Nurses Legal Responsibilities in Medication Administration

Nur­ses must use at least two (2) uni­que iden­ti­fiers other than the room num­ber pri­or to any pro­ce­du­re, inclu­ding the admi­nis­tra­ti­on of medi­ca­ti­on. Examp­les of uni­que iden­ti­fiers inclu­de the client‘s first name, midd­le name and last name, a pass­word or uni­que code num­ber assi­gned to that per­son upon admis­si­on, the client‘s full date of birth in terms of mon­th, day and year, a pho­to and a bar­code encoded with two (2) or more uni­que iden­ti­fiers. Is the task spe­ci­fic and should it be legal­ly and ethi­cal­ly dele­ga­ted (e.g., admi­nis­te­ring a rou­ti­ne drug ins­tead of admi­nis­te­ring a con­trol­led drug)? A nurse‘s respon­si­bi­li­ties under the NMC Medi­ca­ti­on Manage­ment Stan­dards (2016) can usual­ly be sum­ma­ri­zed in “5 rights” that lead the nur­se to easi­ly con­si­der the­se points. The right pati­ent must recei­ve the right dosa­ge of the right medi­ca­ti­on through the right rou­te at the right time. This has been exten­ded by some experts to the “7‑right rule” or even the “9‑right rule” to cover other aspects of drug admi­nis­tra­ti­on cove­r­ed in this sec­tion. The­se rules extend the “5‑right rule” by also che­cking that the cor­rect form of the drug has been pre­scri­bed, that the drug is being admi­nis­te­red for the right rea­son, and that the pati­ent is showing the cor­rect respon­se. After all, after admi­nis­te­ring the drug, the nur­se must fill out the cor­rect docu­men­ta­ti­on. The­se rules are illus­tra­ted below in Figu­re 1. All medi­ca­ti­on pre­scrip­ti­ons are eva­lua­ted by the nur­se for accu­ra­cy and appro­pria­teness. Here are some of the things that are con­si­de­red and eva­lua­ted: The Ame­ri­can Nur­ses Asso­cia­ti­on (ANA) is a pro­fes­sio­nal orga­niz­a­ti­on that repres­ents the inte­rests of the country‘s 4 mil­li­on regis­tered nur­ses and is at the fore­front of impro­ving the qua­li­ty of health care for all. [1] The ANA has deve­lo­ped the Code of Ethics for Nur­ses as a gui­de for the per­for­mance of nur­sing duties in a man­ner con­sis­tent with the qua­li­ty of care and ethi­cal obli­ga­ti­ons of the pro­fes­si­on. [2] Several pro­vi­si­ons of the Code of Ethics affect how nur­ses should admi­nis­ter medi­ca­ti­ons ethically.

A sum­ma­ry of each pro­vi­si­on of the Code of Ethics and its impact on drug admi­nis­tra­ti­on is pro­vi­ded below. Risk fac­tors asso­cia­ted with medi­ca­ti­on errors and other medi­cal errors such as a bad pati­ent or bad sur­ge­ry at the site are dis­cus­sed below: Care­gi­vers should the­re­fo­re start a new drug with the lowest dose pos­si­ble, and then slow­ly incre­a­se the dose over time until the the­ra­peu­tic effect is achie­ved. The star­ting dose may be as low as half the recom­men­ded adult dose. The nur­se informs a pati­ent about the medi­ca­ti­on befo­re dischar­ge. The nur­se pro­vi­des a docu­ment with inst­ruc­tions and a list of cur­rent medi­ca­ti­ons. The nur­sing teacher‘s role in pro­vi­ding stu­dents with cli­ni­cal sce­n­a­ri­os that for­ce nur­sing trai­nees to make decisi­ons in unclear cli­ni­cal situa­tions, act as a com­pe­tent mem­ber of an inter­pro­fes­sio­nal team, and prac­ti­ce with advan­ced modes of medi­ca­ti­on admi­nis­tra­ti­on was cited as a cen­tral role in refer­ring future care­gi­vers to medi­ca­ti­on admi­nis­tra­ti­on rights. [5] For more infor­ma­ti­on on admi­nis­te­ring intra­venous flu­ids and medi­ca­ti­ons and star­ting an intra­venous line, see the “Edu­ca­ting the Cli­ent on the Ratio­na­le and Care for a Venous Access Device” sec­tion of this NCLEX-RN Review Gui­de. Just as nur­ses know the five rights of medi­ca­ti­on admi­nis­tra­ti­on, they should also know what rights they have when admi­nis­te­ring medi­ca­ti­on. The­se “Six Rights for Medi­ca­ting Nur­ses” will hope­ful­ly gui­de nur­ses as they con­ti­nue to care for pati­ents des­pi­te the­se tur­bu­lent times.

The Chap­ter 2 Con­trol­led Drug Sto­rage and Dis­po­sal Case Stu­dy sce­n­a­rio now con­ti­nues to inclu­de the cor­rect admi­nis­tra­ti­on of a con­trol­led drug. As a remin­der, Cla­re is a nur­se who recent­ly recei­ved a new ship­ment of con­trol­led drugs and then pre­pa­red a dose of 25 mg of mor­phi­ne sul­fa­te for her pati­ent Mary. This medi­ca­ti­on was pre­scri­bed to Mary by the atten­ding phy­si­ci­an as an anal­ge­sia for pain asso­cia­ted with Mary‘s advan­ced bre­ast can­cer. Clare‘s actions are obser­ved by ano­t­her nur­se, Fio­na, in accordance with con­trol­led medi­ca­ti­on regu­la­ti­ons (moni­to­ring, manage­ment and uti­liz­a­ti­on), NMC medi­ca­ti­on manage­ment gui­de­li­nes, and her hospital‘s local pro­to­cols and pro­ce­du­res. Cla­re has alrea­dy per­for­med the cor­rect dis­po­sal pro­ce­du­re for the 5 mg of excess mor­phi­ne sul­fa­te con­tai­ned in the ori­gi­nal ampoule in accordance with the­se rules. The cli­ent should be edu­ca­ted on the safe and cor­rect method of self-admi­nis­tra­ti­on of medi­ca­ti­on. In addi­ti­on to the trai­ning men­tio­ned abo­ve, some cli­ents may also need to learn spe­cial pro­ce­du­res such as pro­per use of an inha­ler, taking insu­lin, mixing insu­lins, admi­nis­te­ring an intra­mus­cu­lar injec­tion, or self-admi­nis­te­ring pro­bes. Eye medi­ca­ti­ons are used using a ste­ri­le tech­ni­que, which is one of the few means that requi­re more than medi­cal asep­sis or clean tech­ni­que. The admi­nis­tra­ti­on of the drug should be immedia­te­ly recor­ded clear­ly and accu­rate­ly in the patient‘s notes, with the nur­se signing and prin­ting the patient‘s name and record­ing the date and time of admi­nis­tra­ti­on of the drug. If the drug was not admi­nis­te­red deli­ber­ate­ly, for examp­le, if the nur­se felt the need to ques­ti­on its admi­nis­tra­ti­on to the pre­scrib­ing phy­si­ci­an, or if the pati­ent refu­sed it, this should also be noted in the notes with the rea­son. Nur­ses are requi­red by law to ensu­re that they clear­ly record this information.

This should also be done if the regis­tered nur­se has dele­ga­ted the admi­nis­tra­ti­on of medi­ca­ti­on to ano­t­her per­son, but this will be dis­cus­sed in more detail later in the chap­ter. Safe medi­ca­ti­on admi­nis­tra­ti­on will be dis­cus­sed in more detail in the next chap­ter. Drug orders are often manu­al­ly trans­fer­red to a Medi­ca­ti­on Admi­nis­tra­ti­on Record (MAR) or Medex if the faci­li­ty does not use com­pu­te­ri­zed pre­scrip­ti­on ent­ry. Accord­ing to the NMC Code (2015), nur­ses may pre­scri­be or admi­nis­ter medi­ca­ti­ons wit­hin the limits of their trai­ning, the law, and any local or natio­nal gui­de­li­nes. This inclu­des com­pli­an­ce with the spe­ci­fic restric­tions on the admi­nis­tra­ti­on of con­trol­led drugs dis­cus­sed in the pre­vious chap­ter. In accordance with pre­scrib­ing rules for other health pro­fes­sio­nals, nur­ses should not pre­scri­be to a per­son with whom they have a clo­se per­so­nal rela­ti­ons­hip or pre­scri­be medi­ca­ti­on for them­sel­ves unless abso­lute­ly necessa­ry. Nur­ses have achie­ved this pati­ent invol­ve­ment by edu­ca­ting them about their medi­ca­ti­ons and the impor­t­ance of their invol­ve­ment during medi­ca­ti­on admi­nis­tra­ti­on to build trust and respect. [2] Many stu­dies high­light the value of nur­ses‘ cli­ni­cal rea­so­ning skills, defi­ned as the abi­li­ty to think about a cli­ni­cal situa­ti­on as it unfolds, as well as the con­cerns and con­text of the pati­ent and fami­ly. [8] Safe medi­ca­ti­on admi­nis­tra­ti­on requi­res much more than the five rights and medi­ca­ti­on manage­ment to avoid cos­t­ly mista­kes. The lite­ra­tu­re is begin­ning to show more and more evi­dence that new efforts to main­tain safe­ty should also high­light the emer­gence of nur­ses‘ cli­ni­cal thin­king as an ele­ment that dri­ves nur­ses to beco­me high­ly com­pe­tent in their pro­fes­si­on. [8] Com­pe­tence is mea­sura­ble in the pre­sen­ta­ti­on of cli­ni­cal and phar­ma­co­lo­gi­cal know­ledge, cli­ni­cal expe­ri­ence, and the abi­li­ty to per­form com­pre­hen­si­ve situa­tio­nal assess­ments of the pati­ent pri­or to drug administration.

[8] The sites of intra­mus­cu­lar drugs are the glu­teus maxi­mus, del­to­id mus­cle, late­ral vas­tus, rec­tus femo­ral mus­cle, and ven­tro­glu­te­al mus­cle. The glu­teus maxi­mus mus­cle and del­to­id mus­cle are NOT used for infants or young child­ren under 3 years of age. One of the recom­men­da­ti­ons to redu­ce medi­ca­ti­on errors and dama­ge is to use the “five rights”: the right pati­ent, the right medi­ca­ti­on, the right dose, the right way, and the right time. If a medi­ca­ti­on error occurs during the admi­nis­tra­ti­on of a medi­ca­ti­on, we quick­ly bla­me the nur­se and accu­se her of not respec­ting the five rights. The five rights should be accep­ted as the goal of the medi­ca­ti­on pro­cess, not the “anything and ever­ything” of medi­ca­ti­on safe­ty. Imple­ments INTER­VEN­TI­ONS by with­hol­ding meto­pro­lol at this time, docu­men­ting the drug reten­ti­on inci­dent, and noti­fy­ing the pro­vi­der. Sam then makes sure she gives Phil clear inst­ruc­tions on the tasks he needs to do.