTC.


(1.) Senior Series Volume 2, The Center on Rural Elderly, University of Missouri System. See also

(2.) Bootman JL, Harrison DL, Cox E. Archives of Internal Medicine, 1997;157(18):2089-96.

Prescription for quality care

* Follow appropriate infection-control techniques. Wash hands with soap and water before each resident administration. Keep covered applesauce, puddings, and juices on top of the medication cart. Store unused medication cups upside down.

* Lock unattended medication carts. Controlled drug drawers should be locked at all times.

* Don't leave resident medications and alcohol gel on top of the medication cart.

* Document administration on the Medication Administration Record as soon as possible after giving a drug so other providers have access to this information.

* Document PRNs according to facility policy, usually on the back of the Medication Administration Record. Include date, time, reason for giving, and initials of nurse. Chart results of the PRN after observing its effect.

* Document a controlled drug on the control sheet at the time it is given. Do not wait until the end of the med pass or shift to do the recording.

* If a resident refuses a medication, circle his or her initials on the front of the Medication Administration Record and, on the back, document the reason for refusal. if refusal happens regularly, evaluate the reasons, document, and discuss with physician.

* Protect confidentiality of resident records in the Medication Administration Record book by flipping pages face down when book is unattended.

Control Rx costs

To administer the same quality of care in a more cost-efficient manner, consider the following strategies:

Contract pricing. Negotiate the purchase price of your pharmaceuticals.

Look for cash back. Drug suppliers often offer financial rewards in return for greater market share.

Substitute generics. Dispense a generic or therapeutically equivalent version of brand-name products where appropriate.

Dispensing good advice

Examine these systems to see if they are in place in your facility:

* Education. This includes adequately orienting new staff to medication administration practices, providing ongoing in-service training for all staff, and utilizing resources such as nurse practitioners, consultant pharmacists, and medical directors to keep staff current. Keep current drug handbooks at each nursing station and encourage their use.

* Standardization and quality assurance. Procedure manuals must be in place, updated regularly, and accessible to staff. Lists of "Do not crush" medications should be in each Medication Administration Record book. Nursing staff members must be regularly audited in their administration techniques. Use an interdisciplinary team to review medication errors regularly and provide feedback for revising systems. Instruct staff that physicians must be notified and alternatives explored when optimum benefits cannot be achieved.

* Workflow and equipment. The work environment must be structured to minimize distractions during medication delivery. Medication times should be evaluated regularly for effectiveness for both resident and nurse. Medication administration should not coincide with other busy times for the nursing staff. Equipment and supplies should be accessible and in good working order. Medication sheets and labels must be accurate. Carts should be organized so nurses can locate needed items quickly. Utilize computerized technology as much as possible.

* Medication documentation records. The Medication Administration Record must be user-friendly. Crowded spaces can result in illegible handwriting and failure to document important information. Avoid documenting the same information in multiple places; it is a waste of time and a potential source of error. Regularly review principles of documentation with nurses.
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Title Annotation:tips on how to prevent medication errors
Author:Olson, Janice K.
Publication:Contemporary Long Term Care
Geographic Code:1USA
Date:Jun 1, 2000
Previous Article:People who make a difference.
Next Article:High court rebuffs challenge to survey enforcement process.

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