Pharmacology Basics, part 2: Prescriptions, Safe Medication Administration

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In this article, we'll explain the key facts you need to know about how prescriptions work, including the different types, the components of a complete prescription, and what it really means when a drug is ordered "STAT"! We'll also explain the basic facts of safe medication administration and best practices steps you can take to ensure safety for your patients.

This series follows along with our Pharmacology Basics and Safe Medication Administration Flashcards for Nursing Students which are intended to help RN and PN nursing students build a strong foundation going into Pharmacology and as preparation for the ATI, HESI, and NCLEX.

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Prescriptions

In this section, we'll cover types of prescriptions, components of a complete prescription, telephone orders and error-prone abbreviations you should avoid.

Types of prescriptions

There are several types of prescriptions, as it pertains to timing and immediacy of administration, including time-critical scheduled medications, non-time-critical scheduled medications, one-time single dose prescriptions, STAT orders, PRN (as needed) medications, and standing orders.

Time-critical scheduled medications

Time-critical scheduled medications are given on a regular schedule that is important to adhere to. These medications need to be administered within 30 minutes of the scheduled time—so they can be up to 30 minutes early or 30 minutes late, but it has to fall in that window.

Some medications that fall into the time-critical category are antibiotics, anticoagulants, and insulin.

Non time-critical scheduled medications

Non-time-critical scheduled medications are given on a regular schedule, but the timing is not as strictly enforced as with the time-critical medications.

Medications that are scheduled daily, weekly, or monthly can be given within two hours of the scheduled time.

If a medication is prescribed more frequently than daily, e.g. BID (twice daily) or TID (thrice daily) can be given within one hour of the scheduled time. This excludes medications administered more frequently than every four hours, which are usually considered in the time-critical category anyway.

Every facility will have its own policies, so definitely follow your facility's guidelines on when you need to give different medications for your patients.

One-time (single dose)

A one-time or single-dose prescription is given once at a specific time. This might include a drug given prior to a procedure specifically for the procedure.

STAT

A STAT order is a medication that is given once immediately. This is the same "stat!" that you hear providers order on TV, and stat is short for the latin statim, which means immediately.

PRN

PRN prescriptions are given as needed—PRN stands for the latin pro re nata, which means as needed. PRN prescriptions will include the dose, frequency, and under what circumstances you can give the medication. The most common PRN medications include pain medications and nausea medications.

Standing

Standing orders are pre-written medication orders that can be given for defined circumstances on a particular unit or floor. These may be replaced by protocols in some facilities, but the idea is that they are generalized to the floor or unit, and are not written for a specific patient.

For example, there are often standing orders for hypoglycemia. So if your patient experiences hypoglycemia, you can refer to those standing orders and get them glucagon right away. That way you don't have to call the provider and wait for them to call you back, in an emergency situation while your patient is in a hypoglycemic coma. Standing orders are very useful in this circumstance.

Another example of a standing order may be nitroglycerin for chest pain, so that you can automatically give nitroglycerin to your patient who is having chest pain. These two examples were provided by Cathy based on what she has seen at her facility, but it will depend on your facility's protocols.

Components of a prescription

There are certain components of a prescription required for it to be considered complete. Every prescription needs to include:

  • Patient's name
  • Date and time of the prescription
  • Medication name
  • Dose, strength, and form of the medication
  • Frequency of administration
  • Route of administration
  • Refills, if allowed
  • Provider's signature.

Telephone orders

As a nurse, it is usually standard practice that you will be taking telephone orders. There are some best practices to follow when it comes to taking a telephone order.

Have a second RN listen in on the call to be sure that you're getting an accurate prescription.

Repeat the prescription back. The provider will give you the prescription over the phone, you will write that down, and then repeat back what you have written to ensure accuracy.

Finally, make sure the provider signs that prescription within 24 hours.

Error-prone abbreviations

There are a number of abbreviations that you should not use in your prescriptions because they are error-prone. A complete list of error-prone abbreviations can be found with the Institute for Safe Medication Practices (ISMP). Here, we've included a list of the most important ones to avoid.

MS and MSO4 should not be used when prescribing morphine. Spell out morphine.

Do not use MgSO4 for magnesium sulfate. Spell out magnesium sulfate. This and the rule above are related because MsO4 and MgSO4 can be easily visually confused, which could lead to harmful results.

Do not use U or IU for units. U and IU can look like numbers, leading to a 10-fold overdose or greater. Spell out the word units.

Do not use q.d. for daily, because it can be confused with q.i.d., which means four times daily. Spell out daily.

Do not use q.o.d. for every other day, because it can be confused with q.d. or q.i.d., meaning daily or four times daily. Spell out every other day

Do not use SC, SQ, or sub-Q for subcutaneously. SC can be mistaken for SL which means sublingual, and SQ can look like "5 every." That's why subcutaneously is spelled out.

Decimals and leading/trailing zeros best practices

Use a leading zero on decimals under 1. This means you would write 0.5, not just .5.

For example, if your patient is prescribed 0.5 mg of dilaudid, but you wrote .5mg, the decimal by itself is not very visible. It could easily be mistaken for 5mg dilaudid, which is a 10-fold overdose.

Do not use a trailing zero on decimals. This means you would write 2mg, not 2.0mg.

For example, if your patient was prescribed 2 mg of Dilaudid but you wrote 2.0mg, again, the decimal is not very visible. It could easily be mistaken as 20mg of dilaudid, which hopefully you would immediately question, but would not be good.

Cathy's hint for remembering this is that you want to be a leader (leading zero) and not a follower (trailing zero).

Medication administration

In this section, we'll explain the "rights" of safe medication administration, as well as some medication administration best practices to help keep your patients safe.

Rights of safe medication administration

The rights of safe medication administration are a list of things that you want to make sure you get right during administration! Depending on which textbook or source you reference, you may see anywhere from 5 rights to 12 rights—it varies across sources, but we have prioritized them here for you.

There are around 5 rights that are common across many sources, including:

Other rights that may be included in your textbook or source include:

Medication administration best practices

These are some core best practices to follow when administering medications. We will go into more detail in the rest of this series, and also in your Fundamentals studies, but this is a good starter list.

Allergies

Identify your patient's allergies before you give them any medication.

Questioning prescriptions

Question any illegible or incomplete medication order. Remember the list of prescription components above? If any of those pieces are missing (with the exception of a signature for a telephone order you just took), the prescription is not complete.

Also, if you see a prescription for a contraindicated medication or an inappropriate dose (e.g., the aforementioned 20mg of dilaudid!) then you should contact the provider to question those prescriptions.

Preparing medications

Only prepare medications for one patient at a time, and only administer medications that you have personally prepared.

High-alert medications

There are also several high-alert medications that often require an independent double-check with another RN. For example, this could include heparin or insulin.

Medication supervision

Don't leave a medication at the patient's bedside. If you attempt to give your patient a medication and they say, "I don't really want to take it right now. You can just leave it here at the bedside," don't do that. You would bring it with you, and then bring it back when the patient is willing to take that medication.

Incident reports

Complete an incident report for any medication error. Don't include this incident report in the patient's chart, or refer to this incident report in the patient's chart, because the incident report's purpose is to be used for quality improvement at the facility.

Full Transcript: Pharmacology Basics, part 2: Prescriptions, Safe Medication Administration

Hi, I'm Cathy with Level Up RN. In this video, we are going to talk about prescriptions as well as safe medication administration. And if you watch the video until the end, I'll give you guys a little quiz, a little knowledge check, to make sure you've been listening. So definitely stay tuned for that.

Let's first talk about the types of prescriptions that you may encounter.

First of all, we have our time-critical scheduled medications. So what are some examples of time-critical medications? These can include antibiotics, anticoagulants, as well as insulin. So for these time-critical medications, we need to give them within 30 minutes of the scheduled time. So they can be up to 30 minutes early or 30 minutes late, but it has to fall in that window.

All right. Next, let's talk about our non-time-critical scheduled medications. So for medications that are scheduled daily, weekly, or monthly, we can give those within two hours of the scheduled time. However, if the medication is prescribed more frequently, so twice a day, which is BID, or three times a day, which is TID, then we need to give those within one hour of the scheduled time. And again, every facility will have its own policies, so definitely follow your facility's guidelines on when you need to give different medications for your patients.

Then we have our one-time or single-dose prescription. This is where you give the medication once at a specified time.

And then a STAT order means that you're going to give that medication once immediately.

And then we have our PRN, or as-needed prescriptions. PRN prescriptions include the dose, frequency, and under what circumstances you can give the medication. So the most common PRN medications include pain medications and nausea medications.

Then, finally, we have what's called standing orders. Standing orders are pre-written medication orders that can be given for defined circumstances on a particular unit.

So, for example, there are often standing orders for hypoglycemia. So if your patient experiences hypoglycemia, you can refer to those standing orders and get them glucagon right away. That way you don't have to call the doctor and wait for them to call you back, and in the meantime, your patient is dying from a hypoglycemic coma. So that's why we have standing orders in place.

Another example of a standing order set may be for chest pain, so that you can automatically give nitroglycerin to your patient who is having chest pain. So those are just some examples of standing orders that I've seen at my hospital.

So let's now talk about the components of a prescription.

Every prescription needs to include the patient's name,

the date and time of the prescription,

the medication name,

the dose, strength, and form of the medication,

the frequency of administration,

and the route of administration.

And then if any refills are allowed, that needs to be noted on the prescription.

And then the provider needs to sign that prescription.

So as a nurse, you will be taking telephone orders. That is standard practice. So there are some best practices when it comes to taking a telephone order.

So you ideally would like to have a second RN listen in on the call to be sure that you're getting an accurate prescription.

You want to repeat the prescription back. So the provider will give you the prescription over the phone. You want to write that down, and then you want to repeat back what you have written to ensure accuracy.

And then make sure the provider signs that prescription within 24 hours.

There are a number of abbreviations that you should not use in your prescriptions because they are error-prone, and a complete list of error-prone abbreviations can be found with the Institute for Safe Medication Practices, so ISMP. I've included a smaller list here on card number six with what I feel like are the most important ones to avoid.

So first of all, we have MS and MSO4, which we should not use when prescribing morphine. So you want to spell out morphine.

We should not use MgSO4 for magnesium sulfate.

We should also not us a U or IU for units.

We should not use QD for daily or QOD for every other day.

And we should not use SC, SQ, or sub-Q for subcutaneously. So again, we want to spell out subcutaneously.

Now let's talk about decimals and leading or trailing zeroes. Definitely important to know best practices. So let's say your patient is prescribed 0.5 mg of Dilaudid. You want to put a zero before the decimal point, so 0.5 mg of Dilaudid. You don't want to have just .5 because if you miss that point, like it's not super visible, then it looks like 5 mg of Dilaudid, which would be a very bad thing for your patient. So you always want that leading zero before the decimal point.

Let's talk about that trailing zero. So if your patient was prescribed 2 mg of Dilaudid and you put 2.0, if you put a trailing zero, well, if that point is not really visible, it's going to look like 20 mg of Dilaudid, which you should absolutely question as a nurse, for sure. So we do not want that trailing zero. So we just want to write this as 2 mg of Dilaudid, no point zero.

So my little hint for remembering this is you want to be a leader and not a follower.

In terms of the rights of safe medication administration, depending on what textbook or website you're looking at, you may see 5 rights of safe medication administration, up to 12 rights of safe medication administration. So it really varies across sources.

There are kind of 5 core rights that you'll find that are common across all of these sources, and this includes

the right patient,

the right medication,

the right dose,

the right route,

and the right time.

Other rights that may be included in your textbook include

the right patient education,

the right for a patient to refuse their medication,

the right nursing documentation, meaning charting,

and then the right assessment before and after medication administration.

All right. Now that you have the rights of safe medication administration down, let's talk about some other best practices for medication administration.

First of all, you want to identify your patient's allergies before you give them any medication.

You should also question any illegible or incomplete medication order. Or if you see a prescription for a contraindicated medication or an inappropriate dose, definitely reach out to the provider to question those prescriptions.

You only want to prepare medications for one patient at a time,

and you only want to administer medications that you have personally prepared.

There are also several high-alert medications that often require an independent double-check with another RN. So this may include heparin or insulin.

And then, another thing that's important to remember is that you never want to leave a medication at the patient's bedside. So if you go in to give your patient a medication and they're like, "I don't really want to take it right now. You can just leave it here at the bedside," no. You don't want to do that. You bring it with you, and then bring it back when the patient is willing to take that medication.

And then, finally, you need to complete an incident report for any medication error. And you never want to include this incident report in the patient's chart or refer to this incident report in the patient's chart because it's an internal document used for quality improvement at the facility.

And better yet, how about no medication errors? Make sure you do your triple checks so you don't perform a medication error and harm your patient, and so you don't have to fill out one of those incident reports which my understanding is, not really a good time.

So that is it for the material I'm going to cover in this video. Next up, we have a quiz. All right. I have three questions for you. The first question is a true/false question. Time-critical scheduled medications should be given within 30 minutes before or after the scheduled time. True or false? The answer is true. Second question. Which of the following is correctly written, 0.5 mg, .5 mg, or .50 mg? The answer is 0.5 mg. Last question is also a true/false question. If a medication error occurs, you need to complete an incident report and include that in your patient's chart. True or false? The answer is false. We do not include that incident report in the patient's chart.

Hope this was helpful. If you got any of those questions wrong, be sure to go back and watch this video or review our flashcards so that you can better understand the material. I'll see you on another video soon. Thank you so much.

[BLOOPERS]

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