Adm of Oral Medication-sep 08_edited 3 Dec 2008

NATIONAL NURSING AUDIT MINISTRY OF HEALTH MALAYSIA ELEMENT

5: CONTINUUM

OF CARE

5.1 ADMINISTRATION OF ORAL MEDICATION 1.

INTRODUCTION

“First, do no harm” is the ethical imperative for every patient safety effort. In working to reduce the frequency of medication errors, first priority must be to prevent those errors with the greatest potential for harm. The leading cause of patient harm is medication errors, which account for almost 20 percent of medical injuries.

The The defi defini niti tion on of a medi medica cati tion on erro errorr as appr approv oved ed by the the Nati Nation onal al Coordinating Council for Medication Error and Prevention 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 care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems including: prescribing, order communication, product labeling, packaging packaging and nomenclat nomenclature, ure, compoundin compounding, g, dispensin dispensing, g, distributio distribution, n, administration, education, monitoring, and use."

Adm Admin inist ister erin ing g oral oral medi medica cati tion onss is a core core func functi tion on of nurs nurses es.. Thei Their r respon responsib sibili ility ty is to comply comply with with safe safe medica medicatio tion n use proces processes ses and practices in order rder to pre preven vent occu occurr rre ence nce of medic edica ation tion erro errors rs / misadventures.

National Nursing Audit, Ministry of Health Malaysia : Version 1 / September 2008, Bahagian Kejururawatan , Kementerian Page 1 Kesihatan Malaysia

2.

OBJECTIVES 2.1.

To prevent occurrence of oral medication errors / misadventures

2.2.

To ensure nurses serve medications according to the 6 R’s of Medication use.

2.3.

3.

*

Right patient

*

Right drug

*

Right dose

*

Right route

*

Right time

*

Right documentation

To ensure that nurses exhibit the caring component when administering oral medication.

STANDARD 3.1. 3.1.

Nurs Nurses es serv serve e ora orall med medic icat atio ions ns acco accord rdin ing g to the the 6 R’s R’s of medication use.

3.2.

Nurses exhibit the caring component during the administration of oral medication.

3.3.

Nurses document accurately and completely the medication administered.


4.

CRITERIA Structure

Process

1. Each Each pati patien entt has has curre current nt lega legall 1.

Greet patient.

written prescription /

2.

Identify right patient

medication profile

3.

Verify prescription

4.

Assess patient, take

2. There is a Nursing

Outcome 1. All All med medic icat atio ions ns are are served according to the 6 R’s of medication use 2. Pati Patien entt rece receiv ives es safe medication during hospital stay

appropriate nursing

Operating Procedure (NOP)

measures and document

for administration of

5.

Medication.

Dish out the correct 3. Medicatio tion misadventures misadventures are Explain and inform detected early and appropriate patients. measures taken timely Listen/Responds promptly medication

6. 3. The nurse nurse is competent in the serving of medication, medication,

7.

has knowledge on the effect

and politely to patient’s

and adverse drug reaction

/carer questions.

and the appropriate

8.

Administer and ensure

measures to be taken when

patient takes oral

there is an adverse reaction.

medication. 9.

4. Pati Patien entt is is info inform rmed ed of his medication. 5. Docu Docume ment ntat atio ion n is accurate and complete.

Document medication served / omitted.

10. Monitor patient’s response and document. 11. Take appropriate appropriate measure if adverse reaction identified.

TECHNICAL

DOCUMENTATION

SOFT SKILL


identify patient

document

•

greet patient

accordingly

assessment

•

explain and inform

•

verify prescription.

findings

•

assess patient prior to

•

•

•

•

•

listen,respond

administration of

medication served /

promptly and politely

selected medication

omitted – date, time

to patient’s questions.

dish out medication

and signature

accurately – right

•

drug and right dose. •

document

patient

administer and

•

•

exhibit caring

document adverse

component when

reactions identified

assessing patient

document

ensure patient takes

appropriate

the medication

measures taken if adverse reactions identified

6.

AUDIT GUIDE FOR ADMINISTRATION OF ORAL MEDICATION 6.1. INCLUSION CRITERIA All patients in the ward who are on oral medication

6 .2 .

INSTRUMENT Audit Form (E5 AF 5.1) – one audit form for one observation

6.3 .

Methodology 6.3.1. Direct observation observation of nurse administering administering oral medication and also gather information from documents 6.3.2. 6.3.2. Settin Setting g : All wards wards 6.3.3. Population: Staff Nurses

6.3.4 Sample Design: Convenient sampling


6.4. Sample Size - 200 of staff nurses from each activity / program, equally divided among the wards for Hospital with Specialist and 100 staff nurses for non-specialist hospital

6.5. Time Frame -One month.

7.

DEFINITION OF OF OP OPERATIONAL TE TERMS 7.1.

Written prescription 7.1.1. Any legal orders orders of oral medication endorsed endorsed in the patient’s medication profile / patient’s case notes

7.2.

Medication profile 7.2.1. Legal document document where the doctor prescribes and the nurses endorse the administration of the medication

7.3.

Patient’s response 7.3.1. 7.3.1. Refers to to favorable favorable / adverse adverse reactions reactions of medica medication tion administered. E.g. favorable - pain relieved; relieved; adverse –

develop rashes.

7.4.

Dish out medication accurately 7.4.1. Read patient’s medication profile 7.4. 7.4.2 2. Selec electt

requi equire red d

medica dicati tio on

from from

pati patie ent’s nt’s

draw drawer er

of

medication cart 7.4.3. Calculate dosage before dishing out 7.4.4. Reconfirm the medication medication and and dosage dosage before putting back back the balance.

7.5. 7.5.

Iden Identi tify fy righ rightt patie atient nt 7.5.1. 7.5.1. Confirm Confirm patient’s patient’s identity identity by by 2 identifier identifier 7.5.1.1.

His/ her name

7.5.1.2.

Registration number


7.5.2. 7.5.2. Ask patient patient to confirm confirm name. name. 7.5.2.1. Cross check with patient’s wrist band for name and registration number. 7.5.2.2. Verify accuracy of identifier with patient’s medication profile.

7.6.

Verify prescription by checking for 7.6.1. 7.6.1. Prescribing Prescribing doctor doctor – name, signature signature,, and date ordered ordered 7.5.2. 7.5.2. Drug – generic generic name, name, dose, frequency frequency,, route, duration duration

7.7. 7.7.

Assess Assessme ment nt of Patien Patientt for for Adm Adminis inistra tratio tion n of of Sele Selecte cted d

Medication:

7.7.1. 7.7.1. Nurses Nurses need to determin determine e the patient’s patient’s current current status prior to administration of selected medication to confirm its continuity. E.g. Anti-hypertensive, oral hypoglycemic agents, digitalis, analgesics, antipyretics, betablockers.

7.7. 7.7.2. 2. Nurs Nurses es when when asse assess ssin ing g the the pati patien entt will will exhi exhibi bitt the the cari caring ng component: 7.7. 7.7.2 2.1. .1.

Com Communic unicat atiing wel well in a res respec pectful tful manne anner r

7.7. 7.7.2 2.2. .2.

Givin iving g the the patie atient nt the the priv privac acy, y, dign ignity ity and modesty

7.8.

6 R’s of Medication Use 7.8. 7.8.1 1 Righ Rightt pati patien entt 7.8. 7.8.2 2 Righ Rightt medi medica cati tion on 7.8. 7.8.3 3 Righ Rightt dose ose 7.8. 7.8.4 4 Righ Rightt ro route ute


7.8.4.1. Correct method of taking medication according to type: i. Tab. Magnesium Trisilicate - chewable ii. Tab. Glycerl Trinitrate - sublingual iii. Lugol’s Iodine – straw

7.8. 7.8.5. 5. Righ Rightt time time:: 7.8.5.1. An allowance of ± 30 minutes 7.8.5.2. Initial dose served immediately or within a maximum of 30 minutes upon prescription /acquisition of medication and subsequent doses according to time as stated in SOP of the unit / ward.

7.8.6. Right documentation - implies accuracy and completeness 7.8.6.1.

Record assessment findings

7.8.6.2.

signature of nurse who serve medication in the appropriate column

7.8.6.3.

for for drug drugs s not not serv served ed,, it shou should ld be indic indicat ated ed in medication profile

7.8.6.4.

docum document ent explan explanati ation on of any any omitte omitted d doses doses in patient’s case notes

7.8.6.5.

Document the evaluation of the patient response to the medication, when appropriate.

7.8.6.6.

document any any identified adverse adverse reaction to the medications administered.

7.8.6.7.

date and time of administration must be indicated in the medication profile


7.9 7.9

Com Complia plianc nce e of of Med Medic icat atio ion n Saf Safet ety y Aud Audit it 7.9.1. Technical - Every step in the process process must be performed. i.

Identify patient accordingly, verify prescription.

ii.

Assess patient prior to administration of selected medication

iii.

Dish out medications accurately – right drug and right dose.

iv.

Administer and ensure patient takes the medication

7.9.2. Essence of Care (Soft Skills): –

i.

Greet patient

ii.

Explain and inform patient

iii.

Responds promptly and politely to patient’s questions.

iv. iv.

Exhi Exhibi bitt cari caring ng com compo pone nent nt whe when n asse assess ssin ing g patie patient nt

7.9.3. Documentation - Every step in the process must be

performed. i.

document assessment findings

ii.

document medication served / omitted – date, time and signature

iii. iii. v.

docu docum ment adver dverse se rea reactio ctions ns ide identif ntifie ied d

document appropriate measures taken if adverse reactions identified

8.

Audit Form


NATIONAL NURSING AUDIT MINISTRY OF HEALTH MALAYSIA

VERSION 2/04

ELEMENT 5 : CONTINUUM OF CARE TOPIC

: 5.1 ADMINISTRATION OF ORAL MEDICATION

DOCUMENT NO : E5 AF 5.1

DATE : 8.5.08

PAGE No. 1/3

Standard: 1.

All medi medicat cation ion are are serve served d accor accordin ding g to the the 6 Righ Rights ts of medic medicati ation on use. use.

2.

All nurses nurses will exhibit exhibit the caring caring compone component nt during during the the administr administration ation of oral medication.

Objectives: 1.

To prevent occurrence of medication errors / misadventures

2.

To ensure nurses serve medications according to the 6 R’s of medication use.

3.

To ensure that nurses exhibit the caring component when administering oral medications

Date of Audit: Locality: Auditors: Auditors: 1. ……………… ……………………… ……………… …………... …... 2.

……………………………………

N.B. Instructions for Auditors 1.

To tick [√] at appropriate column.


2. Item 4 is not not rated if no no specific specific nursing nursing measur measures es required required.. S/N

ITEM

SOURCE OF

YES

NO

N/A

YES

NO

N/A

INFORMATION *1.

Greet patient.

Listen / Observe nurse.

2.

Identify right patient.


3.

Verify prescription.

Observe nurse.

*4.

Assess patient.

Observe nu nurse / check fo for written evidence.

5.

Dish out correct medication : 5.1. 5.1. Read Read pat patie ient nt’s ’s

Observe nurse.

medication profile 5.2. 5.2. Sele Select ct requi require red d

Observe nurse.

medication from patient’s drawer of medication cart. 5.3. 5.3. Calcul Calculate ate dosage dosage before dishing out 5.4 5.4 Reco Reconf nfir irm m the the

Observe nurse and countercheck calculation. Observe nurse.

medication and dosage before putting back the *6. *6.

balance Expl Explai ain n and and infor inform m pati patien entt Obse Observ rve e nur nurse se

*7.

Responds promptly and


politely to patient’s /carer questions.

S/N

ITEM

SOURCE OF INFORMATION

8.

Adm Adminis nister ter and and ens ensure patients take oral


medication:

8.1 right patient.


8.2 righ ight medica ication


8.3 right dose


8.4 right time

Listen / Observe nurse

8.5 right route

Listen / Observe nurse

8.6

9

Document: 9..1 9..1 Medic dicatio ation n

Observe nurse.

administered. 9.2 Assessment

Observe nurse.

findings. 9.3 9.4

AUDIT REPORT (Please [√] the appropriate box) Conformance

Non-Conformance

REMARKS Auditor 1[Name and Signature]: …………………………… …………………………… Auditor 2 [Name and Signature]: …………………………… ……………………………


Adm of Oral Medication-sep 08_edited 3 Dec 2008

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