Safe Medication Administration:
From Policy to Practice
Medication and Patient Safety Advisory Committee
August 2011
Faculty of Nursing
University of Windsor
© Faculty of Nursing 2011, University of Windsor
Standard Operating Procedure
Instructor’s Observations of Medication Administration of 2nd & 3rd Yr
1. Student and instructor review patient’s medication
administration record (MAR).
2. Student and instructor verify medications with physician
orders.
3. Student evaluates assessment information (vital signs;
lab results; tests).
4. Student demonstrates knowledge of patient’s
medications (purpose, side effects, lab monitoring, etc)
verbally and/or in writing to instructor.
5. Instructor observes medication preparation.
6. Instructor & student complete independent double
checks on high alert medications with nurse.
7. Instructor observes student matching patient with MAR
before administering medication using 2 identifiers
(full name, birth date and/or medical record number).
8. Instructor observes student opening medication at bedside
and involving and educating patient.
9. Student documents medications and education.
10. Student assesses the patient’s response to medications. (&
reports/ documents any abnormal observations).
Instructor co-signs.
11. Instructor guides/observes student’s hand-off
communication of medications given/not given to staff
nurse.
Standard Operating Procedure
Medication Competencies for 2nd & 3rd Yr Students Not Administering Medications
1. Student reviews patient’s medication
administration record (MAR).
2. Student verifies medications with
physician orders.
3. Student evaluates assessment
information (vital signs; lab results;
tests).
4. Student demonstrates knowledge of
patient’s medications (purpose, side
effects, lab monitoring, etc) verbally
and/or in writing to instructor.
5. Student educates patient on
medications (assesses knowledge;
provides education; uses techniques
such as “teach back” to evaluate
learning).
6. Student assesses the patient’s
response to medications.
(& reports any abnormal observations)
7. Student documents patient education.
MEDICATION ERROR REPORTING PROCESS
University of Windsor Student Nurse Medication Error Report and Follow-up
This form is to be completed by the clinical instructor and nursing student for all medication
errors. The original completed form is to be submitted to the Associate Dean. Please note: all
errors must also be reported via the hospital or agency reporting mechanism (i.e. Risk Pro
Monitor).
Date of Incident: _________________________ Time of incident: _____________________
Agency and unit (if applicable): ___________________________________________________
Student name and level: __________________________________________________________
Clinical Instructor name: _________________________________________________________
Was agency error report submitted (i.e. electronic or agency form)?
Yes
No
If ‘No’, please explain: ____________________________________________________
Name of Medication involved in error: ______________________________________________
Type of Incident:

Extra dose/duplication

Missed dose

Incorrect dose/quantity

Wrong patient

Wrong time

Wrong route

Wrong medication

Prescribing error






Wrong administration technique
Drug prepared incorrectly
Mislabelling
Deteriorated/expired product
Wrong dosage form
Other (please specify)
Contributing Factors (check all that apply):
 Abbreviation issue
 Administration error
 Communication failure (i.e. physician to nurse or nurse to nurse/student)
 Confusion with physician order
 Confusion with MAR (i.e. illegible or incomplete)
 Documentation error (i.e. dose not documented)
 Drug delivery device problem (free flow, pump issue)
 Drug labelling issue (i.e. look-alike drugs, look-alike packaging)
 Drug storage or delivery issue (i.e. missing dose, problem with delivery)
 Environmental problem (i.e. interruptions, noise)
 Lack of independent double check
 Lack of knowledge related to the drug
 Missing patient information (circle all that apply): lab values, vital signs, allergies, age,
weight, diagnosis, renal impairment, pregnancy
 Transcription error
 Other (please specify): ____________________________________________________
Brief factual description of incident:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Immediate Actions Taken Post Incident:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Patient Condition Post Incident:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Recommendations (check all that apply):
 Improved communication with unit staff
 Improved communication with physician or pharmacy
 Use of 2 patient identifiers
 Bring MAR to bedside
 Administer medication to one patient at a time
 Check physicians orders
 Complete 3 checks of medication labels
 Increase knowledge of medication
 Improve preparation for clinical and medication administration
 Complete an IDC with all high risk medications according to agency policy
 Clarify unclear handwriting, orders or abbreviations
 Ensure documentation is completed after med is given
 Follow up on any medications that are on hold (i.e. post procedure)
 Label IV medications correctly
 Other (please specify):
________________________________________________________________________
________________________________________________________________________
Institution Recommendations and Follow-up (completed by Associate Dean)
Type of Medication Error:
o Human Error (product of our current system design)
o At-Risk Behaviour (a choice: risk believed insignificant or justified)
o Reckless Behaviour (intentional or deliberate risk-taking)
Follow-up Recommendations:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Signature: _______________________________ Date: _______________________________
Overview: Just (Accountable) Culture
Purpose:
 To promote the understanding and implementation of a Just (Accountable) Culture with Faculty,
sessional and clinical instructors, students and hospital and community partners
 To support the incorporation of Just (Accountable) Culture concepts into nursing curricula at
every level, and the adherence to these concepts in our academic setting.
Introduction to Just Culture
Excerpted directly from: ANA Position Statement (2010) Just Culture Retrieved from:
http://www.justculture.org/Downloads/ANA_Just_Culture.pdf
Development of the Just Culture Concept
In 1997, John Reason wrote that a Just Culture creates an atmosphere of trust, encouraging and
rewarding people for providing essential safety-related information. A Just Culture is also explicit about
what constitutes acceptable and unacceptable behavior. Therefore a Just Culture is the middle
component between patient safety and a safety culture (Reason, 1997). Marx argues that discipline
needs to be tied to the behavior of individuals and the potential risks their behavior presents more than
the actual outcome of their actions (Marx, 2001).
The Just Culture model addresses two questions: 1) What is the role of punitive sanction in the safety of
our health care system and 2) Does the threat and/or application of punitive sanction as a remedy for
human error help or hurt our system safety efforts? The model acknowledges that humans are destined
to make mistakes and because of this no system can be designed to produce perfect results. Given that
premise, human error and adverse events should be considered outcomes to be measured and
monitored with the goal being error reduction (rather than error concealment) and improved system
design (Marx, 2001).
In addition, the model describes three classes of human behavior that create predictability in error
occurrence. The first is simple human error - inadvertently doing other than what should have been
done. The second, at-risk behavior occurs when a behavioral choice is made that increases risk where
risk is not recognized or is mistakenly believed to be justified. Finally, reckless behavior is action taken
with conscious disregard for a substantial and unjustifiable risk.
Under the Just Culture model, creating an open, fair and Just Culture relies on developing managerial
competencies that appropriately hold individuals accountable for their behaviors, and investigates the
behavior that led to the error. With regard to human error, managers console the individual, then
consider changes in processes, procedures, training and design. At-risk behavior suggests the need for
coaching and managing through removing incentives for at-risk behavior; creating incentives for
healthy behaviors; and increasing situational awareness. With reckless behavior, it is necessary to
manage through remedial action and/or punitive action (Marx, 2001).
Ultimately, the Just Culture model is about creating an open, fair and Just Culture, creating a learning
culture, designing safe systems, and managing behavioral choices. The model sees events not as things
to be fixed, but as opportunities to improve understanding of both system risk and behavioral risk. It is
also about changing staff expectations and behaviors to ones such as looking for the risks in the
environment; reporting errors and hazards; helping to design safe systems; and making safe choices,
including following procedure; making choices that align with organizational values; and never signing
for something that was not done.
To mitigate errors, Marx created the Just Culture Algorithm, a methodology for considering what a
manager should do when a breach occurs and suggests actions to address the breach from both the
system and employee perspective (Marx, 2008).
Just Culture: The Three Behaviors
Source: David Marx, www.justculture.com
Human
Error
At-Risk
Behavior
Product of Our Current
System Design
A Choice: Risk Believed
Insignificant or Justified
Manage through changes in:
•
•
•
•
•
Processes
Procedures
Training
Design
Environment
Console
Manage through:
• Removing incentives for
•
•
at-risk behaviors
Creating incentives for
healthy behaviors
Increasing situational
awareness
Coach
Reckless
Behavior
Conscious Disregard of
Unjustifiable Risk
Manage through:
• Remedial action
• Disciplinary action
Discipline
Implementation
1. Assess root cause(s) of incident. Was it a result of human error, at-risk behaviour or reckless
behaviour?
2. Manage based on outcome of investigation.
3. Complete Student Nurse Medication Error Report and Follow-up form and forward to
appropriate individual.
References and Additional Resources
Agency for Healthcare Research and Quality. Patient safety network glossary.
http://www.psnet.ahrq.gov/glossary.aspx#J
Association of periOperative Registered Nurses. (2006). AORN Just Culture tool kit.
http://www.aorn.org/PracticeResources/ToolKits/JustCultureToolKit/DownloadTheJustCultureToolKit/
George, J., Chastain, K., & Burhans, L. (2008). The North Carolina Board of Nursing Just Culture pilot
project toolbox. (Unpublished work).
Leape, L. (January 25, 2000). Testimony, United States Congress, United States Senate Subcommittee on
Labor, Health and Human Services, and Education.
Marx, D. (2001). Patient Safety and the “Just Culture”: A Primer for Health Care Executives. New York,
NY: Columbia University.
Available at: http://www.mers-tm.org/support/Marx_Primer.pdf
Marx, D. (2008). The Just Culture Algorithm. Outcome Engineering, LLC.
www.justculture.org
Minnesota Alliance for Patient Safety. (n.d.). Minnesota statement of support for a statewide culture of
learning, justice, and accountability. www.mnpatientsafety.org
Missouri Center for Patient Safety. (n.d.). Missouri Just Culture Collaborative.
http://www.mocps.org/initiatives/index.asp
Reason, J. (1997). Managing the risks of organisational accidents. London: Ashgate Publishing.
Safe Medication Practices
•
Verify the right patient, right medication, right reason, right dose, right frequency, right
route, right site, right time + right documentation
•
Note: Medication information available in Lexicomp at local hospitals
•
Involve patient/family in medication administration
•
Always take the medication administration record (MAR) to the bedside (patient) and
match the patient to the medication
•
For patients in isolation/precautions: Best practice TBD
•
Use two patient identifiers (e.g., name and birth date; name and medical record number)
•
Eliminate interruptions and distractions during medication administration
•
Do not interrupt others (e.g., instructor and student; staff nurses) when they are
administering medications
•
Reinforce the benefits of safety technology and the dangers of overriding safety functions
(e.g., PYXIS)
•
Use extra caution when administering sound-alike and look-alike medications
•
Complete an independent double check (IDC) on all high risk medications
•
•
High risk medications include: all insulin; all anticoagulants; all narcotics and opiates;
TPN/TNA
•
IDC includes instructor, student and another nurse (RN or RPN)
Although students do not participate in these activities discuss/reinforce their importance
•
Take verbal orders only in an emergency and use “read back”
•
Use “read back” for all telephone orders
•
“Read back” involves writing it down and reading back the entire order to ensure
accuracy