As we work with preceptors in supporting the orientation of new nurses in our facilities, we continue to look for new ideas and approaches that can provide structure and confidence to the orientation process. One of the difficulties we sometimes have is understanding the shorthand language nurses use to communicate to each other about important processes such as medication administration. How many times have you heard preceptors talk about ensuring that the new orientee knows how to "pass meds?" The phrase passing meds is really short hand for a very complex process involving multiple steps, safety checks, and clinical judgments. Recent research (Eisenhauer, Hurley, & Dolan, 2007) identified 10 descriptive categories of nurse thinking surrounding medication administration all bound up in the shorthand of "passing meds."

Recently, Dolores Morrison and her colleague Susan Paparella sent us a list of nurse competencies for medication administration based on The Joint Commission, the Institute for Safe Medication Practice, and Institute of Medicine standards. You may find these useful in understanding nurses' shorthand language and enhancing confidence that the critical process of medication administration is thoroughly addressed during nursing orientation. We would like to pass along the ideas of Morrison and Paparella to you.

Mary Beth and Mary

ASSESSING MEDICATION ADMINISTRATION COMPETENCY OF THE NEW NURSE HIRE

By Dolores Morrison, MSN, RN, and Susan Paparella, MSN, RN

Medication administration can be a risky, complex task for healthcare practitioners but especially for the new nurse hire. How to verify the new nurse's competency in this area can be even more daunting for the preceptor and staff development educator. Traditionally, before new nurse hires are permitted to administer medications in a healthcare setting, they are required to achieve a passing grade on a "medication administration competency" test. The test is used to help the organization evaluate nurses' knowledge of drugs and their ability to administer medications safely. A convenience sampling of 22 medication administration competency tests currently used in staff development settings were analyzed by the authors in an attempt to describe questions typically found on entry to practice medication examinations. The passing grade ranged from 80% to 100%. Assessment of mathematical calculation abilities was a dominant feature of the tests. Only 2.7% of the tests included questions about the safety of the medication administration. Since correct calculation of medication dosage is only one aspect of medication competency, successful completion of these examinations cannot determine administration competency without additional verification methods. To assess competency adequately, we must first describe the knowledge, skills, and abilities inherent in medication administration, then craft appropriate measures of competency.

To assist the preceptor and the staff development educator, the authors have compiled a list of 14 medication administration competencies, which are congruent with the Institute for Safe Medication Practice's (ISMP) 10 Key Elements of the Medication Use Process (2003), The Joint Commission (TJC) National Patient Safety Goals for 2009, and the Institute of Medicine (IOM) standards (2003). By verifying these competencies with the new hire, preceptors can ensure the basic safety practices of the new nurse hire.

1. Assist in the medication reconciliation process as per agency policy. For example, the nurse's role might include the following:

* Verify home medications with patient at time of admission assessment; use Medication Reconciliation Form (MRF) to assist assessment.

* Add additional home medications, if identified, to the MRF and notify physician.

* Ask the patient if he or she has brought the medications to the hospital.

* Ask the patient "How often do you forget to take your medications?"

2. Demonstrate communication of essential patient information between nurse-physician groups and between nurse-nurse groups. The IOM stresses the importance of adopting an interdisciplinary approach to patient care by establishing a system that encourages teamwork, communication, and cooperation. For example, using the SBAR (situation, background, assessment, recommendation) format, the nurse should notify the physician when the patient does not respond as expected to medication therapy. In addition, the nurse should follow hospital and unit protocols to ensure information about medication is communicated at shift-to-shift report and at other points of patient handoff including unit transfers.

3. Demonstrate the correct procedure for patient identification. TJC recommends using at least two patient identifiers (neither to be the patient's room number) whenever giving a medication, taking blood samples, or administering blood products. The new nurse should demonstrate use of two patient identifiers during medication administration according to institution policy.

4. Question orders that do not appear to be appropriate based on the patient's disease process and past history (e.g., age, weight, pregnancy status, lab values, vital signs, allergy prone situations, drug-drug interactions, inappropriate doses, drug duplications). According to the ISMP, many harmful prescribing errors share a common factor: at least one person believed there was a problem with the order before the medication was administered. It is recommended that if a nurse suspects an order is potentially harmful, the new nurse should pursue the matter until satisfied that it is safe to proceed.

5. Monitor the patient for therapeutic or non-therapeutic response. Following administration of any medication, especially new medications, the new nurse should monitor the patient for expected and unexpected responses. Patient responses to medication should be documented and communicated according to institution policy.

6. Identify high-alert medications and the special precautions required with these drugs.ISMP (2008) offers a list of high-alert medications which include but are not limited to heparin, insulin, potassium, and opiates (especially morphine and hydromorphone). These medications have an increased risk of significant harm when used in error; therefore, ISMP recommends that these medications receive an independent double check prior to administration.

7. Use appropriate drug resources as necessary. When unsure of the indication, action, side effect, or appropriate dose of a drug, the new nurse should check drug reference materials.

8. Follow hospital procedure for accessing and dispensing medications. This may include assuring that hospital policy on verification of first dose medication is followed. ISMP strongly recommends that first dose medications are verified to prevent a drug-drug interaction or allergic response.

9. Demonstrate correct use of medication-related devices such as infusion pumps, patient controlled analgesia (PCA) pumps, syringes, and insulin pens.

10. Participate in patient education regarding medication use. The new nurse should be familiar with the teaching materials afforded by the agency's patient education committee and other standardized patient medication education materials available at the facility. The education should include the importance of follow-up monitoring, adherence issues, dietary considerations, and the potential for adverse side effects. Asking questions such as "Do you know why you are taking this medication? Can you show me how to measure the prescribed dose? What should you do if you miss a dose? If the instructions tell you to take the medication an hour before eating and you eat at 12:30 p.m., what time should you take the medicine?" (American Society on Aging and American Society of Consultant Pharmacists Foundation, 2008) can help the nurse assess patient comprehension of medication instruction.

11. Verbalize the importance of reporting "near misses" through the incident reporting mechanism. TJC defines a near miss as "any process variation which did not affect the outcome, but for which a recurrence carries a significant chance of serious adverse outcome" (Youngberg & Hatlie, 2004, p. 139). By studying an error that was stopped or avoided before the patient was harmed, employees in the system can identify process problems that may result in serious errors in the future and eliminate these problems. Nurses' reports of near misses can help identify faulty processes and result in improved medication safety.

12. Demonstrate accurate documentation of medication administration in the medication administration record.

13. Adhere to TJC's unacceptable abbreviation list as well as institution's acceptable abbreviations.

14. Adhere to safeguards in storage, preparation, and administration of high-risk medication. This may include having the new nurse prepare a narcotic from the automated dispensing cabinet with the medication administration record in view or verbalizing the risks associated with "stockpiling" drugs most commonly used on the unit.

Competency assessment should be a dynamic, ongoing process, which measures the individual's abilities to carry out the task. Focusing on the above competencies can help the preceptor and the staff development educator observe the new hire nurse as he or she completes the steps of safe medication administration in real time, asks questions to probe the individual's thinking, and adds and/or corrects thinking and habits of behavior in order to ensure the basic safety practices of medication administration.

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