19. Medication Handling


There are four standard statements, each with accompanying indicators that describe a nurse’s accountabilities related to medical practice. The standard statements describe broad principles that guide nursing practices and are listed in a manner that reflects the steps of the nursing process.

  1. Assessment – Nurses use their knowledge, skill, and judgment in the assessment of the client and the medication, as well as the practice and supports prior to administering medication.
  2. Planning – Nurses are accountable for ensuring the accuracy, appropriateness, and completeness of a client’s plan of care in regards to medication order(s). They are also responsible for communicating concerns about the treatment plan to other members of the healthcare team.
  3. Implementation – Nurses prepare and administer medication(s) to clients in a safe, effective, and ethical manner.
  4. Evaluation – Nurses evaluate client outcomes following medication administration and take appropriate steps for follow-up.


To support safe medication practice, systems need to be in place to track, address and learn from any medication errors that occur in the practice environment.

Medication Errors

A medication error is defined as any preventable event by a health care professional that may lead to improper medication use or the harm of a patient. These errors may be related to product labeling, procedures, professional practice, administration, order communication, dispensing, etc.

Medication errors can be further classified into errors of commission (e.g., giving the wrong medication) and errors of omission (e.g., not administering an ordered medication). The error can result in an adverse drug event which may then cause harm, injury or death. It is also possible for the result to be a “near-miss”; in this situation, an error does not reach the client, but if it had the client could have been harmed (e.g., a wrong dose is prescribed but is intercepted before administration).

Preventing and reducing errors involves collaboration between the nurses, other healthcare professionals, and the facility. Nurses can often identify and correct errors before they occur.

When an error is made, the nurse must:

  • Ensure the well-being of the client.
  • Limit the client’s exposure to any potential harm.
  • Determine a plan of action that is suitable for the problem(s) identified.

Examples of strategies to address problems that may create opportunities for errors are:

  • System modifications
  • Education
  • Individual assistance
  • Performance management

Safe medication practice includes:

  • Advocating for accessible and current information pertaining to medication
  • Evaluating the need for a colleague to conduct an independent double-check on a prepared medication
  • Being aware of expectations for independently double-checking preparations
  • Being knowledgeable on high alert medications
  • Avoiding the use of error-prone abbreviations, dose designations, and symbols
  • Reporting all errors and near misses using formal practice-setting communication
  • Having organizational systems and policies that promote continuity and safety of client medication administration during transfer of care and at transition points
  • Ensuring that the client or the client’s substitute decision-maker has the most complete and accurate list possible of all medications currently being taken
  • Communicating with the client and appropriate caregivers the current list of medications during transfer of accountability
  • Addressing system issues that contribute to medication errors
  • Advocating for and/or participating in interdisciplinary error-reporting and root cause system analysis
  • Following legislation and/or advocating for practice setting policies and procedures regarding the storage, counting, administration, and disposal of medication

Medication Reconciliation

Medication reconciliation is the process that is intended to prevent medication errors when a client’s care is transferred. This assists in reducing the risk of preventable adverse events and is an important client safety initiative. The medication reconciliation process may involve all members of the healthcare team and would involve:

  • Creating the most complete, accurate list of all medications a client is currently taking and the time the last medication was given (for example, a best possible medication history)
  • Using this list when writing admission medication orders
  • Comparing the list and the admission medication orders
  • Identifying any discrepancies and bringing them to the attention of the prescriber and making appropriate changes to the orders
  • Communicating the current list of medications to the client and appropriate caregivers
  • Comparing the medication history to ensure that the client’s medications are reconciled at transfer or discharge

Client Identification (f.k.a Two Identifiers)

Using person-specific identifiers to confirm that clients receive the service or procedure intended for them can avoid harmful incidents such as privacy breaches, allergic reactions, and discharge of clients to the wrong families, medication errors, and wrong-person procedures.

The person-specific identifiers used are dependant on the population served and client preferences. Examples of person-specific identifiers include the client’s full name, home address (when confirmed by the client or family), date of birth, personal identification number, or an accurate photograph. In settings where there is long-term or continuing care and the team member is familiar with the client, one person-specific identifier can be facial recognition.

NOTE: The client’s room or bed number, or using a home address without confirming it with the client or family, is not person-specific and should not be used as an identifier.

Client identification is done in partnership with the client and their family by depicting the reasoning for this safety practice as well as its importance before asking them for the identifiers (e.g., “What is your name?”). When clients and families are not able to provide this information, other sources of identifiers can include wristbands, health records, or government-issued identification. Two identifiers may be taken from the same source.


A serious adverse drug reaction (ADR) is defined as a noxious and unintended response to a drug that occurs at any dose and requires in-patient or extended hospitalization. It causes congenital malformation, persistent or significant disability/incapacity, is life-threatening or results in death. A nurse who assesses a serious Adverse Drug Reaction should report it or advocate to report it to the Canada Vigilance Program.


Dispensing is a controlled act authorized by health care professionals including Pharmacists, Nurse Practitioners, Physicians and Dentists. It involves the selection, preparation, and transfer of one or more prescribed drug doses to a client for administration. Dispensing applies to prescription medications only, it does not include over the counter medications. Dispensing involves:

  • Receiving/reading the prescription
  • Adjusting the order according to approved policy (for example, substitution) if appropriate
  • Selecting the drug to dispense
  • Checking the expiry date
  • Reconstituting the product, if needed
  • Repackaging the drug and labelling the product
  • Completing a final physical check to ensure the accuracy of the finished product

RNs and RPNs do not have access to the controlled act of dispensing. However, some health care professionals may delegate the act of dispensing to RNs and RPNs, physicians, pharmacists. Nurse Practitioners are not authorized to delegate dispensing.


  1. Right Patient
    •   Check the name on the order and the patient.
    •   Use 2 identifiers.
    •   Ask the patient to identify himself/herself.
    •   When available, use technology (for example, bar-code system).
  2. Right Medication
    •   Check the medication label.
    •   Check the order.
  3. Right Dose
    •   Check the order.
    •   Confirm appropriateness of the dose using a current drug reference.
    •   If necessary, calculate the dose and have another nurse calculate the dose as well.
  4. Right Route
    •   Again, check the order and appropriateness of the route ordered.
    •   Confirm that the patient can take or receive the medication by the ordered route.
  5. Right Time
    •   Check the frequency of the ordered medication.
    •   Double-check that you are giving the ordered dose at the correct time.
    •   Confirm when the last dose was given.
  6. Right Documentation
    •   Document administration AFTER giving the ordered medication.
    •   Chart the time, route, and any other specific information as necessary. For instance; the site of an injection, any laboratory value, or a vital sign that needed to be checked before giving the drug.
  7. Right Reason
    •   Confirm the rationale for the ordered medication; what is the patient’s history? Why is he/she taking this medication?
    •   Revisit the reasons for long-term medication use.
  8. Right Response
    •   Make sure that the drug led to the desired effect. If an antihypertensive was given, has his/her blood pressure improved? Does the patient verbalize improvement in depression while on an antidepressant?
    •   Be sure to document you’re monitoring of the patient and any other nursing interventions that are applicable.


Medication errors are the largest identified source of preventable medical error and a large percentage of those were attributed to abbreviation use. Misinterpreted abbreviations can result in extra or improper doses, administration of the wrong drug, or administration of a drug in the wrong manner, which can lead to a wide array of health risks for seniors. The use of some abbreviations, symbols, and dose designations has been identified as an underlying cause of serious and even fatal medication errors. The following three examples illustrate abbreviations in common use that were involved in medication errors reported to ISMP Canada.

  1. The use of drug name abbreviations increases the likelihood of confusion between drugs with look-alike or sound-alike names. In this example, although the order was also communicated verbally, as “morphine”, the widespread practice of abbreviating drug names (e.g., “morph” for “morphine”) was found to be one of the contributing factors in a fatal event where “hydromorphone” was given instead of morphine. This example also emphasizes the need for legible handwriting.
    Example 1
  2. The “u”, representing the whole word “units” has often been misinterpreted as a “0” (zero), leading to a 10-fold dose error. Here, the intended “6u” was misinterpreted as “60” and the patient received 60 units of regular (short-acting) insulin. Note, insulin is the most commonly reported medication identified as causing harm in the ISMP Canada database of voluntarily reported medication errors.
    Example 2
  3. In this third example, an octreotide infusion was administered at 25 mL/h instead of 5 mL/h as intended. Whether handwritten or computer-generated, the “@” symbol can be misread as the number “2” or “5”, leading to substantial overdoses of medication.
    Example 3

Abbreviations “Do Not Use” List

The abbreviations, symbols, and dose designations found in the following chart have been reported as being frequently misinterpreted and involved in harmful medication errors. They should never be used when communicating medical information.

Abbreviations Table

Reference: https://www.ismp-canada.org/dangerousabbreviations.html

The following is a quick reference from the Institute for Safe Medication Practices Canada, of commonly used terminology when dealing with medications:

Best Possible Medication History (BPMH) – BPMH is a history created using 1) a systematic process of interviewing the patient(resident)/family, and 2) a review of at least one other reliable source of information to obtain and verify all of a patient’s/resident’s medication use (prescribed and non-prescribed). Complete documentation includes drug name, dosage, route, and frequency. The BPMH is more comprehensive than a routine primary medication history, which is often a quick preliminary medication history that may not include multiple sources of information. The BPMH is a ‘snapshot’ of the patient’s/residents actual medication use, which may be different from what is contained in their records. This is why patient/resident involvement is vital.

Computerized Medication Administration Record – A paper medication administration form, usually generated from a pharmacy dispensing computer system is forwarded to the LTC facility. Staff document, by pen on this form, indicates the doses of medication administered. Staff may also need to make changes to the form manually to reflect drug order modifications.

Computerized Physician/Prescriber Order Entry (CPOE) – Computerized physician or prescriber order entry (CPOE) is the process of entering medication orders or other physician instructions electronically into a computer system as opposed to using paper. The use of a CPOE system can help reduce incidents related to poor handwriting or transcription of medication orders. This order entry can be performed by any healthcare practitioner acting within their scope of practice. If they are not a prescriber, their order entry is followed by a verification process by another practitioner, e.g., a check against a handwritten order documented on a paper health record.

Dangerous Abbreviations, Symbols, and Dose Designations – Abbreviations, symbols and dose designations that have been identified as easily misinterpreted or involved in medication incidents leading to harm and should be avoided in medication-related communications.

Dosing Window – When a first dose is administered at a non-standard time, nurses need an agreed-upon method of converting subsequent doses to the standardized schedule. Many facilities have guidelines for this purpose. These “dosing windows” or “staggered dosing times” provide a matrix for determining the safest time to administer the second dose according to when the first dose was administered. Patients usually are back on a standard dosing schedule by the third dose. Schedules must sometimes be changed to accommodate patient procedures or to prevent the administration of incompatible medications at the same time.

eMAR – Refers to electronic medication administration record and indicates that the documentation is kept on-line. Often this technology/software is linked to CPOE and used with barcode labels on medication packaging, as well as patient/resident barcode identification bands.

High-Alert Drugs – Drugs that bear a heightened risk of causing significant resident harm when they are used in error. Although mistakes may not be more common with these drugs, the consequences of an error are clearly more devastating to patients/residents.

Independent Double Check – A process in which a second practitioner conducts a verification step, i.e., two individuals separately check each component of the work process. For example, one person calculates a medication dose, a second individual independently performs the same calculation and the results are checked for a match. Such verification can be performed in the presence or absence of the first practitioner. The most critical aspect is to maximize the independence of the double check by ensuring that the first practitioner does not communicate what he or she expects the second practitioner to see, which would create bias and reduce the visibility of an error. An error in calculation is more likely to be detected if the second person performs all calculations independently without knowledge of (seeing) any prior calculations.

Maximum Dose – The dose of a medication that represents the upper limit that is normally found in the literature or in manufacturer recommendations. Maximum doses may vary according to age, weight, diagnosis, or comorbidity.

Medication Device – Equipment such as infusion pumps, implantable pumps, syringes, pen devices that contain medication (e.g., insulin, epinephrine), tubing, patient-controlled analgesia pumps, and other related devices that are used for medication preparation, dispensing, and administration.

Medication Incident – Any preventable event that may cause or lead to inappropriate medication use or patient/resident harm while the medication is in the control of the healthcare professional, patient/resident, or consumer. Medication incidents may be related to professional practice, drug products, procedures, and systems, and include prescribing, order communication, product labeling/packaging/nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.

Medication Incident: Near Miss or Close Call – An event that could have resulted in unwanted consequences but did not because either by chance or through timely intervention the event did not reach the patient/resident.

Medication Reconciliation – This is a formal process in which healthcare providers work together with patients [residents], families and care providers to ensure accurate and comprehensive medication information is communicated consistently across transitions of care. Medication reconciliation requires a systematic and comprehensive review of all the medications a patient/resident is taking (known as a BPMH) to ensure that medications being added, changed or discontinued are carefully evaluated. It is a component of medication management and will inform and enable prescribers to make the most appropriate prescribing decisions for the patient (resident).

Medication Management – Medication management refers to medication-use processes involving promotion of medication safety, medication selection and procurement (i.e., formulary considerations), labeling and storage, ordering/prescribing and transcribing, preparing and dispensing, administration, and monitoring.

Multidose Drug Packaging – A ready-to-administer and labeled resident-specific dose of one or more medications required for one administration time on a specified date. (i.e. dose of all oral solid medications required for one administration time such as 8 am for one person on a specific date.

Senior Administrative Representative – The title and responsibilities of this person may vary from Home to Home, facility-to-facility. This could be the Director of Care, Administrator, Manager, General Manager, Vice-President, Nurse Manager, etc.

TALL man Lettering – TALL man lettering is a method used to assist in the differentiation of look-alike/sound-alike drug names by using mixed case letters to help draw attention to the dissimilarities of these confusable names, e.g., vinCRIStine and vinBLAStine). A list of look-alike drug names with recommended TALL man lettering can be found at: http://www.ismp.org/Tools/tallmanletters.pdf.

Unit Dose – A single package that contains one dose of a medication ordered for a specific resident (e.g., a package with one tablet/oral solid dose, one single-use vial of parenteral medication, 5 mL container holding one dose of liquid) and labeled with the drug name and strength.

Reference: https://www.ismp-canada.org/lmssa/index.php