What are the steps of the medication use process?

Medication use is a complex process that comprises the sub-processes of medication prescribing, order processing, dispensing, administration, and effects monitoring. The Key Elements of the Medication Use System™ which affect the medication-use process are listed below. The inter-relationships among these key elements form the structure within which medications are used.

Patient information: Obtaining the patient’s pertinent demographic (age, weight) and clinical (allergies, lab results) information that will assist practitioners in selecting the appropriate medications, doses and routes of administration. Having essential patient information at the time of medication prescribing, dispensing and administration will result in a significant decrease in preventable adverse drug events (ADEs).
Drug information: Providing accurate and usable drug information to all healthcare practitioners involved in the medication-use process reduces the amount of preventable ADEs. Not only should drug information be readily accessible to the staff through a multitude of sources (drug references, formulary, protocols, dosing scales…), it is imperative that the drug information is up to date as well as accurate.
Communication of drug information: Miscommunication between physicians, pharmacists, and nurses is a common cause of medication errors. To minimize the amount of medication errors caused by miscommunication it is always important to verify drug information and eliminate communication barriers.
Drug labeling, packaging and nomenclature: Drug names that look-alike or sound-alike, as well as products that have confusing drug labeling and non-distinct drug packaging significantly contribute to medication errors. The incidence of medication errors is reduced with the use of proper labeling and the use of unit dose systems.
Drug storage, stock, standardization, and distribution: Standardizing drug administration times, drug concentrations, and limiting the dose concentration of drugs available in patient care areas will reduce the risk of medication errors or minimize their consequences should an error occur.
Drug device acquisition, use, and monitoring: Appropriate safety assessment of drug delivery devices should be made both prior to their purchase and during their use. Also, a system of independent double-checks should be used within the institution to prevent device related errors such as, selecting the wrong drug or drug concentration, setting the rate improperly, or mixing up the infusion line with another.
Environmental factors: Having a well-designed system offers the best chance of preventing errors; however, sometimes the work environment contributes to medication errors. Environmental factors that often contribute to medication errors include poor lighting, noise, interruptions and a significant workload.
Staff competency and education: Staff education should focus on priority topics, such as: new medications being used in the hospital, high- alert medications, medication errors that have occurred both internally and externally, protocols, policies and procedures related to medication use. Staff education can be an important error prevention strategy when combined with the other key elements for medication safety.
Patient education: Patients must receive ongoing education from physicians, pharmacists, and the nursing staff about the brand and generic names of medications they are receiving, their indications, usual and actual doses, expected and possible adverse effects, drug or food interactions, and how to protect themselves from errors. Patients can play a vital role in preventing medication errors when they have been encouraged to ask questions and seek answers about their medications before drugs are dispensed at a pharmacy or administered in a hospital.
Quality processes and risk management: The way to prevent errors is to redesign the systems and processes that lead to errors rather than focus on correcting the individuals who make errors. Effective strategies for reducing errors include making it difficult for staff to make an error and promoting the detection and correction of errors before they reach a patient and cause harm.

Many of the risks associated with each part of the medication management pathway can be avoided by using systems and processes that are designed to improve safety and are based on evidence from initiatives that have demonstrated significant benefit. These initiatives focus on addressing the common contributing factors to medication errors, which include1:

Lack of knowledge of the medicine
Lack of information about the patient
Slips and memory lapses
Transcription errors
Failure in communication
Lack of patient education
Poor medicines distribution practices.

Medication safety initiatives should focus on systems and standardisation to reduce unnecessary variation, coupled with judicious use of tools and resources that improve knowledge and skills.

The actions and strategies described in this criterion aim to achieve safe and effective medicines use through:

Best use of information and decision support tools in clinical decision-making
Compliance and safety in medicines distribution and storage systems
Targeting known risk areas (for example, high-risk medicines), and embedding processes, practices and tools within the organisation to prevent error
Integration of work practices that underpin safe medication management (such as standardisation, monitoring and risk assessment)
Using medication safety strategies and tools to create an environment for the best communication of medicine-related information (for example, using an MMP).

Actions within this criterion require health service organisations to:

Make a variety of up-to-date and evidence-based medicine-related information and decision support tools available to clinicians
Ensure the effectiveness of the supply chain in the safe delivery of medicines
Ensure compliance with relevant requirements for maintaining the integrity of medicines, minimising wastage and disposing of medicines appropriately
Implement strategies for safe and secure storage and selection of medicines, including high-risk medicines.

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Chapter 6. Non-Parenteral Medication Administration

In the Institute of Medicine’s often-cited book To Err Is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 2000), it is estimated that approximately 1.5-million preventable adverse drug events (ADEs) occur annually. The Joint Commission (TJC) defines medication errors as any preventable event that may cause inappropriate medication use or jeopardize patient safety (TJC, 2012).

Medication errors are the number-one error in health care (Centers for Disease Control [CDC], 2013). Safe and accurate medication administration is an important and potentially challenging nursing responsibility. Medication administration requires good decision-making skills and clinical judgment, and the nurse is responsible for ensuring full understanding of medication administration and its implications for patient safety.

Medication errors have a substantial impact on health care in Canada (Butt, 2010). When preparing and administering medication, and assessing patients after receiving medication, always follow agency policy to ensure safe practice. Review Table 6.1 for guidelines for safe medication administration.

Table 6.1 Guidelines for Safe Medication Administration

Agency policy on medication administration and medication administration record (MAR) may vary. Always receive the required training on the use of the medication system for each agency to avoid preventable errors.

Be vigilant when preparing medications.	Avoid distractions. Some agencies have a no-interruption zone (NIZ), where health care providers can prepare medications without interruptions.
Check for allergies.	Always ask patient about allergies, types of reactions, and severity of reactions.
Use two patient identifiers at all times. Always follow agency policy for patient identification.	Use at least two patient identifiers before administration and compare against the MAR.
Assessment comes before medication administration.	All medications require an assessment (review of lab values, pain, respiratory assessment, cardiac assessment, etc.) prior to medication administration to ensure the patient is receiving the correct medication for the correct reason.
Be diligent in all medication calculations.	Errors in medication calculations have contributed to dosage errors, especially when adjusting or titrating dosages.
Avoid reliance on memory; use checklists and memory aids.	Slips in memory are caused by lack of attention, fatigue, distractions. Mistakes are often referred to as attentional behaviours where lack of training or knowledge is the cause of the error. Slips account for most errors in heath care. If possible, follow a standard list of steps for every patient.
Communicate with your patient before and after administration.	Provide information to patient about the medication before administering it. Answer questions regarding usage, dose, and special considerations. Give the patient an opportunity to ask questions. Include family members if appropriate.
Avoid workarounds.	A workaround is a process that bypasses a procedure, policy, or problem in a system. For example, a nurse may “borrow” a medication from another patient while waiting for an order to be filled by the pharmacy. These workarounds fail to follow agency policy to ensure safe medication practices.
Ensure medication has not expired.	Medication may be inactive if expired.
Always clarify an order or procedure that is unclear.	Always ask for help whenever you are uncertain or unclear about an order. Consult with the pharmacist, charge nurse, or other health care providers and be sure to resolve all questions before proceeding with medication administration.
Use available technology to administer medications.	Bar-code scanning (eMAR) has decreased errors in administration by 51%, and computerized physician orders have decreased errors by 81%. Technology has the potential to help decrease errors. Use technology when administering medications but be aware of technology-induced errors.
Report all near misses, errors, and adverse reactions.	Reporting allows for analysis and identification of potential errors, which can lead to improvements and sharing of information for safer patient care.
Be alert to error-prone situations and high-alert medications.	High-alert medications are those that are most likely to cause significant harm, even when used as intended. The most common high-alert medications are anticoagulants, narcotics and opiates, insulins, and sedatives. The types of harm most commonly associated with these medications include hypotension, delirium, bleeding, hypoglycemia, bradycardia, and lethargy.
If a patient questions or expresses concern about a medication, stop and do not administer it.	If a patient questions a medication, stop and explore the patient’s concerns, review the physician’s order, and, if necessary, notify the practitioner in charge of the patient.
Data source: Agency for Healthcare Research and Quality, 2014; Canadian Patient Safety Institute, 2012; Debono et al., 2013; Institute for Healthcare Improvement, 2015; National Patient Safety Agency, 2009; National Priority Partnership, 2010; Prakash et al., 2014

Technological Advances That Help Mitigate Medication Errors

Computerized physician order entry (CPOE) is a system that allows prescribers to electronically enter orders for medications, thus eliminating the need for written orders. CPOE increases the accuracy and legibility of medication orders; the potential for the integration of clinical decision support; and the optimization of prescriber, nurse, and pharmacist time (Agrawal, 2009). Decision support software integrated into a CPOE system can allow for the automatic checking of drug allergies, dosage indications, baseline laboratory results, and potential drug interactions. When a prescriber enters an order through CPOE, the information about the order will then transmit to the pharmacy and ultimately to the MAR.

The use of electronic bar codes on medication labels and packaging has the potential to improve patient safety in a number of ways. A patient’s MAR is entered into the hospital’s information system and encoded into the patient’s wristband, which is accessible to the nurse through a handheld device. When administering a medication, the nurse scans the patient’s medical record number on the wristband, and the bar code on the drug. The computer processes the scanned information, charts it, and updates the patient’s MAR record appropriately (Poon et al., 2010).

Automated medication dispensing systems (AMDS) provide electronic automated control of all medications, including narcotics. Each nurse accessing the system has a unique access code. The nurse will enter the patient’s name, the medication, the dosage, and the route of administration. The system will then open either the patient’s individual drawer or the narcotic drawer to dispense the specific medication. If the patient’s electronic health record is linked to the AMDS, the medication and the nurse who accessed the system will be linked to the patient’s electronic record.

Read the Top Ten Tips PDF to review the importance of medication reconciliation.

Checklist 43 outlines the steps for safe medication administration.

Checklist 43: Safe Medication Administration


Plan medication administration to avoid disruption: Dispense medication in a quiet area. Avoid conversation with others. Follow agency’s no-interruption zone policy. Prepare medications for ONE patient at a time. Follow the SEVEN RIGHTS of medication preparation (see below). Check that the medication has not expired. Perform hand hygiene. Check room for additional precautions. Introduce yourself to patient. Confirm patient ID using two patient identifiers (e.g., name and date of birth) AND check against MAR. Check allergy band for any allergies, and ask patient about type and severity of reaction. Complete necessary focused assessments, lab values, and/or vital signs, and document on MAR. Provide patient education as necessary. If a patient questions or expresses concern regarding a medication, stop and do not administer.

1. Check MAR against doctor’s orders.	Check that MAR and doctor’s orders are consistent. Compare physician orders and MAR Compare MAR with patient wristband. Night staff usually complete and verify this check as well.
2. Perform the SEVEN RIGHTS x 3 (this must be done with each individual medication): The right patient The right medication (drug) The right dose The right route The right time The right reason The right documentation Medication calculation: D/H x S = A (D or desired dosage/H or have available x S or stock = A or amount prepared)	The right patient: check that you have the correct patient using two patient identifiers (e.g., name and date of birth). Compare MAR with patient wristband The right medication (drug): check that you have the correct medication and that it is appropriate for the patient in the current context. The right dose: check that the dose makes sense for the age, size, and condition of the patient. Different dosages may be indicated for different conditions. The right route: check that the route is appropriate for the patient’s current condition. The right time: adhere to the prescribed dose and schedule. Check the right patient, medication, dose, route, time, reason, documentation The right reason: check that the patient is receiving the medication for the appropriate reason. The right documentation: always verify any unclear or inaccurate documentation prior to administering medications. NEVER document that you have given a medication until you have actually administered it.
3. The label on the medication must be checked for name, dose, and route, and compared with the MAR at three different times: When the medication is taken out of the drawer When the medication is being poured When the medication is being put away/or at bedside	Perform seven checks three times before administering medication These checks are done before administering the medication to your patient. If taking the drug to the bedside (e.g., eye drops), do a third check at the bedside.
4. Circle medication when poured.	Pour medication. Circle MAR to show that medication has been poured. Circle medication once it has been poured
5. Positioning: Position patient appropriately for medication administration. Ensure proper body mechanics for health care provider. Position patient safely and appropriately once medication is administered.	This ensures patient safety and comfort. Position patient appropriately for medication administration
6. Post-medication safety check: Complete post assessment and/or vital signs (if applicable). Sign MAR; place in the appropriate chart. Perform hand hygiene.	This ensures patient safety. This step prevents the transfer of microorganisms. Hand hygiene with ABHR
Data source: Lilley, Harrington, Snyder, & Swart, 2011; Lynn, 2011; Perry et al., 2014

Discuss why you think medication reconciliation is important for patient safety.
List five steps you can take to ensure safe medication administration practice.