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Perianesthesia medication administration: can we be too careful?
LEADERSHIP/MANAGEMENT
Perianesthesia Medication Administration: Can We Be Too Careful? Maureen Iacono, BSN, RN, CPAN “PERIANESTHESIA NURSING is a specialty area that takes pride in developing and maintaining the highest standards of care.”1 This statement, taken from ASPAN’s Standards for Ethical Practice, has broad implications for the care of our patients. The focus of this column is to consider individual nursing practice directly related to medication administration. Perianesthesia nurses require specific knowledge regarding sedation, anesthesia, and analgesia. Basic nursing education, initial perianesthesia orientation, and core competency completion provides information for the novice nurse in any perianesthesia unit to begin to care for vulnerable patients and to administer medications judiciously to these patients. Preceptors and unit educators continue to teach as nurses learn the myriad of anesthetic techniques and observe patients’ physiologic responses to variations in practice and individualized care. Advanced critical care classes enhance adult learning with in-depth information on vasoactive medications, classes in core systems, and critical thinking. Did we all benefit from these courses? Did we all attend them? If we did, do we remember what we learned? Do we strive to remain current on new products and procedures affecting practice? Are we com-
Maureen Iacono, BSN, RN, CPAN, is a PACU Nurse Manager at St. Joseph’s Hospital Health Center, Syracuse, NY. Address correspondence to Maureen Iacono, BSN, RN, CPAN, 102 Cedar Ln, Jamesville, NY 13078. © 2003 by American Society of PeriAnesthesia Nurses. 1089-9472/03/1803-0009$35.00/0 doi:10.1016/S1089-9472(03)00090-X 196
petent in current advanced cardiac life support and pediatric advanced life support information? Each nurse must maintain personal accountability for professional competency. Staff nurses, as well as managers and educators, have a responsibility to improve, and in some cases, develop systems that work and minimize errors.2 Participation on committees such as “Medication Safety,” “Nursing/Pharmacy,” “Critical Care Education,” “Nursing Policy,” “Pharmacy and Therapeutics,” and “Pain Committee” provide interactive opportunities for nurses at every level to contribute to the body of knowledge regarding patient medications and to enhance safety in medication administration. If our institutions are not providing education specific to medications and our practices, we need to accept the responsibility for this information. There are countless resources for ongoing continuing education such as textbooks, journals, on-line information, and resource books within your own units. Use your facility pharmacy. Read all memos that arrive from the pharmacy (with increasing frequency) telling you of medication shortages, substitutions, and new additions to the formulary. Ensure that you clearly understand your institutional policies and procedures regarding medication administration. Familiarize yourself with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards regarding medications, particularly those related to optimal pain management and drug diversion.3 Avail yourself of every opportunity to attend lectures Journal of PeriAnesthesia Nursing, Vol 18, No 3 (June), 2003: pp 196-199
PERIANESTHESIA MEDICATION ADMINISTRATION
and conferences that enhance your knowledge of professional practice, particularly practice related to the care of your patient population. Make sure you understand what reporting practices your institution expects related to medication errors, adverse reactions, sentinel events, and drug diversion. Follow policies that are established in your unit, and in your institution specific to narcotic control. There are 5 areas regarding perianesthesia medication administration that should be closely examined.
Physician’s Orders Physician’s orders should be written in a timely manner, with clarity, legibility, and accuracy. They should be dated and signed by a physician or designee, reviewed, signed, and followed per policy by the perianesthesia nurse before implementation. The orders written by both the anesthesiologist (to cover care in PACU) and the surgeon should be complete and comply with the hospital/surgicenter policy before transfer of patient care. Verbal orders should be rarely accepted and should be verified and signed at the earliest possible moment. The accepted practice for many perianesthesia units, however, may look and feel different from what actually should be. The reality of our practice is that patient needs may be imminent, episodic, and ongoing. Written orders obtained at the initiation of patient care frequently do not suffice for a patients’ stay in our units. Standing orders, per established protocol, may work more effectively for your unit. Preprinted physician’s orders with prompts for routine orders can improve efficiency and complete order sets. Verbal orders should be clarified immediately, and can, if not written down, lead to multifaceted errors. Know your institutional policy related to accepting verbal orders. If you are in the habit of always making it “easy” for the physician, break the habit now and facilitate written orders.
197
Be sure to know your institution’s policy for inappropriate orders. Speak to the physician or designee first, to clarify what has been written or verbally ordered. Communicate your concerns in a professional manner (“This narcotic drip is not allowed in this strength,” or “The antibiotic ordered here is in grams, not milligrams,” or, “The patient is allergic to a medication that is ordered.”) Use the chain of command (your manager, a director, supervisor) if orders are not revised.
Patient Identification Patient identification is imperative. The goal is to protect patients from harm and advocate for their welfare. Remember that patients are brought to our environment, our unit, unknown to us. Make sure your personal practice always includes correct patient identification. It is good practice to identify a patient by stating his or her name and checking the identification bracelet with the transferring nurse. This is particularly true with patients leaving the Preinduction Area to go to the OR. It is equally imperative that the patient be identified in this same manner by the OR nurse to the PACU nurse. If the patient is awake and alert on transfer out of PACU to the clinical unit, a verbal identification is not only correct, it is polite. Make it a habit to introduce the awake and alert patient to the accepting nurse. Patients who remain disoriented or unconscious require the verbal and physical identification when transferred to the ICU or floor. Make sure to review the name and the identification bracelet with the receiving nurse.
Obtaining Medications Many perianesthesia units do not have a satellite pharmacy nearby or a pharmacist assigned to meet their specific needs. As noted by Beyea, Hicks, and Becker, “. . .clinicians often have direct access to medications without the benefit
MAUREEN IACONO
198
of having a pharmacist involved in the medication review process.”4 Variations in practice may include perianesthesia staff counting and accounting for stock medications, including controlled substances. Some may have the benefit of dispensing systems that are automated and can eliminate the need for unit-based medication counts. If a policy exists to perform counts and document these counts, however, make sure you follow this policy completely, every day. Never sign without reading, reviewing, witnessing wastes and discards, and without truly counting. The acceptance of narcotic drips from the pharmacy should also be documented according to policy. Specific policies may exist (or may need to be instituted) for special needs. For instance, administration of medications to pediatric patients in our PACU requires the registered nurse to enlist another licensed practitioner (nurse or physician) to calculate doses separately, and then concur for each and every medication given to a child under the age of 16 years. Both must sign the administration record.
Administering Medications The perianesthesia nurse performs multiple tasks rapidly. These tasks may include, but certainly are not limited to ongoing assessment, critical evaluation of patients’ responses, verbal and nonverbal communication with the patient and the health care team members, and administration of numerous medications. As such, there are crucial issues that must be addressed with medication administration.
● Follow the 5 rights of medication administration. These fundamental “5 rights” apply for both novice and advanced nurses. They are the cornerstone of safe medication practice and include right patient, right drug, right dose, right route, and right time. ● Make certain that your patient has been correctly identified.
● Question every medication order with which you are uncomfortable.
● Clarify any medication order you are unsure of.
● Document your medications immediately, accurately, and per policy.
● Label medications you withdraw from
●
● ●
●
vials and ampules with name and dilution. Do not administer medications you don’t draw up yourself. Never use medications brought to you by another practitioner if the medication syringe is unlabelled. Make this a personal practice, and be consistent and adamant on this point. Follow best practice and your unit directives regarding the assessment of patients’ responses to medications. Waste unused portions of controlled substances per policy. Make sure you truly witness the waste if you are signing your name as a witness. Chart and sign only medications you administer. If you are in the habit of signing your initials to help a colleague, change the habit. Your good name and your signature are worth too much to compromise your own integrity.
Professional Accountability Protecting your practice and providing optimal care for your patients includes maintaining knowledge and information on problems and concerns in practice and medication administration. Areas that should be closely followed or evaluated include the following:
● Keep informed, on every level, of unsafe or improper practices in your workplace regarding medication administration. ● Performance improvement initiatives can provide data on an individual’s practice and your unit’s success and opportunities for improvements. Pain assessment, use of a pain scale, and patients’ responses to analgesics are easy but important issues to investigate. Medication errors that occur in your unit can be
PERIANESTHESIA MEDICATION ADMINISTRATION
reviewed and presented to staff to provide awareness and corrective actions. ● Accountability for diversion of controlled substances is shared by the entire professional staff. Report concerns about potential narcotic diversion carefully, professionally, and privately with your supervisor. Watch for forged signatures or signatures of persons who do not work in your unit on the narcotic signout sheet. Investigate patients who are complaining of terrible pain but whose chart indicates an appropriate dosing of analgesics; this is particularly significant when patterns are identified for a specific nurse, nurse anesthetist, or anesthesiologist. Report concerns of the following warning signs to your direct supervisor: rapid mood swings, defensiveness, false charting, and lengthy disappearances from the unit on unexcused breaks. Careful medication administration is imperative. Perianesthesia nurses have an obligation to maintain current knowledge of medications commonly used in our practice and to ensure
199
that they can tap into resources for those notso-common medications. Reviewing our personal practice of medication administration and eliminating any practice patterns that are not in accordance with unit policy and standards, institutional policy, and ASPAN standards, will promote the highest standards of care for our patients.
References 1. American Society of PeriAnesthesia Nurses: Standards of PeriAnesthesia Practice. Cherry Hill, NJ, ASPAN, 2002, p 8 2. Vasbinder M: Safe Practices. Advance for Nurses 4:36, 2002 3. JCAHO Briefings. Keep track of narcotics and watch out for drug theft and diversion. Briefings on JCAHO 13:1-4, 2003 4. Beyea S, Hicks R, Becker S: Medication errors in the OR—A secondary analysis of Medmarx. AORN J 77:122-143, 2003
Suggested Readings 1. Richards J, Creamer L: Solving the Microgram/Kilogram Puzzle. Am J Nurs 99:12, 1999 2. Shojania K, Duncan B, McDonald K, et al: Safe but sound: Patient safety meets evidence-based medicine. JAMA 288:508513, 2002 3. Summerfield M, Lawrence T: Rethinking approaches to reducing medication errors: An Examination of 10 core processes. Formulary 37:462-472, 2002
Perianesthesia Medication Administration: Can We Be Too Careful? Maureen Iacono, BSN, RN, CPAN “PERIANESTHESIA NURSING is a specialty area that takes pride in developing and maintaining the highest standards of care.”1 This statement, taken from ASPAN’s Standards for Ethical Practice, has broad implications for the care of our patients. The focus of this column is to consider individual nursing practice directly related to medication administration. Perianesthesia nurses require specific knowledge regarding sedation, anesthesia, and analgesia. Basic nursing education, initial perianesthesia orientation, and core competency completion provides information for the novice nurse in any perianesthesia unit to begin to care for vulnerable patients and to administer medications judiciously to these patients. Preceptors and unit educators continue to teach as nurses learn the myriad of anesthetic techniques and observe patients’ physiologic responses to variations in practice and individualized care. Advanced critical care classes enhance adult learning with in-depth information on vasoactive medications, classes in core systems, and critical thinking. Did we all benefit from these courses? Did we all attend them? If we did, do we remember what we learned? Do we strive to remain current on new products and procedures affecting practice? Are we com-
Maureen Iacono, BSN, RN, CPAN, is a PACU Nurse Manager at St. Joseph’s Hospital Health Center, Syracuse, NY. Address correspondence to Maureen Iacono, BSN, RN, CPAN, 102 Cedar Ln, Jamesville, NY 13078. © 2003 by American Society of PeriAnesthesia Nurses. 1089-9472/03/1803-0009$35.00/0 doi:10.1016/S1089-9472(03)00090-X 196
petent in current advanced cardiac life support and pediatric advanced life support information? Each nurse must maintain personal accountability for professional competency. Staff nurses, as well as managers and educators, have a responsibility to improve, and in some cases, develop systems that work and minimize errors.2 Participation on committees such as “Medication Safety,” “Nursing/Pharmacy,” “Critical Care Education,” “Nursing Policy,” “Pharmacy and Therapeutics,” and “Pain Committee” provide interactive opportunities for nurses at every level to contribute to the body of knowledge regarding patient medications and to enhance safety in medication administration. If our institutions are not providing education specific to medications and our practices, we need to accept the responsibility for this information. There are countless resources for ongoing continuing education such as textbooks, journals, on-line information, and resource books within your own units. Use your facility pharmacy. Read all memos that arrive from the pharmacy (with increasing frequency) telling you of medication shortages, substitutions, and new additions to the formulary. Ensure that you clearly understand your institutional policies and procedures regarding medication administration. Familiarize yourself with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards regarding medications, particularly those related to optimal pain management and drug diversion.3 Avail yourself of every opportunity to attend lectures Journal of PeriAnesthesia Nursing, Vol 18, No 3 (June), 2003: pp 196-199
PERIANESTHESIA MEDICATION ADMINISTRATION
and conferences that enhance your knowledge of professional practice, particularly practice related to the care of your patient population. Make sure you understand what reporting practices your institution expects related to medication errors, adverse reactions, sentinel events, and drug diversion. Follow policies that are established in your unit, and in your institution specific to narcotic control. There are 5 areas regarding perianesthesia medication administration that should be closely examined.
Physician’s Orders Physician’s orders should be written in a timely manner, with clarity, legibility, and accuracy. They should be dated and signed by a physician or designee, reviewed, signed, and followed per policy by the perianesthesia nurse before implementation. The orders written by both the anesthesiologist (to cover care in PACU) and the surgeon should be complete and comply with the hospital/surgicenter policy before transfer of patient care. Verbal orders should be rarely accepted and should be verified and signed at the earliest possible moment. The accepted practice for many perianesthesia units, however, may look and feel different from what actually should be. The reality of our practice is that patient needs may be imminent, episodic, and ongoing. Written orders obtained at the initiation of patient care frequently do not suffice for a patients’ stay in our units. Standing orders, per established protocol, may work more effectively for your unit. Preprinted physician’s orders with prompts for routine orders can improve efficiency and complete order sets. Verbal orders should be clarified immediately, and can, if not written down, lead to multifaceted errors. Know your institutional policy related to accepting verbal orders. If you are in the habit of always making it “easy” for the physician, break the habit now and facilitate written orders.
197
Be sure to know your institution’s policy for inappropriate orders. Speak to the physician or designee first, to clarify what has been written or verbally ordered. Communicate your concerns in a professional manner (“This narcotic drip is not allowed in this strength,” or “The antibiotic ordered here is in grams, not milligrams,” or, “The patient is allergic to a medication that is ordered.”) Use the chain of command (your manager, a director, supervisor) if orders are not revised.
Patient Identification Patient identification is imperative. The goal is to protect patients from harm and advocate for their welfare. Remember that patients are brought to our environment, our unit, unknown to us. Make sure your personal practice always includes correct patient identification. It is good practice to identify a patient by stating his or her name and checking the identification bracelet with the transferring nurse. This is particularly true with patients leaving the Preinduction Area to go to the OR. It is equally imperative that the patient be identified in this same manner by the OR nurse to the PACU nurse. If the patient is awake and alert on transfer out of PACU to the clinical unit, a verbal identification is not only correct, it is polite. Make it a habit to introduce the awake and alert patient to the accepting nurse. Patients who remain disoriented or unconscious require the verbal and physical identification when transferred to the ICU or floor. Make sure to review the name and the identification bracelet with the receiving nurse.
Obtaining Medications Many perianesthesia units do not have a satellite pharmacy nearby or a pharmacist assigned to meet their specific needs. As noted by Beyea, Hicks, and Becker, “. . .clinicians often have direct access to medications without the benefit
MAUREEN IACONO
198
of having a pharmacist involved in the medication review process.”4 Variations in practice may include perianesthesia staff counting and accounting for stock medications, including controlled substances. Some may have the benefit of dispensing systems that are automated and can eliminate the need for unit-based medication counts. If a policy exists to perform counts and document these counts, however, make sure you follow this policy completely, every day. Never sign without reading, reviewing, witnessing wastes and discards, and without truly counting. The acceptance of narcotic drips from the pharmacy should also be documented according to policy. Specific policies may exist (or may need to be instituted) for special needs. For instance, administration of medications to pediatric patients in our PACU requires the registered nurse to enlist another licensed practitioner (nurse or physician) to calculate doses separately, and then concur for each and every medication given to a child under the age of 16 years. Both must sign the administration record.
Administering Medications The perianesthesia nurse performs multiple tasks rapidly. These tasks may include, but certainly are not limited to ongoing assessment, critical evaluation of patients’ responses, verbal and nonverbal communication with the patient and the health care team members, and administration of numerous medications. As such, there are crucial issues that must be addressed with medication administration.
● Follow the 5 rights of medication administration. These fundamental “5 rights” apply for both novice and advanced nurses. They are the cornerstone of safe medication practice and include right patient, right drug, right dose, right route, and right time. ● Make certain that your patient has been correctly identified.
● Question every medication order with which you are uncomfortable.
● Clarify any medication order you are unsure of.
● Document your medications immediately, accurately, and per policy.
● Label medications you withdraw from
●
● ●
●
vials and ampules with name and dilution. Do not administer medications you don’t draw up yourself. Never use medications brought to you by another practitioner if the medication syringe is unlabelled. Make this a personal practice, and be consistent and adamant on this point. Follow best practice and your unit directives regarding the assessment of patients’ responses to medications. Waste unused portions of controlled substances per policy. Make sure you truly witness the waste if you are signing your name as a witness. Chart and sign only medications you administer. If you are in the habit of signing your initials to help a colleague, change the habit. Your good name and your signature are worth too much to compromise your own integrity.
Professional Accountability Protecting your practice and providing optimal care for your patients includes maintaining knowledge and information on problems and concerns in practice and medication administration. Areas that should be closely followed or evaluated include the following:
● Keep informed, on every level, of unsafe or improper practices in your workplace regarding medication administration. ● Performance improvement initiatives can provide data on an individual’s practice and your unit’s success and opportunities for improvements. Pain assessment, use of a pain scale, and patients’ responses to analgesics are easy but important issues to investigate. Medication errors that occur in your unit can be
PERIANESTHESIA MEDICATION ADMINISTRATION
reviewed and presented to staff to provide awareness and corrective actions. ● Accountability for diversion of controlled substances is shared by the entire professional staff. Report concerns about potential narcotic diversion carefully, professionally, and privately with your supervisor. Watch for forged signatures or signatures of persons who do not work in your unit on the narcotic signout sheet. Investigate patients who are complaining of terrible pain but whose chart indicates an appropriate dosing of analgesics; this is particularly significant when patterns are identified for a specific nurse, nurse anesthetist, or anesthesiologist. Report concerns of the following warning signs to your direct supervisor: rapid mood swings, defensiveness, false charting, and lengthy disappearances from the unit on unexcused breaks. Careful medication administration is imperative. Perianesthesia nurses have an obligation to maintain current knowledge of medications commonly used in our practice and to ensure
199
that they can tap into resources for those notso-common medications. Reviewing our personal practice of medication administration and eliminating any practice patterns that are not in accordance with unit policy and standards, institutional policy, and ASPAN standards, will promote the highest standards of care for our patients.
References 1. American Society of PeriAnesthesia Nurses: Standards of PeriAnesthesia Practice. Cherry Hill, NJ, ASPAN, 2002, p 8 2. Vasbinder M: Safe Practices. Advance for Nurses 4:36, 2002 3. JCAHO Briefings. Keep track of narcotics and watch out for drug theft and diversion. Briefings on JCAHO 13:1-4, 2003 4. Beyea S, Hicks R, Becker S: Medication errors in the OR—A secondary analysis of Medmarx. AORN J 77:122-143, 2003
Suggested Readings 1. Richards J, Creamer L: Solving the Microgram/Kilogram Puzzle. Am J Nurs 99:12, 1999 2. Shojania K, Duncan B, McDonald K, et al: Safe but sound: Patient safety meets evidence-based medicine. JAMA 288:508513, 2002 3. Summerfield M, Lawrence T: Rethinking approaches to reducing medication errors: An Examination of 10 core processes. Formulary 37:462-472, 2002