Beruflich Dokumente
Kultur Dokumente
5: CONTINUUM OF CARE
The definition of a medication error as approved by the National Coordinating Council for Medication Error and Prevention is ". . .any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems including: prescribing, order communication, product labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use." Administering oral medications is a core function of nurses. Their responsibility is to comply with safe medication use processes and practices in order to prevent occurrence of medication errors / misadventures.
National Nursing Audit, Ministry of Health Malaysia : Version 1 / September 2008, Bahagian Kejururawatan , Kementerian Kesihatan Malaysia Page 1
2.
OBJECTIVES 2.1. 2.2. To prevent occurrence of oral medication errors / misadventures To ensure nurses serve medications according to the 6 Rs of Medication use. * * * * * * 2.3. Right patient Right drug Right dose Right route Right time Right documentation
To ensure that nurses exhibit the caring component when administering oral medication.
3.
STANDARD 3.1.
3.2.
Nurses serve oral medications according to the 6 Rs of medication use. Nurses exhibit the caring component during the administration of oral medication. Nurses document accurately and completely the medication administered.
3.3.
National Nursing Audit, Ministry of Health Malaysia : Version 1 / September 2008, Bahagian Kejururawatan , Kementerian Kesihatan Malaysia Page 2
4.
Outcome
1. All medications are served according to the 6 Rs of medication use 2. Patient receives safe medication during hospital stay
1. Each patient has current legal 1. written prescription / medication profile 2. There is a Nursing Operating Procedure (NOP) for administration of Medication. 3. The nurse is competent in the serving of medication, has knowledge on the effect and adverse drug reaction and the appropriate measures to be taken when there is an adverse reaction.
7.
TECHNICAL
DOCUMENTATION
SOFT SKILL
National Nursing Audit, Ministry of Health Malaysia : Version 1 / September 2008, Bahagian Kejururawatan , Kementerian Kesihatan Malaysia Page 3
document assessment findings document medication served / omitted date, time and signature
greet patient explain and inform patient listen,respond promptly and politely to patients questions.
document adverse reactions identified document appropriate measures taken if adverse reactions identified
6.
AUDIT GUIDE FOR ADMINISTRATION OF ORAL MEDICATION 6.1. INCLUSION CRITERIA All patients in the ward who are on oral medication
6.2.
INSTRUMENT Audit Form (E5 AF 5.1) one audit form for one observation
6.3 .
Methodology 6.3.1. Direct observation of nurse administering oral medication and also gather information from documents 6.3.2. Setting : All wards
6.3.3. Population: Staff Nurses
National Nursing Audit, Ministry of Health Malaysia : Version 1 / September 2008, Bahagian Kejururawatan , Kementerian Kesihatan Malaysia Page 4
6.4. Sample Size - 200 of staff nurses from each activity / program, equally divided among the wards for Hospital with Specialist and 100 staff nurses for non-specialist hospital 6.5. Time Frame -One month. 7. DEFINITION OF OPERATIONAL TERMS 7.1. Written prescription 7.1.1. Any legal orders of oral medication endorsed in the patients medication profile / patients case notes 7.2. Medication profile 7.2.1. Legal document where the doctor prescribes and the nurses endorse the administration of the medication 7.3. Patients response 7.3.1. Refers to favorable / adverse reactions of medication administered. E.g. favorable - pain relieved; adverse develop rashes. 7.4. Dish out medication accurately 7.4.1. Read patients medication profile 7.4.2. Select required medication from patients drawer of medication cart 7.4.3. Calculate dosage before dishing out 7.4.4. Reconfirm the medication and dosage before putting back the balance. 7.5. Identify right patient 7.5.1. Confirm patients identity by 2 identifier 7.5.1.1. 7.5.1.2. His/ her name Registration number
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7.5.2. Ask patient to confirm name. 7.5.2.1. Cross check with patients wrist band for name and registration number. 7.5.2.2. Verify accuracy of identifier with patients medication profile. 7.6. Verify prescription by checking for 7.6.1. Prescribing doctor name, signature, and date ordered 7.5.2. Drug generic name, dose, frequency, route, duration 7.7. Assessment of Patient for Administration of Selected
Medication: 7.7.1. Nurses need to determine the patients current status prior to administration of selected medication to confirm its continuity. E.g. Anti-hypertensive, oral hypoglycemic agents, digitalis, analgesics, antipyretics, betablockers. 7.7.2. Nurses when assessing the patient will exhibit the caring component: 7.7.2.1. 7.7.2.2. Communicating well in a respectful manner Giving the patient the privacy, dignity and modesty 7.8. 6 Rs of Medication Use 7.8.1 Right patient 7.8.2 Right medication 7.8.3 Right dose 7.8.4 Right route
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7.8.4.1. Correct method of taking medication according to type: i. Tab. Magnesium Trisilicate - chewable ii. Tab. Glycerl Trinitrate - sublingual iii. Lugols Iodine straw 7.8.5. Right time: 7.8.5.1. An allowance of 30 minutes 7.8.5.2. Initial dose served immediately or within a maximum of 30 minutes upon prescription /acquisition of medication and subsequent doses according to time as stated in SOP of the unit / ward. 7.8.6. Right documentation - implies accuracy and completeness 7.8.6.1.
7.8.6.2.
Record assessment findings signature of nurse who serve medication in the appropriate column for drugs not served, it should be indicated in medication profile document explanation of any omitted doses in patients case notes
7.8.6.3.
7.8.6.4.
7.8.6.5.
Document the evaluation of the patient response to the medication, when appropriate. document any identified adverse reaction to the medications administered. date and time of administration must be indicated in the medication profile
7.8.6.6.
7.8.6.7.
National Nursing Audit, Ministry of Health Malaysia : Version 1 / September 2008, Bahagian Kejururawatan , Kementerian Kesihatan Malaysia Page 7
7.9
Compliance of Medication Safety Audit 7.9.1. Technical - Every step in the process must be performed.
i. ii.
Identify patient accordingly, verify prescription. Assess patient prior to administration of selected medication Dish out medications accurately right drug and right dose. Administer and ensure patient takes the medication
iii.
iv.
i.
ii. iii.
Greet patient Explain and inform patient Responds promptly and politely to patients questions. Exhibit caring component when assessing patient
iv.
document assessment findings document medication served / omitted date, time and signature document adverse reactions identified
8.
Audit Form
National Nursing Audit, Ministry of Health Malaysia : Version 1 / September 2008, Bahagian Kejururawatan , Kementerian Kesihatan Malaysia Page 8
NATIONAL NURSING AUDIT MINISTRY OF HEALTH MALAYSIA ELEMENT 5 : CONTINUUM OF CARE TOPIC : 5.1 ADMINISTRATION OF ORAL MEDICATION DOCUMENT NO : E5 AF 5.1 Standard: 1. 2. All medication are served according to the 6 Rights of medication use. All nurses will exhibit the caring component during the administration of oral medication. Objectives:
1. 2.
VERSION 2/04
DATE : 8.5.08
To prevent occurrence of medication errors / misadventures To ensure nurses serve medications according to the 6 Rs of medication use. To ensure that nurses exhibit the caring component when administering oral medications
3.
2. Item 4 is not rated if no specific nursing measures required. S/N ITEM SOURCE OF INFORMATION *1. Greet patient. 2. 3. Identify right patient. Verify prescription. Listen / Observe nurse. Listen / Observe nurse. Observe nurse. Observe nurse / check for written evidence. YES NO N/A
*4. Assess patient. 5. Dish out correct medication : 5.1. Read patients medication profile 5.2. Select required medication from patients drawer of medication cart. 5.3. Calculate dosage before dishing out 5.4 Reconfirm the medication and dosage before putting back the
Observe nurse.
Observe nurse.
balance *6. Explain and inform patient Observe nurse *7. Responds promptly and
politely to patients /carer questions.
S/N 8.
SOURCE OF INFORMATION
YES
NO
N/A
National Nursing Audit, Ministry of Health Malaysia : Version 1 / September 2008, Bahagian Kejururawatan , Kementerian Kesihatan Malaysia Page 10
medication: 8.1 right patient. 8.2 right medication 8.3 right dose 8.4 right time 8.5 right route 8.6 9 Document: 9..1 Medication administered. 9.2 Assessment findings. 9.3 9.4 Observe nurse. Observe nurse. Listen / Observe nurse. Listen / Observe nurse. Listen / Observe nurse. Listen / Observe nurse Listen / Observe nurse
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