Safe Medicine Administration Policy

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Transcription:

Safe Medicine Administration Policy

Objectives Students under the direction of Nursing & midwifery staff will be able to : Identify important practice in the new Safe Medicine Administration policy Use critical thinking at each checking step / rights of medication administration when administering medicines Implement practice changes required, including the independent double checking

What s important in the revised policy? Defined health care practitioner (HCP) roles and responsibilities Risks, precautions and responsibilities before, during and after medication preparation and administration Checking steps / rights and practice changes Independent double checking High risk medications and situations Smart Page verbal orders

5 rights plus critical thinking and documentation Two ID checks against NHI in medication chart label One must be NHI on patient wrist ID Ask patient to identify themselves and their DOB Check the medication label Check the prescription order and Check the chart & ask the patient if any ALLERGIES & adverse drug reactions (ADR) Check the prescription order Confirm CORRECT dose, know expected effect & contraindications using a drug reference resources & Look when last administered Give the drug at right time & over the right time NHI number Right patient NHI number has the right to REFUSE (unless a legal mandate) Right MEDICATION for the right REASON and no known allergies or ADR that prevent administration Right DOSE for the Right REASON Right TIME includes right delivery RATE Right patient Right medication Right dose Right time Again, check order & make sure it is the right drug form for the delivery route Communicate the reason and expected action & ask the patient to report effect COMPLETE documentation and sign AFTER giving the medication Chart the actual delivery time, route & why it is withheld or refused/declined or when to restart PO IV Subcutaneous IM Epidural Right ROUTE with the right FORM for administration & monitor response WRITE it right in medication chart & write patient response in the progress notes Be sure to document any relevant information Right route Right documentation Document NEW allergy or ADR

Is this the right patient? Two checks against the patient label in the national medication chart Check 1: Requires NHI patient s ID band against the patients NHI number on the chart. Two ID checks against NHI in medication chart label One must be NHI on patient wrist ID Ask patient to identify themselves and their DOB Check the medication label Check the prescription order and Check the chart & ask the patient if any ALLERGIES & adverse drug reactions (ADR) Check the prescription order Confirm CORRECT dose, know expected effect & contraindications using a drug reference resources & Look when last administered Give the drug at right time & over the right time NHI number Right patient NHI number has the right to REFUSE (unless a legal mandate) Right MEDICATION for the right REASON and no known allergies or ADR that prevent administration Right DOSE for the Right REASON Right TIME includes right delivery RATE Right patient Right medication Right dose Right time Check 2: Ask patent to identify themselves (name & DOB) Again, check order & make sure it is the right drug form for the delivery route Communicate the reason and expected action & ask the patient to report effect COMPLETE documentation and sign AFTER giving the medication Chart the actual delivery time, route & why it is withheld or refused/declined or when to restart PO IV Subcutaneous IM Epidural Right ROUTE with the right FORM for administration & monitor response WRITE it right in medication chart & write patient response in the progress notes Be sure to document any relevant information Right route Right documentation Document NEW allergy or ADR

Two ID checks against NHI in medication chart label One must be NHI on patient wrist ID Ask patient to identify themselves and their DOB NHI number Right patient NHI number has the right to REFUSE (unless a legal mandate) Right patient Is the right medication being given for the right reason? Check the medication label against the prescription Check the medication label Check the prescription order and Check the chart & ask the patient if any ALLERGIES & adverse drug reactions (ADR) Check the prescription order Confirm CORRECT dose, know expected effect & contraindications using a drug reference resources & Look when last administered Give the drug at right time & over the right time Right MEDICATION for the right REASON and no known allergies or ADR that prevent administration Right DOSE for the Right REASON Right TIME includes right delivery RATE Right medication Right dose Right time Check for any allergies / ADR and ask the patient if they have any drug allergies / ADR Again, check order & make sure it is the right drug form for the delivery route Communicate the reason and expected action & ask the patient to report effect COMPLETE documentation and sign AFTER giving the medication Chart the actual delivery time, route & why it is withheld or refused/declined or when to restart PO IV Subcutaneous IM Epidural Right ROUTE with the right FORM for administration & monitor response WRITE it right in medication chart & write patient response in the progress notes Be sure to document any relevant information Right route Right documentation Document NEW allergy or ADR

Two ID checks against NHI in medication chart label One must be NHI on patient wrist ID Ask patient to identify themselves and their DOB NHI number Right patient NHI number has the right to REFUSE (unless a legal mandate) Right patient Check the medication label Check the prescription order and Right MEDICATION for the right REASON and Right medication Is this the right dose? Check the prescription Check the chart & ask the patient if any ALLERGIES & adverse drug reactions (ADR) Check the prescription order Confirm CORRECT dose, know expected effect & contraindications using a drug reference resources & Look when last administered Give the drug at right time & over the right time no known allergies or ADR that prevent administration Right DOSE for the Right REASON Right TIME includes right delivery RATE Right dose Right time Check drug calculations Know the drug, it s expected effects & side effects Again, check order & make sure it is the right drug form for the delivery route Communicate the reason and expected action & ask the patient to report effect COMPLETE documentation and sign AFTER giving the medication Chart the actual delivery time, route & why it is withheld or refused/declined or when to restart PO IV Subcutaneous IM Epidural Right ROUTE with the right FORM for administration & monitor response WRITE it right in medication chart & write patient response in the progress notes Be sure to document any relevant information Right route Right documentation Document NEW allergy or ADR

Two ID checks against NHI in medication chart label One must be NHI on patient wrist ID Ask patient to identify themselves and their DOB NHI number Right patient NHI number has the right to REFUSE (unless a legal mandate) Right patient Check the medication label Check the prescription order and Right MEDICATION for the right REASON and Right medication Is it being given at the right time, over the right time? Check time of last dose Check dose and delivery rate calculations Check the chart & ask the patient if any ALLERGIES & adverse drug reactions (ADR) Check the prescription order Confirm CORRECT dose, know expected effect & contraindications using a drug reference resources & Look when last administered Give the drug at right time & over the right time Again, check order & make sure it is the right drug form for the delivery route Communicate the reason and expected action & ask the patient to report effect COMPLETE documentation and sign AFTER giving the medication Chart the actual delivery time, route & why it is withheld or refused/declined or when to restart Document NEW allergy or ADR PO IV Subcutaneous IM Epidural no known allergies or ADR that prevent administration Right DOSE for the Right REASON Right TIME includes right delivery RATE Right ROUTE with the right FORM for administration & monitor response WRITE it right in medication chart & write patient response in the progress notes Be sure to document any relevant information Right dose Right time Right route Right documentation

Two ID checks against NHI in medication chart label One must be NHI on patient wrist ID Ask patient to identify themselves and their DOB NHI number Right patient NHI number has the right to REFUSE (unless a legal mandate) Right patient Check the medication label Check the prescription order and Right MEDICATION for the right REASON and Right medication Check the chart & ask the patient if any ALLERGIES & adverse drug reactions (ADR) Check the prescription order Confirm CORRECT dose, know expected effect & contraindications using a drug reference resources & Look when last administered Give the drug at right time & over the right time no known allergies or ADR that prevent administration Right DOSE for the Right REASON Right TIME includes right delivery RATE Right dose Right time Is the right drug being given via the right route? Check the prescription & the drug Again, check order & make sure it is the right drug form for the delivery route Communicate the reason and expected action & ask the patient to report effect COMPLETE documentation and sign AFTER giving the medication Chart the actual delivery time, route & why it is withheld or refused/declined or when to restart Document NEW allergy or ADR PO IV Subcutaneous IM Epidural Right ROUTE with the right FORM for administration & monitor response WRITE it right in medication chart & write patient response in the progress notes Be sure to document any relevant information Right route Right documentation

Two ID checks against NHI in medication chart label One must be NHI on patient wrist ID Ask patient to identify themselves and their DOB NHI number Right patient NHI number has the right to REFUSE (unless a legal mandate) Right patient Check the medication label Check the prescription order and Right MEDICATION for the right REASON and Right medication Is the documentation complete? Document after giving medication Document variance to the prescription Document any new allergy / ADR Check the chart & ask the patient if any ALLERGIES & adverse drug reactions (ADR) Check the prescription order Confirm CORRECT dose, know expected effect & contraindications using a drug reference resources & Look when last administered Give the drug at right time & over the right time Again, check order & make sure it is the right drug form for the delivery route Communicate the reason and expected action & ask the patient to report effect COMPLETE documentation and sign AFTER giving the medication Chart the actual delivery time, route & why it is withheld or refused/declined or when to restart PO IV Subcutaneous IM Epidural no known allergies or ADR that prevent administration Right DOSE for the Right REASON Right TIME includes right delivery RATE Right ROUTE with the right FORM for administration & monitor response WRITE it right in medication chart & write patient response in the progress notes Be sure to document any relevant information Right dose Right time Right route Right documentation Document NEW allergy or ADR

Responsibilities Before Discuss the risks, precautions and responsibilities BEFORE medication is prepared Interpreting the prescription orders Allergies and adverse reactions SmartPage

Responsibilities During Checking steps/rights of medication administration Double checking terminology changes Independent two person (double) check A procedure when two health care practitioners independently check (alone and apart from each other, then compare results) the medicine (prescription, calculation, preparation). Independent two person (double) checking may be limited to a medicine independent two person (double) check only i.e. the right medicine and form and dosage is prepared, or may require a FULL independent two person (double) check.

Responsibilities During FULL independent two person (double) check Two HCP use this procedure when there is high risk associated with the medicine, route and its delivery. A FULL independent two person (double) checking procedure includes: Medicine independent two person (double) check to ensure the Right medicine, Right dosage and Right form is prepared Patient administration independent two person (double) check is to ensure the drug is administered correctly to the Right patient in the Right form by the Right route. Both HCP must sign the medication chart following administration.

Responsibilities After Monitoring Documentation Recognising and managing a suspected or new allergies Withholding medications Errors

Medication Policy

Scenario

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