Recommendations to Enhance Accuracy of Administration of Medications

Personnel to whom this applies: 1) nursing staff involved in administration of medications; 2) prescribers and other personnel involved in administration of medications (e.g., respiratory therapists, non-licensed personnel who are delegated tasks by a licensed professional, and others); 3) pharmacy staff; and 4) healthcare administrators/managers.

Technology plays an important role in the delivery of healthcare. Use technology, as appropriate, but evaluate its effectiveness on an ongoing basis. Although technology can reduce medication errors and enhance patient safety, it also has the potential to cause new types of unintentional errors.

The Council recommends the following:

  1. Any order that is incomplete, illegible, or poses any concern should be clarified before administration by using an established process for resolving issues.
  2. The use of patient-safety technology to enhance the safety of medication administration—such as computer order entry, bar codes, and smart pumps—is encouraged when appropriate.
  3. As one aspect of the overall medication use system, the following checks are to be performed immediately before medication administration: the right medication, in the right dose, to the right person, by the right route, using the right dosage form, at the right time, for the right reason, with the right response, with both desired effect and potential adverse effects in mind, and with the right patient education and documentation.
  4. Organizations/companies will provide employees with adequate training regarding medication administration devices and routinely monitor or verify that users of such devices demonstrate competency regarding the device’s proper operation and limitations.
  5. When electronic infusion control devices are used, only those that prevent free-flow upon removal of the administration set should be used.
  6. The safety of devices used within the medication use system should be continuously monitored and evaluated.
  7. Integrated automated systems (e.g., direct order entry, computerized medication administration record, or bar coding) can be used to: facilitate the appropriate ordering of medications, facilitate review of prescriptions and medication orders, increase the accuracy of administration, and reduce transcription errors.
  8. All persons who administer medications have adequate and appropriate access to patient information—which includes medical history, known allergies, patient weight, diagnoses, list of current medications, laboratory data and treatment plan—as close to the point of use as possible to assess the appropriateness of administering the medication.
  9. A complete and accurate listing of all current medications and dosages is available during all transitions of care. (e.g., admission into hospital, change in level of care, discharge, transfer of patients to new sites of care).

    All persons who administer medications have easily accessible product information as close to the point of use as possible and are knowledgeable about the following:

    • Indications for use of the medication as well as precautions and contraindications 
    • The expected outcome from its use 
    • Potential adverse drug effects and interactions with food or other medications
    • Actions to take when adverse drug effects or interactions occur
    • Storage requirements
    • Drug preparation requirements
    • Patient specific dosing guidelines
  10. Healthcare professionals only administer medications that are properly labeled, and labels should be read during the following 3 steps in the administration process: 
    • When reaching for or preparing the medication

    • Immediately before administering the medication

    • When discarding the container or replacing unused medication it into its storage location.

  11. During first-time administration, the name, purpose, and effects of the medication are discussed with the patient and/or caregiver. The information is reviewed upon subsequent administrations.
  12. Ongoing patient monitoring should occur for the desired therapeutic effect(s) and for potential adverse drug effects. 
  13. The role of the work environment is considered when assessing safety of the drug administration process. Factors such as lighting, temperature control, noise level, and potential for distractions (e.g., telephone and personal interruptions, performance of unrelated tasks, and others) should be examined. Sufficient staffing and other resources must be provided for the given workload. The science of ergonomics should be used in the design of safe systems (see USP–NF General Chapter <1066> Physical Environments that promote Safe Medication use). 
  14. Policies and procedures be established and maintained to guide the safe preparation of parenteral medications outside of the pharmacy using CDC Recommendations for Safe Medication Preparation and Administration1 as a reference. [this reference only addresses the safe preparation of parenteral drugs]
  15. Data regarding the actual and potential errors of administration be collected and analyzed for the purpose of continuous quality improvement.
  16. Conduct both initial and ongoing training of staff—including licensed staff, support/non-licensed staff, and relief staff—on accepted standards of practice related to accurate medication administration with the ultimate goal of medication error reduction.
  17. Every organization shall establish policies and procedures for the medication administration process. This will ensure that all personnel—including licensed staff, support/non-licensed staff, and relief staff—are informed of all possible outcomes related to the medication administration process. The personnel can then teach patients and their families at the bedside about the medication administration procedure, the purpose of the medication, how the medication works, how to recognize possible adverse events, and what to do if an adverse event occurs.

(See also the Council's Recommendations to Reduce Medication Errors in Non-Health Care Settings pertaining to the storage and administration of medications in a variety of non-health care settings.) Accessed August 2, 2014

Actions/Decisions are those of the Council as a whole and may not reflect the views/positions of individual member organizations.

June 29, 1999
May 1, 2015