Part Three

1.
2.
3.
4.
5.
Using CPOE: Challenges and Solutions to
Address HFAP Standards
Procurement, Preparation and Dispensing
Administration of medications – timing, unit dose, bedside medication verification
Monitoring of therapy, Medication Use
Evaluations
TBD

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The 6 rights
Collaborative Process (nurses, RT, pharmacists, physicians)
Routes of administration
BMV
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Advantages
Disadvantages
What to do if you see medication errors (wrong patient, wrong drug, wrong time)
Patient process
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Hand hygiene
Identification
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Education of the patient
Verification of the medication (double verification)
Medications at the bedside and self-administration
Observe for reactions

 Oral: sublingual, buccal
 Parenteral: intradermal, subcutaneous, intramuscular, intravenous
 Topical
 Inhalation
 Intraocular

 Metric
 Apothecary (grains)
 Household

 Grams (g), milligrams (mg), kilograms (kg)
 Liters (L), milliliters (ml)

 Tablespoons
 Teaspoons
 Ounces
 Cups
 Pints
 Quarts

 Conversions within systems
 Conversions between systems

 Six rights
 Triple-check before administration
 Patient assessment

 Right medication
 Right dose
 Right patient
 Right route
 Right time
 Right documentation

 Information
 Refusal
 Careful assessment
 Informed consent
 Safe administration
 Supportive therapy
 No unnecessary medications

 Collaborative process
 Nurses
 Pharmacists
 Respiratory Therapists
 Psychiatric Technicians
 Physicians

 Infants and children
 Older adults
 Polypharmacy
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
Self-prescribing
Over-the-counter medications
 Misuse
 Noncompliance

 Patient response to medications
 Patient and family ability to administer medications

 Presence of GI alterations
 Ability to swallow
 Use of gastric suction
 Positioning

 Skin applications
 Use of gloves or applicators
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
Preparation of skin
Thickness of application

 Assessment of nares
 Patient instruction and self-administration
 Positioning

 Drops, ointments, disks
 Assessment of eyes
 Asepsis
 Positioning

 Assessment of ear canal
 Warming of solution
 Straightening of canal for children and adults
 Positioning

 Metered-dose inhalers (MDIs) and dry powder inhalers (DPIs)
 Patient assessment and instruction
 Use of spacer
 Determination of doses in canister

 Medications used to wash out a body cavity delivered with a stream of solution (sterile water, saline, or antiseptic)
 Asepsis

 Equipment
 Syringes: sizes (volume), types
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Needles: length, gauge
Disposable units: Tubex, Carpuject
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Ampules
Vials

 Mixing medications
 Determine compatibility of the medications
 Do not contaminate one medication with another
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Ensure the final dose is accurate
Maintain aseptic technique

 Insulin
 Syringes and needle sizes
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 Types of insulin
Mixing of insulins
Rotation of vials before withdrawal of solution

 Minimize discomfort
 Use smallest suitable needle
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 Position client comfortably
Select proper site
Divert client’s attention
 Insert the needle quickly and smoothly
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Hold the syringe steady
Inject the medication slowly and steadily

 Subcutaneous injections
 Sites: condition of area, rotation of use
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Amount of solution
Length and gauge of needle
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Pinch or spread skin
Angle of insertion

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Intramuscular injections
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Sites: landmarks, condition of area
Amount of solution
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Length and gauge of needle
Angle of insertion
Aspiration
Air-lock method
Z-track technique

 Sites
 Ventrogluteal
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Vastus lateralis
Deltoid

 Intradermal injections
 Skin testing
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Sites
Length and gauge of needle
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Angle of insertion
Formation of small bleb

 Needleless devices
 Sharps disposal
 One-handed recapping technique

 Large volume infusions
 Bolus injection
 Volume-controlled infusions Piggyback
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Tandem
Volume-control set
 Mini-infusor pump

 Hand hygiene
 Identification
 Education of the patient
 Verification of the medication (double verification)
 Medications at the bedside and self-administration
 Observe for reactions

 Wash hands with soap and water or with waterless hand sanitizer before and after patient contact
 Gloves

 Must use at least two patient identifiers whenever administering medications.
 Acceptable identifiers may be the person’s name, an assigned identification number, a telephone number, a photograph, or another personal identifier.
 If bar code scanning is available, scan the patient’s armband

 Scan barcode
 Verify that this is the correct medication
 Verify dose
 Double verify
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High risk medications (heparin, insulin)
Controlled substances

More people die in a given year as a result of medical errors than from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516).
Kohn, Corrigan & Donaldson, “To Err is Human”, Institute of Medicine, 1999

Ordering
56%
Transcription
6%
Administration
34%
Dispensing
4%
Bates, Cullen, Laird, et al. “Incidence of Adverse Drug Events and Potential Adverse Drug Events.” JAMA, 1995, 274, 29-34.

Nationally 2 of every 100 admissions experienced a preventable adverse drug event, resulting in increased hospital costs of $4,700 per admission.
This is $2.8 million annually for a 700-bed teaching hospital.
Kohn, Corrigan & Donaldson, “To Err is Human”, Institute of Medicine, 1999


*Barcode Medication Administration (BCMA) in VA Medical Centers*:
Right drug
 Right dose
 Right patient
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
Right time
Missed meds
75% improvement
62% improvement
93% improvement
87% improvement
70% improvement
*Johnson, Carlson, Tucker, & Willette Using BCMA in VA Medical Centers
Journal of Healthcare Information Management-Vol 16, No.1

*Eastern Kansas Health Care System (VA) 1994-2001*:
 8,000,000 doses dispensed
 549,000 errors prevented
 0 documented errors

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Physician order received
Order faxed to Pharmacy
Pharmacists edit and verify electronic orders into patient profile
Pharmacy dispenses ordered medications in Bar-
Coded packages
Nurse accesses BMCA software on computer via log on
Nurse scans unique patient bar-coded ID band

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Nurse utilizes two unique patient identifiers to verify armband
Nurse verifies patient profile medications as per order
Nurse scans bar-code on medications
Nurse administers medications

• Reduction in medication errors
• The FDA estimated that over a 20 year period the number of medication errors would be reduced by 50% and up to 500,000 adverse events would be avoided by utilizing BCMA
(Food and Drug Administration, 2004).
• Ease of checking the five rights of medication administration
• Automatic MAR creation
• Lab results can be displayed at the point of care
• Alerts for missed medications

 Estimated to cost $1,799 per bed to implement BCMA, with an additional $1,000 yearly for maintenance
 No universally accepted bar codes
 Bar codes that are unable to be scanned
 Equipment malfunction
 Over reliance on BCMA to catch errors
 Stat medication turnaround time
(ZIH, 2006)

 Over 15 types have been identified that could potentially lead to errors
 For example:
 Nurses override alerts for 4.2 % of patients cared for and for 10.3% of meds charted
(Karsh, Koppel, Telles, & Wetterneck, 2008)

 Require special order from physician
 Must be stored in a secure manner
 Avoid using home medications unless they are unavailable from the hospital pharmacy
 If using home medications, they must be stored in and dispensed from the hospital pharmacy only upon positive identification
 Patient education on self-administration
 Example: inhalers

 Assessment
 Vital signs
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Blood glucose
Pain level
 Education
 What drug is for
 Side effects

 Reassessment

 Types of errors:
 Omissions
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Drug administration without a physician’s order
Wrong drug
Wrong dose
Wrong time
Failure to follow manufacturer specifications
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Do not crush
Shake well
Inadequate fluids

 Administration without adequate fluids
 Administration through enteral feeding tube:
 Example: phenytoin
 Administration of eye drops
 Contact time with eye
 Inhalers
 Administration with regard to meal times

 Monitoring of Therapy
 Medication Use Evaluations
 Trending of medication errors