Columns, Documentation & Patient Care Reporting

Pro Bono: Medication Administration

Issue 6 and Volume 42.

Medication administration is one of the most essential skills of EMS providers. Giving medications, especially IV medications is also one of the more risky procedures that providers perform because of the potential adverse effects on the patient as well as the potential liability that comes from medication errors. We’ve defended EMS agencies in cases involving medication errors and in almost every one the errors were easily preventable.

Most often, the errors we’ve seen involved giving the wrong dosage of the right medication. This can happen in cases where there are two concentrations of the same medication and the higher concentration form is given in the same quantity as the lower concentration (e.g., 1:1,000 vs. 1:10,000 concentration). The stress of the situation, especially where medications must be administered quickly, can add to the potential for errors.

The Six Rights

One of the best ways we’ve found to avoid liability and ensure proper documentation of medication administration is to follow the “six rights” of medication administration.1 Administering medications is a technical ALS skill where the use of checklists and acronyms can come in handy to ensure that every step of the process is followed every time it’s done. The six rights is a useful acronym that’s easy to remember:

1. Right Patient. Make sure you verify the patient’s identity. Confirm the patient’s name verbally and with family members if possible. Remember that in situations where there are multiple family members on scene, make sure there’s no confusion as to who is to get the medication.

2. Right Medication. Double-check your protocol, standing orders or medical command instructions to be certain of the name and concentration of the medication you’re administering. Once you’re clear on the exact medication and dosage, carefully read the medication label both on the outside box and the vial or ampule that the medication is in to confirm you have it right.

3. Right Dose. Most drugs are supplied in unit-dose forms, so there’s usually, very little calculation to be done. Make certain that you understand how to administer the medication to ensure you’re not giving more than the amount that’s required. Medications given by IV infusion after being mixed into a solution require more focus to get the dosage correct. If your gut tells you the medication dosage you’re about to give is higher or lower than the “usual” amount, double-check to make sure you have it right-you can’t take it back once you give it!

4. Right Time. Though most medications given in emergency situations are administered immediately, some medications are titrated over a period of time or given over a series of smaller dosages in specific time increments. Make sure you know when and how much to give the patient. You also need to ensure the medication isn’t expired.

5. Right Route. Since most medications can be administered by several routes, it’s critical to make sure the proper route is used. Medications given by direct IV access will have a more immediate effect on the patient than that same medication given by the intramuscular route, and the dosages may vary depending on the route used.

6. Right Documentation. As the saying goes, if it isn’t documented, it didn’t happen. We’ve seen cases where the patient care report (PCR) didn’t indicate that a medication had been given yet the paramedics testified in court that it was given and they just didn’t document it. A jury isn’t likely to believe you if it wasn’t documented with the PCR for that incident.

The key to minimizing risk is to clearly document all aspects of medication administration. Ask and document whether the patient had any known allergies to the medication being given. This should be followed by documenting the name of the medication given, the dose, the method or route of administration, the speed in which the medication was given and its effect on the patient’s condition.

It’s critical to document patient condition both before and after medication administration. This “before and after” assessment should include full sets of vital signs, an assessment of the patient’s level of consciousness and whether the pain or other patient difficulty changed after medication administration.

Finally, the PCR documentation must be explicitly clear regarding the name and credentials of the health care provider who administered the medication. Following these steps every time you administer medications will avoid harm to the patient and will also help keep you and your EMS agency out of legal trouble. jems

Reference

1. Bledsoe B, Clayden D. Prehospital Emergency Pharmacology, 6th Edition. Pearson/Prentice Hall: Upper Saddle River, N.J., 2005.