Nursing Program Medication Administration Policy

MAPE #1: 14 Questions

• Med Admin Principles (2 questions)
• Drug Calculations (12 questions)

MAPE #2: 12 Questions

• Med Admin Principles (2 questions)
• Drug Calculations (10 questions)

MAPE #3: 10 Questions

• Med Admin Principles (2 questions)
• Drug Calculations (8 questions)

The guidelines for rounding principles to be used in math calculations are included in this policy (see below).

The three MAPEs are given each semester. Students will be notified by course faculty about the type of drug calculations that will be tested. A MAPE may include tablets, capsules, liquids, injectables, and intravenous calculations. Hand calculators and #2 pencils will be provided. The MAPE may be scheduled prior to the beginning of classes. Students will be notified of the dates of exams. Students who do not attend the scheduled test date will forfeit that testing opportunity and will not be able to makeup or retest.

Students who do not achieve 100% on the Medication Administration Exam will not be able to continue in the core theory/clinical course, with the exception of the first semester.

Students who are not successful with the first MAPE should make individual appointments with faculty for remediation. Students are strongly advised to practice drug dose calculations, or seek assistance from the Tutoring and Learning Center.

Medication Administration Principles

All medications are expected to be administered safely through use of the seven rights. Medications are to be administered in a timely manner and documented accurately

Confirm the following seven "Rights" each time a medication is administered. Compare the medication label with the Medication Administration Record (MAR).

1. Right Patient: Verify a patient's identity by checking the ID bracelet while asking them to state their name and birth date; this would prevent the Right Drug from being administered to the Wrong Patient. Two patient identifiers must be used and compared to the MAR.
2. Right Medication: Read the medication and check for spelling or "sound alike" medications.
3. Right Dose: Re-check any dosage calculations, and verify with the physician if the order is illegible or incomplete. Administering the wrong dose can have fatal consequences. Verify with the physician if the dose seems out of the ordinary. A nurse can be held liable even if the physician's order was wrong.
4. Right Route: For example, administering Insulin intravenously instead of subcutaneously could send a diabetic patient into shock or a coma due to excessively fast absorption. Also, if the patient isn't supposed to have anything to eat or drink but the drug route states PO (by mouth), the nurse should consult the physician.
5. Right Time: Some medications have blood serum levels that must be maintained in a therapeutic range. Delayed administration could compromise the effectiveness of some medications.
6. Right Documentation: Accurate documentation of the medication administration time, patient response to the drug, and any refusal is essential for continuity of care between providers and for maintaining legal records. Co-signature by a staff RN or clinical faculty is required with the documentation of each medication given by a student.
7. Right of Patient to Refuse: A patient may refuse any medication. Accurate documentation and physician notification impact the plan of care.

Students must prepare medications for only one patient at a time for safety. Students must perform four checks to ensure the correct medication is being administered to the right patient.

1. First Check: After collecting the medication from the stocked location(s), return to the EMR and compare the medication label against the MAR. Check the generic name and expiration date.
2. Second Check: Double-check the medication label against the MAR, perform any calculations, and gather supplies necessary for preparation and administration (i.e., syringes, pill cutters, pill crushers, needles, alcohol swabs).
3. Third Check:  A third check of the medication label against the MAR is done prior to administration of the medication and before entering the patient’s room or vicinity.

Note: The three checks should be performed prior to entering the patient's room.

One final and fourth check MUST be made at the patient’s bedside prior to administration. The student will use a minimum of two patient identifiers when administering medications. This can include the patient’s verbalized name and birth date. The student must compare the verbalized information with the patient ID band and the MAR, computer printout, or computer screen information. The student must advise the patient of the reason for medication and at least one side effect. After the patient has agreed to receive the medication, the student will prepare the medication appropriately prior to administration.

High-alert medications may require additional verification by two licensed professionals. High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error. The consequences of an error with these drugs are more devastating to patients. Employing redundancy, such as requiring independent double-checks is a strategy to reduce the risk of error. Some high-alert drug classifications include anticoagulants (Heparin), all insulins, IV antiarrhythmics, and many more. Students should be familiar with hospital policy regarding which drugs are considered high-alert.

Guidelines for Rounding of Medication Calculations

1. If the number is ≥ 5 then round up (example: 1.57= 1.6; 1.45 = 1.5; 0.686 = 0.69).
   If the number is < 5 then round down (example: 0.543 = 0.54).
   Round at the end of the problem.
2. Leading and Trailing Zeroes:
   1. Use leading zeros for decimals (i.e., use 0.6 mg)
   2. Do not use trailing zeros (i.e., DO NOT USE 6.0 mg)
3. Converting Pounds and Kilograms: carry out to the nearest 100th (example: 120 pounds = 54.54 KG).
4. Drops (gtt) and Units: Drops and units are too small to divide into parts. Always round to the nearest whole number (example: 89.5 = 90; 89.4 = 89).
5. Tablets:
   Scored tablets, as a rule, can only be given whole or broken in half. Round to the nearest half (0.5) tablet (example: 1.45 tablets = 1.5 tablets; 1.2 tablets = 1 tablet).
6. IV Calculations:
   Intravenous infusions can be calculated in drops per minute (gtt/min), or milliliters per hour (ml/hr).

The purpose of the MAPE is to determine a student’s ability to calculate a safe medication dose.

Medication Administration

After scoring 100% on the MAPE, students may administer medications as outlined below. Students may give medications to the patients they are caring for provided clinical faculty or a staff RN supervises all dosage calculations, pouring/drawing up, administration, and documentation of medications.

1. LPNs may not administer medications with students.
2. Each semester, students will be evaluated by clinical faculty for medication administration safety. Once the student has been taught medication administration for the individual course and passed the MAPE exam, medications can be administered during clinical. The first time medications are administered by a new route or in a new clinical rotation, clinical faculty will supervise the administration and the process. The nursing clinical instructor will determine if supervision can be provided by a staff RN. The student will be notified when the process is accomplished.
3. During the second semester, students may give secondary intravenous (IV) medications (IV piggy back, [IVPB]) under the supervision of the TMCC clinical faculty or staff RN. No IV "push" or direct IV administration of medications will be allowed in the second semester. Students may use a saline flush to ensure patency of an IV site upon initiation of an IV and prior to connecting an IVPB medication or IV fluids at faculty discretion. Students may give all routes of medications in semesters 3 and 4 under the supervision of clinical faculty or the designated staff nurse for that patient.
4. Nursing students will not administer medications of any kind in Labor and Delivery or NICU. If vitamins or other medications have been added to formula by an RN, students may not feed newborns the formula or breast milk.
5. No student will give medications without knowledge of generic name, classification, mechanism of action, reason for patient receiving medication, patient dose and route, safe dosage range, relevant nursing implications and incompatibilities of drugs concurrently given. The student must have the required pharmacology references available during the clinical experience, as outlined in each clinical syllabus.
6. When administering IV medications, the student is required to utilize IV medication textbook required by the nursing program. Students must have the required textbook with them in the clinical setting.
7. Under no circumstances will students give meds without supervision by either faculty or a staff RN.
8. Failure to follow this policy may result in withdrawal from the program.

Clinical Requirements

1. At the beginning of each shift, the student will check the medication record to determine which medications are to be administered that shift and their respective times of administration.
2. Medications will be prepared for administration ideally within 30 minutes of the actual written time of administration, except for extenuating circumstances (i.e., SNF, patient off floor, patient NPO, missing meds, etc.).
3. Oral medication will be placed in a medicine or soufflé cup in their unit dose package (do not open packages to half a tablet until checked by the instructor but be sure to state that tablet is to be halved). The medications should be secured until the time of administering them. Equipment needed for medications delivered by other routes (syringes, IV tubing, etc.) should be available.
4. Asepsis (medical and/or surgical) must be maintained during the entire medication procedure.
5. PATIENT ID BAND MUST BE CHECKED PRIOR TO MEDICATION ADMINISTRATION.
6. Prior to check by the instructor or staff RN: the student will be knowledgeable about:
   
   1. Drug action/type (i.e., antihypertensive-type ace inhibitor)
   2. Major side effects and incompatibilities
   3. Correct IV drip rate (ml/hr) or IV pump rate for IV meds
   4. The correct medication dosage: i.e., a tablet must be halved, a fraction of the medication is to be used, and/or if more than one tablet, vial etc. needs to be used
   5. Proper needle/syringe size, appropriate site selection, and appropriate amount of medication to be injected at each site
   6. All proper abbreviations related to medication administration
   7. Saline flush procedures
   8. Safe dose ranges
7. Prior to check by the instructor or staff RN: the student will have the following drug information documented:
   
   1. BP and apical pulse taken by the STUDENT within one hour of medication administration of vasoactive drugs and/or drugs that will affect heart rate or rhythm
   2. Appropriate laboratory values needed for specific medications. For example:
      1. PT, PTT levels, and INR levels
      2. Potassium and sodium levels
      3. Dilantin, phenobarbital, digoxin
      4. Aminophylline and theophylline levels
      5. Blood glucose levels, whether laboratory results or point of care equipment for glucose monitoring
8. The student will be knowledgeable of normal ranges and/or therapeutic ranges and of inappropriate vital signs and/or levels (based on the normal and/or therapeutic ranges) that will cause a medication to be held and will state these to the instructor at the time of the medication check. Failure to have vital signs and lab or drug values will be considered as failure to meet the provision of this policy and will require remediation.
9. The students will demonstrate skill proficiency in all medication administration.
10. All students must have the following with them at all clinical sites:
    1. A working watch with a second hand;
    2. A stethoscope; and.
    3. Access to program-required current drug resources and hospital computer drug references.
11. All medications must be documented immediately following administration, or no more than 10 minutes later, unless a special circumstance has prevented it.

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