Adm of Oral Medication-sep 08_edited 3 Dec 2008

NATIONAL NURSING AUDIT MINISTRY OF HEALTH MALAYSIA

ELEMENT 5: CONTINUUM OF CARE

5.1 5.1 ADMINISTRATION OF ORAL MEDICATIONADMINISTRATION OF ORAL MEDICATION

1. INTRODUCTION

“First, do no harm” is the ethical imperative for every patient safety effort. In

working to reduce the frequency of medication errors, first priority must be to

prevent those errors with the greatest potential for harm. The leading cause of

patient harm is medication errors, which account for almost 20 percent of

medical injuries.

The definition of a medication error as approved by the National

Coordinating Council for Medication Error and Prevention is

". . .any preventable event that may cause or lead to

inappropriate medication use or patient harm, while the

medication is in the control of the health care professional,

patient, or consumer. Such events may be related to professional

practice, health care products, procedures, and systems

including: prescribing, order communication, product labeling,

packaging and nomenclature, compounding, dispensing,

distribution, administration, education, monitoring, and use."

Administering oral medications is a core function of nurses. Their

responsibility is to comply with safe medication use processes

and practices in order to prevent occurrence of medication errors /

misadventures.

National Nursing Audit, Ministry of Health Malaysia : Version 1 / September 2008, Bahagian Kejururawatan , Kementerian Kesihatan Malaysia Page 1

2. OBJECTIVES

2.1. To prevent occurrence of oral medication errors / misadventures

2.2. To ensure nurses serve medications according to the 6 R’s of

Medication use.

* Right patient

* Right drug

* Right dose

* Right route

* Right time

* Right documentation

2.3. To ensure that nurses exhibit the caring component when administering oral medication.

3. STANDARD

3.1. Nurses serve oral medications according to the 6 R’s of

medication use.

3.2. Nurses exhibit the caring component during the administration of

oral medication.

3.3. Nurses document accurately and completely the medication

administered.


4. CRITERIA

Structure Process Outcome

1. Each patient has current

legal written prescription /

medication profile

2. There is a Nursing

Operating Procedure (NOP)

for administration of

Medication.

3. The nurse is competent in

the serving of medication,

has knowledge on the effect

and adverse drug reaction

and the appropriate

measures to be taken when

there is an adverse reaction.

1. Greet patient.

2. Identify right patient

3. Verify prescription

4. Assess patient, take

appropriate nursing

measures and document

5. Dish out the correct

medication

6. Explain and inform

patients.

7. Listen/Responds promptly

and politely to patient’s

/carer questions.

8. Administer and ensure

patient takes oral

medication.

9. Document medication

served / omitted.

10. Monitor patient’s response

and document.

11. Take appropriate measure

if adverse reaction

identified.

1. All medications are served according to the 6 R’s of medication use

2. Patient receives safe medication during hospital stay

3. Medication misadventures are detected early and appropriate measures taken timely

4. Patient is informed of his medication.

5. Documentation is accurate and complete.


TECHNICAL DOCUMENTATION SOFT SKILL

identify patient

accordingly

verify prescription.

assess patient prior to

administration of

selected medication

dish out medication

accurately – right

drug and right dose.

administer and

ensure patient takes

the medication

document

assessment

findings

document

medication served /

omitted – date, time

and signature

document adverse

reactions identified

document

appropriate

measures taken if

adverse reactions

identified

greet patient

explain and inform

patient

listen,respond

promptly and politely

to patient’s questions.

exhibit caring

component when

assessing patient

6. AUDIT GUIDE FOR ADMINISTRATION OF ORAL MEDICATION

6.1. INCLUSION CRITERIA

All patients in the ward who are on oral medication

6.2. INSTRUMENT

Audit Form (E5 AF 5.1)

– one audit form for one observation

6.3. Methodology

6.3.1. Direct observation of nurse administering oral

medication and also gather information from documents

6.3.2. Setting : All wards

6.3.3. Population: Staff Nurses

6.3.4 Sample Design: Convenient sampling


6.4. Sample Size

- 200 of staff nurses from each activity / program, equally

divided among the wards for Hospital with Specialist and 100

staff nurses for non-specialist hospital

6.5. Time Frame

-One month.

7. DEFINITION OF OPERATIONAL TERMS

7.1. Written prescription

7.1.1. Any legal orders of oral medication endorsed in

the patient’s medication profile / patient’s case notes

7.2. Medication profile

7.2.1. Legal document where the doctor prescribes and the

nurses endorse the administration of the medication

7.3. Patient’s response

7.3.1. Refers to favorable / adverse reactions of medication

administered. E.g. favorable - pain relieved; adverse –

develop rashes.

7.4. Dish out medication accurately

7.4.1. Read patient’s medication profile

7.4.2. Select required medication from patient’s drawer of

medication cart

7.4.3. Calculate dosage before dishing out

7.4.4. Reconfirm the medication and dosage before putting back

the balance.

7.5. Identify right patient

7.5.1. Confirm patient’s identity by 2 identifier

7.5.1.1. His/ her name

7.5.1.2. Registration number


7.5.2. Ask patient to confirm name.

7.5.2.1. Cross check with patient’s wrist band for

name and registration number.

7.5.2.2. Verify accuracy of identifier with patient’s

medication profile.

7.6. Verify prescription by checking for

7.6.1. Prescribing doctor – name, signature, and date ordered

7.5.2. Drug – generic name, dose, frequency, route, duration

7.7. Assessment of Patient for Administration of Selected

Medication:

7.7.1. Nurses need to determine the patient’s current

status prior to administration of selected medication to

confirm its continuity. E.g. Anti-hypertensive, oral

hypoglycemic agents, digitalis, analgesics, antipyretics, beta-

blockers.

7.7.2. Nurses when assessing the patient will exhibit the caring

component:

7.7.2.1. Communicating well in a respectful manner

7.7.2.2. Giving the patient the privacy, dignity and

modesty

7.8. 6 R’s of Medication Use

7.8.1 Right patient

7.8.2 Right medication

7.8.3 Right dose

7.8.4 Right route


7.8.4.1. Correct method of taking medication according to

type:

i. Tab. Magnesium Trisilicate - chewable

ii. Tab. Glycerl Trinitrate - sublingual

iii. Lugol’s Iodine – straw

7.8.5. Right time:

7.8.5.1. An allowance of ± 30 minutes

7.8.5.2. Initial dose served immediately or within a

maximum of 30 minutes upon prescription

/acquisition of medication and subsequent

doses according to time as stated in SOP

of the unit / ward.

7.8.6. Right documentation - implies accuracy and completeness

7.8.6.1. Record assessment findings

7.8.6.2. signature of nurse who serve medication in

the appropriate column

7.8.6.3. for drugs not served, it should be indicated in

medication profile

7.8.6.4. document explanation of any omitted doses in

patient’s case notes

7.8.6.5. Document the evaluation of the patient response

to the medication, when appropriate.

7.8.6.6. document any identified adverse reaction to the

medications administered.

7.8.6.7. date and time of administration must be indicated

in the medication profile


7.9 Compliance of Medication Safety Audit

7.9.1. Technical - Every step in the process must be performed.

i. Identify patient accordingly, verify prescription.

ii. Assess patient prior to administration of selected

medication

iii. Dish out medications accurately – right drug and right

dose.

iv. Administer and ensure patient takes the medication

7.9.2. Essence of Care (Soft Skills): –

i. Greet patient

ii. Explain and inform patient

iii. Responds promptly and politely to patient’s questions.

iv. Exhibit caring component when assessing patient

7.9.3. Documentation - Every step in the process must be

performed.

i. document assessment findings

ii. document medication served / omitted – date, time and

signature

iii. document adverse reactions identified

v. document appropriate measures taken if adverse

reactions identified


8. Audit Form

NATIONAL NURSING AUDIT MINISTRY OF

HEALTH MALAYSIA VERSION 2/04

ELEMENT 5 : CONTINUUM OF CARE

TOPIC : 5.1 ADMINISTRATION OF ORAL

MEDICATION DATE : 8.5.08

DOCUMENT NO : E5 AF 5.1 PAGE No. 1/3

Standard:

1. All medication are served according to the 6 Rights of medication use.

2. All nurses will exhibit the caring component during the administration of

oral medication.

Objectives:

1. To prevent occurrence of medication errors / misadventures

2. To ensure nurses serve medications according to the 6 R’s of medication

use.

3. To ensure that nurses exhibit the caring component when administering

oral medications

Date of Audit:

Locality:

Auditors: 1. …………………………………...

2. ……………………………………


N.B. Instructions for Auditors

1. To tick [√] at appropriate column.

2. Item 4 is not rated if no specific nursing measures required.

S/N ITEM SOURCE OF

INFORMATION

YES NO N/A

*1. Greet patient. Listen / Observe nurse.

2. Identify right patient. Listen / Observe nurse.

3. Verify prescription. Observe nurse.

*4. Assess patient. Observe nurse / check for written evidence.

5. Dish out correct

medication :

5.1. Read patient’s

medication profile

Observe nurse.

5.2. Select required

medication from

patient’s drawer of

medication cart.

Observe nurse.

5.3. Calculate dosage

before dishing out

Observe nurse and

countercheck calculation.

5.4 Reconfirm the

medication and

dosage before

putting back the

balance

Observe nurse.

*6. Explain and inform patient Observe nurse

*7. Responds promptly and

politely to patient’s /carer

questions.

Listen / Observe nurse.

S/N ITEM SOURCE OF YES NO N/A


INFORMATION

8. Administer and ensure

patients take oral

medication:

8.1 right patient. Listen / Observe nurse.

8.2 right medication Listen / Observe nurse.

8.3 right dose Listen / Observe nurse.

8.4 right time Listen / Observe nurse

8.5 right route Listen / Observe nurse

8.6

9 Document:

9..1 Medication

administered.

Observe nurse.

9.2 Assessment

findings.

Observe nurse.

9.3

9.4

AUDIT REPORT (Please [√] the appropriate box)

Conformance Non-Conformance

REMARKS

Auditor 1[Name and Signature]: ……………………………

Auditor 2 [Name and Signature]: ……………………………


Documents

Adm of Oral Medication-sep 08_edited 3 Dec 2008