DMC MEDICATION STUDY GUIDE
Welcome to Nursing at the Detroit Medical Center
CONTENT
Topics
__Page #
1. Calculation Review
1
2. Safe Medication Delivery
Best Practices
Key Issues in Medication Administration
13
3. Therapeutic Administration
Anticoagulation
Anti-infective agents
Diabetes management
19
4. References and Resources
21
Within the DMC, all nurses who work in adult areas of practice are required to take a
written evaluation on medication and IV calculations within the first 2 weeks of
orientation. The test is comprised of 20 questions related to medications, medication
dosages and IV calculations.
A passing score of 80% is required. Your score will be the number of questions you
answer correctly in the time allowed. Basic calculators may be used.
If a retest is necessary, it is scheduled before the end of the second week of
orientation. It CANNOT be taken on the same day as the original test.
A reference list of available and helpful resources at the DMC has been prepared to
assist you in your review.
Good Luck!
DMC Patient Care Services Education Department
Med study guide revised by DMC Educator Task Force 5/10
Calculation Review
ABBREVIATIONS:
q4hr
q8hr
bid
tid
qid
ac
pc
- every four hours
- every eight hours
- twice a day
- three times a day
- four times a day
- before meals
- after meals
mg
Gm
mL
L
gtts
mcg
prn
- milligram
- gram
- milliliters
- Liter
- drops
- micrograms
- whenever necessary
Note: bid, tid, qid administration times are not necessarily evenly spaced. Times
are generally defined by hospital policy, e.g. qid might be 9 AM, 1 PM, 5 PM and 9
PM. Drugs ordered to be administered at regularly scheduled spaced times
during each 24 hour period, e.g., q 4HR (9AM, 1 PM, 5 PM, 9 PM, 1 AM, and 5 AM).
Note JC guidelines for abbreviations cited later in this document.
EQUIVALENTS:
1000 mg = 1 Gm
1000 mL
=1L
1000 mcg = 1 mg
1 tsp = 5 mL
1 Tbsp = 15 mL
1 Ounce = 30 mL
CONVERSIONS:
Gm to mg
mg to Gm
 Multiple by 1000 or move decimal point
3 places to the right.
 Divide by 1000 or move decimal point
3 places to the left.
L to mL
mL to L
 Multiply by 1000
 Divide by 1000
mg to mcg
mcg to mg
 Multiply by 1000.
 Divide by 1000.
Kg to Lb
 Multiply by 2.2
 (Divide by 2.2 to convert Lb to Kg)
Med study guide revised by DMC Medication Exam Taskforce, 4/10
Page 2
DOSAGE CALCULATIONS:
There are two basic methods for solving all dosage problems.
1. The first method uses the principles of common or decimal fractions. Used to solve
dosage problems dealing with tablets, capsules, and suppositories.
Desire
Have
(dosage) = Quantity to be given
(on hand)
Example: A medication order reads, “ASA 650 mg po. q 4hr prn for headaches”. ASA
is available in tablets containing 325 mg.
D
X
= 650 mg = 2 tablets
325 mg
2. The second method uses the principles of ratios or proportions. This is particularly
useful to solve problems dealing with liquid medications, either oral or injection.
NOTE: Either of these two methods can be used to solve common medication
calculation issues.
Desire
mg : mL
Have
=
mg : mL
Example: A medication order reads, “Dilantin Suspension 100 mg p.o. t.i.d.” Dilantin
liquid is available 125mg/5mL.
D
H
mg : mL
100 : X
=
=
mg : mL
125 : 5
125 X
=
500
X
=
=
500
125
X
=
Med study guide revised by DMC Medication Exam Taskforce, 4/10
4 mL
Page 3
CALCULATING FLOW RATES FOR IV DRIP INFUSIONS
Method 1
1. Take the total amount of the milliliters, e.g. 1000mL, which you are to give in a
stated time period and divide by the number of hours, e.g., 8 hours. This gives the
number of mLs to be given in one hour.
Give: 1000mL D5W q 8hr
1000mL
8hr
=
125mL/hr
2. Divide the total number of milliliters, per hour, e.g. 125mL/hr, by 60 (the number of
minutes in one hour). This gives the number of mLs to be given in one minute.
125mL
60min
=
2.1mL/min (Rounding off to the nearest tenth)
3. Multiply the number of mLs to be given in one minute, e.g. 2.1mL/min, by the
number of drops in 1mL for the IV tubing you are using. This gives the drip rate in
the IV per minute. Example: Macro drip is 10drops/mL.
mL per minute X 10 drops/mL = drops/minute
2.1 X 10
= 21 drops per minute
ANSWER: The drip rate for the IV is regulated at 21 drops per minute to
administer 1000mL of D5W q 8 hr using a macro drip IV tubing with a drop factor
of 10 drops per minute.
Med study guide revised by DMC Medication Exam Taskforce, 4/10
Page 4
IVPB ADMINISTRATION
Give Lasix 40 mg. IVPB q 6 hr. Administer in 50mL of 5% D5W. Run solution over 30
minutes using macro tubing (10gtts/mL)
Method 1
50mL
30 min
= 1.7mL/min (Rounded off to the nearest tenth)
ANSWER: 1.7mL /mL x 10gtts/mL
= 17gtts/min
Method 2
Total volume x drip factor
Total duration in minutes
(hours x 60 minutes)
= drip rate
Give: 1000mL D5W q 8hr (using regular tubing 10gtts/mL)
1000 x 10
8 x 60
=
drip rate
10000
480
Med study guide revised by DMC Medication Exam Taskforce, 4/10
=
21
ANSWER: 21gtts/min
Page 5
Mini vs Macro: The Great Debate
Ever have trouble deciding which type of IV tubing to use or how to calculate mL/hour
and drops per minute? Here are some simple guidelines:
1. To calculate mL/hr:
Total amount of IV fluid
Length of time over which it is to infuse
Example: 250mL = 62mL
4 hours 1 hour
1000mL = 25mL
8 hours I hour
= mL per hour
2. To decide whether or not to use micro (Pediatric) or macro (Adult) drip tubing using
the following rule of thumb:
a. Use the Pediatric Microdrip tubing if IV is to infuse at 50mL/hr or less ( for
example: KVO, q 24hr).
b. Use Adult Macrodrip tubing if IV is to infuse at 75mL/hr or greater (q 8hr,
q 6hr, and q 4hr IVs)
3. To calculate drops/min:
Amount of fluid to be infused in one hour (60 min) x drip factor = drop rate
60 minutes
a) Micro tubing relationship is 1:1. Whatever amount of fluid you want to infuse
each hour is the number of drops per minute. E.g. If you are to infuse 75mL
per hour, you will infuse 75 drop per minute.
b) Macro tubing drop factor is 10 drops per mL. Short Cut: Since 10/60 cancels
out to1/ 6, simply divide amount of fluid to be infused by 6 in order to give drops
per minute. 125mL/ 6 = 20.8 or 21 drops per minute.
Be sure you look carefully at the tubing you’ve selected. If you accidentally use
MACRO when you meant to use MICRO and you infuse at the rate for MICRO,
patient will receive SIX TIMES as much fluid as they should have. Remember
during a Code Blue/Emergency situation MACRODRIP tubing should be hung.
Medicated drips should be placed on pumps. Remove saline lock devices (small
bore extension sets, etc) during emergency situations. They make bolusing IV
Fluids very difficult.
Med study guide revised by DMC Medication Exam Taskforce, 4/10
Page 6
Calculating Heparin Dosages
Order is for 25,000units heparin in 250mL to run at 800 units per hour. How many mLs
per hour will you regulate the IV?
You can set it up as a ratio and proportion. But first it’s always easier to simplify by
reducing your fractions if possible.

25,000 units per 250mL reduces to 100 units per 1mL

Set up your ratio / proportion to solve for how many mLs will contain 800
units.
100 units 1mL 800 units: x mL


Multiply the means and the extremes (product of the inner numbers = the
product of the outer numbers)
100 x = 800
x = 8 You will need to run 8mLs per hour
Calculating Lidocaine Drip Rate
Order is for 2 grams of lidocaine in 500mL to run at 2 mg per minute. How many mLs
per hour will you regulate the IV?

Convert grams to mg by multiplying by 1000
2 x 1000 = 2000

Simplify 2000 mg per 500mL
2000 mg per 500mL reduces to 4 mg per mL

Set up your ratio / proportion to solve for how many mLs will contain 2 mg
4mg: 1mL
2 mg: x mL
Multiply the means and the extremes (product of the inner numbers = the
product of the outer numbers)

2 = 4x

x = 0.5 (one half) of a mL
Now how many mLs per hour is 0.5mL per minute?
0.5mL : 1 minute = x mL : 60 min
x = 30mLs Run the lidocaine at 30mLs per hour (30minidrips per min)
Med study guide revised by DMC Medication Exam Taskforce, 4/10
Page 7
REFERENCE ONLY:
Calculating critical care dosages (Eg: Dopamine dosages (mLs per hour and mcg
per kg per min.)
Patient Care Services Critical Care Educators teach a 5 step method which will work for
calculating many meds including:
Mcg / kg / min (ex: dopamine, dobutamine)
Mcg / min (ex: epinephrine, nitroglycerin)
Mg / min (ex: lidocaine)
Units / hour (ex: heparin)
Use only the steps which are necessary. For example if the medication is not ordered
according to body weight, you can skip the step where you divide by kg.
I.
Start with the concentration of mg / mL or grams / mL
II.
Multiply by 1000 if you need to change mg to mcg or grams to mg
(For example the concentration of dopamine might be 800 mg in 250mL
and the final order is written in terms of mcg so you need to multiply by
1000 so that you will end up with mcg.)
III.
Divide by 60 if you need to end up with a rate per minute or per hour.
IV.
Divide by kg if ordered according to weight.
Above steps will give you a numerical constant for this patient at this kg weight and
this drug concentration. What’s great about this is that if the order changes from 5
mcg/kg/min to 6 mcg/kg/min, you have already done the calculating, taking into
amount the patient's weight, the concentration of the drug, and the time constant of
60 min per hour. You can use the numerical constant and plug it into the last step
shown below.
V. Now decide: Do you need to know the dose or the rate?
If you need to know the dose: Dose = mL / hour X numerical constant
If you need to know the rate: Rate = Dose divided by numerical constant
Example: When you come on duty you find the dopamine 400 mg in 250 mL is
running at
22mL/hour. The patient weighs 55 kg. You want to know how many mcg/kg/min
this is:
i. Start with the concentration
ii. Multiply by 1000
Med study guide revised by DMC Medication Exam Taskforce, 4/10
400 mg
250mL
400 x 1000 = 1600
250
Page 8
iii. Divide by 60
1600 = 26.6
60
iv. Divide by weight
26.6 =0.48
55
v. Need to know the dose, so multiply mL/hour by numerical
constant, which is 0.48
22 x 0.48 = 10.5
Patient is receiving 10.5mcg/kg/min
Another example: The order is for dopamine to run at 5mcg/kg/min. The
concentration is 800mg /500 mL. Patient weight is 70 kg.
i. Start with the concentration (mg / mL)
ii. Multiply by 1000
iii. Divide by 60
(mcg / mg)
(min / hour)
iv. Divide by weight (kg)
800
500
800 x 1000 = 1600
500
1600 = 26.6
60
26.6 = 0.38
70
v. Need to know the rate, so divide Dose ordered by the numerical
constant, which is 0.38
5 = 13
0.38
Run the IV at 13mLs per hour
Alternate methods for calculating Dopamine:

To Find mcg/kg/min use this formula
mcg/mL x mL/hr
60min/hr x kg of body weight

= mcg/kg/min
To Find mL/hr use this formula
Dose mcg/kg/min x 60min/hr x body weight
mcg/mL of solution
= mL/hr
Med study guide revised by DMC Medication Exam Taskforce, 4/10
Page 9
PRACTICE PROBLEMS: EQUIVALENTS
1. 0.25 Gm
=
mg
8. 2 L
=
mL
2. 0.4 Gm
=
mg
9. 0.4 mg
=
mcg
3. 2 GM
=
mg
10. 0.125 mg
=
mcg
4. 125 mg
=
Gm
11. 250 mcg
=
mg
5. 750 mg
=
Gm
12. 200 mcg
=
mg
6. 50 mg
=
Gm
13. 154 Lb
=
Kg
7. 250mL
=
L
14. 1.5 ounces
=
mL
Practice Problems: DOSAGE CALCULATIONS
1. The physician’s order reads: prochlorperazine (Compazine) 10mg IM stat. You have a 2mL
pre-filled syringe, 5mg/mL. How many mLs will you administer?
Answer:
2. How many capsules are necessary to administer diphenhydramine (Benadryl) 50 mg, from
capsules labeled Benadryl 25mg?
Answer:
3. Meperidine HCL (Demerol) 35mg IM q 4hr prn pain is ordered. The pre-filled cartridgeneedle unit is labeled: Meperidine 50mg/mL. (Express your answer in a decimal fraction,
i.e., ½ = 0.5)

What volume will you discard?
Answer:

Answer:
What volume will you administer?
4. Dexamethasone (Decadron) 1.5mg is ordered qid and is supplied by the pharmacy as 750
mcg scored tablets. How many tablet(s) would you prepare to comply with the physician’s
order?
Answer:
5. Digoxin (Lanoxin) elixir 0.125mg (p.o.) qam (daily) is ordered. You have been given Digoxin
elixir 50mcg(0.05mg) per mL. What volume will you prepare?
Answer:
Med study guide revised by DMC Medication Exam Taskforce, 4/10
Page 10
Practice Problems: IV CALCULATIONS AND IV MEDICATIONS
1. The physician’s order reads: 1000mL D 5W with 20meq KCL every 12 hours. Calculate the
drops/minute using macro drip tubing (10gtts/mL).
Answer:
2. The physician’s order reads: 1000mL D 5W every 24 hours at a KVO (keep open rate).
Calculate the drop rate using microdrip tubing (60gtts/mL) is used?
Answer:
3. The physician order reads: 500mL D5 and 0.33 Sodium Chloride, with 1 ampule of MVI every
24 hours. Calculate the drop rate per minute using micro drop tubing (60gtts/mL).
Answer:
4. The physician’s order reads: Ampicillin 500mg IVPB every 6 hours in 100mL D 5W. The
secondary administration rate delivers 10 gtts/mL.
a. Calculate the drop rate per minute administering the medication over 30 minutes
Answer:
b. Calculate the drop rate per minute administering the medication over 45 minutes.
Answer:
5. 10% Fat Emulsion (Intralipids) 500mL is ordered daily at 1300. Calculate drops per minute,
using tubing that is calibrated at 20gtts/mL. Infuse the “lipids” over 4 hours.
Answer:
6. Your patient is to receive a unit of blood (350mL), using tubing that is calibrated at 10gtts/mL.
How fast should you run it to complete the transfusion in 2 hours?
Answer:
7. Heparin 25,000 Units in 250mL is ordered at 1000 units per hour. How many mLs per hour
will you run?
Answer:
8. Lidocaine 2grams in 250mL is ordered at 2mg per minute. How many mLs will you run per
hour?
Answer:
Med study guide revised by DMC Medication Exam Taskforce, 4/10
Page 11
Answer Key
EQUIVALENTS
Page 9
1. 250 mg
2. 400 mg
3. 2000 mg
4. 0.125 Gm
5. 0.75 Gm
6. 0.05 Gm
7. 0.25 L
8. 2000mL
9. 400 mcg
10. 125 mcg
11. 0.25 mg
12. 0.2 mg
13. 70 Kg
14. 45 mL
DOSAGE
Page 9
1. 2mL
2. 2 capsules
3. Discard: 0.3mL
administer: 0.7mL
4. 2 tablets
5. 2.5mL
Med study guide revised by DMC Medication Exam Taskforce, 4/10
IV CALCULATIONS AND IV MEDICATIONS
Page 10
1.
2.
3.
4.
5.
6.
7.
8.
14 gtts/min
41 gtts/min
21 gtts/min
A. 33 gtts/min B. 22 gtts/min
41 – 42 gtts/min
29 gtts/min
10 mL per hour
15 mL per hour
Page 12
Safe Medication Delivery
ABBREVIATIONS
 The use of abbreviations is discouraged.
 Avoid the use of abbreviations for drug names and drug regimens.
 The following abbreviations / dose designations are considered dangerous and will
NOT be accepted on medication orders, MARs and on verbal/telephone orders.
Safe abbreviations must be used throughout the ENTIRE patient medical record, not
only for medication orders.
Information from the Joint Commission
In May 2005, The Joint Commission affirmed its “do not use” list of abbreviations. The
list was originally created in 2004 by The Joint Commission as part of the requirements
for meeting National Patient Safety Goal Requirement 2B (Standardize a list of
abbreviations, acronyms and symbols that are not to be used throughout the
organization)
For accreditation purposes, the official “do not use” list applies, at a minimum, to all
orders and all medication-related documentation that is handwritten (including free-text
computer entry) or on pre-printed forms. This requirement does not currently apply to
preprogrammed health information technology systems (for example, electronic medical
records or CPOE systems), but remains under consideration for the future.
Organizations contemplating introduction or upgrade of such systems should strive to
eliminate the use of dangerous abbreviations, acronyms, symbols, and dose
designations from the software.
For more information see Facts about the Official "Do Not Use" List.
Med study guide revised by DMC Medication Exam Taskforce, 4/10
Page 13
OFFICIAL JOINT COMMISSION “DO NOT USE” LIST
Citation: http://www.jointcommission.org/NR/rdonlyres/2329F8F5-6EC5-4E21-B93254B2B7D53F00/0/dnu_list.pdf
Med study guide revised by DMC Medication Exam Taskforce, 4/10
Page 14
Medication Administration Information
THE 5 RIGHTS OF MEDICATION ADMINISTRATION INCLUDE:
12345-
GIVING THE RIGHT ROUTE
GIVING THE RIGHT DOSE
GIVING THE RIGHT DRUG
GIVING IT TO THE RIGHT PATIENT
GIVING IT AT THE RIGHT TIME
NOTE: SOME RESOURCES NOW CITE 10 RIGHTS OF MEDICATION ADMINISTRATION:
1. RIGHT SAFETY MEASURES
2. RIGHT MEDICATION
3. RIGHT TIME FRAME
4. RIGHT DOSE AND STRENGTH
5. RIGHT ROUTE AND METHOD
6. RIGHT PATIENT
7. RIGHT OF PATIENT TO UNDERSTAND ALL MEDICATIONS
8. RIGHT OBSERVATIONS (ABOUT PATIENT RESPONSE TO MEDICATIONS)
9. RIGHT INTERVENTIONS AND NOTIFICATIONS
10. RIGHT DOCUMENTATION
KEY ASPECTS OF MEDICATION ADMINISTRATION
1. Indication /Action
2. Side Effects
3. Associated Laboratory Tests
4. Contraindications
5. Antidotes
6. Patient Teaching
7. Nursing Interventions
8. Drug Interactions (drug-drug, drug-food, drug-alcohol)
9. Legal Aspects of Drug Administration
10. Administration Techniques
BEST PRACTICES for Safe Medication Administration
DMC Medication Turn-Around times:
STAT ≤ 20 minutes
Now ≤ 1 hour
Routine ≤ 4 hours
Med study guide revised by DMC Medication Exam Taskforce, 4/10
Page 15
Confirmation of Identification:
Safe medication use necessitates the confirmation of identification—identification of
patients and of medications. Medication errors are the most common type of medical
error and contribute to 7000 deaths a year, with an estimated $3.5 million to treat drugrelated injuries occurring in hospitals (IOM, 2006). How much time does it really take to
confirm the patient identification and be certain about the medication being prescribed,
prepared, dispensed and administered? The time taken to confirm all elements of
identification may save a life. When in doubt, check it out!
Verbal and Telephone orders:
Read Back all verbal/telephone orders following receipt.
Exercise precaution when transcribing any medication order.
Medication Reconciliation:
Medication reconciliation is the process of comparing a patient's medication orders to
all of the medications that the patient has been taking. This reconciliation is done to
avoid medication errors such as omissions, duplications, dosing errors, or drug
interactions. It should be done at every transition of care in which new medications are
ordered or existing orders are rewritten. Transitions in care include changes in setting,
service, practitioner or level of care.
NPSG: Medication Reconciliation
This National Patient Safety Goal, “Selected Risk Points in Medication Reconciliation,”
addresses significant risk points associated with maintaining and communicating
patient’s medication information. The risk points include obtaining current medication
information when the patient enters the hospital, comparing the patient’s current
medications to any new medications ordered for the patient, and providing the patient
with updated medication information when he or she leaves the hospital’s care.
This goal complements existing Joint Commission standards that currently address
components of medication reconciliation, including, but not limited to,
 The hospital plans its medication management processes.
 A pharmacist reviews the appropriateness of all medication orders for
medications to be dispensed in the hospital.
 The hospital safely administers medications.
 The hospital coordinates the patient’s care, treatment, and services based on the
patient’s needs.
 The hospital provides patient education and training based on each patient’s
needs and abilities.
 Before the hospital discharges or transfers a patient, it informs and educates the
patient about his or her follow-up care, treatment, and services.
 When a patient is discharged or transferred, the hospital gives information about
the care, treatment, and services provided to the patient to other service
providers who will provide the patient with care, treatment, or services.
 The hospital maintains complete and accurate medical records for each
individual patient.
Med study guide revised by DMC Medication Exam Taskforce, 4/10
Page 16
Drug Diversion
 According to evidence, one out of 10 Healthcare workers have a drug addiction.
When you sign for wastage, you are responsible for checking: correct drug, correct
amount and correct patient. By signing you are stating the above are correct.
Through awareness and knowledge of what to look for, you can help stop diversion and
assist dependent co-workers. Be alert to changes in job performance, physical
symptoms and behavior.
POLICIES ASSOCIATED WITH SAFE MEDICATION ADMINISTRATION
MED 121 Controlled Substances Management
Wasting Medication
o Two licensed caregivers are required to waste a controlled substance; one
to waste and one to witness.
o Wasted medication is documented on the CSDR or PMFS and the wasted
portion is to be disposed of according to nursing procedure
2PHA 301 Controlled Substances Proactive Diversion Monitoring
o Monthly PYXIS Controlled Substance Report
o On a monthly basis, RN/LPN/MDA/CRNA PYXIS controlled substance high
user/waster reports are generated by the pharmacy department and sent to the
respective nurse managers.
o The pharmacy department maintains a copy of these reports.
The nurse who is diverting drugs from the unit may...
 Frequently volunteer to give medications.
 Medicate another nurse's patient.
 Use the maximum PRN dosage when other nurses use less, or the maximum
PRN dosage may always be used on one shift but not on another (the PRN
medications afford the greatest opportunity for the nurse to supply his/her habit).
 Have responsibility for patients who complain that the medication given on one
shift is not as effective as the medication given on another shift; or, that the
patient did not receive medication when the records indicate they did.
 Have high narcotic usage and waste reported
 Work on a unit where PYXIS discrepancies occur more frequently.
 Frequently offer to help resolve narcotic discrepancies
 Have pinpoint pupils and/or shaky hands.
 Appear to be sleepy and/or hyper while on duty.
Med study guide revised by DMC Medication Exam Taskforce, 4/10
Page 17
Signs and symptoms – job performance











Late to work
Poor judgment
Disorganization
Blames others
Commits errors
Increased sick day usage
Appears on the unit on days off
Disregards standards of care and practice
Unreasonable excuses for poor performance
Confusion about the work schedule
Frequent breaks or time away from the work area
Signs and symptoms – physical symptoms










GI upset
Shakiness
Difficulty with speech
Inattentiveness
Increased anxiety
Watery Eyes
Diarrhea
Swollen hands
Always cold
Wears long sleeves/sweaters on hot days









Signs and symptoms – behavior changes
Mood swings
Suspiciousness
Drowsiness at work
Depression
Unusual attendance patterns
Defensiveness
Over reaction to criticism
Disappearance from unit after accessing drugs
Telling lies or fabrication of the truth
Citation: Rick McCarty, Director Security Investigation/OP, 2010
Med study guide revised by DMC Medication Exam Taskforce, 4/10
Page 18
Therapeutic Administration
Therapeutic Drug Monitoring
Definitions
Therapeutic Drug Monitoring (TDM): a means of monitoring drug levels in the blood.
TDM is practical tool that can help the healthcare team provide effective and safe drug
therapy in the patients who need medications.
Peak Level: drawn during the drug’s highest therapeutic concentration
Trough Level: drawn during the drug’s lowest therapeutic concentrations
Random level: drawn during any point of the dosing interval
Purpose
TDM is utilized to measure blood drug levels so that the most effective dosage can be
determined, with toxicity prevented.
It is very important that the ACTUAL time of blood draw is documented for proper
interpretation of the level.
Depending on the drug, it may be desirable to measure a peak and/or a trough and/or a
random level.
TROUGH levels should be taken as close to the end of the dosing interval as possible.
In other words, TROUGH levels are drawn immediately before the next dose is due.
PEAK levels are usually drawn 1 hour after the administration of the drug (e.g.
gentamycin, tobramycin). However, the peak levels of some drugs may be several
hours following drug administration (e.g. 4-8 hours after an oral dose of phenytoin). For
these t ypes of medications, random levels are usually sufficient.
When drug levels are required, it is important that it is specifically defined whether a
peak, trough or random level is needed. In addition, if not known, it is important to
clarify any uncertainty regarding the timing of a desired level. Samples should be
analyzed as soon as possible… so send them to the lab immediately after obtaining
them.
DMC Policies
2 MED 607 Therapeutic Drug Monitoring: Antimicrobials and Anticoagulants
2 MED 607 Attachment 1 -- Therapeutic Drug Monitoring: Aminogycosides
2 MED 607 Attachment 2 -- Therapeutic Drug Monitoring: Vancomycin in Adults
2 MED 607 Attachment 3 -- Therapeutic Drug Monitoring-Antimicrobials-Ordering of
Laboratory Tests to Assess for Adverse Drug Events
2 MED 607 Attachment 4 -- Therapeutic Drug Monitoring-Pediatric Dosing of
Aminoglycosides
2 MED 607 Attachment 5 -- Therapeutic Drug Monitoring-Pediatric Dosing of
Vancomycin
Med study guide revised by DMC Medication Exam Taskforce, 4/10
Page 19
DMC Guidelines
Therapeutic Use of Anticoagulants in Adults and DMC Pediatric Anticoagulation
Guidelines:
Go to Pharmacy Home web site:
http://intraweb/default.aspx?ifsrc=/pharmweb/
Click on anticoagulation
Reason for Therapeutic Drug Monitoring
Anticoagulation therapy can be used for therapeutic treatment for a number of
conditions, such as atrial fibrillation, deep vein thrombosis, pulmonary embolism, and
mechanical heart valve implant. It is important to note that anticoagulation medications
are more likely than others to cause harm due to complex dosing, insufficient
monitoring, and inconsistent patient compliance.
Antimicrobial therapy is used in the treatment of infectious disease. Maintaining
therapeutic drug levels will improve outcomes.
Glycemic Control -To Hold or Not to Hold Insulin
Do Not Hold
Insulin Glargine (Lantus®)--Basal
Do not hold long acting (basal) insulin even if the patient is NPO, nauseated, vomiting,
going to OR, etc. It is safe to administer in these situations, it has no “peak”. It is
meant to cover glucose produced between meals and during the night. If dosed
appropriately, glargine does not cause hypoglycemia. Basal insulin is required by all
patients with Type I diabetes at all times. Therefore, DO NOT HOLD IT! If blood
sugars are consistently <90 mg/dL call the physician to adjust the dose.
Insulin Aspart (Novolog®)--Correction Doses
Do not hold correction doses which are used to cover existing hyperglycemia regardless
of nutrition status. Give as ordered per blood glucose result within 30 minutes of CBG
test. As long as the patient is eating meals, it is appropriate to give both prandial and
correction doses of insulin aspart as prescribed.
Hold
Aspart (Novolog®) Insulin--Prandial Doses
Many patients have orders for scheduled meal time (prandial) doses of rapid acting
insulin aspart. Hold or decrease this scheduled mealtime dose if the patient is not
eating, NPO, nauseated or vomiting. Giving insulin aspart in this situation can cause
hypoglycemia. Insulin aspart peaks quickly and is meant only to cover the increased
glucose from food.
Contact the physician/LIP when holding any dose of insulin unless there is a specific
order to hold the insulin.
Citation: DMC Short and Sweet, a Publication of the DMC Glycemic Control Team, 6/10
Med study guide revised by DMC Medication Exam Taskforce, 4/10
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MEDICATION GROUPS
It is most helpful to study medications in groups or classifications, rather than as single
drugs. The medication groups REFERENCED ARE:
1. Anti-infective Drugs
2. Cardiovascular System Drugs
3. Central Nervous System Drugs
4. Gastrointestinal Drugs
5. Hormonal Agents
6. Agents for Fluid and Electrolyte Balance
7. IV Fluid therapy and TPN
8. Medication Administration Techniques
9. Miscellaneous
10. Therapeutic Drug Monitoring
REFERENCE RESOURCES:
The following resources are available for additional information:
1. Links for micromedix or other pharmacy sources for finding medications.
http://dmc-micromedex/home/dispatch
DMC pharmacy website
(Intraweb → Pharmacy → Department of Pharmacy Services)
2. Links for patient education material, especially related to medications given
(Intraweb → Library → Patient and Family Education)
3. National Patient Safety Goals:
http://intraweb/default.aspx?ifsrc=/content.aspx?id=299&sid=1
(Intraweb → Quality and Safety → quality and safety resource center →
then regulatory)
4. Links to access DMC (or site specific) Policies :
http://intraweb/
(Go to intraweb, click on the header 'Policies')
Med study guide revised by DMC Medication Exam Taskforce, 4/10
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5. Other notable medication administration policies:
2MED 121 Controlled Substances Management
2MED 500 EMR Medication: Order, Administration and Documentation
2MED 501 Intravenous Push(IVP) Medication, Approval of
2 MED 607 Therapeutic Drug Monitoring: Antimicrobials and Anticoagulants
2MED 1004 Medication Administration by an LPN
2PC 412 Pain Management: Epidural, Interplural or Nerve Block Infusion
2 PC 413 Pain Management: Patient Controlled Analgesia (PCA)
2 PC 563 Intravenous Piggyback Infusion
6. Non-DMC useful sites:
http://www.jointcommission.org/PatientSafety/DoNotUseList/
Med study guide revised by DMC Medication Exam Taskforce, 4/10
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