What are these eight rights anyway?

The picture posted with this column of a nurse on her way to give medications gives rise to many thoughtsNurse Medication Picture and memories. For me, it brings memories of my early years in nursing practice.  We wore white uniforms, white shoes, white nylons and white caps.  . I remember learning how to safely and accurately administer medications through each of the steps from the physician’s order to setting up medications, to administration and documentation. I also remember how much emphasis was placed on giving the right patient the right medications. Like the nurse in the picture, medication rounds were done using a tray holding medication in cups and small cards with the patient information and medication on them.

Years later, the safety of administering medications was outlined in the Five Rights of Medication Administration.  I cannot tell from the literature when these became formalized but when I returned to school in the mid 1980’s, the Five Rights were prominent in nursing practice, risk management and patient safety.

Health Care Advances

As the body of knowledge for nursing practice evolves, we continuously improve our practice to assure our patients receive the highest level of care with an emphasis on patient safety and error reduction. Because of this, three more rights have been added to the body of knowledge for medication administration, making a total of eight rights.

In corrections settings, medication administration is completed by a variety of job classifications. No matter who gives medications to patients, they must be qualified and trained in medication administration and follow the Eight Rights, as described below:

  1. Right Patient: check the name on the medication administration record (MAR), use two identifiers; ask patient to identify themselves, check name &/or picture on ID wrist band or badge.
  2. Right Medication: check the order, select medication, compare to the order, check the MAR, and then check the medication against the MAR before giving to the patient. If it is a new medication does the patient know what it is for and are there any allergies that would contradict giving it.
  3. Right Dose: check the order or the MAR, confirm the appropriateness of the dose, for medications with high risk consequences from dosing errors have someone double check the calculation.
  4. Right Route: check the order and MAR, confirm the route is the correct for that medication and dose, confirm that the patient can receive it by the ordered route.
  5. Right Time: check frequency the medication is to be given on the MAR and the time is correct for this dose, confirm when the last dose was given.
  6. Right Documentation: document administration AFTER giving the medication, document the route, time and other specifics such as site, if injectable, lab value, pain scale or other data as appropriate.
  7. Right Reason: confirm the rationale for the ordered medication; why is it prescribed, does the patient know why they are taking this medication. If they have been taking it for long is its continued use justified?
  8. Right Response: has the drug had its desired effect, does the patient verbalize improvement in symptoms, and does the patient think there is a need for an adjustment in the medication?  Document your monitoring of the patient for intended and unintended effects.

Adapted from Bonsall, L. M. (2011). 8 rights of medication administration. Retrieved June 17, 2016 from http://www.nursingcenter.com/ncblog/may-2011/8-rights-of-medication-administration

The Important Three

When you examine the new three rights closely, their importance becomes clear and explains why they are included as best practices:

  • Right Documentation:  We hear from our legal representatives, instructors, managers and peers, that “if it was not documented, it was not done”. No excuses can make up for a patient receiving double dose of medications when it was not documented or a provider changing a medication when they thought a patient was not taking the medication. Besides accurate and timely documentation of medications administered, this right also includes the accurate documentation of the order on the MAR.
  • Right Reason: When taking off orders or preparing to administer a medication, knowing why the patient is taking a medication is the foundation for patient education and evaluating the effects of the treatment. This is especially important when a particular medication, such as gabapentin, may be ordered to address one of several different conditions (seizure, nerve pain, restless leg syndrome etc.). Information in the patient’s chart will often clarify why this medication is being ordered; if not, consult the provider so that you know what the patient can expect from the treatment.
  • Right Response: We cannot effectively teach a patient about a certain medication and the desired effects of treatment if we do not know the drug ourselves.  Knowing about medications is a continual learning process, which grows day by day.  Make a habit of learning about new drugs each day.  This information can be found in the drug reference books kept in the medication room, by talking with providers, consult with the pharmacist, discussing medications at shift or team reports and exchanging information with team members.  See also a previous post that describes all of the online drug references that are available without charge.

Spread the Word about the 8

Even though these additional best practices have been discussed in the literature and have been topics in nursing education for several years, I still hear nurses refer to the Five Rights. They are called rights because they are not a request or desire—but a RIGHT. Each one of the eight rights is fundamental to nursing practice and when used together better promote patient care and enhance safety. By following these steps, nurses promote wellness and identify and prevent harm to our patients. What do the eight rights of medication administration mean to you?  How has understanding the eight rights in your practice, improved your patients care?  Share your experiences and challenges with medication administration in the comment section below.

Read more about correctional nursing in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

Photo credit:  Yahoo Images

 

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From the Archives: Evidence-Based Practice

Archives4Research published in the Journal of Nursing Administration (JONA) confirms that nurses want to practice based on the best evidence but are not consistently putting that desire into action. Many challenges were identified by the national sample of nurses surveyed for the research study. These challenges may be even more acute in the correctional setting where resources can be lacking and technology limited. These past blog posts review how to find evidence for your correctional nursing practice.

Encouraging Evidence-Based Nursing Practice in Corrections

Evidence-Based Practice: Asking the Right Questions

Evidence-Based Practice: Where to Look

Are you applying evidence in nursing practice in your setting? Share your experiences in the comments section of this post.

Read more about Evidence-Based Nursing Practice in Chapter 18 from Essentials of Correctional Nursing. Order your copy directly from the publisher.

From the Archives: Juvie Health

Archives3If you work in a correctional setting, chances are great that you have patients under 19 years of age. Many jails throughout the country house adolescents onsite. In addition, most states have adult sentencing for some form of juvenile crime. Although the Federal Bureau of Prisons does not house adolescents in adult facilities, 149 federally-sentenced youth were being housed in contracted facilities in 2011. While the criminal justice system struggles with the advisability of incarcerating youth, correctional nurses must establish a program of care that attends to their health and well-being while behind bars. Read these post blog posts to learn the particulars of juvie care behind bars.

Troubled Youth: Adolescents Behind Bars

Troubled Youth: Physical Development Challenges Behind Bars

Troubled Youth: Psychosocial Development Behind Bars

Troubled Youth: Asthma Management

Do you provide health care to troubled youth? Share your experiences in the comments section of this post.

To read more about the unique aspects of juvenile health care in the correctional setting see Chapter 11 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher.

From the Archives: Correctional Nurse Peer Review

Archives1The Essentials of Correctional Nursing Blog has over 200 informational posts to help you in your correctional nursing practice. This month we are searching through the archives to bring back a few series you may have missed. Here are links to a set of posts about peer review in our specialty.

Correctional Nursing Peer Review: What it is and What it isn’t

Correctional Nursing Peer Review: Determining Discipline-Specific and Community Standards

Correctional Nursing Peer Review: Making it Practical

Correctional Nursing Peer Review: Some Examples

Are you developing a Nursing Peer Review program in your setting? Share your experiences in the comments section of this post.

To read more about professional practice issues see Chapter 19 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher 

From the Archives: Moral Courage

Archives2The Essentials of Correctional Nursing Blog has over 200 informational posts to help you in your correctional nursing practice. This month we are searching through the archives to bring back a few series you may have missed. Here are links to a set of posts about the need for moral courage in our specialty. 

Moral Courage: Do You Have What It Takes?

Moral Courage: How Do I Find Some?

Moral Courage: Dealing with Uncertainty

Moral Courage: Being Assertive

Have you needed to confront a moral dilemma in your correctional nursing work experience? Share your thoughts and experiences in the comments section of this post.

Read more about ethical practice in corrections in Chapter 2: Ethical Principles of Correctional Nursing from Essentials of Correctional Nursing. Order your copy directly from the publisher.http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4 

Medication Reconciliation

Fotolia_85555232_XSAn inmate approaches you at morning med line and asks for his medication. When he gives you his name and identification number you are unable to find a corresponding Medication Administration Record (MAR) and there is no medication with his name on it in the drawer. This is the psych step down unit so he is probably correct to expect to have medication. When asked he tells you that he arrived on the unit last evening from 3E, the acute psych unit. You tell him that there is no medication for him on the cart and that you will contact the pharmacy and will get back to him later that morning. You are thinking that his medication is still in the med cart on 3E and will call the nurse on the unit as soon as you get back to the clinic.

Does this example sound familiar? How many times are you approached to administer a medication and it is not there? It could be because the inmate was just admitted to the facility or just saw the provider and the medication hasn’t been received from the pharmacy. It could be that the inmate was transferred from one unit to another and his or her medication was not transferred to the new location. Maybe the inmate just returned from an off-site procedure and the provider hasn’t reviewed the specialist’s recommendations.

Each admission, provider visit, transfer or change in level of care is an opportunity for omission, duplication, dosing errors, drug-drug interactions and drug-disease interactions to occur and with it the potential for an adverse patient outcome. Almost half of all medication errors in the general health care community occur because medication is not reconciled adequately when there is a handoff in responsibility for the patient’s care and 20% of these result in harm to the patient. Transitions in the responsibility for an inmate’s health care have the same risk. Medication reconciliation prevents mistakes in patient care.

The Institute for Healthcare Improvement and the Joint Commission recommend reconciling medication whenever there is a change in the patient’s setting, condition, provider or level of care required. In corrections medication reconciliation is done when inmates at admission report taking medication prescribed by providers in the community. These medications will need orders to continue or the inmate’s treatment modified by the provider at the correctional facility assuming responsibility for the patient’s care. Medication reconciliation also takes place when an inmate returns to the facility after receiving specialty care in the community, upon admission and discharge from infirmary or another type of inpatient care and whenever their primary care provider changes. There are only three simple steps involved in reconciliation. These are:

  1. Verify the name, dosage, time and route of the medication (s) taken or recommended.
  2. Clarify the appropriateness of the medication and dosing.
  3. Reconcile and document any changes between what is reported or recommended.

The following paragraphs discuss how medication reconciliation is done at several key points in correctional health care.

When Inmates Arrive at a Facility

Intake screening routinely includes an inquiry into what medications an inmate is taking. Sometimes this question is only briefly discussed. However, if an inmate reports recent hospitalization or receipt of health care in an ambulatory care setting it would be a good idea to inquire again about what medications may have been recommended or prescribed. The same is recommended if an inmate reports having a chronic condition. It may be that they are not currently taking medication because they can’t afford it or were unable to obtain the medication for another reason. Inquiry about medications should also include the inmate’s use of over-the-counter or other alternative treatments.

Offenders arriving at a facility from the community, especially jails and juvenile facilities, may have medications on their person and sometimes, family will bring in medications after learning their family member has been detained. It is best practice to verify that the medication received is the same as that on the label. There are several excellent sites for verification of drugs including Drugs.com, Pillbox, and Epocrates.com. Once verified, document the name of the medication, dose, and frequency, date of filling, quantity remaining, physician, pharmacy and prescription number.

Whether it is the inmate’s report or the inmate has brought in their own medication the prescription must next be verified with the pharmacy or community prescriber. Once this is done, notify the institution provider who will determine if the medication should be started urgently so there is no lapse in treatment or if the patient should wait until seen for evaluation.

When Inmates Return From Offsite care

Medication should also be reconciled whenever a patient returns to the facility from a hospitalization or specialty care. The clinical summary or recommendations by the offsite provider should accompany the patient, if not, the nurse should obtain this information right away. Recommendations from off-site specialists or hospital discharge instructions should be reviewed as soon as possible by the nurse and provider in order to continue the patient’s care. When clinical recommendations from off-site care are missed or not followed up on needed treatment is delayed and the patient’s health may deteriorate.

When Inmates Are Followed in Chronic Care Clinic

Chronic care patients are another group that require nursing attentiveness to medication reconciliation including:

  • Evaluating whether the patient is actually taking it as ordered.
  • Following up whenever the medication or the patient is not available and if so, getting scheduled doses to the patient promptly. Also helping the patient to request refills and reorders in time may be necessary so doses are not missed. Also account for the whereabouts of each no show so that medication can be provided as scheduled.
  • Coaching the patient about what to discuss with their provider if they want to make a change or are having side effects. Often patients who want to change or discontinue prescribed treatment will refuse single doses or not pick up their KOP medications. Each of these lapses should be discussed, the patient coached about the next steps to take and the provider notified as well.

When Medications Are Missing

When patients come to the pill cart or widow expecting to receive medication and there is either no medication or MAR asking the patient a few questions as listed below will narrow down where the medication may be located:

  • when was the last dose received (this indicates there is an active prescription and will help determine the urgency for resolution)?
  • If the inmate says that he or she haven’t had any medication yet, ask when they saw the provider who ordered it? (maybe the prescription has not been dispensed yet or it has arrived but hasn’t been unpacked and put away).

Other questions to help narrow down the problem are:

  • if they have been moved recently from another part of the facility (medication and MAR were not transferred).
  • when did they arrive at the facility or were transferred from another (check the transfer sheet, medications and MAR were not transferred).
  • is it a prescription brought in from the community (may be stored elsewhere)?
  • if they have gone by any other names (may be filed elsewhere).

Based upon the answers to these question you may instruct the patient to wait (i.e. “It was just written last night and hasn’t been filled yet, please check back tomorrow.”) or tell the patient that you will look for it and administer it at by at least the next pill call. If you are not able to resolve the problem promptly be sure to assess the patient to determine if the provider should be contacted. Allowing patients to miss medication, even if somebody else is responsible, is equivalent to not providing treatment that is ordered and can be a serious violation of a patient’s constitutional rights in the correctional setting, much less exacerbate their medical condition.

Easing the Burden of Medication Reconciliation

Other recommendations to ease the burden of medication reconciliation from the Institute for Healthcare Improvement are:

  1. Identify responsibilities for medication reconciliation such as standardizing where information about current medications is located, specifying who is responsible for gathering information about medications and when medication reconciliation is to take place, establishing a time frame for resolution of variances and standardizing documentation of medication variance and resolution.
  2. Use standardized forms to ensure that information about medications is elicited and documented.
  3. Establish explicit time frames for when medication is to be reconciled and variances resolved such as within 24 hours of admission, within four hours of identification of variance in high risk medications (antihypertensives, anti seizure, antibiotics, etc.), at every primary care visit.
  4. Educate patients about their medications and their role in reconciliation at every transition in care.

When do you obtain information about the medications a patient takes and how do you verify the patient’s information? Do you provide patients with a list of the medications they take? What is the patient’s role in medication reconciliation at your facility?

If you wish to comment, offer advice about medication reconciliation in correctional health care please do so by responding in the comments section of this post.

Read more about correctional nursing in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

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Protective Gear for Correctional Nurses

The post last week talked about the problem of nurses being exposed to inappropriate and hostile sexual behaviors by inmates and the kinds of interventions that should be in place to minimize or control antisocial inmate behavior. Nurses were advised not to confront this behavior single handedly but to look to the facility for guidance. But that is just half the solution, the other half, which is the subject of today’s post, is that individuals can take steps on their own to minimize the adverse effects of these unfortunate situations on themselves.

The reality is that bad things do happen in corrections. Even in the best run correctional facilities inmates are injured and sometimes staff are injured as a result of violence and on some of these occasions died as a result of the violence. The nature of the correctional environment is that it always has the potential for immediate violence and direct trauma. Another pervasive aspect of our working environment is that because of the involuntary conditions of incarceration, there is inherent conflict, particularly between staff and inmates. These two features of the work environment combined with operational stressors, such as high workload, contribute to what has been called “Corrections Fatigue”.

It has been suggested that correctional staff prepare themselves to be in this environment the same way that they don other protective gear. An analogy for correctional nurses would be gowning, gloving and putting on a properly fitted mask before going into the isolation room of a patient with active tuberculosis. By wearing protective gear staff minimize their exposure. The same concept applies to the trauma associated with repeated exposure to violence or threatening behavior. What kind of “gear” minimizes our repeated exposure to trauma in the corrections environment?

Resilience is a characteristic that refers to an individual’s ability to cope with adversity; it is the ability to “bounce back” after a stressful experience. Resilience varies from one person to another but we can each tend to and build our resilience. Resilience, then is our protective gear. The following four behaviors have been identified as building resilience in correctional workers.

Build Supportive Relationships at Work – Building and maintaining social support among co-workers has been found to correlate with resilience for the person offering support. By building genuine bonds with co-workers we increase our sense of safety, reduce interpersonal tension and staff conflict. Examples of behaviors that are supportive of relationships at work include:

  • being friendly and respectful,
  • asking how a co-worker is and paying attention to their answer,
  • acknowledging a job well done,
  • looking for ways to assist others when you have time,
  • thanking others for their assistance, and
  • being compassionate with others’ experiences.

Take Care of Yourself – How many times have we as health care providers offered this advice to others? And yet we are known to neglect ourselves, making us vulnerable to burnout, compassion fatigue and now, corrections fatigue. Being healthy is a basic tenet of resilience. Healthy habits and lifestyle behaviors include those that attend not just to your physical needs, but psychological, spiritual and social needs as well. Healthy habits and lifestyle behaviors include:

  • maintaining balance between work and home life
  • mindfully transition to and from work
  • prioritize free time to be with people who are significant in your family and social life
  • engaging in pleasant activity-having fun
  • regulate negative emotions (emotional intelligence)
  • establish a regular and healthy sleep schedule.

Be Confident and Perseverant – These behaviors build competence handling complex or challenging circumstances at work. Confidence and perseverance are a result of:

  • a resolution to complete tasks even when it is difficult,
  • using self-talk to motivate oneself to persevere in the face of adversity,
  • rehearsing and repeating training so that it becomes more automatic and built in,
  • being flexible, open and adaptive to change
  • being ethical and acting with integrity.

Use Logic to Solve Problems – This approach is recommended as a way to keep your cool in the face of the complex or challenging problems we deal with in correctional health care. Thinking logically about situations means considering more than one possible cause and weighing possible responses before choosing the one that is most likely to have the effect you are seeking. This way you maintain control and composure in frustrating or disappointing circumstances. Practical ways to practice logical problem solving and self-control include:

  • divide complex problems into parts and tackle one component at a time,
  • learn how to detach emotionally from challenging situations,
  • view mistakes as learning opportunities,
  • regulate fear and other negative emotions while acting constructively,
  • accept that you cannot always be in control.

These four behaviors, supporting workplace relationships, taking care of yourself, being confident and perseverant, and logical problem solving are your protective gear (resilience) to reduce the effects of violence and other antisocial behaviors, conflict and other operational stressors that are inherent in the correctional setting on your health and well-being.

For more information about promoting wellness among staff who work in correctional settings please see the National Institute of Corrections has collected articles and other resources on this subject. They also sponsored a podcast on the subject in 2014 which can be accessed on the NIC website. Much of this information was adapted for correctional nursing from a series of articles written by Caterina Spinaris PhD., Executive Director of Desert Waters Correctional Outreach which provides training and other materials to support wellness of correctional staff including a monthly newsletter, Correctional Oasis.

I was most surprised to learn from my research for this blog post that when I offered support to co-workers it had a positive effect on me by building resilience. This new idea has me thinking about my work relationships and how I support others to see what I could do better. What resilience building behaviors have caused you to reflect on your own behaviors? Is there more you could do to protect yourself from the negative attributes of your working environment?

If you wish to comment, offer advice or share an experience concerning the subject of staff wellness please do so by responding in the comments section of this post.

Read more about correctional nursing in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

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