Medication administration in long-term care is complicated

A reader submitted a question about whether it was legal for a nursing supervisor in a long-term care facility to ask one of its nurses to pass medications on two floors. Here is my response.

Long-term care facilities are highly regulated at both the state and federal levels. I am not familiar with all of these regulations so it would be difficult to respond to this question without doing extensive research. But let’s assume that such a request is not illegal.

Even though it’s not against the law, other questions come to mind: Is such a request safe for patients? Is accepting this request a potential problem under the Nurse Practice Act?

The medication administration process is not to be taken lightly. It is highly structured and regulated by standards of nursing practice. Specific requirements must be followed to avoid, insofar as possible, medication pouring and medication administration errors.

Nursing literature has tons of information on the right ways in which to execute the medication administration process. Some experts have written there are “Five Rights” to the medication administration process, while others list six or more. Nurse consultant Vivian Nwagwa lists 10 in her training session, and they include:

Explore Your Higher Education options at Nurse.com/Schools.

— Right patient
— Right medication
— Right dose
— Right time
— Right route
— Right education (of patient or family)
— Right to refuse (the medication)
— Right assessment (of patient before administration of medication)
— Right evaluation (of patient after administration of medication)
— Right documentation

Regardless of which model you use, the medication administration process in long-term care can be troublesome because of many factors, including no on-site physicians to directly observe residents’ condition and medication needs, off-site pharmacies and limited time spent by pharmacists on site, according to a study.

Other factors include a medically frail patient population, multiple medications ordered for each patient and the timeliness of administering medications.

An earlier study by Scott-Cawiezell,Vogelsmeier and others, “Nursing Home Error and Level of Staff Credential,” revealed the average medication pass in nursing homes involves 73 medications and takes an average of 113 minutes.

Assuming these numbers are fairly common in most long-term care facilities, the next question that arises is, what about the propensity for a medication error or errors if you double the numbers when passing medications on two floors?

A medication error, defined in part by the National Coordinating Council for Medication Error Reporting and Prevention, a medication error is “any preventable event that may cause or lead to inappropriate use or harm while the medicine is in control of the healthcare practitioner.” This definition includes professional practice and [healthcare] procedures and systems.

Nursing literature contains volumes of research and articles on medication errors in long-term care. One study done in 25 nursing homes in North Carolina over a 1-year period found 23 (92%) of the sites reported 631 error reports for 2,731 “discrete error instances when weighted by the number of times the errors were repeated.” Fifty-one of the errors were grouped as being serious enough to require nursing monitoring or intervention or more.

The most common errors included dose omission (203, or 32%), wrong patient (38, or 6%), and wrong product (38, or 6%).

The errors normally took place during medication administration (296, or 47%), according to, “Preventing Medication Errors in Long-Term Care: Results and Evaluation of a Large Scale Web-Based Error Reporting System.”

In addition to this information, state boards of nursing are empowered to discipline a nurse for a medication error that causes serious injury or death to a patient. Even if the medication error does not result in patient injury or death, a nurse licensee who does not comply with acceptable and current standards of nursing practice when handling the medication administration process may also be disciplined.

And there is that all-encompassing phrase for potential discipline if you are engaged in unprofessional or dishonorable conduct that might harm the public. Although the specific language varies in the acts, it remains a plausible basis for discipline when you are involved in the medication administration process.

How would you respond to this request?

Editor’s note: Nancy Brent’s posts are designed for educational purposes only and are not to be taken as specific legal or other advice. Individuals who need advice on a specific incident or work situation should contact a nurse attorney or attorney in their state.  Visit The American Association of Nurse Attorneys website to search its attorney referral database by state.

Courses related to ‘medication administration’

60150: Preventing Medication Errors
(2 contact hrs)
Despite the efforts of healthcare providers, medical error rates in communities, healthcare facilities, and homes remain high. Patients and families pay for errors through disability and death. Preventable medical errors not only affect patients, family members, and healthcare professionals, but also contribute to soaring healthcare costs. This activity will explore approaches to prevent medical errors that are both system-based and human performance-based and describe The Joint Commission National Patient Safety Goals as they pertain to medical errors in hospitals

WEB318: Eagle Eye: Exercises in Reducing Medication Errors 
(1 contact hr)
Medication error safety is an issue of ongoing importance and concern in the healthcare field. Despite significant attention, the estimated cost of morbidity and mortality associated with medication errors is $21 billion. This module has been designed to provide sample cases of medication errors for the healthcare team to review and apply skills to. It is recommended that prior to taking this course, the attendee first complete a more in-depth course on medication errors. By maintaining constant vigilance, honing skills related to recognizing and reporting medication errors, and developing strategies to address deficiencies in the healthcare delivery system, it is possible to make a significant impact on this epidemic.

CE214-60: Polypharmacy in the Elderly 
(1 contact hr)
Polypharmacy, the concurrent use of several drugs, increases the risk of adverse drug reactions and interactions in older adults. Besides adverse drug reactions and drug-drug interactions, other clinical consequences of polypharmacy include nonadherence, unintentional overdose, increased risk of hospitalizations and medication errors. While taking more than two drugs can increase the risk of an adverse effect, taking more than five drugs increases that risk. As the number of drugs taken and the age of the person increases, so does the risk for adverse drug interactions.