FAR EASTERN UNIVERSITY

INSTIITUTE OF NURSING

NUR1207 PHARMACOLOGY

MODULE 3: SAFETY AND QUALITY OF DRUG ADMINISTRATION

I. Introduction:

Drug administration should entail quality and safety. This module involves a
discussion of safety initiatives and interventions that include the “five-plus-five”
rights of medication administration, the nurse’s rights when administering
medications, and the Patient Safety Goals. Also, this module will give emphasis on
the nurses need to know about safety risks of handling and disposing medication.

1.1 Goal and Objectives:

This module aims to develop students understanding of the concepts and apply it in
the clinical settings. To achieve this, the students are expected to appropriately
manage their time and critically utilize their learning modalities to be able to:
1. List and understand the importance of “five-plus-five” rights of medication
administration
2. Determine the nurse’s rights when administering medications
3. Critically analyse and document the drug order
4. Apply the safety risks of handling, administering, and disposing medication

1.2 Activities for this module

A. For MIXED ONLINE LEARNING (MOL) – Synchronous + Asynchronous

Learning: Online meeting with faculty for consultation and clarification of
modules + independent learning of content (with options to watch, read or
listen) + online quiz
B. For ASYNCHRONOUS LEARNING: independent learning of content (with
options to watch, read or listen) + online quiz
C. For TOTAL ANALOGUE LEARNING (TAL) : independent learning of
content (with options to watch, read or listen) + critical thinking activity to be
collected in a portfolio

II. Pre-Lecture Activity: Practice Questions

Choose the best answer

1. The nurse is aware that The Joint Commission has recommended which
abbreviation be on the “Do Not Use” list for ordering or documenting
medications?
A. q.o.d C. Subling
B. NPO D. bid
2. The nurse prepares to administer medications. Which are complete drug orders?
(Select all that apply.)
A. Aspirin 81 mg PO daily
B. Multivitamin
C. Vitamin D 2000 units PO

Prepared by: Mayla D. Rivera, MAN, RN, IPC Page 1

 D. Ciprofloxacin hydrochloride (Cipro) 500 mg PO q12h × 7d
E. Promethazine 50 mg IV q3-6h PRN for nausea

III. Discussions:

Five-Plus-Five” Rights of Medication Administration

The “five-plus-five” rights of medication administration are important goals for
medication safety.
Five plus Five Rights of medication administration:
1. Right patient 1. Right assessment
2. Right drug 2. Right documentation
3. Right dose 3. Patient’s right to education
4. Right route 4. Right evaluation
5. Right time 5. Right to refuse
Note: The original five rights and the subsequent additions are important safety for
drug administration.

1. Right patient – determining patient identification is an integral part of ensuring

patient safety.
Two important ways of identifying the patient:
A. Ask the patient to state his or her full name and birth date and compare these with the
patient’s identification (ID) band and the medication administration record (MAR).
Many facilities have electronic health records (EHRs) that allow the nurse to directly
scan the bar code from the patient’s ID band. Once the band is scanned, the nurse can
see the patient’s medication record.
B. If the patient is an adult with a cognitive disorder or a child, verify the patient’s name
with a family member. In the event a family member is unavailable, and the patient is
unable to identify self, follow the facility’s policy. Many facilities have policies that
include a photo ID on the band with the patient’s name and birth date affixed to the
band.

Example of a barcode reader used to scan the patient wrist band.

2. Right Drug - The nurse must accurately determine the right drug prior to
administration. Medication order must only be given by those disciplines with
prescriptive authority such as the medical doctor (MD), dentist (doctor of dental
surgery [DDS]), podiatrist (doctor of podiatric medicine [DPM]), certified nurse
practitioner (CNP), advanced practice registered nurse (APRN), physician assistant

Prepared by: Mayla D. Rivera, MAN, RN, IPC Page 2

 (PA), veterinarian, chiropractor, and optometrist. In addition, medical clinical
psychiatrists and pharmacists have prescriptive authority with strict guidelines set by
the state.
o Prescriptions may be done by handwritten, telephone order (T/O) or verbal
order (V/O), or directly entered the patient’s EHR. Handwritten prescriptions
are written on a provider’s legal prescription pad and are filled by a
pharmacist.
o All telephone orders or verbal orders for medications are either handwritten by
the nurse taking the order or entered directly into a computer and “read back”
to ensure accuracy and affixing his/her signature. If controlled drugs, 2 nurses
are required to listen and affix their signature.
o After dictating a verbal order, the provider must sign it within 24 hours.
Note: Nursing students are not allowed to accept or take provider orders.
The components of a drug order are as follows:
A. Patient name and birth date
B. Date the order is written
C. Provider signature or name if an electronic order, T/O, or V/O
D. Signature of licensed staff who took the T/O or V/O, if applicable
E. HCPs who wish to prescribe controlled drugs must register with the Drug
enforcement agency (DEA). When prescribing controlled substances, the
HCP’s DEA number must be on the prescription.
F. Drug name and strength
G. Drug frequency or dose (e.g., once daily)
H. Route of administration
I. Duration of administration (e.g., × 7 days, × 3 doses, when applicable)
J. Number of pills to be dispensed
K. Any special instructions for withholding or adjusting dosage based on nursing
assessment, drug effectiveness, or laboratory results

Example of Drug order:

Note:
 It is the nurse’s responsibility to administer the drug ordered by the provider. If the
drug order is incomplete, the drug should not be administered. Verification must be
done by the nurses in a timely and respected manner.

Prepared by: Mayla D. Rivera, MAN, RN, IPC Page 3

  Nurses are legally liable if they give a prescribed drug and the dosage is incorrect, or
if the drug is contraindicated for the patient’s health status. Once the drug has been
administered, the nurse becomes liable for the predicted effects of that drug

To avoid drug errors, the drug label should be read three times:
1. When you pick up the medication and remove it from the drug cabinet
2. As you prepare the drug for administration
3. When you administer the drug

3. Right Dose - The right dose refers to verification by the nurse that the dose administered is
the amount ordered and that it is safe for the patient for whom it is prescribed. Also, the right
dose is based on the patient’s physical status including the patient’s weight to determine the
right dose.
Note:
 Always recheck the drug calculation if the dose is within a fraction or if it is an
extremely large dose. Consult another nurse or the pharmacist when in doubt.
 Note the method of dispensing the drug. It could be thru automated dispensing
cabinets (computerized drug storage cabinet), or thru the Unit dose method (single
dose [has reduced dosage errors because no calculations are required]) or thru a
Multidose vial method which required calculations to withdraw an exact amount of
drug according to the dose required.
o If something left in the multidose vial, it should be properly disposed
according the sanitation or hospital policy.

4. Right Time - refers to the time the prescribed dose is ordered to be administered. To
maintain therapeutic level of the drug in the blood plasma level, a daily prescribed order
should have specified intervals. It could be:
1. Once a day
2. twice a day (bid) or every 12 hours
3. three times a day (tid) or every 8 hours
4. four times a day (qid), or every 6 hours (every 6hrs)
Note: Use of military time (24-hour clock) is recommended in the healthcare facility rather
than the standard time because it reduces administration errors.

Types of Drug order:

5. Right Route - The right route is necessary for adequate or appropriate absorption. It is
ordered by the health care provider and indicates the mechanism by which the medication

Prepared by: Mayla D. Rivera, MAN, RN, IPC Page 4

enters the body. It composes of: Oral, sublingual, buccal, transdermal, topical, instillation,
inhalation, nasogastric and gastrostomy tubes, suppositories, and parenteral.

6. Right Assessment - requires the collection of appropriate baseline data before

administration of a drug (e.g., taking a complete set of vital signs and checking lab levels
prior to drug administration).
 It is important for the nurse to identify high-risk patients (e.g., patients with
medication allergies, patients on dialysis, those with liver disease, diabetic patients,
cardiac and pulmonary patients, and the elderly and pediatric populations). If at-risk
patients are identified, precautions must be taken to reduce risk.

7. Right Documentation - requires the nurse to record immediately the appropriate

information about the drug administered.
 Method of documenting drug administration:
o Paper medication administration record (MAR) - is the commonly used
method specially in the Philippines as per observation
o Computerized charting - nurse enters a personal identification and password
to get access into the system. The computerized system interfaces with other
departments, including the pharmacy, laboratory, and sometimes the
physician’s office.
Note: it is important that nurses must remember that drugs should be signed off
immediately after the drug is administered. A drug that is given but not documented is
considered not given and a drug that is not given but documented is considered given. To
prevent ethico- moral cases, always follow the appropriate documentation process.

Prepared by: Mayla D. Rivera, MAN, RN, IPC Page 5

Sample documentation method

8. Right to Education - The nurse should accurately and thoroughly inform the patient about
the drugs they are taking and how each drug relates to their condition. Teaching the patient
also includes why the patient is taking the drug, what is the expected result of the drug, it
possible good /therapeutic effects, side effects and adverse effects, and if there are any dietary
restrictions or requirements. Patients also has the right to know the laboratory test result

Prepared by: Mayla D. Rivera, MAN, RN, IPC Page 6

monitoring and the necessary skills of drug administration he/she should with return
demonstration before discharge. This is to facilitate continuity of care at home upon
discharge. Informing the patients and families are also integral aspects of preventing
medication errors.

9. Right Evaluation - determines the effectiveness of the drug based on the patient’s
response to the drug. The nurse should ask the patient whether the medication improve the
present health condition. Also, the nurse should evaluate the therapeutic effect of the
medication by assessing the patient response to the drug. Evaluation is an ongoing and is an
important aspect of patient safety.

10. Right to Refuse - patient has the right to refuse the medication, and it is the nurse’s
responsibility to determine the reason for the refusal, explain to the patient the risks involved
with refusal, and reinforce the important benefits of and reasons for taking the medication.
When a medication is refused, the refusal must be documented immediately, and follow-up is
always required. The primary nurse and health care provider should be informed because the
omission may pose a specific threat to the patient (e.g., a change in the lab values with insulin
and warfarin).

Nurses’ Rights when Administering Medication - These rights provide an additional layer
of safety by ensuring that the nurse has what is needed to provide safe medication
administration.
Nurses six rights of administering medication:
1. the right to a complete and clear order (e.g., nurses may clarify a HCP order
that is not clear because it is not legibly written or a verbal or telephone order
that are sounds like or sounds alike.
2. the right to have the correct drug, route (form), and dose dispensed
3. the right to have access to information
4. the right to have policies to guide safe medication administration
5. the right to administer medications safely and to identify problems in the
system
6. the right to stop, think, and be vigilant when administering medication

The Joint Commission National Patient Safety Goals (TJC)

Two important goals that have already become standards for all TJC
1. “Do not use” abbreviations - orders that should be written to avoid
misinterpretation

Prepared by: Mayla D. Rivera, MAN, RN, IPC Page 7

 2. List of acceptable abbreviations - are abbreviations that are frequently used in drug
therapy and must be known by the nurse

Prepared by: Mayla D. Rivera, MAN, RN, IPC Page 8

 Disposal of Medication – appropriate disposals of used drugs are important to decrease
the amount of controlled substances released into the environment, especially into water
and sewage system.
 Facilities may contract with an independent or local collection program authorized by
the state and the FDA/DEA to dispose medical waste and hazardous materials
 Hospital should orient the healthcare team including nurses of the convenient, and
responsible methods for collecting and destroying medications and controlled
substances
 The drugs are disposed of in a receptacle that must comply with strict security and
record-keeping requirements as established by the FDA/DEA.

Sharps Safety / Needle-stick Injury- Nurses should not risk their lives every time they
use a sharp object or needle. Sharps safety prevent incidents of blood-borne related
disease such as the HIV/AIDS or Hepatitis B. The Occupational Safety and Health
Administration (OSHA) Needle-stick Safety and Prevention Act (NSPA) of 2000 resulted
from the American Nurses Association (ANA) campaign Safe Needles Save Lives.
 The NSPA requires that employers implement safer medical devices for their
employees, provide a safe and secure workplace environment with educational
opportunities, and develop written policies to help prevent sharps or needle-stick
injuries. This will include a flowchart of pre-post exposure management.
 Use puncture-proof containers to dispose of sharps and needles. Containers must be
closed, puncture resistant, leak proof, color coded, and emptied routinely to prevent
overfilling

Prevention of needle-stick injury in the clinical settings

Safety Risks with Medication Administration - risk to safety includes the following:
1. Tablet splitting. To counteract steeply rising drug costs, some patients are cutting
their pills in half. However, this is not recommended by the FDA. The only time
tablet splitting is advisable is when it is specified by the pharmacist on the label
2. Buying drugs over the Internet. Consumers may find it convenient to order drugs
over the Internet, but precautions must be taken because drugs sold online may be too
old, too strong, or too weak to be effective and are unsafe to use with other
medications

Prepared by: Mayla D. Rivera, MAN, RN, IPC Page 9

 3. Dosage Forms: To Crush or Not to Crush - Do not crush any extended- or
sustained-release drugs because this will change the pharmacokinetic phase of the
drug. Although some drugs can be used crushed, some should not be crushed. Always
consult with the pharmacist or, when possible, the health care provider prior to
crushing a patient’s drug.
4. High-Alert Medications - High-alert drugs can cause significant harm to the patient.
If a high-alert medication is given in error, it can have a major effect on the patient’s
organs. This includes cardiac, respiratory, vascular, and neurologic systems.

Examples of high alert drugs:

1. epinephrine
2. Insulin (all forms)
3. magnesium sulfate injection
4. opium tincture
5. potassium chloride concentrates for injection
6. promethazine IV
7. vasopressin, IV or IO.

Lists to reduce risk of errors in administering high alert medication:

1. Simplify the storage, preparation, and administration of high-alert drugs
2. Write policies concerning safe administration
3. Improve information and education
4. Limit access to high-alert medications
5. Use labels and automated alerts
6. Use redundancies (automated or independent double-checks)
7. Closely monitor the patient’s response to the medication (possibly the most
important step)

Look-Alike and Sound-Alike Drug Names - Nurses should be aware and give emphasis
that certain drug names sound alike and are spelled similarly is prone to medication error
and should not be practiced in the clinical settings. Example: Amaryl (glimepiride) with
Reminyl (galantamine). To prevent this incident, nurses should always practice the five
plus five Rights of medication administration.

God Bless and Happy Learning…

Prepared by: Mayla D. Rivera, MAN, RN, IPC Page 10