Math and Dosage Calculations Math and Dosage Calculations for Health Carefor Health Care Third EditionThird Edition

Booth & WhaleyBooth & Whaley

McGraw-Hill 5-1

Chapter 5: Drug OrdersEdited by B. Holmes MSN/Ed, RN

Learning OutcomesLearning Outcomes

Summarize the Rights of Medication Administration.

Interpret a written drug order.

Identify on physicians’ orders and prescriptions the information needed to dispense medication.

Learning Outcomes Learning Outcomes (cont.)(cont.)

Locate on medication administration records or electronic medication records the information needed to administer medication.

Recognize drug orders that do not contain all of the necessary information to carry out the orders safely.

Select appropriate action for confusing, incomplete, or illegible drug orders.

IntroductionIntroduction

It is important to be able to read and understand a drug order to correctly calculate medication dosages.

You can be held responsible for medication errors regardless of the source.

Rights of Medication Rights of Medication AdministrationAdministration

Basic Rights

Right patient

Right drug

Right dose

Right route

Right time

Right

documentation

Additional Rights

Right reason

Right to refuse

Right to know

Right technique

Right PatientRight Patient

Before giving a medication to a patient

◦Check for two identifiers.

Patient’s full name

Another identifier – date of birth, SSN, or medical record number

◦Ask the patient state his/her full name and second identifier.

Right Patient Right Patient (cont.)(cont.)

◦Check that the name on medication order is exactly the same as the name of the patient.

Outpatient – photographic identification

Inpatient – identification number, identification bracelet, bar code scanning

◦Check the bed number.

Right DrugRight Drug

To be sure a patient receives the right drug.◦Only give drugs that you prepared

yourself◦Check the expiration date.◦Check original order before

administration◦If the patient questions a medication,

make sure you are able explain the drug, purpose, and side effect

Right Drug Right Drug (cont.)(cont.)

◦A patient always has the right to refuse a medication.

Dispose of refused medications according to facility guidelines.

Right Drug Right Drug (cont.)(cont.)

Rule 5 – 1Rule 5 – 1 Check medication three times:

1. when you take it off the shelf2. when you prepare it3. when you replace it on the shelf

Check it three times even if it is prepackaged, labeled, and ready to be administered.

Right DoseRight Dose

Preparing and administering the right dose may require calculations.◦ Conversion from dosage

ordered to desired dose◦ Amount to administer

Use extreme caution when calculating dosages.◦ Pay special attention to decimal

points

Right RouteRight Route

A drug intended for one route may not be safe if administered via another route.

◦ Be especially careful between ophthalmic and otic routes.

Right Route Right Route (cont.)(cont.)

Some medications are produced in different versions for different routes.

ExampleExample aspirin is available as tablets or as suppositories

Check that route listed on drug label matches route ordered.

Right TimeRight Time

Most often within 30 minutes of schedule◦ Absolute time – 9:00 a.m.◦ Relative time – before breakfast

Drug order should identify special timing considerations if needed.

PRN medications ◦ Given when needed with a specified time

interval.◦ Check when previous dose was given.

Right DocumentationRight Documentation

Sign the medication administration record (MAR) immediately after the patient takes the medication.◦ Do not document prior to giving the

medication.◦ If documentation not done, medication

administration is not complete

Also document if the patient◦ Refuses a medication◦ Consumes only part of the dose ◦ Vomits after taking the drug

Right ReasonRight Reason

Know why a medication is being given.

◦ Check medication record

◦ Check order

◦ Check with prescribing physician

Right to KnowRight to KnowPatients must be educated about

their medications, including the

◦Reason for taking the medication

◦Expected effect of the medication

◦Side effects of medications

Right TechniqueRight Technique

Medications must be given correctly according to the order. ◦ For example:

Buccal -- between cheek and gum Sublingual -- under the tongue

If unsure of technique◦ Physicians’ Desk Reference (PDR)◦ Facility policy or procedure manual◦ Valid Internet source

Roman NumeralsRoman Numerals

Are used sometimes in drug orders.

Calculating dosages may involve changing Roman numerals to Arabic numbers.

Letters represent numbers.

Commonly used Roman numerals◦ ss = ½◦ I = 1◦ V = 5◦ X = 10

Combining Roman Combining Roman NumeralsNumerals

Rule 5 – 2Rule 5 – 2 When reading a Roman numeral containing more than 1 letter, follow these two steps:

1. If any letter with a smaller value appears before a letter with a larger value, subtract the smaller value from the larger value.

2. Add the value of all the letters not affected by Step 1 to those that were combined.

Combining Roman Numerals Combining Roman Numerals (cont.)(cont.)

IX = 10 –1 = 9

XIV = 10 + (5-1) = 14

XXVIII = 20 + (5+3) = 28

Doctor’s orders are most likely to contain Roman numerals from 1 to 30.

Most common Roman numerals are: V & X

ExamplesExamples

Practice Practice

1. Convert the following Roman numerals to Arabic numbers:

a. viiss

b. XII

c. XIX

d. ixss

2. Provide the answers to the following in Arabic numbers:

a. V + V

b. xxii – vii

c. XXXV – XIV

d. xvi + xii

7½

12

19

9½

10

15

21

28

Physician’s Orders and Physician’s Orders and PrescriptionsPrescriptionsAbbreviations used when writing orders:

◦ General abbreviations◦ Form of medication◦ Route◦ Frequency

Approved abbreviations vary among facilities◦ Memorize commonly used abbreviations◦ Keep facility's approved list available

Commonly Used General Commonly Used General AbbreviationsAbbreviations

Abbreviations Commonly Used for Abbreviations Commonly Used for Form of MedicationForm of Medication

Abbreviations Commonly Used Abbreviations Commonly Used for Routes of Administrationfor Routes of Administration

Abbreviations Commonly Used Abbreviations Commonly Used for Frequencyfor Frequency

AbbreviationsAbbreviations

Joint Commission on Accreditation of Healthcare Organization (JCAHO) ◦“Do Not Use” abbreviations◦“Undesirable” abbreviations

Check abbreviations carefully in drug orders.

““Do Not Use” Abbreviations Do Not Use” Abbreviations

Undesirable AbbreviationsUndesirable Abbreviations

Undesirable Abbreviations Undesirable Abbreviations (cont.)(cont.)

Do Not Use Potential Problem Use Instead

> (greater than) < (less than) Misinterpreted as the number “7” (seven) or the letter “L” Confused for one

another

Write “greater than” Write “less than”

Abbreviations for drug names Misinterpreted due to similar abbreviations for

multiple drugs

Write drug names in full

Apothecary units Unfamiliar to many practitioners

Confused with metric units

Use metric units

@ Mistaken for the number “2” (two)

Write “at”

cc Mistaken for U (units) when poorly written

Write "mL" or “milliliters”

µg Mistaken for mg (milligrams) resulting in one

thousand-fold overdose

Write "mcg" or “micrograms”

Undesirable Abbreviations Undesirable Abbreviations (cont.)(cont.)

Physician’s Drug OrderPhysician’s Drug Order

Essential elements◦ Full name of the

patient

◦ Full name of the

drug

◦ Dosage

◦ Route

◦ Time

◦ Frequency

◦ Signature of prescribing physician

◦ Date

◦ PRN order must include the reason

Outpatient SettingsOutpatient SettingsPhysicians’ orders are given as

prescriptions.

Prescriptions include all the elements of a physician’s order plus ◦Physician’s name and prescriber

number◦Quantity to be dispensed◦Number of refills◦Instructions for the label

Prescription Prescription FormForm

Drug and dose Quantity to

dispense

Instructions to appear on the label

Number of refills permitted

Patient’s full

name

Date

Physician name

Inpatient SettingsInpatient SettingsPhysicians’ order form

◦Multiple orders on one form◦Essential elements of a medication

order◦Patient’s name and physician

signature appear once

Orders may be entered into a computer

Physician’sOrder Form

Error Alert!Error Alert!

Never guess what the prescriber meant!◦If the order is not legible, always

contact the prescribing physician to clarify the order.

Verbal OrdersVerbal Orders

Acceptable if the physician is unable to write an orderthat must be carried out quickly

Governed by state laws

If permitted to accept a telephone order◦ Write it carefully and legibly as you receive it

◦ Read the order back to the physician

◦ Ask for clarification of spelling if unsure

Error Alert!Error Alert!Always be certain that you are

dispensing the correct medication.

◦Many drugs have names that are similar.

Acular—Ocular Benadryl—BentylCafergot—Carafate Darvon—DiovanDigitoxin—Digoxin Eurax—UrexIodine—Lodine Nicobid—Nitrobid

ExamplesExamples

PracticePractice

What, if anything, is wrong with this prescription?

Allen Capsella, MDWesttown Medical Clinic

989-555-1234

Name: M Ward Date: 8/15/2008

Address:

Rx: Lopressor

QUANTITY:

SIG: 1 tab BD

Refills: 2

MD398475 A Capsella, MD Prescriber ID # Physician Signature

PracticePractice

ANSWER 1. It does not include patient’s full

name.2. There is no dosage strength for the

lopressor.3. There is no quantity to be dispensed.4. No route is given.

Click to return to prescription

Medication Administration Medication Administration SystemsSystemsStandard schedule for

administering medication ◦Varies by facility

Verifier ◦Ensures that the times listed for

administration are appropriate ◦Adjust times as necessary

Mealtimes Conflicting medication schedule

Sample Times for Medication Sample Times for Medication AdministrationAdministration

Frequency Ordered Times to Administer

qd 0800

bid 0800 – 2000

tid 0800 – 1400 – 2000

qid 0800 – 1200 – 1600 – 2000

q 12 hrs 0800 – 2000

q 8 hrs 2400 – 0800 – 1600

q 6 hrs 2400 – 0600 – 1200 – 1800

Every night at bedtime 2000

Medication Administration Medication Administration Records (MAR)Records (MAR)

Legal documents that may be handwritten or computerized

Contain same information as the order form

Specify the times to administer the medication

Provide a place to document each medication administration

Medication Administration Medication Administration Records (MAR)Records (MAR)(cont.)(cont.)

Rule 5-3 Rule 5-3 MARs must include the following information:

1. Name of medication, dose, route, frequency

2. Times that accurately reflect the frequency specified

3. Name and identification number of patient

4. Date order was written (including start and end dates as necessary)

5. Special instructions or information required by the facility

PracticePractice

Is the following MAR complete? If not, what is missing?

Dateinit.

Medication, dose, duration,frequency, route

D/Cdateinit

Admin time

2/5

CS

Vasotec 10 mg po BID

hold for systolic BP < 100

0800x

2000x

ANSWER The order is transcribed correctly and all information is complete.

Is the following MAR complete? If not, what is missing?

PracticePractice

Dateinit.

Medication, dose, duration,frequency, route

D/Cdateinit

Admin time

2/5

CS

Synthroid 50 mcg

PO Bid

0800xxx

2/5

CS

Erythromycin tab i

po q6h

0800x

2000x

2/5

CS

Persantine 75 mg

po q6h

240008001600

x

2/5

CS

heparin 10,000 units

q 8 hr

240008001600

Practice Practice

ANSWER 1. Order A is correct.

2. Order B does not include the strength of the medication and there is an error in the times listed. The “hours” reflect only a q 12 hr dosing rather than a q 6 hr dosing.

3. Order C contains an error in the times listed. There are only 3 times listed and it should be q 6 hours (4 times).

4. Order D does not include a route.Click to return to MAR

Medication CardsMedication CardsRarely used

One drug per card

Disadvantages◦Easily misplaced◦Increased potential for omitting a

medication◦Do not list allergies or diagnoses

Medication Card Medication Card (cont.)(cont.)

Patient’s nameRoom numberFull name of drugDose, route, frequencySpecial instructionsAdministration timesDate ordered

Computerized Medical Computerized Medical RecordsRecords Patient information is entered directly into a

computer. Information is easily updated and accessible. Includes

Orders Lab resultsAllergies Appointments Discharge plans

Computerized Computerized Medical Medical RecordRecord

Computerized Medical Computerized Medical Records Records (cont.)(cont.)Electronic Medication Administration Records (eMARs)

◦Ongoing working document

◦Records medications as they are

administered

◦Users must log into system using

secure passwords

eMAR

Medication Reference Medication Reference MaterialsMaterialsTo dispense or

administer medications◦ Know effects of the

drugs

◦ Be familiar with drug information sources

Medication Reference Medication Reference Materials Materials (cont.)(cont.)Resources

◦ Package inserts

◦ Physicians’ Desk Reference (PDR)

◦ United States Pharmacopeia National Formulary

◦ Drug handbooks

◦ Reputable Internet sites

◦ Software programs used with personal digital assistant (PDA)

Apply Your KnowledgeApply Your Knowledge

Which of the basic rights of medication administration is not listed?Right patientRight drugRight doseRight timeRight techniqueRight documentation

Answer right route

Apply Your KnowledgeApply Your Knowledge

What do the following abbreviations mean?

pcBidhssuppBP

after meals

Twice a day

At bedtime

suppository

blood pressure

Click for each answer.

Apply Your KnowledgeApply Your Knowledge

Even though these are inappropriate abbreviation, what do they mean?

QdAuMSO4ccug

Apply Your KnowledgeApply Your KnowledgeQd = dailyAu = both earsMSO4 = Morphinecc = millilitersug = microgram

End of Chapter 5End of Chapter 5

You must motivate yourself EVERYDA

Y!~Matthew

Stasior