06 Medication Administration and Safety

Verify the order and patient

Safe administration combines accurate interpretation of an order, sound dose calculation, route-specific technique, patient assessment, and follow-up monitoring. Give a medication only when the order is clear, the patient and medication are verified, and the nurse is authorized and competent to perform the task. Practical-nursing scope and delegation rules vary by jurisdiction, so follow applicable law, employer policy, and supervision requirements.

A Medication order should identify the patient, drug, dose, route, and timing or frequency, as well as any required parameters. Check the order against the medication administration record (MAR), product label, and relevant patient information. Do not guess when an order is incomplete, illegible, conflicting, or clinically questionable; clarify it with the prescriber or pharmacist before administration.

The Rights of administration are a reasoning aid, not a substitute for clinical judgment or required procedures. A common core is the right patient, medication, dose, route, and time. Programs and facilities may also include the right indication, assessment, education, documentation, evaluation or response, and the patient’s right to refuse.

Assess and communicate before administration

Before administration, review allergies, the patient’s current condition, relevant history, and medication profile. Include prescription drugs, over-the-counter products, and supplements when available. Determine whether required assessments or results are available: for example, blood pressure before an antihypertensive, pulse before a medication with a pulse parameter, or blood glucose before insulin as specified by the order and policy.

Compare the medication label with the MAR during preparation and again at the point of administration, following facility procedure. Use at least $2$ approved patient identifiers; do not use a room number as an identifier. Explain the medication and invite questions. Respect a capable patient’s refusal, assess the reason, explain relevant risks as appropriate, and notify the appropriate clinician according to policy.

Document administration promptly and accurately. If a dose is held, omitted, delayed, refused, or unavailable, document the reason and any required notifications.

Calculate doses and convert units

Use a consistent method and verify that units cancel correctly. The basic formula is:

The desired and available doses must use matching units. Dimensional analysis is another reliable method: arrange conversion factors so unwanted units cancel and the answer has the requested unit.

Common metric conversions are:

• $1\,\text{kg} = 2.2\,\text{lb}$

• $1\,\text{g} = 1{,}000\,\text{mg}$

• $1\,\text{mg} = 1{,}000\,\text{mcg}$

• $1\,\text{L} = 1{,}000\,\text{mL}$

Convert before calculating when the order and supply use different units. Use a leading zero for doses less than $1$, such as $0.5\,\text{mg}$, and avoid trailing zeros: write $5\,\text{mg}$, not $5.0\,\text{mg}$, because a trailing zero can be misread.

Apply calculations safely

Apply the formula with matching units, then check whether the result is plausible.

• Tablets: For an order of $500\,\text{mg}$ with $250\,\text{mg}$ per tablet, $(500\,\text{mg} \div 250\,\text{mg}) \times 1\,\text{tablet} = 2\,\text{tablets}$.

• Liquid: For an order of $300\,\text{mg}$ with $150\,\text{mg}$ per $5\,\text{mL}$, $(300\,\text{mg} \div 150\,\text{mg}) \times 5\,\text{mL} = 10\,\text{mL}$.

• Weight-based dose: For an order of $8\,\text{mg/kg}$ per dose and a patient weighing $18\,\text{kg}$, the dose is $8\,\text{mg/kg} \times 18\,\text{kg} = 144\,\text{mg}$ per dose. With a supply of $80\,\text{mg}$ per $2\,\text{mL}$, the volume is $(144\,\text{mg} \div 80\,\text{mg}) \times 2\,\text{mL} = 3.6\,\text{mL}$ per dose.

• Infusion rate: An order to infuse $1{,}000\,\text{mL}$ over $8\,\text{hours}$ gives $1{,}000\,\text{mL} \div 8\,\text{hours} = 125\,\text{mL/hour}$.

For weight-based orders, confirm whether the dose is per dose or per day. Use the current measured weight in the required units, and check the calculated dose against the prescribed range using an approved reference. Recheck calculations and follow policy for required independent checks, especially for high-alert medications. If the result seems implausible, stop and verify the order, units, and calculation.

For gravity infusions, calculate drops per minute using the prescribed volume, time in minutes, and tubing drop factor. Use the correct tubing factor and facility-approved rounding rules.

Use route-specific techniques

Use only the route specified in the order. Each route has distinct technique, absorption, and safety considerations.

• Oral (PO): Check swallowing ability and aspiration risk. Give with or without food as directed. Do not crush or split tablets unless the product and order permit it; modified-release and enteric-coated products generally require special caution. Do not leave medication at the bedside unless authorized.

• Sublingual or buccal: Place the medication under the tongue or against the cheek as directed and allow it to dissolve. Avoid chewing or swallowing it unless instructed.

• Enteral tube: Confirm the correct tube and placement according to policy. Check whether the formulation can be given through the tube; administer medications separately and flush as directed by policy. Do not mix medications together or with formula unless specifically supported.

• Topical or transdermal: Apply to the specified site, using gloves when indicated. For patches, remove the old patch, inspect the skin, rotate sites, and record the new patch’s time and location. Avoid cutting patches unless product information specifically allows it.

• Ophthalmic or otic: Use the correct eye or ear product and avoid contaminating the dropper tip. For eye drops, place drops in the conjunctival sac. For ear drops, position the patient and administer as directed for the patient’s age and the product.

• Inhaled or intranasal: Use the correct device and teach the patient the inhalation technique. Assess the patient’s response, such as breathing effort or symptom relief, as indicated.

• Rectal or vaginal: Provide privacy, explain the procedure, use appropriate gloves and lubricant if indicated, and follow product-specific placement instructions.

• Subcutaneous, intramuscular, or intravenous: Use route-appropriate equipment, site selection, aseptic technique, and monitoring. Verify compatibility, dilution, and rate for injectable medications using authoritative references and facility policy. Intravenous medication errors can cause rapid harm.

Apply safeguards for injections and high-alert medications

For injections, use aseptic technique and a new sterile needle and syringe for every patient and every entry. Never reuse a syringe, even if the needle is changed, and do not use single-dose containers for multiple patients.

High-alert medications, including insulin, anticoagulants, and opioids, can cause serious harm if used in error. Use safeguards required by policy, including standardized procedures, appropriate technology, and independent checks when specified. A double check must be performed independently rather than by simply confirming another person’s calculation.

Monitor effects and reconcile medications

Administration does not end when the dose is given. Monitor for the intended therapeutic effect and for adverse effects, allergic reactions, toxicity, or worsening condition. The type and timing of monitoring depend on the medication, route, dose, and patient. Check required vital signs, laboratory results, pain or symptom response, level of alertness, and infusion or injection site as appropriate.

At transitions of care, Medication reconciliation compares the patient’s medication history with new orders to identify omissions, duplications, or unintended dose changes. Include prescription and nonprescription medicines, supplements, and other products in the history when possible, and resolve discrepancies with the appropriate clinician.

Prevent and respond to medication errors

Reduce risk by minimizing interruptions during preparation, using approved identifiers and the MAR, checking labels and expiration dates, storing medications correctly, and using barcode or other safety systems as directed. Report system hazards, including look-alike or sound-alike products, confusing labels, and recurring interruptions, through established channels.

If an error or unexpected reaction occurs, respond in this order:

1. Assess the patient first and provide immediate care within your role and training.

2. Notify the appropriate clinician and follow emergency and facility procedures. Provide accurate information about the medication, amount, route, and time.

3. Continue monitoring and carry out ordered interventions.

4. Document the patient’s condition, assessment, notifications, and care factually in the health record according to policy. Complete any required safety or incident report separately; it does not substitute for clinical documentation.

5. Report near misses and hazards through the designated system so the organization can address contributing factors.

A Medication error is a preventable event that may lead to inappropriate medication use or patient harm. Prompt, accurate reporting supports patient care and organizational learning.