Patients and family members can help improve medication safety during a hospitalization


A consumer contacted us recently after visiting a hospitalized patient. While there, she had the opportunity to observe nurses administering medications. She told us that the nurses would bring a clear plastic cup with loose tablets and capsules into the room, hand the pills to the patient, and ask the patient to swallow them. The person who wrote to us noted that none of the pills were labeled. She wanted to know if this was the proper procedure, since it would be difficult to assure that these unlabeled medications were right for the patient.

For many years nurses were in fact taught to administer medications after preparing the doses in medication cups. They used to have bulk supplies of each patient’s medications in bottles kept in a drug room. When it came time to give patients their medications, they would remove them from these bottles and place them into cups. However, about 30 years ago, hospital medication systems changed and began embracing the “unit dose” concept. In a unit dose system each and every medication – even injectable drugs and oral liquids - are prepared in a single dose package, labeled with the name of the drug, dose, and other important information. Unit dose medications can be properly identified right up to the time they are brought into the patient’s room. They even have bar codes that can be scanned. However, old habits are hard to break. Some nurses are so used to giving pills that way, they still empty the packages outside the room and put them in the cup. This unfortunately defeats an important safety feature - being able to identify the drug right up to the time medications are given to the patient. In hospitals with bar code systems (about 20% of US hospitals have such systems in 2009), it also makes it impossible to scan the medication at the bedside and match the patient’s identity band. That's the best way of all to assure that each patient is getting the proper drug and dose.

It's too easy to mix things up when working with multiple patients. For safety reasons, consumers should ask that each medication brought into the hospital room remains with its labeling intact. The patient might in some cases even be handed the unit dose package so that they can read the label. This allows patients to get to know name of their medication and the dose and therefore question anything that is unexpected. We also tell nurses giving the first dose to always tell the patient the name of the drug and dose and what it is for (in general terms). Hopefully the doctor has already given the patient this information. So, again, this gives the patient a chance to question anything that is unfamiliar.

Of course the above procedure would need to be modified if the patient is unable to communicate or understand well. It’s also difficult for busy and sometimes overworked nurses to strictly adhere to this process. Still, leaving the unit dose package intact right up to drug administration often allows patients, parents of hospitalized children, or other visiting caregivers a way to assist in assuring the right med/dose is getting to them. If this isn't being done, consider discussing it with the nurses.

Created on April 9, 2009

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