1. Dosage and Calculations: Desired
over Have

2. Safe Dose
 Identify the nurse’s legal responsibility of med
administration
 Identify the six rights of safe administration
 Use the nursing process to administer med safely
to clients of all ages
 Identify components of a med prescription
 Describe strategies to minimize medication errors
 Identify strategies to deliver traumatic care to
pediatric clients when administering med
 Recognize risks for adverse med reactions

3. Administration
 Nurse are responsible for
 Preparing, administering, and evaluating client responses to meds
 Developing and maintaining an up to date knowledge base of meds
administered, including uses, mechanisms of action, routes of
administration, safe dosage range, side/adverse/toxic responses,
precautions, and contraindications
 Skill competency
 Knowledge of acceptable practice
 Determining accuracy of med orders
 Reporting all med errors
 Safeguarding and storing medications

4. 6 Rights of Administration
 Right client
 Right med
 Right route
 Right time
 Right dose
 Right documentation

5. The Right Client
 The right client by the Joint commission
requires two client identifiers to be used
when administering meds. Acceptable
identifiers include the client’s name, an
assigned identification number, telephone
number, birth date, or other person-specific
identifier

6. The Right Medication
 The right medication should be sure this is
the medication prescribed by the primary
care provider
 Check the med label to ensure it matches
the MAR
verify the medication’s expiration date
 Consult a med guide or pharmacist if
unfamiliar with the medication prescribed

7. The Right Route
 The right route compare the route
instruction written on the med label with t
he route instruction written by the primary
care provider
 Clarify any discrepancies with the primary
care provider or supervisor

8. The Right Time
 The right time ensure it is the correct time
for administration
 Check the health care facility’s guideline for
acceptable med administration time
variations. Acceptable practice may include
safely administering meds 30 mins. before
or after the prescribed time

9. The Right Dose
 The right dose ensure the dose is what has
been prescribed
 Perform any necessary conversions or
calculations
 Check before cutting or crushing any meds.
(A complete list is available at
http://www.ismp.org/Tools/DoNotCrush.pdf

10. The Right Documentation
 Do not record any medications before
administration
 Document on the MAR immediately after
giving the medication
 Indicate on the MAR any medications not
given. Document in the nurse’s notes the
medication omitted and the reason it was
not given
 Only document meds that you have given

11. Types of Medication Prescriptions
 Routine order/standard order
 May or may not have a termination date
 Without a specified termination date, the
order will be the effect until the primary
care provider discontinues it or the client is
discharged
 Certain meds (opioids, antibiotics) must be
reordered within a specified amount of time
or will automatically be discontinued

12. Types of Medication Prescriptions
 Single/one time order
 A single/one time order is to be given at a
specified time or as soon as possible
 For example: furosemide (Lasix) 40 mg PO
at 1000

13. Types of Medication Prescriptions
 PRN order
 A PRN order stipulates at what dosage,
what frequency, and under what conditions
a medication may be give. The health care
professional uses clinical judgment to
determine the client's need for the med
 For example: acetaminophen (Tylenol) 325
mg PO every 3 hr. PRN

14. Types of Medication Prescriptions
 Standing orders
 Standing orders may be written for specific
circumstances and/or for specific units
 For example: the critical care unit has
standing orders to treat a client with
asystole

15. Components of a Medication Prescription
 Name of client
 Date of order
 Time of order
 Name of med
 Dosage
 Route of administration
 Time and frequency: exact times or number
of times per day
 Signature of prescribing provider

16. Medication Errors
 Common med errors include
 Wrong medication or IV fluid
 Incorrect dose or IV rate
 Wrong client, route, or time
 Administration of known allergic
medications
 Omission of dose
 Incorrect discontinuation of meds or IV
fluids

17. Using the Nursing Process
 Using the nursing process to administer meds safely
 Assessment data collection
 Obtain information regarding the client's condition relevant to med
administration
 Obtain necessary pre-administration data (heart rate, blood pressure)
 Omit or delay doses as indicated by client’s condition identify client
allergies
 Determine if the medication prescription is complete – to include name
of client, date and time, name of medication, dosage, route of
administration, time and frequency, and signature of prescribing
provider
 Interpret the med prescription accurately
 Question the provider if the prescription is unclear or seems
inappropriate for the client’s condition

18. Using the Nursing Process
 Planning using the nursing process in
medication administration:
 Calculate and measure doses accurately
 Be sure the medication is the correct strength
 For example: Heparin is available in strengths of
10 units, 100 units, 1000 units or 10,000 units
per 1 mL
 Verify high alert medications with a colleague if
necessary
 Avoid distractions during medication preparation

19. Using the Nursing Process
 Implementing:
 Always use the six right medication administration
 Only administer medications that you have prepared
 Follow correct procedures for all routes of administration
 Use verbal orders only for emergencies
 Follow agency protocol for telephone prescriptions
 Follow all laws and regulations when administering
controlled substances
 Omit or delay a dose if client questions size of dose or
appearance of medication

20. Using the Nursing Process
 Evaluation:
 Evaluate client response to a medication,
and document and report appropriately
 Recognize side/adverse effects, and
document and repost appropriately
 Report all errors and take corrective
measures immediately

21. Medication Error
 If an error occurs:
 Assess the client for any signs of an adverse reaction
 Notify the client’s primary care provider and the supervisor
 Document the event, along with the actions taken in
response to the event to treat or prevent adverse reactions
 Document the event on an incident report according to
agency policy
 Evaluate the cause of the error in order to prevent a
reoccurrence

22. Tools for Safe Medication Practice
 The institute for safe medication for practice
is a nonprofit organization working to
educate health care providers and
consumers regarding safe medication
practices. Tools have been developed to
decrease the risk of medication errors. Go
to http://www.ismp.org for a complete list

23. Tools for Safe Administration Practice
 Error-Prone Abbreviation List
 Certain abbreviation have been associated
with a high number of medication errors
 IU International Units

24. Medication Errors
 Confused medication Name List
 The names of some medications look and
sound alike, which can lead to medication
errors
 For example: Actos confused with Actonel

25. Medication Errors
 High-Alert Medication List
 Some medications, if given in error, have a
high risk for resulting in significant patient
harm
 For example: adrenergic agonist IV
(epinephrine) – Insulin, subcutaneous/IV

26. Medication Errors
 Tall Man Letters
 Tall Man Letters are recommended for
differentiating between look-alike
medications names
 acetoHEXADINE (Dimelor) &
acetaZOLAMIDE (Acetazolam)

27. Medication Errors
 A high number of medication errors have been associated wit the
inappropriate placement of zeros
 The universal guideline is to always use a leading zero before a
decimal, but never a trailing one
 For example this prescription reads five tenths of a milliliter .5 mL
 It could easily be mistaken as 5 milliliter, or 10 times the intended
dose. A leading zero is placed before the decimal point to ensure that
the dose is read correctly
 0.5 mL: Always use a zero before a decimal point when the dose is
less than one
 5.0 mL reads five milliliters it could easily be mistaken as 50 milliliters.
The trailing zero should not be placed following the decimal point to
ensure that the dosage is read correctly
 5 mL: never use a trailing zero following a decimal point

28. Medication Errors
 Sound-alike medications be careful with:
 Common medication suffixes – the use of med suffixes has
the potential for causing med errors. There is no
standardized nomenclature or definition. Suffixes may be
confused with medical abbreviations, acronyms, dosing
intervals, etc.
 For example: ER, XL, and SR all indicate some type of
delayed response. This response may be delayed until the
medication has passed through the stomach or the
medication may be delivered over a longer interval than a
similar med that has immediate release

29. Safe and Atraumatic Care
 Atraumatic care is the provision of
therapeutic care in settings, by personnel,
and through the use of interventions that
eliminates or minimizes the psychological
and physical distress experienced by
children and their families in the health care
system

30. Safe and Autraumatic Care
 Prevent or minimize physical stressors:
 Educate on environment, diagnosis, treatment
 Use non-threatening models (dolls)
 Make environments less threatening; provide ”safe areas”
 Keep a neutral thermal environment
 Explain all noises, including alarms
 Close doors to room when possible to allow privacy
 Allow rest periods between invasive procedures
 Allow transitional items at bedside, such as blankets and
dolls

31. Safe and Autraumatic Care
 Prevent or minimize child/parent separation
 Ask parents about interventions that are
comforting for the child if they choose to be
together
 Always accompany the parents to the
bedside on the first visit
 Allow parents to hold their child, providing
accommodation for equipment such as
ventilators and monitors

32. Safe and Autraumatic Care
 Promote autonomy
 Orient parents to the environment as well as time
limitations related to visitation
 Allow parents and children time to be alone together when
possible
 Encourage parents to take time for themselves to eat and
sleep
 Ask children and parents if they wish to be together for
procedures
 Respect their decision
 Use time structuring to maintain a consistent and normal
schedule

33. Safe and Autraumatic Care
 When administering medications to pediatric
clients, use the same six rights of
medication administration that are used for
adult clients

34. Safe and Autraumatic Care
 Developmental approach for infants (birth to 1 year)
 Place in a semi-reclining position for oral medication
 Expect that the infant may spit or drool and be ready to
collect as much of the discarded medication as possible
 Use an appropriate dosing device (such as an oral syringe,
a hollow spoon, or a dropper) to deliver a precise dose
 Allow the parent to give the medication with a health care
professional observing

35. Safe and Autraumatic Care
 Developmental approach for toddlers (1-2
years)
 Allow the child to touch and become familiar
with the dosing device
 Give simple choices (i.e. a cup or a spoon,
but the medication must be taken now)
 Follow home routines
 Disguise the taste of the medication if
necessary

36. Safe and Autraumatic Care
 Developmental approach for preschoolers (3-5 years)
 Check with the child or the child’s parent about the child’s
ability to swallow pills. Crush tablets and capsules if
necessary
 Allow the child to participate in decisions regarding how
the medication will be administered: when, from whom,
and where. The child’s parent may be the best person to
administer the medication
 Explain to the child what the medication will do
 Use therapeutic play with dolls or stuffed animals

37. Safe and Autraumatic Care
 Developmental approach for school-aged children
(6-12 years)
 Check with the child or the child’s parent about
the child’s ability to swallow pills. Crush tablets
and capsules if necessary
 Allow the child to have a sense of control by
participating in decision making regarding how the
medication will be administered
 Explain the purpose of the medication to enhance
cooperation
 Praise the child after administration

38. Safe and Autraumatic Care
 Development approach for adolescents (12-
20 years)
 Give clients in this age group detailed
information about medications, including
the purpose, effects, side effects, availability
of an alternative, etc.
 Provide honest information regarding the
medication
 Encourage questions

39. Safe and Autraumatic Care
 Selecting the appropriate size equipment to
safely administer pediatric meds
 When using a calibrated syringe, be sure to
choose the appropriate size to get the most
precise measure of med
 These syringes are commonly used to
administer precise pediatric meds. They do
not accommodate a needle are also
available for home use

40. Safe and Autraumatic Care
 Liquids:
 Liquids must be measured accurately especially when small
doses (less than 1 m: or less than 1 tsp) are prescribed.
Many devices such as standard medicine cups are not
accurate for measuring small doses, and the household tsp
comes in many different sizes and shapes
 Liquid meds should be measured in specifically marked
droppers or hollow-handled medicine spoons, or drawn
into needleless syringes if the volume prescribed is less
than 5 mL
 Prescriptions for liquid meds should be written in mg, mL
or mg/mL, not in tsp.

41. Safe and Autraumatic Care
 Pills, tablets, and capsules are not recommended
for young children because these items may be
difficult to swallow, become lodged in the throat
or esophagus, or be aspirated by a crying child
 Chewable tablets are available for some
preparations, primarily vitamins. Check before
crushing or allowing the child to chew any pill,
tablet or caplet, because crushing or dilution may
alter the action of the medication. Some pills may
be crushed and the contents placed in food such
as applesauce or ice cream

42. Safe and Autraumatic Care
 Using the principles of atraumatic care
medication administration
 Oral medication administration
 Give a popsicle or ice to number the mouth
before giving the child medication
 Mix medication with a pleasant-tasting
substance such as cherry syrup
 Have a pleasant-tasting substance ready to
eliminate the unpleasant taste of the medication

43. Safe and Autraumatic Care
 Using the principles of atraumatic care for med administration
 IM/SBQ med administration
 Apply transdermal anesthetic eutectic mixture of lidocaine and prilocain
(EMLA cream)
 Use the smallest size needle that permits free flow of medication
 Bring medication to room temperature
 Use distraction; talk with child through procedure
 Cover with bandage (if age-appropriate)
 Hold and cuddle post-injection (if age-appropriate) or allow parents to
do so
 Praise the child

44. Safe and Autraumatic Care
 Administering IM injectable med to children
 The size, wt., developmental level, and condition of the
child will determine the most appropriate injection site and
the size of needle to be used
 Infants and young children have small, underdeveloped
muscles, which limits the available sites and dictates the
length of needles to be used
 Neonate 5/8 inch length
 Children < 1 year 5/8 to 1” length
 Children > 1 year 1” length
 Adolescent 1 ½ -2” for gluteal site

45. Safe and Autraumatic Care
 IM injection sites
 The vastus lateralis located at the
anterolateral thigh, is the most preferred
site for IM injections in infants and children
of all ages
 The deltoid muscle may also be used to
inject small volumes of nonirritating fluid in
older children

46. Safe and Autraumatic Care
 SBQ injections
 Use 5/8”, 23-25 gauge needle
 Pinch the skin to avoid muscle tissue
 Infants: use the fatty region of the anterolateral
thigh
 Toddlers: use the fatty region of the anterolateral
thigh or posterior area of upper arm
 Children: use the fatty region of the anterolateral
thigh or posterior area of upper arm

47. Safe and Autraumatic Care
 IV delivery
 A soluset is an IV delivery device between
the IV fluid bag and the IV catheter
 Many institutions require a volume control
device for delivery of IV meds as well as an
infusion pump
 Solusets allow the provider to give
medications using the maximum amount of
fuid and allows for the maximum
concentration

48. Safe and Autraumatic Care
 Equipment for IV insertion
 Choose the appropriate size needle for the
size of vein selected and the type of
infusion require
 Newborn – 1yr 22 – 24 gauge
 1 – 8 years 20 – 22 gauge
 More than 8 years 18 – 22 gauge

49. Safe and Autraumatic Care
 Injection sites
 Preferred (upper extremity)
 Forearm veins
 Veins on the dorsum of the hand
 Other less well known are saphenous vein or small veins on ventral
surface of wrist or larger one on inner aspect of wrist proximal to
thumb
 The veins in children in crisis are difficult to assess and cannulate.
Insertion of an intraosseous needle in the lateral aspect of the tibia
bone allows administration of all meds, fluids, and blood products that
could be given intraosseously ( within the bone marrow) it takes
approximately 60 seconds to insert.

50. Safe and Autraumatic Care
 Endotracheal tube
 The ET can be used to administer
resuscitation medication if IV access is
unobtainable. The following medications can
be given via the ET tube
 LEAN
 Lidocaine, Epinephrine, Atropine, Naloxone
 Vascular access is preferred because
absorption via the ET tube is inconsistent

51. Adverse Reactions to Meds
 Reporting adverse reactions all serious adverse reactions to
medications must be reported to the Food and Drug Administration so
that other health care professionals may be alerted to potential
problems
 FDA defines a serious medication reaction as one that is life-
threatening, causes death, leads to hospitalization or prolonged
rehabilitation, results in serious or permanent disability
 The Joint Commission requires each hospital to create a process to
report adverse medication reactions
 Most health care facility establish internal committees that review all
adverse med reactions. These committees must review the events
associated with adverse medication reactions, including: the med
suspected of causing the adverse reaction, the treatment administered
and the client’s response to treatment and any increase in length of
stay in the facility

52. Step to Improve Client Safety
 Follow these steps to reduce the risk of an
adverse reaction to a med
 Document a complete med history, including meds,
food, or environmental agent allergies
 Eliminate excessive or duplicate medications
 Understand the indications, intended effects, and
possible adverse reactions of each medication
 Anticipate adverse reactions when therapy is started or
stopped
 Regularly monitor liver and kidney function
 Suspect adverse medication reaction if unexpected
complications develop