Medication Administration

Right patient: verify two identifiers (name + DOB) against the medication label and the patient's wristband, never room number. Mislabeled medications cause fatal errors (e.g., chemotherapy given to the wrong patient). Right drug: read the label three times (at pick-up, preparation, and bedside) to catch sound-alike names (metoprolol vs. metformin) and look-alike packaging. Right dose: calculate carefully and double-check with a colleague if needed; 10 units vs. 100 units of insulin is life-threatening. Right route: oral, IV, IM, subcut, topical, inhaled, or rectal — each has different absorption and side effects. A drug given IV instead of IM can cause anaphylaxis. Right time: administer at the scheduled time within 30 minutes (or per protocol) unless there is a contraindication. Timing affects peak drug levels. Right documentation: chart the drug name, dose, route, time, and site (if injection), plus your initials or signature, before you leave the bedside. This creates the record for accountability and allows tracking of allergies and interactions.

Top error categories: (1) wrong patient — always use two identifiers; (2) dosing errors — verify dose with a reference or colleague if unfamiliar; (3) allergies — ask the patient and cross-check the EHR (10 seconds can save a life); (4) drug interactions — check if the patient is on aspirin before giving another NSAID (bleeding risk), or ACE inhibitor before giving potassium-sparing diuretic (hyperkalemia). Common look-alike pairs: morphine vs. hydromorphone (different potencies), metoprolol vs. methyldopa (different drug classes), amoxicillin vs. amoxapine (antibiotic vs. antidepressant). Be extra cautious with high-alert drugs: insulin, warfarin, chemotherapy, opioids, and potassium. Use a double-check system: another clinician verifies the order, calculation, and patient before high-risk medications. Slow down and ask questions; a three-second pause before administration catches 70% of potential errors.

Educate before, during, and after administration. Before: 'This is your blood pressure medicine; it may make you dizzy at first.' During: 'Take it with food' or 'This shot will pinch a bit.' After: 'You may feel sleepy in 30 minutes — rest is OK.' Cover common side effects (nausea, dizziness, drowsiness, rash), when to call the provider (chest pain, difficulty breathing, severe headache), interactions with food (grapefruit with statins, dairy with antibiotics), and adherence (take it every day, not just when you feel bad). Written materials help, especially for elderly and non-English-speaking patients. Address health beliefs: a patient may skip antibiotics when they 'feel better,' not knowing they still have infection. Motivational interviewing and teach-back methods ('Tell me back what you will do') improve compliance.

Use aseptic technique: clean hands, clean the work surface, and keep all items sterile until the moment of use. Draw up from a multi-dose vial by first cleaning the rubber stopper with an alcohol swab, then inserting a sterile needle and withdrawing the plunger to draw back air equal to the volume of drug you need, then inserting the needle into the vial at an angle and injecting the air. This prevents a vacuum and allows easy withdrawal. For a single-dose vial, use a fresh needle and syringe for each patient (never reuse). If you contaminate the needle tip (touch it to anything other than the vial or patient), discard it and use a sterile one. Check the label, expiration date, and clarity of the fluid (cloudiness or particles = discard). Measure the dose at eye level to avoid parallax error. Label the syringe if you are not giving it immediately, including drug name, dose, route, time, and patient name. Never leave a filled syringe unattended.

Intramuscular (IM): injected into muscle (deltoid, vastus lateralis, gluteus maximus); deeper penetration for slower absorption than subcut; used for antibiotics, vaccines, antihistamines, and certain hormones. Needle gauge 21–23, 1–1.5 inches long. Subcutaneous (subcut): injected just under the skin; slower absorption; used for insulin, epinephrine auto-injectors, some antibiotics, and vaccines. Needle gauge 25–27, 0.5–0.625 inches. Intradermal (ID): injected just under the epidermis; used for TB skin test (Mantoux) and some vaccines. Needle 27–28 gauge, 0.625 inches, injected at a 15-degree angle. Intravenous (IV): injected directly into a vein; fastest onset; used for fluids, antibiotics, contrast dye, and critical drugs. Requires a patent IV line and strict asepsis. Each route has different onset times (IV minutes, IM 10–30 minutes, subcut 30 minutes to hours) and side effect profiles. Know the drug's approved routes; some drugs are fatal if given via the wrong route.

Minor side effects (nausea, drowsiness, mild rash) are common and often improve after a few doses; counsel the patient and reassure. Offer comfort measures (ginger for nausea, frequent rest for drowsiness). Major adverse reactions (anaphylaxis, severe rash, chest pain, difficulty breathing) are medical emergencies: call the provider immediately, stop the medication, position the patient safely, have epinephrine and oxygen ready, and monitor vital signs. Anaphylaxis requires epinephrine IM immediately (not IV), IV access, and transport to the ED. Allergic rash may progress to Stevens-Johnson syndrome if not caught early. Document the reaction in detail and time, notify the provider, and place an allergy alert in the EHR so the drug is never given again. Always ask about new or worsening symptoms during and after medication administration; patients often underreport side effects unless asked directly.

IV push (or bolus): rapid injection of a small volume of medication directly into a vein or IV line over seconds to minutes (e.g., anti-nausea medication, pain relief). Highest peak levels; used for acute symptoms. IV infusion: slow administration of medication mixed in a large volume of fluid (50–1000 mL) over 30 minutes to several hours (e.g., antibiotics, blood products, chemotherapy). More gradual peak levels; often used for medications that are irritating or require slow delivery. Rate is controlled by infusion pump and must be verified before and during infusion. Patient-controlled analgesia (PCA): a pump the patient operates with a button to self-deliver small doses of pain medication (usually opioids) on demand, with a lockout interval to prevent overdose. Allows patients to manage their pain without waiting for a nurse. Requires patient education and monitoring for signs of respiratory depression. Each method has different pharmacokinetics and risks; know which drugs can be given by which route.