Patient Assessment

The nurse should always assess a client’s health status and obtain a medication history prior to giving any medication. The extent of the assessment depends on the client’s illness or current condition, the intended drug, and the route of administration. For example, if a client has dyspnea, the nurse assesses respirations carefully before administering any medication that might affect breathing.

Patient and Medication History

The medication history includes information about the drugs the client is taking currently or has taken recently. This includes prescription, OTC, and recreational drugs. Sometimes an incompatibility with one or more of these drugs affects the choice of a new medication. Clients often overlook disclosing vitamins, herbs, food supplements, and folk remedies. Many of these have unknown or unpredictable actions and side effects and should be noted.

An important part of the history is the client’s knowledge of their drug allergies. The nurse should clarify with the client any side effects, adverse reactions, or allergic responses due to medications. Other clients may not be use about allergic reactions.

The nurse also tries to obtain information about drug dependencies. How often drugs are taken and the client’s perceived need for them are measures of dependence.

The client’s normal eating habits can affect medication administration as some medication schedules are coordinated with mealtimes or the ingestion of foods. Some foods may also be incompatible with certain medications (e.g., milk with tetracycline).

The patient’s ability to self-administer medications is also important if they will be tasked with self-administration. Common barriers include poor eyesight, unsteady hands, difficulty opening certain containers, etc.

Socioeconomic factors are important for all clients, and especially for older clients. Two common problems are lack of transportation to obtain medications and inadequate finances to purchase medications. When aware of these problems, the nurse can refer the client to the proper resources to ensure that medications are purchased.

It is important to determine whether the route of administration is suitable. For example, a client who is nauseated may not be able to keep down a drug taken orally. In general, the nurse assesses the client prior to administering any medication to obtain baseline data by which to evaluate the effectiveness of the medication.

Medication Administration Errors

Medication errors can occur at all stages of the medication administration process: prescribing, transcribing, dispensing, administering, or monitoring. Nurses who do not follow the five rights (right drug, right client, right dose, right time, right route) of medication administration contribute to medication errors. Common reasons to fail to follow these rights is poor pharmacologic knowledge, miscalculations, interruptions, increased workloads, and fatigue.

Preventive Measures

The nurse should not be disturbed with nonurgent matters during medication preparation. This includes a “sterile cockpit rule” where the medication area is not interrupted or disturbed. Common disturbances include monitor alarms, telephone calls, family inquiries, and most frequently due to nurse colleagues and other healthcare team members.

No single system of prevention works universally. A set of systems set to prevent medication errors work best. Technology allows for barcode medication administration (BCMA), smart IV pumps that have error-prevention software, and other innovations that prevent medication errors.

Stage	Safety Strategy
Prescribing	• Computerized provider order entry • Medication reconciliation at times of transitions in care
Transcribing	• Computerized provider order entry to eliminate handwriting errors
Dispensing	• Clinical pharmacists to manage the medication dispensing process • Use of “tall man” lettering (e.g., DOPamine and DOBUTamine) to minimize confusion between look-alike, sound-alike, or confusing medications • Automated dispensing cabinets for high-risk medications
Administering	• Follow the “five rights” of medication administration • Institute strategies to minimize interruptions while nurse is administering medications • Use BCMA to ensure medications are given to the correct client • Use smart infusion pumps for IV infusions • Keep current in pharmacology knowledge and medication calculations • Identify high-alert medication (e.g., anticoagulants, sedatives, insulin, and opioids)

Medication Reconciliation

Approximately half of hospital medication errors occur when clients transition in care both within and outside of the organization. Medication reconciliation is the process of identifying the most accurate list possible of all medications is taking—including name, dosage, frequency, and route—and using this list to provide correct medications for patients anywhere within the healthcare system. Reconciliation involves comparing the patient’s current list of medications against the physician’s admission, transfer, or discharge orders.

Medication reconciliation is crucial during admission, unit transfers, and discharge to prevent medication errors. Nurses must:

Make a complete list of all medications (including prescriptions, OTCs, supplements) upon admission.
Compare the list with any new medication orders throughout the stay.
Ensure medications to be administered around the time of shift report are communicated during shift change. It is important that the oncoming nurse know if the medication was given or not.
Share the full medication list with the next care provider during transfers or with the client at discharge.
Provide written and oral instructions for all discharge medications.

Elements of Medication Reconciliation

The Joint Commission mandates its accredited facilities to have protocols and processes in place for medication reconciliation, particularly on admission, during transfer between units, and at discharge.

At admission: Collect a list of the medications the client is currently taking when he or she is admitted to the hospital or seen in an outpatient setting. Compare the medication information the client brought to the hospital with the medications ordered for the client by the hospital in order to identify and resolve discrepancies.

At discharge: Provide the client (or family as needed) with written information on the medications the client should be taking when he or she is discharged from the hospital or at the end of an outpatient encounter. Explain the importance of managing medication information to the client.

Additionally, the Institute for Healthcare Improvement recommends that medication reconciliation also occur when transferring the client from one care setting to another.

At transfer: Compare the medication information the client brought to the hospital with the current medications ordered for the client by the hospital and to the transfer orders to identify and resolve any discrepancies.

Process of Administering Medications

Identify the client. Administering to the wrong client is a common error. The Joint Commission’s National Patient Safety Goals requires a nurse to use at least two client identifiers when administering medications. Acceptable identifiers may be the client’s name, an assigned identification number, a telephone number, or other client-specific identifier. In most hospitals, clients wear a wristband with their name and hospital identification number. Before giving the client any drug, always check the client’s identification band.
- Many hospitals are using BCMA technology for medication administration.
- In long-term care and home care settings, the requirement for two identifiers is appropriate for the first encounter. Thereafter, and in any situation of continuing one-to-one care in which the clinician knows the resident, one identifier can be facial recognition.
Inform the client. The nurse should explain the medication’s intended action as well as any side effects or adverse effects that might occur if the client is unfamiliar. Listen to the client—nurses engrossed by the task of timely medication administration may miss relevant information provided by the client. For example, if the client says that he does not take a pill for high blood pressure, this should be a red flag for the nurse to stop and check if this is the correct medication for the client.
Administer the drug. Read the MAR carefully and perform the three checks with the labeled medications. Then administer the medication in the prescribed dosage, by the route ordered, at the correct time.
- Check Three Times for Safe Medication Administration:
  1. First Check: read the MAR and remove medication(s) from the client’s drawer. Verify that the client’s name and room number match the MAR. Compare medication labels against the MAR. If dosages do not match, perform calculations as appropriate. Check the expiration date of the medication.
  2. Second Check: while preparing the medication (e.g., pouring, drawing up, or placing unopened package in a medication cup), look at the medication label and check against the MAR.
  3. Third Check: recheck the label on the container (e.g., vial, bottle, or unused unit-dose medications) against the MAR before returning to its storage place or before giving the medication to the client.
- The “correct time” of administration has historically been “within 30 minutes before and after the scheduled time”. However, many nurses clearly state that this was unsafe, led to more errors, and difficult to follow given the current complex process of medication administration. A system for timely administration was produced by the Institute for Safe Medication Practices:

Acute Care Guidelines for Timely Administration of Scheduled Medications

Time-critical Medications must be administered at the exact time indicated when necessary (e.g., rapid-acting insulin), otherwise, within 30 minutes before or after the scheduled time. These medications include medications that may cause harm or a sub-therapeutic effect if administered early or late by more than 30 minutes—this includes medications with a dosing frequency less than every 4 hours.

Non-time-critical Medications:

Daily, weekly, monthly medications: within 2 hours before or after the scheduled time.

More frequently than daily, but no more frequently than every 4 hours: within 1 hour before or after the scheduled time.

Provide assistive interventions as indicated. Clients may require physical assistance (e.g. when assuming positions for intramuscular injections). They may also require guidance about measures to enhance drug effectiveness and prevent complications, such as drinking fluids. Listening carefully to the client’s concerns and giving correct information helps allay fears about medications.
Record the drug administered. Record the name of the drug, dosage, method of administration, specific relevant data such as pulse rate (taken in most settings prior to the administration of digitalis), and any other pertinent information. The record should also include the exact time of administration and the signature of the nurse providing the medication.
Evaluate the client’s response to the drug. The kinds of behavior that reflect the action or lack of action of a drug and its untoward effects are as variable as the purposes of the drugs themselves. The anxious client may show the desired effects of a tranquilizer by behavior that reflects a lowered stress level (e.g., slower speech or fewer random movements). How well a client slept can often measure the effectiveness of a sedative, and the effectiveness of an analgesic can be measured by how much pain the client feels.

Rights	Definition
RIGHT MEDICATION	The medication given was the medication ordered.
RIGHT DOSE	The dose ordered is appropriate for the client. Give special attention if the calculation indicates multiple pills or tablets or a large quantity of a liquid medication. This can be an indication that the math calculation may be incorrect. Double-check calculations that appear questionable. Know the usual dosage range of the medication. Question a dose outside of the usual dosage range.
RIGHT TIME	Give the medication at the right frequency and at the time ordered according to agency policy. Medications should be given within the agency guidelines.
RIGHT ROUTE	Give the medication by the ordered route. Make certain that the route is safe and appropriate for the client.
RIGHT CLIENT	Medication is given to the intended client. Check the client’s identification band with each administration of a medication. Know the agency’s name alert procedure when clients with the same or similar last names are on the nursing unit.
RIGHT CLIENT EDUCATION	Explain information about the medication to the client (e.g., why receiving, what to expect, any precautions).
RIGHT DOCUMENTATION	Document medication administration after giving it, not before. If time of administration differs from prescribed time, note the time on the MAR and explain the reason and follow-through activities (e.g., pharmacy states medication will be available in 2 hours) in nursing notes. If a medication is not given, follow the agency’s policy for documenting the reason why.
RIGHT TO REFUSE	Adult clients have the right to refuse any medication. The nurse’s role is to ensure that the client is fully informed of the potential consequences of refusal and to communicate the client’s refusal to the healthcare provider.
RIGHT ASSESSMENT	Some medications require specific assessments prior to administration (e.g., apical pulse, blood pressure, laboratory results). Medication orders may include specific parameters for administration (e.g., do not give if pulse less than 60 or systolic blood pressure less than 100).
RIGHT EVALUATION	Conduct appropriate follow-up (e.g., was the desired effect achieved or not? Did the client experience any side effects or adverse reactions?).

Developmental Considerations

Infants and Children

Oral medications for children are usually prepared in sweetened liquid form to make them more palatable.
The parents may provide suggestions about what method is best for their child.
Do not use necessary foods such as milk or orange juice to mask the taste of medications, because the child may develop unpleasant associations and refuse that food in the future.
Children tend to fear any procedure in which a needle is used because they anticipate pain or because the procedure is unfamiliar and threatening. The nurse needs to acknowledge that the child will feel some pain; denying this fact only deepens the child’s distrust. After the injection, the nurse (or the parent) can cuddle and speak softly to the infant and give the child a toy to dismiss the child’s association of the nurse only with pain.

Older Adults

Older adults can have special problems, most of which are related to physiologic changes, to past experiences, and to established attitudes toward medications.

Physiologic Changes Associated with Aging That Influence Medication Administration and Effectiveness

Altered memory

Decreased visual acuity

Decrease in renal function, resulting in slower elimination of drugs and higher drug concentrations in the bloodstream for longer periods

Less complete and slower absorption from the GI tract

Increased proportion of fat to lean body mass, which facilitates retention of fat-soluble drugs and increases potential for toxicity

Decreased liver function, which hinders biotransformation of drugs

Decreased organ sensitivity, which means that the response to the same drug concentration in the target organ is less in older people than in the young

Altered quality of organ responsiveness, resulting in adverse effects becoming pronounced before therapeutic effects are achieved

Decrease in manual dexterity due to arthritis or decrease in flexibility

Older adults face increased risk of medication toxicity, errors, and drug interactions due to taking multiple medications and age-related changes in how drugs are processed. For example, medications like digoxin can accumulate and become toxic.

Key considerations:
- Older adults usually need lower doses, especially of CNS depressants (e.g., sedatives).
- Side effects may be unusual or severe (e.g., confusion, restlessness, incontinence).
- Use the principle “start low and go slow” with dosage adjustments.
- Monitor closely for adverse reactions and effectiveness.
Attitudes toward medications:
- Some older adults passively resist meds (e.g., spitting them out).
- Others may be suspicious and refuse them outright.
- Nurses should stay and observe medication intake when necessary.
Education:
- Explain purpose, timing, side effects, and when to contact a provider.
- Help prevent misuse or premature discontinuation of meds (e.g., diuretics).
Support strategies:
- Simplify regimens with routines (e.g., at meals or bedtime).
- Use pill organizers and large-print instructions.
- Address vision or memory impairments.
- Provide tools or involve family if dexterity issues affect administration (e.g., insulin, drops, inhalers).

The nurse’s role is to ensure safe, effective, and realistic medication management tailored to the older adult’s abilities and circumstances.

Mneme

Explorer

Safe Medication Administration