Nursing 3703 Pharmacology in Nursing

From Brain to Bedside: Incorporating fundamental pharmacology-related topics into practical patient care Terry Altringer, Pharm.D. Clinical Pharmacy Coordinator – Trinity Health Residency Program Director – Trinity Health Adjunct Preceptor – NDSU College of Pharmacy Disclosure Statement • The presenter has no actual or potential conflicts of interest in relation to this presentation Objectives 1. Review the general principles of safe and accurate drug administration 2. Describe how basic pharmacologic and pharmacokinetics parameters impact bedside care 3. Discuss common patient specific variables that affect the actions of drugs 4. Discuss how to safely monitor patients after drug administration 5. Review the importance of patient-directed medication education Secondary Objectives • To provide an overview of medication safety • To encourage you to continue to learn and practice ways to improve the safety of medication use The Unthinkable Day https://www.youtube.com/watch?v=XEbf9bl iOus Story: Admission of a patient… 3 month old male admitted with respiratory distress most likely due to bronchiolitis. Staff Nurse: “I received report at 7 p.m. and was reviewing the orders and saw that he had some medications due.” Both Reglan and Digoxin were due at 2000. I went to the medication room and prepared the medications. “I saw that he had some medications due…” “I checked the online • Looked meds up on the formulary and confirmed the online formulary. Reglan and Digoxin were ordered in the correct dose • Checked the dose. and route. I checked the labels on the syringe and double • Checked the med. checked the dose against the • Took labeled syringes to order on the medication patients room. administration record. I took the medication to the bedside.” “Preparing to administer the medication…” Next steps... • Open the patient’s MAR to do the 5 R’s • What questions do you have? • What are the clinical indications for these two meds in this infant? • Prepare to barcode scan patient ID band and medications. “I told mom I was giving Digoxin and Reglan..” Mom said, “At home I give the Reglan, the other medication must be a new one.” I told her it was ordered by the doctor for the baby’s heart. Mom said, “Is there something wrong with his heart?” Mom said “Is there something wrong with his heart?” • I said “Let me double check his • The charge nurse called chart.” the senior resident who • I looked at the chart. The said the child had no patient was here for cardiac issues and should respiratory distress. I did not not have an order for see anything about a heart Digoxin. problem. • Turns out the order was • I called the resident who electronically placed in reported, “I do not know of the wrong chart. any heart problems in this patient.” • “What if mom had • I called my charge nurse. not been there?” 21st Century Nursing The Basic Medication Management Process Planning Selection & Evaluation Procurement Nursing’s Role Monitoring Storage Last Line of Defense for Patient (26-32% of medication errors) Ordering & Administration Transcribing Preparing & Dispensing The “Real” Medication Management Process Why understanding medication safety matters • 82% of Americans take at least 1 medication, 29% take >5 • In 1999; 44,000–98,000 deaths occurred each year due to medical mistakes. (IOM Report) • Every year medication errors injure at least 1.5 million Americans and cause 7,000 deaths. • Adverse drug events (ADEs) cause more than 1 million ED visits and 280,000 hospitalizations annually • ADEs comprise the largest single category of adverse events experienced by hospitalized patients, accounting for about 19 percent of all injuries – Increased morbidity, mortality, prolonged hospitalization, and higher cost Medication Error (ME): Adverse Drug Event (ADE): Any mistakes occurring in the medication An injury resulting from medication use process, regardless of whether an use, including physical harm, mental injury occurred or whether the potential for harm, or loss of function. injury was present. • Adverse Drug Reaction (ADR), or non- Preventable ADE: Any ADE that occur due to Potential ADE pharmacological (aka, Near Miss or properties of the Close Call): drug. Medication errors that Preventable ADE (pADE): pose a significant risk ADEs resulting from a but do not cause harm medication error that can be to a patient. avoided. Causes of Fatal Medication Errors • Among fatal medication errors, the Institute of Medicine (IOM) identities 3 main categories: – Human factors Communication mistakes – Account for 90% of all errors – Name confusion (LASA) • More specifically – Performance deficits (29.8%) – e.g., IV instead of IM – Knowledge deficits (14.2%) – drug-drug interaction – Miscalculation of dose (13%) – decimal placement Which patients are most at risk of medication error? • Patients on multiple medications (polypharmacy) • Patients with another condition, (e.g. heart failure, renal impairment, pregnancy) • Patients who cannot communicate well • Patients who have more than one doctor • Patients who do not take an active role in their own medication use • Vulnerable populations (Newborn, children, geriatrics, impaired) In what situations are staff most likely to contribute to a medication error? • Inexperience • Rushing • Doing two things at once – “multitasking” • Interruptions • Fatigue, boredom, being on “automatic pilot” leading to failure to check and double-check • Lack of checking and double checking habits • Poor teamwork and/or communication between colleagues • Reluctance to use memory aids - ?Pride Types of Medication Errors • Wrong patient • Wrong drug • Wrong route • Wrong time • Wrong dose • Omitted dose • Wrong dosage form • Wrong diluent • Wrong strength/concentration • Wrong infusion rate Ways to prevent medication errors 1. Know the patient 2. Know the drug(s) 3. Communication (SBAR) – [60% of sentinel events] 4. Drug packaging & labeling . Double-check high alert medications 5. Storage, stock, standardization, and distribution 6. Drug device acquisition, use, and monitoring 7. Environmental factors 8. Staff education 9. Patient education 10. Quality processes and risk management Application of Pharmacology in Nursing Practice • Your responsibilities with regard to medications extend far beyond the Rights of Drug Administration. • Your medication knowledge has a wide range of practical applications in patient care and patient education. • You are part of the healthcare team that contributes to maximum patient benefit and minimum harm. • Application should be directed at individualized treatment. General Principles of accurate drug administration Five Rights 1. Right patient 2. Right drug 3. Right dose 4. Right route 5. Right time 5 Rights of Medication Administration Right Patient: • Open the correct patient’s Chart/MAR. • Look at the ID Band. • Barcode scan. • Do I have the correct patient? 5 Rights of Medication Administration Right Medication: • Is this the right medication for the right patient? • Meds are located: – Patient specific bin or carts in the medication room – Locked medication alcoves in patient’s room – Automated Dispensing Cabinets (Pyxis, Omnicell) • Know the clinical indication for this patient to be receiving this medication. Why does this specific patient need this specific medication? 5 Rights of Medication Administration Right Dose: • The ordered dose needs to match the dose on the medication label. • Is the dose correct for the weight of the child, if applicable? • Is the dose correct for the clinical indications and route? 5 Rights of Medication Administration Right Route: • Know the correct route of administration: – Oral – Enteral • NG [nasogastric tube], GT [gastrostomy], JT [jejunostomy] – Parenteral • IV [intravenous], IM [intramuscular], SQ [subcutaneous] – Rectal – Intradermal – Transdermal – Transmucosal 5 Rights of Medication Administration Right Time: • Is the medication due at this time? Check to see when it was last given. • Ensure the order has not changed which will impact the time it is due. Key Reminder • The physician order and the corresponding eMAR/MAR entry are the sole source of truth. • Do not rely on other forms of secondary information such as: – Handheld barcode administration device – Notes from a colleague. • Always check the medical record! Develop checking habits • Remember, computerized systems still require checking! • If you always check it will become a habit! • Some useful maxims … – Unlabeled medications should never be administered. – Never administer a medication unless you are 100% sure you know what it is. Legal Responsibilities • Nurse is legally responsible for safe and accurate administration of medications • Nurse is expected to have sufficient drug knowledge to recognize and question erroneous orders Encourage patients to be actively involved in their care! • When prescribing a new (or any) medication provide patients with the following information: – Name and purpose of medication – Common side-effects – Teach-back is a good way to validate patient understanding. – Allow time for questions. General Principles of Drug Therapy • Expected benefits should outweigh potential adverse effects • Drug therapy should be individualized • Drug effects on quality of life should be considered in designing a drug therapy regiment So let’s tackle some technical aspects Pharmacodynamics (PD) Pharmacokinetics (PK) What drug does to the body What body does to the drug Pharmacokinetics https://www.youtube.com/watch?v=IOf- z0D1mHk Finer PK Points Worth Noting Advantages Disadvantages

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