Nursing Continuing Education

Appropriate Prescribing

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This is Your Course on Appropriate Prescribing


Safe Medication Administration and Error Reduction

Providers who may legally write prescriptions in the United States include physicians, advanced practice nurses, dentists, and physician assistants. These providers are responsible for obtaining clients’ medical history, performing a physical examination, diagnosing, prescribing medications, monitoring responses to therapy, and modifying prescriptions as necessary. Nurses are responsible for having knowledge of federal, state (nurse practice act), and local laws, and facilities’ policies that govern the prescribing, dispensing and administration of medications; preparing, administering, and evaluating response to medications; developing and maintaining an up‑to‑date knowledge base of medications they administer, including uses, mechanisms of action, routes of administration, safe dosage range, adverse and side effects, precautions, contraindications, and interactions; maintaining acceptable practice and skills competencies; determining the accuracy of medication prescriptions; reporting all medication errors; safeguarding and storing medications; following legal mandates when administering controlled substances; calculating medication doses accurately; and understanding the responsibilities of other members of the health care team regarding medications.


World Health Organization Recommendations for Appropriate Prescribing

The WHO advocates for a 6-step approach to minimizing errors and poor-quality prescriptions:

  1. Evaluating and clearly defining the patient’s problem
  2. Specifying the goal/objective of the therapy
  3. Selecting the appropriate drug therapy
  4. Initiating therapy with clear details and consider non-pharmacologic approaches
  5. Give all information, instructions, and warnings 
  6. Re-evaluate the necessity of ongoing drug therapy regularly 
The AAFP also adds two additional steps:
  1. Consider the drug’s cost
  2. Use computers and other tools to reduce errors


Being a Responsible Prescriber

At Each Visit:

  • Perform a full review of all medications, including those from other providers and over-the-counter medications and other supplements
  • Review all allergies and history of adverse reactions
  • Check for potential drug-drug interactions
  • Check for potential drug-disease interactions

Before Adding a New Medication:

  • Confirm a diagnosis before prescribing a medication, if possible
  • Consider nonpharmacologic approaches first
  • Identify your therapeutic endpoint, when you will plan to discontinue the medication
  • Make sure that a therapeutic dose has been taken for an adequate amount of time before switching to a new medication
  • Check for potential drug-drug or drug-disease interactions
  • Is there a less expensive comparable form or alternative option?
  • Use the lowest possible effective starting dose
  • Use the simplest medication regimen possible (fewest number of medications and doses per day)


Controlled Substances

The Controlled Substances Act (CSA) is the statute establishing federal U.S. drug policy under which the manufacture, importation, possession, use and distribution of certain substances is regulated. Uncontrolled substances require monitoring by a provider, but do not generally pose risks of abuse and addiction. Antibiotics are an example of uncontrolled prescription medications. Controlled substances have a potential for abuse and dependence and have a “schedule” classification. 

Schedule I 

These substances are described as those that have the following findings:

The drug or other substance has a high potential for abuse, has no currently accepted medical use in treatment in the United States, and there is a lack of accepted safety for use of the drug or other substance under medical supervision.

Schedule II

Substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence.

Schedule III

Schedule III have potential for abuse that is less than the substances in Schedules I or II but abuse may lead to moderate or low physical dependence or high psychological dependence.

Schedule IV

These have a low potential for abuse relative to substances in Schedule III and below. 

Schedule V

Schedule V have a low potential for abuse relative to substances listed in Schedule IV and below.


Heroin is in Schedule I and has no medical use in the United States. Medications in Schedules II through V have legitimate applications. Each subsequent level has a decreasing risk of abuse and dependence. For example, morphine is a Schedule II medication that has a greater risk for abuse and dependence than phenobarbital, which is a Schedule IV medication.

A full list of scheduled medications can be found at the DEA website: https://www.deadiversion.usdoj.gov/schedules/orangebook/c_cs_alpha.pdf

  • New drugs in development undergo the rigorous testing procedures of the U.S. Food and Drug Administration (FDA) to determine both effectiveness and safety before approval. However, new drugs can have unidentified or unreported adverse effects; nurses observing these can report them online at www.fda.gov/medwatch.
  • The FDA’s Pregnancy Risk Categories (A, B, C, D, X) classify medications according to their potential harm during pregnancy, with Category A being the safest and Category X the most dangerous. Teratogenesis from unsafe medications is most likely to occur during the first trimester. Before administering any medication to a woman who is pregnant or could be pregnant, determine whether it is safe for use during pregnancy.


Nurse Responsibilities

  • Having knowledge of federal, state (nurse practice acts), and local laws and facility policies that govern the prescribing, dispensing, and administration of medications
  • Preparing, administering, and evaluating responses to medications
  • Developing and maintaining an up‑to‑date knowledge base of medications they administer
  • Uses
  • Mechanisms of action
  • Routes of administration
  • Safe dosage ranges
  • Adverse effects
  • Precautions
  • Contraindications
  • Interactions
  • Maintaining acceptable practice and skills competencies
  • Determining the accuracy of medication prescriptions
  • Reporting all medication errors
  • Safeguarding and storing medications
  • Following legal mandates when administering controlled substances
  • Calculating medication doses accurately
  • Understanding the responsibilities of other members of the health care team regarding medications

Essential knowledge prior to medication administration

  • Medication category/class
    • Medications have a pharmacological action, therapeutic use, body system target, chemical makeup, and classification for use during pregnancy. For example, lisinopril is an ACE inhibitor (pharmacological action) and an antihypertensive (therapeutic use).
  • Mechanism of action
    • This is how medications produce their therapeutic effect. For example, glipizide is an oral hypoglycemic agent that lowers blood glucose levels primarily by stimulating pancreatic islet cells to release insulin.
  • Therapeutic effect
    • This is the expected effect (physiological response) for which the nurse administers a medication to a specific client. One medication can have more than one therapeutic effect. For example, one client receives acetaminophen to lower fever, whereas another client receives it to relieve pain.
  • Side effects
    • These are expected and predictable effects that result at therapeutic dosages. For example, morphine for pain relief usually results in constipation.
  • Adverse effects
    • These are undesirable, inadvertent, unexpected, and potentially dangerous responses to a medication. Some are immediate, whereas others take weeks or months to develop. For example, the antibiotic gentamicin can cause hearing loss.
  • Toxic effects
    • Medications can have specific risks and manifestations of toxicity. They develop after taking a medication for a long time or when toxic amounts build up due to faulty metabolism or excretion. For example, nurses monitor clients taking digoxin for dysrhythmias, a manifestation of cardiotoxicity. Hypokalemia places these clients at greater risk for digoxin toxicity.
  • Medication interactions
    • Medications can interact with each other, resulting in beneficial or harmful effects. For example, giving the beta‑blocker atenolol concurrently with the calcium channel blocker nifedipine helps prevent reflex tachycardia. An example of an undesirable interaction is the result of giving omeprazole (a proton pump inhibitor) concurrently with phenytoin (an anticonvulsant). This can increase the serum level of phenytoin. Obtain a complete medication history, and be knowledgeable of clinically significant interactions. Be aware that medications can also interact beneficially or harmfully with food and with herbal and dietary supplements.
  • Precautions/Contraindications
    • These are conditions (diseases, age, pregnancy, lactation) that make it risky or completely unsafe for clients to take specific medications. For example, tetracyclines can stain developing teeth. Therefore, children younger than 8 years should not take these medications. Another example is that myasthenia gravis is a contraindication for fentanyl, an opioid analgesic. Some medications require caution with some conditions. For example, the kidneys excrete vancomycin without changing it. Therefore, administering this medication to clients who have kidney impairment requires caution.
  • Preparation, dosage, administration
    • It is important to know any specific considerations for preparation, safe dosages, dosage calculations, and how to administer the medication. For example, morphine is available in many formulations. Oral doses of morphine are generally higher than parenteral doses due to extensive first‑pass effect. Clients who have chronic severe pain, such as with cancer, generally take oral doses of morphine.
  • Nursing implications
    • Know how to monitor therapeutic effects and side effects, prevent and treat adverse effects, provide comfort, and instruct clients about the safe use of medications.


Medication Category and Classification Nomenclature

The chemical name is the name of the medication that reflects its chemical composition and molecular structure (isobutylphenyl propanoic acid). The generic name is the official or nonproprietary name the United States Adopted Names Council gives a medication. Each medication has only one generic name (ibuprofen). The trade name is the brand or proprietary name the company that manufactures the medication gives it. One medication can have multiple trade names (Advil, Motrin).


Considerations

Nurses administer prescription medications under the supervision of providers. Some medications can be habit‑forming, or have potential harmful effects and require more stringent supervision. Uncontrolled substances require monitoring by a provider, but do not generally pose risks of abuse and addiction. Antibiotics are uncontrolled prescription medications. Controlled substances have a potential for abuse and dependence and have a schedule classification. Heroin is Schedule I and has no medical use in the U.S. Medications Schedules II through V have legitimate applications. Each subsequent level has a decreasing risk of abuse and dependence. For example, morphine is a Schedule II medication that has a greater risk for abuse and dependence than phenobarbital, which is Schedule IV.

  • New medications in development undergo the rigorous testing procedures of the U.S. Food and Drug Administration (FDA) to determine both effectiveness and safety before approval. However, new medications can have unidentified or unreported adverse effects. Nurses observing these can report them at www.fda.gov/medwatch.
  • The FDA’s Pregnancy Risk Categories (A, B, C, D, X) classify medications according to their potential harm during pregnancy, with Category A being the safest and Category X the most dangerous. Teratogenesis from unsafe medications is most likely to occur during the first trimester. Before administering any medication to a client who is or could be pregnant, determine whether it is safe for use during pregnancy.

Medication Prescriptions

Each facility has written policies for medication prescriptions, including which providers may write, receive, and transcribe medication prescriptions.

Types of medication prescriptions

Routine or standard prescriptions

  • These prescriptions identify medications nurses give on a regular schedule with or without a termination date or a specific number of doses. Without a termination date, the prescription remains in effect until the provider discontinues it or discharges the client.
  • Providers must represcribe some medications (opioids, antibiotics) within a specific amount of time or they will automatically discontinue. 

Single or one‑time prescriptions

Single or one-time prescriptions are for administration once at a specific time or as soon as possible. These prescriptions are common for preoperative or preprocedural medications. For example, a one‑time prescription instructs the nurse to administer lorazepam 2 mg IM at 0700. Stat prescriptions are only for administration once and immediately, typically in emergencies when a client’s condition changes suddenly. For example, a stat prescription instructs the nurse to administer diphenhydramine 50 mg IM stat. 

PRN prescriptions

PRN prescriptions specify at what dosage, what frequency, and under what conditions a nurse may administer the medication. The nurse uses clinical judgment to determine the client’s need for the medication. For example, a PRN (pro re nata) prescription instructs the nurse to administer tramadol 50 mg PO every 4 hr PRN for back pain. When administering PRN medications, the nurse documents findings that demonstrate the client’s need for the medication and the time of administration.

Standing prescriptions

Providers write standing prescriptions for specific circumstances or for specific units. For example, a critical care unit has standing prescriptions for treating clients who have asystole. Another example is a heparin protocol.

Components of a medication prescription

  • Client’s full name
  • Date and time of the prescription
  • Name of the medication (generic or brand)
  • Strength and dosage of the medication
  • Route of administration
  • Time and frequency of administration: exact times, intervals, or number of times per day (according to the facility’s policy or the specific qualities of the medication)
  • Quantity to dispense and the number of refills
  • Signature of the prescribing provider



Rights of Safe Medication Administration

Right client

Verify clients’ identification before each medication administration. The Joint Commission requires two client identifiers.
  • Acceptable identifiers include the client’s name, assigned identification number, telephone number, birth date, or another person‑specific identifier, such as a photo identification card.
  • Check identification bands for name and identification number.
  • Check for allergies by asking clients, looking for an allergy bracelet or medal, and reviewing the MAR.
  • Use barcode scanners to identify clients.

Right medication

Correctly interpret medication prescriptions, verifying completeness and clarity.

  • Read medication labels and compare them with the MAR three times.
    • Before removing the container
    • When removing the amount of medication from the container
    • In the presence of the client before administering the medication
  • Leave unit‑dose medication in its package until administration.
  • When using automated medication dispensing systems, perform the same checks and adapt as necessary.

Right dose

  • Use a unit‑dose system to help prevent errors. If not available, calculate the correct medication dose.
  • Check a drug reference to make sure the dose is within the expected range.
  • When performing medication calculations or conversions, have another nurse check the dosage calculation.
  • Prepare medication dosages using standard measurement devices (graduated cups, syringes). Some medication dosages (such as some cytotoxic medications) require a second verifier or witness. Automated medication dispensing systems use a machine to control the dispensing of medications.

Right time

Administer medication on time to maintain a consistent therapeutic blood level.

  • It is generally acceptable to administer the medication 30 min before or after the scheduled time. Refer to the drug reference or the facility’s policy for exceptions.
  • Give priority to time‑critical medications that must act at specific times (preoperatively).

Right route

The most common routes of administration are oral, topical, subcutaneous, IM, and IV. Additional routes include sublingual, buccal, intradermal, transdermal, epidural, inhalation, nasal, ophthalmic, otic, rectal, vaginal, intraosseous, and via enteral tubes.

  • Select the correct preparation for the route prescribed (otic vs. ophthalmic topical ointment or drops).
  • Always use different syringes for enteral and parenteral medication administration.
  • Know the scope of practice for the PN outlined in the state nurse practice act regarding specific classifications of medications and routes of administration. This can vary by state.
  • Know how to administer medication safely and correctly.

Right documentation

  • Immediately record the medication, dose, route, time, and any pertinent information, including the client’s response to the medication. Document the medication after administration, not before.
  • For some medications, in particular those to alleviate pain, evaluate the client’s response and document it later, perhaps after 30 min.

Right client education

  • Inform clients about the medication: its purpose, what to expect, how to take it, and what to report.
  • To individualize client education, determine what the client already knows, needs to know, and wants to know about the medication.

Right to refuse

  • Respect clients’ right to refuse any medication.
  • Explain the consequences, inform the provider, and document the refusal.

Right data collection

  • Collect any essential data before and after administering any medication. For example, measure apical heart rate before giving digoxin.

Right evaluation

  • Follow up with clients to verify therapeutic effects as well as side and adverse effects.

Types of Medication Prescriptions

Routine or standard prescriptions

  • A routine or standard prescription identifies medications nurses give on a regular schedule with or without a termination date. Without a termination date, the prescription will be in effect until the provider discontinues it or discharges the client.
  • Providers must re‑prescribe some medications, such as opioids and antibiotics, within a specific amount of time or they will automatically discontinue.

Single or one‑time prescriptions

A single or one‑time prescription is for administration once at a specific time or as soon as possible. These prescriptions are common for preoperative or preprocedural medications. For example, a one‑time prescription instructs the nurse to administer warfarin 5 mg PO at 1700.

Stat prescriptions

A stat prescription is only for administration once and immediately. For example, a stat prescription instructs the nurse to administer digoxin 0.125 mg IV bolus stat.

Now prescriptions

A now prescription is only for administration once, but up to 90 min from when the nurse received the prescription. For example, a now prescription instructs the nurse to administer vancomycin 1 g intermittent IV bolus now.

PRN prescriptions

A PRN (pro re nata) prescription specifies at what dosage, what frequency, and under what conditions a nurse may administer the medication. The nurse uses clinical judgment to determine the client’s need for the medication. For example, a PRN prescription instructs the nurse to administer morphine 2 mg IV bolus every hour PRN for chest pain.

Standing prescriptions

Providers write standing prescriptions for specific circumstances or for specific units. For example, a critical care unit has standing prescriptions for treating clients who have asystole.


Post Test

QIDs 50559, 65882, 65883, 60921, 44561, 38936, 48652, 26766, 23571, 22641

References:

  1. Am Fam Physician. 2007 Jan 15;75(2):231-6. Appropriate prescribing of medications: an eight-step approach. Pollock M1, Bazaldua OV, Dobbie AE.
  2. Guide to Good Prescribing: A practical manual. World Health Organization. Action Programme on Essential Drugs Geneva
  3. ATI Content Mastery Series, Fundamentals for Nursing REVIEW MODULE EDITION 9.0CHAPTER 47 Safe Medication Administration and Error Reduction, 
  4. Br J Clin Pharmacol. 2009 Jun; 67(6): 681–686. Medication errors: prevention using information technology systems. Abha Agrawal
  5. Open Access Emerg Med. 2014; 6: 45–55. Published online 2014 Jul 23. Strategies for reducing medication errors in the emergency department. Kyle A Weant,1 Abby M Bailey,2 and Stephanie N Baker2
  6. Br J Clin Pharmacol. 2009 Jun; 67(6): 656–661. Prevention of medication errors: teaching and training. Robert Likic and Simon R J Maxwell1



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