Registered Nurse: A Case Study

Nurses should be encouraged to question the doctors if a wrong drug is prescribed. They should also restrain from taking verbal orders. Written signed orders should be mandated.

A prescription can be identified as legally authorised written instruction by a prescribing officer to a pharmacist to dispense medication.

the roles and responsibilities of the person prescribing medication are to prescribe in the best interests of the persons. They will need be know the patient’s medical history and the current medication they are taking, give all information to the patient so the patient can make an informed choice, know the current guidance which is published in the BNF, prescribe the current dosage and make a follow up appointment.

Goal three by the National Patient Safety Goal for 2014 is to use medicines safely. Many errors occur regularly with medications which is why communication is so important with the doctors, nurses and patients. One process that Joint Commission requires in accredited HCO’s is medication reconciliation “creating the most accurate list possible off all medications a patient is taking, including drug name, dosage, frequency, and route, and comparing that list against the physician’s admission, transfer, and/or discharge orders with the goal of providing correct medications to the patients at all transition points within the hospital (Finkelman & Kenner, 2012, p. 388)”. Ensuring medication reconciliation to the patient, health providers and any new consults that are

A pharmacist must check any medication that is administered to a patient. This is the

Organisational policy and procedures should include how to receive and record medication, safe storage, prescribing, dispensing, administration, monitoring and

Non care setting - Medications are often stored and administered in a variety of non-health care settings. These settings include: primary and secondary schools, Child day care centres, Board and care homes, Jails and prisons. In all these settings, employees frequently are responsible for handling and administering prescription and over-the-counter medications to clients or residents. Some organizations may employ licensed health professionals to directly manage the medication administration process. However, many of these settings have no licensed health professionals involved. Where medications are stored and administered to individuals, written policies and procedures should address the following: Acquisition of medications (e.g., from parents, caregivers, pharmacies), Specification of which personnel are allowed access to medications and allowed to administer medications to students, clients or residents, Labelling and packaging of medications managed for students, clients

* All medication should be recorded and signed for by the receiving pharmacist and a proper record maintained in-house.

1. In the workplace there is a generic Medication Management Policy and Procedures for Adult Services (Issue 10, 2012) document. This is kept to hand in a locked cupboard, readily available to read. It requires that all Healthcare Staff are given mandatory training and refreshers are provided. Legislation which surrounds the administration of medication includes The Medicines Act 1968, The Misuse of Drugs Act 1971, The Data Protection Act 1998, The Care Standards Act 2000 and The Health and Social Care Act 2001

There are several legislations in place with protocols for the administration of medication which I have listed below. The main policy re admin of drugs and storing of drugs and medicines is the Control Of Substances Hazardous to Health or COSHH but along with this there are other policies in place as per the list below.

6. Right documentation- The seven rights should be documented with great detail along with any adverse events and instructions provided to the patient regarding being alert of reactions and what steps to take. This step should always follow the administration of medications. The person who has administered the medication needs to verify again that all the seven rights were followed to make sure that no medication errors were made. After the end of this order,without leaving any lines or spaces the person administering the order signs his or her name along with there credentials and followed by the date and time the order was given. In some instances the medical assistant may write down the information regarding a medication administered by the provider in the provider’s stead,but the provider still needs to sign, date and time the entry personally. The medical assistant should never document a medication for anyone else nor should anyone else record medication that the medical assistant (you)

When patients are brought back for rooming, the nurse or medical office assistant will review the printed list with the patient prior to documenting in the EMR. During the office visit, we will review polypharmacy and are adding a document to our resources section of the EMR regarding polypharmacy and accurate medication list that will be given to all patients. I have always been aware of the importance of accurate medication list, but was not reviewing this often enough in our patients EMR.

The nurse must verify the physician’s medication order, including the dose and time, and then the pharmacy is responsible for their own checks and balances via the BCMA system in order to complete the dispensing phase of the medication (Gooder, 2011). The nurse enters the BCMA system with a login and password and is able then to see a list of the virtual due list for a specific patient. The computer on wheels is then taken to that patient’s room and the five rights of medication administration begin. As nurses, we are taught to use the five rights of drug administration are (1) right patient (2) right medication (3) right dose (4) right route and (5) right time. By scanning the barcode on the patient’s hospital identification band, the nurse then asks for the patient to verbally state their name and date of birth, which can be verified by the nurse on the virtual due list and then choses the medication that are due for administration at that time. The medication is dispensed and the nurse is able to scan the barcode on the medication, the scanning triggers the automatic documentation of the medication given (Kelly, 2012).

Step2: Main pharmacy pharmacist or clinical pharmacist in the responsible floor verify the order; if it is correct, then go to step3; if the pharmacist has some questions or concerns about the order, contact the physician or nurse practitioner to address. Pharmacists check the indication, effectiveness, safety, and convenience of the medication. Time spent: 5 minutes

Safe medication practices are key to every nurse since it results to safe medication administration. When medication is not administered correctly it results to adverse drug event which refers to harm to the patient that includes mental harm, physical harm, or loss of function which is as a result of a medication error (practices, 2017). Medication errors occur when a mistake is committed by a person administering medication and in order to avoid these errors safe medication practices need to be adhered to. Some of these