Monoplace Delivery System

Monthly Hyperbaric Safety Notice: July 2007

Medication Administration and Documentation

Background

Each year the Joint Commission introduces new National Patient Safety Goals. However, every year the same issue of ensuring safe medication administration and documentation remains one of their goals. When medications are part of the patient treatment plan, their appropriate management is critical to ensuring patient safety. The development of standardized and redundant systems has been shown to decrease errors and improve outcomes.

The Issue

Clinicians are well aware of the standard but sometimes fail to follow the necessary steps due to many reasons; urgency, distractions, multitasking, etc. The fact remains that the results of missing one of the steps can be fatal. The five rights for medication safety are:

Right med
Right dose (strength/amount)
Right time
Right route
Right patient

In order to meet these items, one must first start by reading the written order. Ask questions if things seem unclear. Anyone administering a medication has a responsibility to fully understand the dosing, mechanism of action, drug interactions and anticipated side effects. Reference materials should be available to you and reviewed prior to administering the medication, if considered necessary. NBS now requires documentation every six months for competency with medication and critical care.

After the medication is administered, follow-up assessment and documentation must be completed by the clinician.

Bottom Line

To avoid putting yourself and your patient in jeopardy you must follow the Five Rights every time a medication is administered. Below are some Dos and Don’ts of documentation.

DO’s

Check that you have the correct chart before you begin writing.
Make sure that your documentation reflects the nursing process and your professional capabilities
Write legibly
Chart the time you gave the medication, the administration route, and the patient’s response.
Chart preventative measures used.
Chart each phone call to a physician, including the exact time, message and response.
Chart patient care at the time you provide it.
If you remember an important point afterward, chart the information with a notation that it's a "late entry". Include a date and time of the late entry.
Document often enough to include the whole story.

DONT’s

Don’t chart a symptom, such as "c/o pain," without also charting what was done about it.
Don’t alter a patient’s record – this is a criminal offense.
Don’t use shorthand or abbreviations that are not widely accepted.
Don’t write imprecise descriptions, such as "bed soaked" or "a large amount."
Don’t chart what someone else said, heard, felt or smelled unless the information is critical. In that case, use quotations and attribute the remarks appropriately.
Don’t chart care ahead of time — something may happen and you are unable to actually give care you’ve charted. Charting care that you haven’t done is considered fraud.

Stacy Handley, RN, BSN, ACHRN, CWCN

Stacy Handley Stacy is Vice President of National Baromedical Services. She assumed her present position following several years as nurse manager of the NBS hyperbaric medicine service at Memorial Hospital, in Colorado Springs, Colorado. Stacy oversees the patient care aspects of the NBS network, conducts quality assurance and compliance assessments and preceptors all new NBS nurse managers. Additional responsibilities include marketing and promotion of NBS service lines and generation of monthly safety notices. Stacy is Member at Large for the Undersea and Hyperbaric Medical Society Associates and a board member for the Baromedical Nurses Association. She has trained as a Hyperbaric Safety Director and a UHMS faculty accreditation surveyor, and is a graduate of the Medical University of South Carolina ‘Wound Care Specialty Course’ through which she obtained her wound care certification

Full Panel of Safety and Technical Correspondents

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