Administering Oral Medications (PO) Correctly.

Nurses are required to administer medications by different routes. This lecture deals with oral medications which are in solid / tablet /caplet/capsule form. It is assumed that your patient can swallow and has a gag reflex which is intact. In some instances there will be specific instructions for you to use thickened fluid so that the patient does not have swallowing difficulties.

A medication is said to be given orally if it is to be given by mouth and the patient is to swallow it. Other routes of administration into the stomach include the n/g tube and PEG route. These routes will be discussed in our next lecture.

Key words to remember are: 5 rights, oral, medication error, professional responsibility, registered nurse, mistake, legal responsibility, nebuliser, medication administration record, advocate.

Figure 1. For optimal effect the right medication must be given at the right time, via the right route, to the right patient, and in the right amount. (The 5 – Rs)

As a Nurse you are required to check the “five R” as they are referred to in the Nursing and Hospital environments. Checking the “five Rs” will result in the safe administration of medication and it is a standard of practice in most countries.

1st . R = Right Patient . Make sure you are giving the medication to the right patients. If you had all the other “Rs” but this one is wrong. If your patient is alert, conscious and orientated to time, person, place and time you can confirm his identity with him/her. If your patient is disorientated then you will need to check on his identity bracelet for his name and date of birth. Be very careful, there are times when there are two patients with the same name. Checking everything is all the more important, in this type of situation. If you as the nurse are doing agency work, and are not sure who is who, you are likely to make a mistake. Studies show that more medication mistakes are made by nurses when they are not in their familiar surroundings.

If you gave a medication to the wrong patient, you will have made a medication error. If you make a medication error, you have a professional responsibility to inform the treatment team and physician as soon as you discover the error so that the patient can be treated for the mistake, if treatment is warranted. This action will safe you and the hospital against liability. Even, if you are found libelous, it may be interpreted as a honest mistake. The consequences for lying, delaying and hiding an error are much more severe and could result in losing your license to practice. However, if you disclose that you made an error, it is not likely that any harm will come your way.

Once an error has been committed it is also appropriate to notify the patient, and if the patient is a minor or involuntary, notify the parents/guardian of the patient. Other people who need to be in the loop are the nurse in charge, and your nursing supervisor. Finally, complete the medication error report or the incident report according to the policy of your institution.

If a medication error is made and you follow the policies and procedures of the institution the consequences will be minimal. However, if a medication error is made, you lie about it and it is found out, you will most likely be in court, be paying with “numerous sleepless nights”, thousands of dollars in legal fees, thousands of dollars in compensation and will become unemployable. So act right even when you have made a mistake.

2nd. R = Right Medication . If the prescription says Ampicillin 250 mg capsule. Make sure you give ampicillin capsule and not elixir. In nursing a medication error will said to have been committed if you knowingly gave the wrong form of the drug. The word committed has been chosen very deliberately because it implies that you knew that you were giving the wrong from of the medication. Only a qualified treating physician can alter a prescription. Nurses are not physicians. In practice, if you are feel that a prescription is wrong or is not appropriate for a particular patient you must contact the physician and ask him/her to alter and sign the alteration or rewrite the prescription according to the practice in your area.

It is not sufficient to give the medication. If a patient has been prescribed morphine and you know that the patient does not need it then you are required to notify the physician the prescription is not appropriate. You will not get any “kudos” but you will have saved a medication prescription error.

In some institutions you are allowed to substitute a “brand name” of a medication for a generic drug. Do not do this if the policy is not clear. If in doubt, check with the prescribing physician, the nurse in charge or the Nursing Supervisor. By checking you are effectively transferring responsibility and accountability. Nothing is without a price, when you check a medication, you are also communicating that you are “not sure”. Always think of “risk to benefit ratio”, the benefit of an action must always be greater than the risk.

3rd. R = Right Route . Medications are prescribed by certain routes and must be administered as prescribed. The reason is that medications are formulated and prepared to be given by specified routes. If the route is changed, then the formulation and dosage of the medication has to be changed. For example it is normal to give salbutamol 250mcg by nebulizer. However, if the patient is to be given salbutamol by the oral route, the dosage will need to be increase to 2 or 4 mg. Note that nebuliser is liquid and tablets are solid. Again, a medication error is said to have occurred, if you gave a patient the prescribed medication by the wrong route.

In some instances, it is not sufficient to give the dosage to the patient. It is a professional responsibility to insure that the patient swallows the medication. I am referring to psychiatric settings where the patients are involuntary and “being in the Hospital and taking their medication” may be one of the conditions for their presence in the Hospital. If they do not take their medications there may be legal consequences. Nurses are not policemen/policewomen but are required to uphold the law.

4th. R = Right Dosage . The dosage of a medication has to be correct. Too much is not necessarily better. Sometimes the dosage is not prescribed as a fixed amount for example: Master John Smith, Acetaminophen 250 mg; p.o; prn; the prescription may be written as Master John smith, Acetaminophen 15mg/kg, p.o; prn; In this situation you may have to work it out. [Here, it is obvious that in addition to the above information you will need to know the patients weight]. When you have to work out (calculate) the dosage) it is institutional policy, in most institutions for two nurses to check the calculation and the measurement of the drug.

Caution : A decimal point in the wrong place increases or decreases the dosage by ten times. Both nurses checking the medication are equally responsible legally.

Larger dosage than prescribed can be harmful. Many medications have toxic effects when the dosage is increased. For example if you gave more than the prescribed amount of digoxin to a patient, he/she may become digitalis toxic. Digitalis toxicity will result in sinus bradycardia.

When a patient is on digoxin, it is a good practice to check the patient’s pulse before giving digoxin, even if it does not “say so” on the patient’s Medication Administration Redord/Chart. If the patient is in sinus bradycardia, it is institutional policy in most places to with hold digoxin.

5th. R = Right Time . The time a medication is to be given must be included on the Medication Administration Record/Chart. If in doubt, clarify with the prescribing or duty physician. Mediation prescription times are adjusted to maintain an optimal amount of medication in the patient’s circulation. In some institutions, there is a leeway of one hour. In other words, if a medication is prescribed for 14.00hr it can be given any time between 13.00hr and 15.00hr. This is because, Nurses care for many patients and they cannot be expected to give all the medications due at the same time.

If a medication is prescribed to be given “stat”, you are required to drop all non-emergency procedures and administer the stat medication as a matter of priority.

Please follow the guidelines in paragraphs 2 and 3 under the first “R” after an error has been made. In some situations you may want to go home and document the details of the error because, if things become legal and you have to answer legal questions, you may not recall many details which you will be called upon to provide. This may affect your credibility adversely. Sometimes, the plaintiff may not give you access to the notes etc he may have. Hopefully, if it gets this bad you will have an equally good attorney/lawyer.

Last, but not least, depending upon which study you look at you will know that there are many prescription, transcription and administration errors. These errors cost billions of dollars to Hospitals, Patients, Health Care Providers and Government.

One of the Nurses primary responsibilities is to be an advocate for the patient. Nurses are in a unique position to play a significant role in reducing these errors. Billions of dollars can be saved by acting correctly and judiciously.