NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Pharmacology [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2023.
• Discuss federal and state laws, regulations, and guidelines for safe medication administration
• Identify drug administration guidelines within the State Nurse Practice Act
• Identify ethical responsibilities related to medication administration
• Identify nursing responsibilities associated with controlled substances
• Identify nursing responsibilities to prevent and respond to medication errors
• Explain how nursing response reflects respect for a client’s rights and responsibilities with drug therapy
• Outline nursing actions within the scope of nursing practice as they relate to the administration of medication
• Demonstrate patient-centered care during medication administration by respecting a client’s gender, psychosocial, and cultural needs
• Identify nursing responsibilities associated with safe medication administration
• Identify nursing responsibilities associated with health teaching and health promotion[1]
Medication administration is an essential task nurses perform while providing client care. However, safe medication administration is more than just a nursing task; it is a process involving several members of the health care team, as well as legal, ethical, social, and cultural issues. The primary focus of effective medication administration by all health professionals is patient safety. Although many measures have been put into place over the past few decades to promote improved patient safety, medication errors and adverse effects continue to be a common event. The World Health Organization (WHO) states that unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. Globally, the cost associated with medication errors has been estimated at $42 billion USD annually.[2] This chapter will examine the legal and ethical foundations of medication administration by nurses, as well as the practice standards and cultural and social issues that must be considered to ensure safe and effective administration of medication.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
The American Nurses Association (ANA) is a professional organization that represents the interests of the nation’s four million registered nurses and is at the forefront of improving the quality of health care for all.[1] The ANA establishes ethical and professional standards for nurses that also guide safe administration of medications. These code of ethics and professional standards are described in ANA publications titled Code of Ethics for Nurses and Nursing: Scope and Standards of Practice.
The ANA developed the Code of Ethics for Nurses as a guide for carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession.[2] Several provisions from the Code of Ethics impact how nurses should administer medication in an ethical manner. A summary of each provision from the Code of Ethics and how it pertains to medication administration is outlined below:
Provision 1 focuses on respect for human dignity and the right for self-determination: “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.”
Provision 2 states, “The nurse’s primary commitment is to the client…”[3] In health care settings, nurses often experience several competing loyalties, such as to their employer, to the doctor(s), to their supervisor, or to others on the health care team. However, the client should always receive the primary commitment of the nurse. Additionally, the client has the right to accept, refuse, or terminate any treatment, including medications.
Provision 3 states, “The nurse promotes, advocates for, and protects the rights, health, and safety of the patient…”[4] This provision includes a nurse’s responsibility to promote a culture of safety for clients. If errors occur, they must be reported, and nurses should ensure responsible disclosure of errors to clients. This also includes proper disclosure of questionable practices, such as drug diversion or impaired practice by any professional.
Provision 4 involves authority, accountability, and responsibility by a nurse to follow legal requirements, such as state practice acts and professional standards of care.
Provision 5 includes the responsibility of the nurse to promote health and safety.Provision 6 focuses on virtues that make a nurse a morally good person. For example, nurses are held accountable to use their clinical judgment to avoid causing harm to clients (maleficence) and to do good (beneficence). When administering medications, nurses should validate the medication is doing more “good” than “harm” (adverse or side effects).
Provision 7 focuses on a nurse practicing within the professional standards set forth by their state nurse practice act, as well as standards established by professional nursing organizations.
Provision 8 explains that a nurse must address the social determinants of health, such as poverty, education, safe medication, and health care disparities.[5]
Whenever a nurse provides client care, the ANA’s Code of Ethics should be used as a guide for professional ethical behavior.
A nurse is preparing to administer medications to a client. While reviewing the chart, the nurse notices two medications with similar mechanisms of action have been prescribed by two different providers.
What is the nurse’s best response?
Note: Answers to the Critical Thinking activities can be found in the “Answer Key” sections at the end of the book.
The ANA publishes Nursing: Scope and Standards of Practice. This resource establishes national standards for nurses and is updated regularly.[6]
The ANA defines the scope of nursing as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations.” A registered nurse (RN) is defined as an individual who is educationally prepared and licensed by a state to practice as a registered nurse. Nursing practice is characterized by the following tenets[7]:
Caring and health are central to the practice of the registered nurse. Nursing practice is individualized to the unique needs of the health care consumer.Registered nurses use the nursing process to plan and provide individualized care for health care consumers.
Nurses coordinate care by establishing partnerships to reach a shared goal of delivering safe, quality health care.
The ANA establishes Standards of Practice and Standards of Professional Performance in the Nursing: Scope and Standards of Practice publication. State nurse practice acts further define the scope of practice of RNs and Licensed Practical Nurses/Vocational Nurses (LPNs/VNs) within each state. Nurse practice acts are further discussed in the “Legal Foundations and National Guidelines for Safe Medication Administration” section of this chapter.
The ANA’s Standards of Practice are authoritative statements of duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently. Standards of Practice include assessment, diagnosis, outcome identification, planning, implementation, and evaluation (ADOPIE) components of providing client care, also known as the “nursing process.” When nurses safely administer medication, all components of ADOPIE are addressed.
The “Assessment” Standard of Practice is defined as, “The registered nurse collects pertinent data and information relative to the health care consumer’s health or the situation.”[8] A registered nurse uses a systematic method to collect and analyze client data. Assessment includes physiological data, as well as psychological, sociocultural, spiritual, economic, and lifestyle data. For example, when a nurse assesses multiple pieces of data for a hospitalized client with pain, this is considered part of a comprehensive pain assessment.
The “Diagnosis” Standard of Practice is defined as, “The registered nurse analyzes the assessment data to determine actual or potential diagnoses, problems, and issues.”[9] A nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs. Nursing diagnoses are used to create the nursing care plan and are different than medical diagnoses.[10]
The “Outcomes Identification” Standard of Practice is defined as, “The registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation.”[11] The nurse sets measurable and achievable short- and long-term goals and specific outcomes in collaboration with the client based on their assessment data and nursing diagnoses.
The “Planning” Standard of Practice is defined as, “The registered nurse develops a collaborative plan encompassing strategies to achieve expected outcomes.”[12] Assessment data, diagnoses, and goals are used to select evidence-based nursing interventions customized to each client’s needs and concerns. Goals, expected outcomes, and nursing interventions are documented in the client’s nursing care plan so that nurses, as well as other health professionals, have access to it for continuity of care.[13]
The “Implementation” Standard of Practice is defined as, “The nurse implements the identified plan.”[14] Nursing interventions are implemented or delegated to licensed practical nurses/vocational nurses (LPNs/VNs) or unlicensed assistive personnel (UAP) with supervision. Interventions are also documented in the client’s electronic medical record as they are completed.[15]
The “Implementation” Standard of Professional Practice also includes the subcategories “Coordination of Care” and “Health Teaching and Health Promotion” to promote health and a safe environment.[16]
The ANA standard for coordination of care states, “The registered nurse coordinates care delivery.”[17] When ensuring medications are administered safely, the nurse collaborates with the client and the interprofessional health care team to meet mutually agreed upon outcomes. The nurse also engages the client in self-care to achieve their preferred goals for quality of life. For example, one client with chronic pain may have a pain management goal of “5” with their quality of life preference of having the ability to participate in social activities with friends but not experiencing burdensome side effect of medication. Another client with chronic pain may have a pain management goal of “0” with a quality of life preference of having no pain no matter what the side effects. The nurse advocates for these clients’ goals and preferences with the interprofessional team.
Nurses also serve vital roles in ensuring safe transitions and continuity of care regarding clients’ use of medications. Additional information about safe medication use and transitions of care is discussed in the “Preventing Medication Errors” section of this chapter.
When administering medications, nurses teach clients about the medications and potential side effects to promote optimal health. The ANA standard for health teaching and health promotion states, “The registered nurse employs strategies to teach and promote health and wellness.”[18] Specific behaviors related to teaching about medication are as follows[19]:
Use health teaching and health promotion methods in collaboration with the client’s values, beliefs, health practices, developmental level, learning needs, readiness and ability to learn, language preference, spirituality, culture, and socioeconomic status.
Provide clients with information and education about intended effects and potential adverse effects of the plan of care.
Provide anticipatory guidance to clients to promote health and prevent or reduce risk.In the book Preventing Medication Errors by the Institute of Medicine (2007), the following are additional key national guidelines when teaching clients about safe use of their medications:
Clients should maintain an active list of all prescription drugs, over-the-counter (OTC) drugs, and dietary supplements they are taking, the reasons for taking them, and any known drug allergies. Every provider involved in the medication-use process for a client should have access to this list.
Clients should be provided information about side effects, contraindications, methods for handling adverse reactions, and sources for obtaining additional objective, high-quality information.[20]
The “Evaluation” Standard of Practice is defined as, “The registered nurse evaluates progress toward attainment of goals and outcomes.”[21] During evaluation, nurses assess the client and compare the findings against the initial assessment to determine the effectiveness of the interventions and overall nursing care plan. Both the client’s status and the effectiveness of the nursing care must be continuously evaluated and modified as needed.[22]
ANA’s Standards of Professional Performance describe a competent level of behavior for nurses, including activities related to ethics, culturally congruent practice, communication, collaboration, leadership, education, evidence-based practice, and quality of practice.[23]
The ANA defines culturally congruent practice as the application of evidence-based nursing that is in agreement with the preferred cultural values, beliefs, worldview, and practices of the health care consumer and other stakeholders. Cultural competence represents the process by which nurses demonstrate culturally congruent practice. Nurses must assess the cultural beliefs and practices of their clients and implement culturally congruent interventions when administering medications and teaching about them. Additional information about cultural implications for medication administration is further discussed in the “Cultural and Social Determinants Related to Medication Administration” section later in this chapter.
A nurse is preparing to administer metoprolol, a cardiac medication, to a client and implements the nursing process:
ASSESSES the vital signs prior to administration and discovers the heart rate is 48.
DIAGNOSES that the heart rate is too low to safely administer the medication per the parameters provided. Establishes the OUTCOME to keep the client’s heart rate within normal range of 60-100.
PLANS to call the provider, as well as report this incident in the shift handoff report.
Implements INTERVENTIONS by withholding the metoprolol at this time, documenting the incident that the medication is withheld, and notifying the provider.
Continues to EVALUATE the client status throughout the shift after not receiving the metoprolol.
The nurse is providing health teaching to a client about the medication before discharge. The nurse provides a handout with instructions, as well as a list of the current medications.
What other information should be provided to the client?
Note: Answers to the Critical Thinking activities can be found in the “Answer Key” sections at the end of the book.
Figure 2.1 is an image from Nursing: Scope and Standards of Practice by the ANA that illustrates how the scope of practice, standards of practice, and code of ethics form the “base” of nursing practice.[24] Nursing practice is further guided by the Nurse Practice Act in the state in which a nurse works, federal and state rules and regulations, institutional policies and procedures, and self-determination by the individual nurse. All these components are required to provide quality, safe client care that is evidence-based. These components will be further discussed in the remaining sections of this chapter.
ANA Model of Professional Nursing Practice
The National Council Licensure Examination (NCLEX) is the national exam that graduates must pass successfully to obtain their nursing license after graduating from a nursing program of study. The NCLEX-PN is taken to become a licensed practical/vocational nurse (LPN/VN), and the NCLEX-RN is taken to become a licensed registered nurse (RN). The purpose of the NCLEX is to evaluate if a nursing graduate demonstrates the ability to provide safe, competent, entry-level nursing care. The NCLEX is developed by the National Council of State Boards of Nursing (NCSBN), an independent, nonprofit organization composed of the 50 state boards of nursing and other regulatory agencies.[25]
A new edition of the NCLEX was launched in April 2023 that contains “Next Generation” questions. The Next Generation NCLEX (NGN) assesses how well the candidate can think critically and use clinical judgment. The NCSBN defines clinical judgment as “the observed outcome of critical thinking and decision-making. It is an iterative process with multiple steps that uses nursing knowledge to observe and assess presenting situations, identify a prioritized client concern and generate the best possible evidence-based solutions in order to deliver safe client care.”
The NCLEX uses the NCSBN’s Clinical Judgment Measurement Model (NCJMM) to assess the candidate’s ability to use safe clinical judgment when providing nursing care. Exam questions used to assess clinical judgment may be contained in a case study or as individual stand-alone items. A case study contains six questions that are associated with the same client scenario and addresses the following steps in clinical judgment[26]:
Recognize cues: Identify relevant and important information from different sources (e.g., medical history, vital signs).
Analyze cues: Organize and connect the recognized cues to the client’s clinical presentation.Prioritize hypotheses: Evaluate and prioritize hypotheses (based on urgency, likelihood, risk, difficulty, time constraints, etc.).
Generate solutions: Identify expected outcomes and use hypotheses to define a set of interventions for the expected outcomes.
Take action: Implement the solution(s) that address the highest priority. Evaluate outcomes: Compare observed outcomes to expected outcomes.Throughout this book, learning activities are provided to assist students in learning how to apply the nursing process (i.e., ANA’s Standards of Care) to answer NGN-style questions that evaluate clinical judgment. Some of these activities are written, with answers in the Answer Key at the end of the book, and others are interactive and require use of the online book.
American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. https://www .nursingworld .org/coe-view-only ↵.
American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. https://www .nursingworld .org/coe-view-only ↵.
American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. https://www .nursingworld .org/coe-view-only ↵.
American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. https://www .nursingworld .org/coe-view-only ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (3rd ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
Institute of Medicine. (2007). Preventing medication errors. The National Academies Press. 10.17226/11623 ↵ 10.17226/11623. [CrossRef] [CrossRef]
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
American Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). American Nurses Association. ↵.
NCSBN. (n.d.). 2023 NCLEX-RN test plan. https://www .ncsbn.org/exams/testplans .page ↵.Many federal and state laws, as well as national guidelines, have been established to protect public health and safety related to medication administration. This section will explain how federal and state laws, agencies, and guidelines protect clients from harm from medications.
The United States Food and Drug Administration (FDA) protects public health by ensuring the safety, efficacy, and security of human and veterinary drugs, biological products, and medical devices, as well as the safety of our nation’s food supply, cosmetics, and products that emit radiation.[1] The FDA protects public health by enforcing an official drug approval process based on evidence-based research and issuing Boxed Warnings for medications with serious adverse reactions. These actions are further discussed in the following subsections.
American consumers benefit from having access to the safest and most advanced pharmaceutical system in the world. The main consumer watchdog in this system is the FDA’s Center for Drug Evaluation and Research (CDER). The center’s best-known job is to evaluate new drugs before they can be sold. CDER’s evaluation not only prevents misinformation from being provided to the public, but also provides doctors and clients the information they need to use medicines wisely. CDER ensures that drugs, both brand-name and generic, work correctly and their health benefits outweigh their known risks.
Drug companies conduct extensive research and work to develop and test a drug. The company then sends CDER the evidence from these tests to prove the drug is safe and effective for its intended use. Before the drug is approved as safe for use in the United States, a team of CDER physicians, statisticians, chemists, pharmacologists, and other scientists reviews the company’s data and proposed labeling. If this independent and unbiased review establishes a drug’s health benefits outweigh its known risks, the drug is approved for sale. Before a drug can be tested in people, the drug company or sponsor performs laboratory and animal tests to discover how the drug works and whether it’s likely to be safe and work well in humans. Next, a series of clinical trials involving volunteers is conducted to determine whether the drug is safe when used to treat a disease and whether it provides a real health benefit.
FDA approval of a drug means that data on the drug’s effects have been reviewed by the CDER, and the drug is determined to provide benefits that outweigh its known and potential risks for the intended population. The drug approval process takes place within a structured framework that includes the following:
Analysis of the target condition and available treatments: FDA reviewers analyze the condition or illness for which the drug is intended and evaluate the current treatment landscape, which provide the context for weighing the drug’s risks and benefits. For example, a drug intended to treat clients with a life-threatening disease for which no other therapy exists may be considered to have benefits that outweigh the risks even if those risks would be considered unacceptable for a condition that is not life-threatening.
Assessment of benefits and risks from clinical data: FDA reviewers evaluate clinical benefit and risk information submitted by the drug maker, taking into account any uncertainties that may result from imperfect or incomplete data. Generally, the agency expects that the drug maker will submit results from two well-designed clinical trials to be sure the findings from the first trial are not the result of chance or bias. In certain cases, especially if the disease is rare and multiple trials may not be feasible, convincing evidence from one clinical trial may be enough. Evidence that the drug will benefit the target population should outweigh any risks and uncertainties.
Strategies for managing risks: All drugs have risks. Risk management strategies include an FDA-approved drug label, which clearly describes the drug’s benefits and risks and information pertaining to the detection and management of any risks. Sometimes, more effort is needed to manage risks. In these cases, a drug maker may need to implement a Risk Evaluation and Mitigation Strategy (REMS).
Although many of the FDA’s risk-benefit assessments and decisions are straightforward, sometimes the benefits and risks are uncertain and may be difficult to interpret or predict. The agency and the drug maker may reach different conclusions after analyzing the same data, or there may be differences of opinion among members of the FDA’s review team. As a science-led organization, the FDA uses scientific and technological information to make decisions through a deliberative process.[2]
As discussed in the previous subsection, the FDA approves a drug after determining that the drug’s benefits of use outweigh the risks for the condition that the drug will treat. However, even with the rigorous FDA evaluation process, safety problems can surface after a drug has been on the market and used in a broader population.
Boxed Warnings (formerly known as Black Box Warnings) are the highest safety-related warning that medications can have assigned by the FDA. These warnings are intended to bring the consumer’s attention to the major risks of the drug. Medications can have a boxed warning added, taken away, or updated throughout their tenure on the market. Boxed Warnings appear on a prescription drug’s label and in current, evidence-based drug references. For this reason, it is important for nurses to verify current drug information in drug references.
Levofloxacin is an antibiotic that received FDA approval. However, after the drug was on the market, it was discovered that some clients who took levofloxacin developed serious, irreversible adverse effects such as tendon rupture. The FDA issued a Boxed Warning with recommendations to reserve levofloxacin for use in clients who have no alternative treatment options for certain indications: uncomplicated UTI, acute exacerbation of chronic bronchitis, and acute bacterial sinusitis.[3]
A nurse is preparing to administer medications to a client and notices that levofloxacin has been prescribed for the indication of pneumonia. There is no other documentation in the provider’s notes related to the use of this medication.
What is the nurse’s best response?
Note: Answers to the Critical Thinking activities can be found in the “Answer Key” section at the end of the book.
The U.S. Drug Enforcement Agency (DEA) enforces the federal laws and regulations of controlled substances. This includes enforcement of the Controlled Substances Act (CSA) that pertains to the manufacture, distribution, and dispensing of legally produced controlled substances that nurses administer to clients.[4]
Because controlled substances have a greater chance of being misused and abused, there are additional laws and procedures that must be followed when working with these medications. The DEA is responsible for enforcing these laws, and many federal laws are summarized in a document called the Pharmacist’s Manual. Most controlled substance laws, however, come from state governments. Health care professionals are responsible for following the most stringent of the two laws, whether it be state law or federal law.
The following examples of federal laws are applicable to controlled substances administered by nurses:
Prescriptions: A prescription for a controlled substance may be written only by a provider (physician or mid-level provider such as a nurse practitioner) who has a DEA registration number. The prescription for a Schedule II medication (i.e., opioids) must be written or electronically sent to the pharmacy through DEA approved software. Prescriptions over the phone or fax are not accepted. Refills for Schedule II medication are not allowed and require new prescriptions. Schedule III or IV medications may be refilled only five times. State law determines how long a written Schedule II prescription is valid and if there are any limits on the quantity of medication that can be dispensed. For example, in Wisconsin, a Schedule II prescription is only valid for 60 days after it is written.
Records: There is a “closed system” for record keeping of controlled substances to prevent drug diversion. Hospitals, clinics, and pharmacies must maintain records on the whereabouts of controlled substances from the time the medication is received by the pharmacy, to when it is administered to the client, to disposal of wasted medication by the nurse. Inventory counts of controlled substances occur frequently and may require a physical count by two licensed staff at the start of each shift. Detailed documentation is required for administration of controlled substances. When a full dose of a controlled substance is not administered, this is referred to as waste. Waste is typically disposed of differently than other medications (i.e., flushed down the sink) and often requires the co-signature of a second licensed staff member.
The federal Controlled Substances Act (CSA) categorizes drugs regulated under federal law into one of five schedules. This placement is based on the substance’s medical use, potential for abuse, and safety or dependence liability. Schedule I drugs have a high potential for abuse and the potential to create severe psychological and/or physical dependence, whereas Schedule V drugs represent the least potential for abuse. Sample medications for each schedule are summarized in Table 2.3.[6]
Definitions and Sample Medications for Each Type of Scheduled Medication
| Schedule | Definition | Examples |
|---|---|---|
| Schedule I | No currently accepted medical use and a high potential for abuse. | Heroin, LSD, and marijuana |
| Schedule II | High potential for abuse, with use potentially leading to severe psychological or physical dependence. These drugs are also considered dangerous. | Vicodin, cocaine, methamphetamine, methadone, hydromorphone (Dilaudid), meperidine (Demerol), oxycodone (OxyContin), fentanyl, Dexedrine, Adderall, and Ritalin |
| Schedule III | Moderate to low potential for physical and psychological dependence. Abuse potential is less than Schedule I and Schedule II drugs but more than Schedule IV. | Tylenol with codeine, ketamine, anabolic steroids, and testosterone |
| Schedule IV | Low potential for abuse and low risk of dependence. | Xanax, Soma, Valium, Ativan, Talwin, Ambien, and Tramadol |
| Schedule V | Lower potential for abuse than Schedule IV and consist of preparations containing limited quantities of certain narcotics. Generally used for antidiarrheal, antitussive, and analgesic purposes. | Robitussin AC with codeine, Lomotil, and Lyrica |
Drug overdose continues to be a public health crisis in the United States. The misuse of prescription opioids contributes to a large percentage of overdose deaths. Many problems associated with substance use are the result of legitimately made controlled substances being diverted from their lawful purpose into illicit drug traffic. The mission of DEA’s Diversion Control Division is to prevent, detect, and investigate the diversion of controlled medications from legitimate sources while ensuring an adequate and uninterrupted supply for legitimate medical, commercial, and scientific needs. The DEA provides education regarding related topics that apply to nurses such as drug diversion, state prescription drug monitoring systems, current drug trends, and proper drug disposal.[9]
Drug diversion involves the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use. The most commonly diverted substances in health care facilities are opioids. Diversion of controlled substances can result in substantial risk, not only to the individual who is diverting the drugs, but also to clients, coworkers, and employers. Impaired health professionals can harm clients by providing substandard care or exposing clients to tainted substances.
Tampering is the riskiest and most harmful type of diversion. Tampering occurs when the diverter removes medication from a syringe, vial, or other container and injects themselves with the medication. The diverter then replaces the stolen medication with saline, sterile water, or another clear liquid. The replaced liquid is then unknowingly administered to the client by an unaware nurse.[10],[11]
The DEA provides an online reporting form for individuals to report suspected drug diversion anonymously. [12]
Substance use disorder (SUD) is an illness caused by repeated misuse of substances such as cannabis, opioids, sedatives, and stimulants. Substances taken in excess have a common effect of directly activating the brain reward system and producing such an intense activation of the reward system that normal life activities may be neglected.[14]
Health care professionals are not immune to developing SUD. It is important for nurses to be aware of the warning signs of SUD and to understand that SUD is a disease that can affect anyone regardless of age, occupation, economic circumstances, ethnic background, or gender. In most states, a nurse with SUD may voluntarily enter a professional assistance program for evaluation and treatment.[15] Read more about professional assistance programs under the “State Law, State Nurse Practice Acts, and State Boards of Nursing” subsection below.
The National Council of State Boards of Nursing (NCSBN) created A Nurse’s Guide to Substance Use Disorder in Nursing brochure that states many nurses with substance use disorder (SUD) are unidentified, unreported, untreated, and may continue to practice where their impairment may endanger the lives of their clients or themselves. It can be hard to differentiate between the subtle signs of impairment and stress-related behaviors, but three areas to watch for suspected SUD are behavior changes, physical signs, and drug diversion. Behavioral changes can include changes or shifts in job performance, absences from the unit for extended periods, frequent trips to the bathroom, arriving late or leaving early, and making an excessive number of mistakes, including medication errors. Physical signs include subtle changes in appearance that may escalate over time, increasing isolation from colleagues, inappropriate verbal or emotional responses, and diminished alertness, confusion, or memory lapses. When nurses with SUD commit drug diversion, there are often discrepancies that colleagues notice, such as incorrect opioid counts, a pattern of large amounts of opioid wastage, numerous corrections of medication records, frequent reports of ineffective pain relief from clients assigned to that nurse, increased agitation/combativeness of assigned clients with dementia, and patterns of increased administration of opioids to clients when that nurse is scheduled to work.[16]
As a student nurse and nurse, you have a professional and ethical responsibility to report a colleague’s suspected SUD to your supervisor and, in some states or jurisdictions, to the State Board of Nursing. The earlier that SUD is identified in a nurse and treatment is started, the sooner clients are protected, and the better the chances for the nurse with SUD to recover and safely return to work.[17]
The Secure and Responsible Drug Disposal Act of 2010 allows users to dispose of controlled substances in a safe and effective manner. A Johns Hopkins study on sharing of medication found that 60% of people had leftover opioids they saved for future use; 20% shared their medications; 8% would likely share with a friend; 14% would likely share with a relative; and only 10% securely locked their medication.[18] This act has resulted in “National Take Back Days” in all 50 states, as well as new collection receptacles.[19]
To prevent risk of drug diversion, nurses should teach clients who are prescribed controlled substances how to dispose of them properly so that they don’t end up being misused or overdosed by another person. Figure 2.2[20] shows an example of a controlled substances collection receptacle.[21]
Controlled Substances Collection Receptacle
1. A nurse is providing discharge education to a client who recently had surgery and has been prescribed hydrocodone/acetaminophen tablets to take every four hours as needed at home. The nurse explains that when the medication is no longer needed when the post-op pain subsides, it should be dropped off at a local pharmacy for disposal in a collection receptacle. The client states, “I don’t like to throw anything away. I usually keep unused medication in case another family member needs it.”
What is the nurse’s best response?
2. A nurse begins a new job on a medical-surgical unit. One of the charge nurses on this unit is highly regarded by her colleagues and appears to provide excellent care to her clients. The new nurse cares for a client whom the charge nurse cared for on the previous shift. The new nurse asks the client about the effectiveness of the pain medication documented as provided by the charge nurse during the previous shift. The client states, “I didn’t receive any pain medication during the last shift.” The nurse mentions this incident to a preceptor who states, “I have noticed that the same types of incidents have occurred with previous clients but didn’t want to say anything.”
What is the new nurse’s best response?
Note: Answers to the Critical Thinking activities can be found in the “Answer Key” section at the end of the book.
The Joint Commission is a national organization that accredits and certifies over 20,000 health care organizations in the United States. The mission of The Joint Commission is to continuously improve health care for the public by inspiring health care organizations to excel in providing safe and effective care of the highest quality and value.[22] Some of The Joint Commission’s national initiatives regarding medication safety include creating a “Safety Culture” in health care organizations with associated root cause analysis, the Speak Up Campaign, National Patient Safety Goals, and the Official Do not Use List. Each of these safety initiatives is further discussed in the following subsections.
The Joint Commission Center for Transforming Healthcare develops effective solutions for health care’s most critical safety and quality problems with a goal to ultimately achieve zero harm to clients. Some of the projects the Center has developed include improved hand hygiene,[23] effective handoff communications,[24] and safe and effective use of insulin.[25]
The Center has also been instrumental in building a focus on creating a “Safety Culture” in health care organizations. A Safety Culture empowers staff to speak up about risks to clients and to report errors and near misses. These actions reduce the risk of client harm. According to the Institute of Medicine, “The biggest challenge to moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures, but as opportunities to improve the system and prevent harm.”[26]
A component of Safety Culture is the submission of incident reports according to agency guidelines whenever a medication error or a “near miss” occurs. A near miss is a narrowly avoided error. The incident report triggers a root cause analysis by the organization to identify not only what and how an event occurred, but also why it happened. When investigators determine why an error occurred, they can create workable corrective measures to prevent future errors from occurring.[27]
An example of Safety Culture in action is a tragic event in 2006, when three infants died after incorrect heparin doses were used to flush their vascular access devices. A root cause analysis found that pharmacy technicians accidentally placed vials containing concentrated heparin (10,000 units/mL) in medication storage locations that were designated for less concentrated heparin vials (10 units/mL). Additionally, the heparin vials were similar in appearance, so the nurses did not notice the incorrect dosage until after it was administered. In response to a root cause analysis, the hospital no longer stores vials of heparin in pediatric units and uses saline to flush all peripheral lines. In the pharmacy, 10,000 units/mL heparin vials were separated from vials containing other strengths. In this manner, corrective measures were implemented to prevent future tragedies from occurring as a result of incorrect doses of heparin.[28]
The goal of The Joint Commission’s Speak Up™ campaign is to help clients become more informed and involved in their health care to prevent medication errors. Speak Up™ materials are intended for the public and have been put into a simplified, easy-to-read format to reach a wider audience.[29]
The National Patient Safety Goals (NPSG) are established by The Joint Commission to help accredited organizations address current areas of concern related to patient safety. Annually, The Joint Commission determines the current highest priority patient safety issues with input from practitioners, provider organizations, purchasers, consumer groups, and other stakeholders and develops National Patient Safety Goals.
Two of the current National Patient Safety Goals relate specifically to medication administration: “Identify Patients Correctly” and “Use Medicines Safely.”
Nurses and health care professionals must use at least two ways to identify clients. For example, use the client’s name and date of birth. This is done to make sure that each client gets the correct medicine and treatment.[31]
Before a procedure, label medications that are not labeled. For example, medications in syringes, cups, and basins should be labelled in the area where medications and supplies are set up. Labels should include medication name, dose, date drawn up, and initials of the person who prepared the medication.[32] Additionally, do not leave medications unattended.
Record and pass along correct information about a client’s medications. Find out what medications the client is taking. Compare those medications to new medications given to the client. Make sure the client knows which medications to take when they are at home. Tell the client it is important to bring their up-to-date list of medications every time they visit a doctor. Extra care must be taken with clients who take medications to thin their blood (anticoagulants).[33]
The Joint Commission maintains an Official Do Not Use List of abbreviations. These abbreviations have been found to commonly cause errors in client care. Accredited agencies are expected to not use these abbreviations on any written or preprinted materials.[34]
The Centers for Medicare & Medicaid Services (CMS) is a federal agency within the United States Department of Health and Human Services (HHS). The CMS administers the Medicare program and works in partnership with state governments to administer Medicaid and establishes and enforces regulations to protect client safety in hospitals that receive Medicare and Medicaid funding.[35]
CMS regulations related to the administration of medication by nurses include verifying information included in the prescription for a medication, checking the rights of medication administration, reporting concerns about a medication prescription, assessing and monitoring clients receiving medications, and documenting medication administration. Each of these regulations is further discussed below.
Medications and biologicals are administered in response to a prescription from a health care provider or on the basis of a standing order that is subsequently authenticated by a provider. Biologicals are a diverse group of medications that include vaccines, growth factors, immune modulators, monoclonal antibodies, and products derived from blood and plasma. All provider orders for the administration of drugs and biologicals must include the following:
Name of the clientAge and weight of the client to facilitate dose calculation when applicable. Agency policies and procedures must address weight-based dosing for pediatric client. Dose calculations for newborns are typically based on the metric weight in grams.
Date and time of the order Dose, frequency, and route Dose calculation requirements, when applicable Exact strength or concentration, when applicable Quantity and/or duration, when applicable Specific instructions for use, when applicable Name of the providerThe CMS states that agency policies and procedures must reflect accepted standards of practice that require specific information is confirmed prior to administration of medication. This is commonly referred to as “checking the rights of medication administration.”
When administering medications, it is essential for nurses to vigilantly check the rights of medication administration at least three times to prevent medication errors. What historically began as checking five rights of mediation administration has been extended to eight rights according to the American Nurses Association. These eight rights include the following[36]:
Right patient: Check that you have the correct client using two patient identifiers according to agency policy (e.g., name and date of birth).
Right medication: Check that you have the correct medication and that it is appropriate for the patent in the current context. Understand the purpose of the medication and why the client is receiving it.
Right dose: Check that the dose is safe for the age, size, and condition of the client. Different dosages may be indicated for different conditions, and pediatric dosages are typically much lower than adult dosages.
Right route: Check that the route is appropriate for the client’s current condition. Right time: Adhere to the prescribed scheduling of the medication.Right documentation: Always verify any unclear or inaccurate documentation prior to administering medications.
Right reason: Verify this medication is being administered to this client at this time for the right reason. If signs and symptoms no longer warrant administration of the prescribed medication, notify the prescribing provider.
Right response: After administering medication, the nurse must evaluate for expected outcomes with the time frame of expected onset and peak. The onset of medication administration occurs when the action of the medication begins to take effect. The peak of the medication administration occurs when the medication is at the highest level in the client’s bloodstream. It is important for nurses to be aware of both the peak and onset of medications to know when the client’s response to medication may start to be observed. The nurse must also be aware of potential side effects and adverse effects and evaluate for these unexpected outcomes. The prescribing provider should be notified if expected outcomes are not achieved or if adverse effects occur.
Many agencies have implemented barcode medication scanning to improve safety during medication administration. Barcode scanning systems reduce medication errors by electronically verifying the “rights” of medication administration. For example, when a nurse scans a barcode on the client’s wristband and on the medication to be administered, the data is delivered to a computer software system where algorithms check databases and generate real-time warnings or approvals. Barcode scanning reduces errors resulting from administration of a wrong medication, incorrect dose, or wrong route. However, it is important for nurses to remember that barcode scanning should be used in addition to checking the rights of medication administration, not in place of this important safety process. Additionally, nurses should carefully consider their actions when errors occur during the barcode scanning process. Although it may be tempting to quickly dismiss the error and attribute it to a technology glitch, the error may have been triggered due to a patient safety concern that requires further follow-up before the medication is administered. Nurses must investigate errors that occur during the barcode scanning process just as they would do if an error were discovered while checking the rights of medication administration.
The CMS encourages hospitals to promote a culture in which it is not only acceptable, but also strongly encouraged, for staff to notify prescribing providers regarding concerns they have regarding medication orders.[38] It is essential for nurses to contact the prescribing provider if they have any concerns when checking the rights of medication administration before administering the medication to the client. Furthermore, nurses can be held liable in a court of law if they administer medication that results in client harm if a “prudent nurse” would have had concerns about the order and questioned it.
The CMS states that observing the effects medications have on the client is part of the multifaceted medication administration process. Clients must be carefully monitored to determine whether the medication results in the therapeutically intended benefit and to allow for early identification of adverse effects and timely initiation of appropriate corrective action. Depending on the medication and route/delivery mode, monitoring may include assessment of the following:
Clinical and laboratory data to evaluate the efficacy of medication therapy, potential toxicity, and adverse effects. For some medications, such as opioids, this monitoring may include clinical data such as respiratory status, blood pressure, and oxygenation and carbon dioxide levels.
Physical signs and clinical symptoms relevant to the client’s medication therapy, such as confusion, agitation, unsteady gait, pruritus, etc.
Factors contributing to high risk for adverse drug events. The consequences of errors can be harmful and sometimes fatal to clients. In addition, certain factors place some clients at greater risk for adverse effects of medication. These factors include, but are not limited to, age, altered liver and kidney function, drug-to-drug interactions, and first-time medication use.
The nurse should consider client risk factors, as well as the risks inherent in a medication, when determining the type and frequency of monitoring. It is also essential to communicate information regarding client medication risk factors and monitoring requirements during hand-off reports to other staff.
Adverse client reactions, such as anaphylaxis or opioid-induced sedation and respiratory depression, require timely and appropriate intervention per agency protocols and should also be immediately reported to the prescribing provider. An example of vigilant post-medication administration monitoring is when a nurse closely monitors a post-surgical client who is receiving opioid pain medication via a patient-controlled analgesia (PCA) pump. Opioid medications are used to control pain but also have a sedating effect. Clients can become overly sedated and suffer respiratory depression or arrest, which can be fatal. The nurse should closely monitor the client’s respiratory rate, oxygen saturation, carbon dioxide levels, level of sedation, blood pressure, and pulse to quickly observe and intervene in the event of an adverse event. In addition, the client and/or family members are educated to notify nursing staff promptly when there is difficulty breathing or other changes that might be a reaction to medication.[39]
CMS regulations require the agency’s documentation regarding medication administration contains providers’ orders, nursing notes, reports of treatment, medication administration records, radiology and laboratory reports, vital signs, and other information necessary to monitor the client’s condition. Documentation of medication administration is expected to occur immediately after the medication is administered to the client; documenting prior to the administration of the medication is inappropriate and can result in medication errors. Proper documentation of medication administration and client outcomes is essential for planning and delivering future care of the client.[40],[41]
A nurse is preparing to administer morphine, an opioid, to a client who recently had surgery.
1. Explain the rights of medication administration the nurse must check prior to administering this medication to the client.
2. Outline three methods the nurse can use to confirm patient identification.
3. What should the nurse assess prior to administering this medication to the client?
4. What should be monitored after administering this medication?
5. What should the nurse teach the client (and/or family member) about this medication?
6. What information should be included in the shift handoff report about this medication?
Note: Answers to the Critical Thinking activities can be found in the “Answer Key” section at the end of the book.
In additional to federal laws, regulations, national guidelines, and safety initiatives, state law also protects public health and safety. Each state has a Nurse Practice Act (NPA) that is enacted by the state legislature. The State Board of Nursing (SBON) enforces the NPA.[42] The purpose of the SBON is to protect the public through licensure, education, legislation, and discipline regarding rules of conduct. The SBON regulates the licensure and practice of registered nurses (RNs), licensed practical/vocational nurses (LPNs/VNs), and advanced practice nurse prescribers (APNPs).[43]
Nurses are responsible for knowing the state laws that relate to nursing care in the state in which they work. Furthermore, nurses must follow the scope of practice outlined in the NPA in the state in which they are employed. Nurses are accountable for the quality of care they provide and are expected to practice at the level of education, knowledge, and skill of someone who has completed an approved nursing program. All nurses are expected to recognize the limits of their knowledge and experience and to appropriately address situations that are beyond their competency.[44]
The NPA outlines the standards of care provided by a registered nurse (RN), also known as the nursing process. As previously discussed in this chapter, the steps of the nursing process are also considered a standard of care by the ANA. A nurse utilizes the nursing process when executing nursing care and procedures in the maintenance of clients’ health, prevention of illness, or care of the ill. Review the steps of the nursing process in the “Ethical and Professional Foundations of Safe Medication Administration by Nurses” section of this chapter.
The NPA also outlines rules of conduct expected of nurses. Nurses can receive disciplinary action from the SBON, ranging from a reprimand to revocation of their license, if they do not follow the enacted rules of conduct. A nurse must maintain current knowledge about expected rules of conduct in each state where they practice nursing to protect their nursing license.
A SBON may take disciplinary action against a nurse’s license for many reasons. Common reasons related to medication administration include, but are not limited to, the following:
Noncompliance with federal, jurisdictional, or reporting requirements, including practicing beyond the scope of practice.
Confidentiality, client privacy, consent, or disclosure violations. Fraud, deception or misrepresentation, including falsification of client documentation. Unsafe practice or substandard care, including: Failing to perform nursing care with reasonable skill and safety.Departing from or failing to conform to the minimal standards of acceptable nursing practice that may create unnecessary risk or danger to a client’s life, health, or safety. Actual injury to a client does not need to be established.
Failing to report to or leaving a nursing assignment without properly notifying appropriate supervisory personnel and ensuring the safety and welfare of the client.
Practicing nursing while under the influence of alcohol, illicit drugs, or while impaired by the use of legitimately prescribed pharmacological agents or medications.
Inability to practice safely due to alcohol or other substance use, psychological or physical illness, or impairment.
Executing an order which the licensee knew or should have known could harm a client. Improper supervision. Improper prescribing, dispensing, or administering medication or drug-related offenses.[48]In addition to the NPA, there are other state statutes that guide nursing care and medication administration. State statutes are a compilation of the general laws of the state and often include chapters related to the state regulation of controlled substances (in addition to federal law previously discussed in this section).
Examples of state law related to controlled substances are prescription drug monitoring programs (PDMP). Many states have implemented PDMP to help combat the ongoing prescription substance abuse epidemic, as well as to help prevent drug diversion. Pharmacies and health care providers are often required by state law to participate in a PDMP when dispensing or prescribing controlled substances. A PDMP is a statewide electronic database that collects data on substances dispensed in the state. By providing valuable information about controlled substance prescriptions that are dispensed in the state, PDMPs help health care providers make prescribing and dispensing decisions. PDMPs also foster the ability of pharmacies, health care professionals, law enforcement agencies, and public health officials to work together to reduce the misuse, abuse, and diversion of prescribed controlled substances.
In addition to state statutes related to controlled substances, many states offer professional assistance programs as voluntary, nondisciplinary programs to provide support for health professionals with substance abuse disorders (SUD) who are committed to their own recovery. The goal of professional assistance programs is to protect the public by promoting early identification of professionals with SUD and encouraging their rehabilitation and recovery. Professional assistance programs provide an opportunity for nurses with SUD to continue to be employed while being monitored by the SBON and supported in their recovery.
A nurse is disciplined by the Wisconsin Board of Nursing for an incident reported by her employer that she arrived at her shift intoxicated. The nurse shares with a nursing colleague, “I love taking care of patients. I worked so hard to obtain my nursing license – I don’t want to lose it. I know my drinking has gotten out of control, but I don’t know where to turn.”
What is the best advice by the nursing colleague for this nurse with a drinking problem?
Note: Answers to the Critical Thinking activities can be found in the “Answer Key” section at the end of the book.
U.S. Department of Justice - Drug Enforcement Administration. (n.d.). Drug scheduling. https://www .dea.gov/drug-scheduling ↵.
U.S. Department of Justice - Drug Enforcement Administration. (n.d.). Drug scheduling. https://www .dea.gov/drug-scheduling ↵.
U.S. Department of Justice - Drug Enforcement Administration. (n.d.). Drug scheduling. https://www .dea.gov/drug-scheduling ↵.
Berge, K. H., Dillon, K. R., Sikkink, K. M., Taylor, T. K., & Lanier, W. L. (2012). Diversion of drugs within health care facilities, a multiple-victim crime: Patterns of diversion, scope, consequences, detection, and prevention. Mayo Clinic Proceedings , 87(7), 674–682. https://www .ncbi.nlm .nih.gov/pubmed/22766087 ↵ . [PMC free article : PMC3538481 ] [PubMed : 22766087 ]
U.S. Department of Justice - Drug Enforcement Administration. (n.d.). RX abuse online reporting: Report incident. https://apps2 .deadiversion .usdoj.gov/rxaor /spring/main?execution=e1s1 ↵.
American Psychiatric Association. (2013). Desk reference to the diagnostic criteria from DSM-5. ↵.National Council of State Boards of Nursing (NCSBN). (2018). A nurse's guide to substance use disorder in nursing. https://www .ncsbn.org /public-files/SUD_Brochure_2014.pdf ↵.
National Council of State Boards of Nursing (NCSBN). (2018). A nurse's guide to substance use disorder in nursing. https://www .ncsbn.org /public-files/SUD_Brochure_2014.pdf ↵.
National Council of State Boards of Nursing (NCSBN). (2018). A nurse's guide to substance use disorder in nursing. https://www .ncsbn.org /public-files/SUD_Brochure_2014.pdf ↵.
U.S. Department of Justice - Drug Enforcement Administration. (2017, December 13). Federal regulations and the disposal of controlled substances. https://www .deadiversion .usdoj.gov/mtgs/drug_chemical /2017/wingert .pdf#search=drug%20disposal ↵.
U.S. Department of Justice - Drug Enforcement Administration. (2017, December 13). Federal regulations and the disposal of controlled substances. https://www .deadiversion .usdoj.gov/mtgs/drug_chemical /2017/wingert .pdf#search=drug%20disposal ↵.
“MedRx box.JPG” by York Police is licensed under CC0 ↵.U.S. Department of Justice - Drug Enforcement Administration. (2017, December 13). Federal regulations and the disposal of controlled substances. https://www .deadiversion .usdoj.gov/mtgs/drug_chemical /2017/wingert .pdf#search=drug%20disposal ↵.
The Joint Commission. (n.d.). https://www .jointcommission.org/ ↵.Institute for Safe Medication Practices. (2007, November 29). Another heparin error: Learning from mistakes so we don't repeat them. https://www .ismp.org /resources/another-heparin-error-learning-mistakes-so-we-dont-repeat-them ↵.
U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. (2014). Memo: Requirements for hospital medication administration, particularly intravenous (IV) medications and post-operative care of patients receiving IV opioids. https://www .cms.gov/Medicare /Provider-Enrollment-and-Certification /SurveyCertificationGenInfo /Downloads /Survey-and-Cert-Letter-14-15.pdf ↵.
Kimberly Dunker. (2020, April 6). Mediation Administration. [Video]. YouTube. All rights reserved. https://youtu .be/MUn4Ec2X93g ↵.
U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. (2014). Memo: Requirements for hospital medication administration, particularly intravenous (IV) medications and post-operative care of patients receiving IV opioids. https://www .cms.gov/Medicare /Provider-Enrollment-and-Certification /SurveyCertificationGenInfo /Downloads /Survey-and-Cert-Letter-14-15.pdf ↵.
U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. (2014). Memo: Requirements for hospital medication administration, particularly intravenous (IV) medications and post-operative care of patients receiving IV opioids. https://www .cms.gov/Medicare /Provider-Enrollment-and-Certification /SurveyCertificationGenInfo /Downloads /Survey-and-Cert-Letter-14-15.pdf ↵.
U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. (2014). Memo: Requirements for hospital medication administration, particularly intravenous (IV) medications and post-operative care of patients receiving IV opioids. https://www .cms.gov/Medicare /Provider-Enrollment-and-Certification /SurveyCertificationGenInfo /Downloads /Survey-and-Cert-Letter-14-15.pdf ↵.
American Society of Health-System Pharmacists (Ed.). (2018). ASHP guidelines on preventing medication errors in hospitals. American Journal of Health-System Pharmacy , 75, 1493–1517. https://www .ashp.org /-/media/assets/policy-guidelines /docs/guidelines /preventing-medication-errors-hospitals.ashx ↵ . [PubMed : 30257844 ]
Wisconsin Department of Safety and Professional Services. (n.d.). Board of nursing Wisconsin Administrative Code. https://dsps .wi.gov/Pages /RulesStatutes/Nursing .aspx ↵.
Wisconsin ePDMP. (2019). https://pdmp .wi.gov/ ↵.In addition to the legal and ethical considerations, there are also cultural and social influences that the nurse must consider when administering medication. According to the 2018 U.S. Census report, by the year 2030, the nation’s population is projected to age considerably and become even more racially and ethnically diverse. Though health indicators such as life expectancy and infant mortality have improved for most Americans, some people from racial and ethnic minority groups experience a disproportionate burden of preventable disease, death, and disability compared with non-Hispanic white people.[1]
The American Nurses Association’s (ANA) Scope and Standards of Practice states the need for health care is universal and transcends differences with respect to the culture, values, and preferences of individuals, families, groups, and communities. Diversity characterizes today’s health care environment, and nursing is responsive to the changing needs of society. To effectively promote meaningful client outcomes that maximize quality of life across the life span, the ANA states that nurses must engage in cultural humility. Cultural humility is a humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they can’t possibly know everything about other cultures, and approach learning about other cultures as a lifelong goal and process.[2] As previously discussed in this chapter, culturally congruent practice is the application of evidence-based nursing that is in agreement with the preferred cultural values, beliefs, worldview, and practices of the health care client.
In addition to cultural beliefs, conditions in the places where people live, learn, work, and play can also affect their health, functioning, quality of life, and risks. These conditions are known as social determinants of health (SDOH). Differences in health can be significant in communities with poor SDOH such as unstable housing, low incomes, unsafe neighborhoods, or substandard education. These differences are referred to as health disparities. By applying what we know about SDOH, nurses can not only improve an individual’s health, but also improve health equity for communities and the population as a whole.
Healthy People is a government agency that provides science-based, ten-year national objectives for improving the health of all Americans. Healthy People 2030 highlights the importance of addressing SDOH with a goal to “create social, physical, and economic environments that promote attaining the full potential for health and well-being for all.”[3],[4]
The U.S. Department of Health and Human Services also sets national standards for Culturally and Linguistically Appropriate Services (CLAS) in health and health care. The national CLAS standards are intended to advance health equity, improve quality, and help eliminate health disparities by “providing effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.”[5]
The U.S. Department of Health and Human Services (HHS) defines health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions.” Adequate health literacy may include being able to read and comprehend essential health-related materials such as information on a medication bottle or in a handout. Nurses promote health literacy by including interventions such as visual aids to increase client understanding and, thereby, improve client safety.[6]
There are several instances when a nurse must assess and accommodate a client’s cultural beliefs and social determinants of health when administering medications or teaching about medications. For example, a nurse addresses health literacy and medication safety by assisting a client to read information on a medication bottle or on a handout.
Another example of culturally congruent practice is when a nurse considers cultural or religious beliefs, such as fasting, when administering medications. For example, a Muslim client may participate in Ramadan, which requires 12-hour fasting. A nurse can advocate for the client and assist in altering the scheduling of medication to accommodate the client’s beliefs in order to reduce the risk of treatment failure.
A third example of culturally congruent practice is when a nurse considers how a client’s ethnic background may affect their ability to respond to medications. For example, African Americans often require combination therapy to treat hypertension, and Asian and Hispanic clients often respond better to lower doses of antidepressants.
A nurse is providing health teaching to a mother regarding a liquid antibiotic prescribed for her child to take at home. The prescription states amoxicillin 250 mg, give 1 teaspoon (5 mL) every eight hours for seven days. After talking with the mother, the nurse realizes the family does not have measuring spoons in their home.
What is the nurse’s best response?
Note: Answers to the Critical Thinking activities can be found in the “Answer Key” section at the end of the book.
Centers for Disease Control and Prevention. (2023). Minority health and health equity. https://www .cdc.gov/minorityhealth /index.html ↵.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵.
Social Determinants of Health by Healthy People 2030 is available in the Public Domain. ↵.U.S. Department of Health and Human Services, Office of Minority Health. (n.d.). National standards for culturally and linguistically appropriate services (CLAS) in health and health care. https: //thinkculturalhealth .hhs.gov/assets /pdfs/EnhancedNationalCLASStandards .pdf ↵.
Health Literacy by Health People 2030 is available in the Public Domain. ↵.Aadil, N., Houti, I. E., & Moussamih, S. (2004). Drug intake during Ramadan. BMJ (Clinical Research Ed.) , 329, 778–782. ↵ 10.1136/bmj.329.7469.778. [PMC free article : PMC521001 ] [PubMed : 15459052 ] [CrossRef]
Preventing medication errors has been a key target for improving safety since the 1990s. Despite error reduction strategies, implementing new technologies, and streamlining processes, medication errors remain a significant concern with error rates of 8%-25% during medication administration.[1] Furthermore, a substantial proportion of errors occur in hospitalized children due to the complexity of weight-based pediatric dosing.[2]
Several prevention initiatives have been developed to ensure safe medication administration such as the following strategies[3]:
Routinely checking the rights of medication administrationStandardizing communication such as “tall man lettering,” alerts to “look alike-sound alike” drug names, avoidance of abbreviations, and standards for expressing numerical dosages
Focusing on high-alert medications that have a higher likelihood of resulting in patient harm if involved in an administration error, such as anticoagulants, insulins, opioids, and chemotherapy agents
Standardizing labelling of medication using visual cues as safeguardsOptimizing nursing workflow to minimize errors, such as minimizing interruptions and double checking high alert medications
Implementing technology like barcode medication administration and smart infusion pumpsThe Joint Commission’s National Patient Safety Goals related to mediation administration were previously discussed in the “Legal Foundations and National Guidelines for Safe Medication Administration” section of this chapter. This section will further discuss additional safety initiatives established by the Institute of Medicine (IOM), World Health Organization (WHO), Institute for Safe Medication Practices (ISMP), and Quality and Safe Education for Nurses (QSEN) to prevent medication errors.
The national focus on reducing medical errors has been in place since the 1990s. The Institute of Medicine (IOM) released a historic report in 1999 titled To Err is Human: Building a Safer Health System. The report stated that errors caused between 44,000 and 98,000 deaths every year in American hospitals and over one million injuries. The IOM report called for a 50% reduction in medical errors over five years. Its goal was to break the cycle of inaction regarding medical errors by advocating for a comprehensive approach to improving patient safety. The IOM 1999 report changed the focus of patient safety from dispensing blame to improving systems.[5]
In 2007 the IOM published a follow-up report titled Preventing Medication Errors, reporting that more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized client experiences at least one medication error each day. This report emphasized actions that health care systems, providers, funders, and regulators could take to improve medication safety. These recommendations included actions such as having all U.S. prescriptions written and dispensed electronically, promoting widespread use of medication reconciliation, and performing additional research on drug errors and their prevention. The report also emphasized actions that client can take to prevent medication errors, such as maintaining active medication lists and bringing their medications to appointments for review.[6]
The Preventing Medication Errors report included specific actions for nurses to improve medication safety. The box below summarizes key actions.[7]
• Establish safe work environments for medication preparation, administration, and documentation; for instance, reduce distractions and provide appropriate lighting.
• Maintain a culture of rigorous commitment to principles of safety in medication administration (for example, consistently checking the rights of medication administration and also performing double checks with colleagues as recommended).
• Remove barriers and facilitate the involvement of client surrogates in checking the administration and monitoring the medication effects.
• Foster a commitment to clients’ rights as co-consumers of their care.
• Develop aids for clients or their surrogates to support self-management of medications.
• Enhance communication skills and team training to be prepared and confident in questioning medication orders and evaluating client responses to drugs.
• Actively advocate for the development, testing, and safe implementation of electronic health records.
• Work to improve systems that address “near misses” in the work environment.
• Realize they are part of a system and do their part to evaluate the efficacy of new safety systems and technology.
• Contribute to the development and implementation of error reporting systems and support a culture that values accurate reporting of medication errors.
In 2019, the World Health Organization (WHO) identified “Medication Without Harm” as the theme for the third Global Patient Safety Challenge with the goal of reducing severe, avoidable medication-related harm by 50% over the next five years. As part of the Global Patient Safety Challenge: Medication Without Harm, the WHO has prioritized three areas to protect clients from harm while maximizing the benefit from medication[8]:
Medication safety in high-risk situations Medication safety in polypharmacy Medication safety in transitions of careView the follow YouTube video explaining how to avoid harm from medications.
A summary of strategies to reduce harm and ensure medication safety is provided in Figure 2.3.[10]
Key Steps for Ensuring Medication Safety
The first priority of the WHO Medications Without Harm initiative, medication safety in high-risk situations, includes the components of high-risk medications, provider-client relations, and systems factors.
High-risk medications are drugs that bear a heightened risk of causing significant client harm when they are used in error.[11]
High-risk medication can be remembered using the mnemonic “A PINCH.” The information in the box below describes these medications included with the “A PINCH” mnemonic.
A: Anti-infective Amphotericin, aminoglycosides
P: Potassium & other electrolytes Injections of potassium & other electrolytes
I: Insulin All types of insulin
C: Chemotherapeutic agents Methotrexate and vincristine
H: Heparin & anticoagulants Warfarin and enoxaparin
Note: Based on research, the Institute of Safe Medication Practices (ISMP) has expanded this list of high-risk medications. The updated list can be viewed in the box below.
Strategies for safe administration of high-alert medication include the following:
• Standardizing the ordering, storage, preparation, and administration of these products
• Improving access to information about these drugs
• Employing clinical decision support and automated alerts
• Using redundancies such as automated or independent double-checks when necessary
In addition to high-risk medications, a second component of medication safety in high-risk situations includes provider and client factors. This component relates to either the health care professional providing care or the client being treated. Even the most dedicated health care professional is fallible and can make errors. The act of prescribing, dispensing, and administering a medicine is complex and involves several health care professionals. The client should be the center of what should be a “prescribing partnership.”[12] See Figure 2.4 for an illustration of the prescribing partnership.[13]
Other risk factors can exist in specific clients across the life span. For example, adverse drug events occur most often at the extremes of life (in the very young and very old). In the older adult population, frail clients are likely to receive several medications concurrently, which adds to the risk of adverse drug events. In addition, the harm of some of these medication combinations may be synergistic, meaning the risk is greater when medications are taken together than the sum of the risks of individual agents. In neonates (particularly premature neonates), elimination routes through the kidney or liver may not be fully developed. The very young and very old are also less likely to tolerate adverse drug reactions, either because their homeostatic mechanisms are not yet fully developed, or they may have deteriorated. Medication errors in children, where doses may have to be calculated in relation to body weight or age, are also a source of major concern. Additionally, certain medical conditions predispose clients to an increased risk of adverse drug reactions, particularly renal or hepatic dysfunction and cardiac failure. Interprofessional strategies to address these potential harms are based on a systems approach with a “prescribing partnership” between the client, the prescriber, the pharmacist, and the nurse that includes verifying orders when concerns exist.
In addition to high-risk medications and provider-patient relations, systems factors also contribute to medication safety in high-risk situations. Systems factors can contribute to error-provoking conditions for several reasons. The unit may be busy or understaffed, which can contribute to inadequate supervision or failure to remember to check important information. Interruptions during critical processes (e.g., administration of medicines) can also occur, which can have significant implications for patient safety. Tiredness and the need to multitask when busy or flustered can also contribute to error and can be compounded by poor electronic medical record design. Preparing and administering intravenous medications are also particularly error prone. Strategies for reducing errors include checking at each step of the medication administration process; preventing interruptions; using electronic provider order entry; and utilizing prescribing assessment tools, such as the Beers Criteria, to evaluate for potentially inappropriate medication use in older adults.[14] The Beers Criteria is a list of potentially harmful medications or medications with side effects that outweigh the benefit of taking the medication.
The second priority of the WHO Medications Without Harm initiative relates to medication safety in polypharmacy. Polypharmacy is the concurrent use of multiple medications. Although there is no standard definition, polypharmacy is often defined as the routine use of five or more medications including over-the-counter, prescription, and complementary medicines.
As people age, they are more likely to suffer from multiple chronic illnesses and take multiple medications. It is essential to use a person-centered approach to ensure their medications are appropriate to gain the most benefits without harm and to ensure the client is part of the decision-making process. Appropriate polypharmacy is present when all medicines are prescribed for the purpose of achieving specific therapeutic objectives that have been agreed with the client; therapeutic objectives are actually being achieved or there is a reasonable chance they will be achieved in the future; medication therapy has been optimized to minimize the risk of adverse drug reactions; and the client is motivated and able to take all medicines as intended.
Inappropriate polypharmacy is present when one or more medications are prescribed that are no longer needed. One or more medications may no longer be needed because there is no evidence-based indication, the indication has expired or the dose is unnecessarily high, they fail to achieve the therapeutic objectives they were intended to achieve, one or the combination of several medications put the client at a high risk of adverse drug reactions, or the client is not willing or able to take the medications as intended.[15]
When clients transition across health care settings, medication review by nurses is essential to prevent harm caused by inappropriate polypharmacy.
The third priority of the WHO Medications Without Harm initiative relates to medication safety during transitions of care. View the interactive activity below to see how medications are reconciled during transitions of care from admission to discharge in a hospital setting.
“Medication Reconciliation Process” by E. Christman for Open RN is licensed under CC BY 4.0
Medication errors can occur during transitions across settings. Figure 2.5[17] is an image from the World Health Organization showing ranges of percentage of errors that occur during common transitions of care.
Medication Discrepancies at Various Transitions of Care
Key strategies for improving medication safety during transitions of care include the following:
Implementing formal structured processes for medication reconciliation at all transition points of care. Steps of effective medication reconciliation are to build the best possible medication history by interviewing the client and verifying with at least one reliable information source, reconciling and updating the medication list, and communicating with the client and future health care providers about changes in their medications.
Partnering with clients, families, caregivers, and health care professionals to agree on treatment plans, ensuring clients are equipped to manage their medications safely, and ensuring clients have an up-to-date medication list.
Where necessary, prioritizing clients at high risk of medication-related harm for enhanced support such as post-discharge contact by a nurse.[18]
A nurse is performing medication reconciliation for an elderly client admitted from home. The client does not have a medication list and cannot report the names, dosages, and frequencies of the medication taken at home.
What other sources can the nurse use to obtain medication information?
Note: Answers to the Critical Thinking activities can be found in the “Answer Key” section at the end of the book.
The Institute for Safe Medication Practices (ISMP) is respected as the gold standard for medication safety information. It is a nonprofit organization devoted entirely to preventing medication errors. ISMP collects and analyzes thousands of medication error and adverse event reports each year through its voluntary reporting program and then issues alerts regarding errors happening across the nation. The ISMP has established several prevention strategies for safe medication administration, including lists of high-alert medications, error-prone abbreviations to avoid, do not crush medications, look-alike and sound-alike drugs, and error-prone conditions that lead to error by nurses and student nurses. Each of these initiatives is further described below.[19]
ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations contains abbreviations, symbols, and dose designations that have been reported through the ISMP National Medication Errors Reporting Program as being frequently misinterpreted and involved in harmful medication errors. These abbreviations, symbols, and dose designations should never be used when communicating medical information. Note that this list has additional abbreviations than those contained in The Joint Commission’s Do Not Use List of Abbreviations. Review the information below for the ISMP list of error-prone abbreviations to avoid. Some examples of abbreviations that were commonly used that should now be avoided are qd, qod, qhs, BID, QID, D/C, subq, and APAP.[20]
Strategies to avoid mistakes related to error-prone abbreviations include not using these abbreviations in medical documentation. Furthermore, if a nurse receives a prescription containing an error-prone abbreviation, it should be clarified with the provider and the order rewritten without the abbreviation.
The IMSP maintains a list of oral dosage medication that should not be crushed, commonly referred to as the “Do Not Crush” list. These medications are typically extended-release formulations.[21] Strategies for preventing harm related to oral medication that should not be crushed include requesting an order for a liquid form or a different route if the client cannot safely swallow the pill form.
ISMP maintains a list of drug names containing look-alike and sound-alike name pairs such as Adderall and Inderal. These medications require special safeguards to reduce the risk of errors and minimize harm.
Safeguards may include the following:
Using both the brand and generic names on prescriptions and labels Including the purpose of the medication on prescriptions Changing the appearance of look-alike product names to draw attention to their dissimilarities Configuring computer selection screens to prevent look-alike names from appearing consecutively[22]When analyzing errors involving student nurses reported to the USP-ISMP Medication Errors Reporting Program and the PA Patient Safety Reporting System, it appears that many errors arise from a distinct set of error-prone conditions or medications. Some student-related errors are similar in origin to those that seasoned licensed health care professionals make, such as misinterpreting an abbreviation, misidentifying drugs due to look-alike labels and packages, misprogramming a pump due to a pump design flaw, or simply making a mental slip when distracted. Other errors stem from system problems and practice issues that are rather unique to environments where students and hospital staff are caring together for clients. View the list of error-prone conditions that should be avoided using the following box.
A nurse is preparing to administer insulin to a client. The nurse is aware that insulin is a medication on the ISMP list of high-alert medications.
What strategies should the nurse implement to ensure safe administration of this medication to the client?
Note: Answers to the Critical Thinking activities can be found in the “Answer Key” section at the end of the book.
The Quality and Safety Education for Nurses (QSEN) project’s vision is to “inspire health care professionals to put quality and safety as core values to guide their work.” QSEN began in 2005 and is funded by the Robert Wood Johnson Foundation. Based on the Institute of Medicine (2003) competencies for nursing, QSEN further defined these quality and safety competencies for educating nursing students:
