Medication Distribution

Medication Distribution and the Patient Safety Advocate

An all too common practice in hospitals is still an ancient custom that the nurse brings the medication to the patient in a cup, out of the wrapper. I have seen this in numerous hospitals in numerous states. When asking about this, it seems to be easier for the nurse to prepare the medications at his or her work station and then bring them to the patient.

I questioned some of the experts in this field and was given a big thumbs down to this practice. Medication should always be in its original wrapper when given to the patient.

Grena Porto, from QRS Healthcare Consulting remarked “this system that you described leaves no room for patients to participate in their care and in error prevention. Even without state of the art technology, there is still no reason that a nurse can’t go into a patient’s room with the meds still in their wrappers and confirm them with the patient.”

A nurse can be distracted easily, and walk into the wrong room with medications. Or, while preparing the medication, she can mix then up. This error would be completely preventable but unknown to us until it’s too late. Without the patient’s name on the medication themselves the nurse is working completely off memory.

When asked the best way to handle this dilemma, I received this response from Michael R. Cohen, RPh, MS, ScD President Institute for Safe Medication Practices “I think the patient (or advocate on behalf of patient) should ask to see the packages if they are not brought into the room. Just let the nurse know this expectation right up front and they could put on the med sheet or Electronic Medication Administration Record (e-MAR)”

How we speak to the medical staff is important. Hospitals are stressful enough. Jennifer Gold, a Pennsylvania nurse gave this advice ” you could say ‘Would you mind bringing the pills in it's original packaging because it is very helpful for me to keep track of everything." If you said: "You should bring the pills in the original packages because you could easily make a mistake.’ Then the nurse would become defensive, because she would feel like you were telling her what she was doing wrong.”

All great information and great advice. Now we need to make sure we speak up.