Chapter 4: Medication Administration — Rights, Routes, and Safety

Medication errors are among the most preventable causes of patient harm. Nurses are the last line of defense in the medication administration process. Mastery of the rights, routes, and pharmacology fundamentals is essential for safe practice.

The 10 Rights of Medication Administration

1. Right Patient — verify with two identifiers (name + date of birth or MRN)
2. Right Medication — compare MAR to label three times
3. Right Dose — calculate and verify; question unusually large doses
4. Right Route — confirm the prescribed route is appropriate
5. Right Time — within 30 minutes before/after scheduled time (30/30 rule)
6. Right Documentation — document immediately after administration
7. Right Reason — understand why the patient is receiving the medication
8. Right Response — monitor for therapeutic effect and adverse reactions
9. Right to Refuse — respect patient autonomy; document refusal
10. Right Education — teach the patient about their medications

Routes of Administration

Route	Abbreviation	Onset	Key Nursing Considerations
Oral	PO	30–60 min	Check swallow ability; some must not be crushed
Sublingual	SL	1–3 min	Do not swallow; do not eat/drink until dissolved
Intravenous	IV	Immediate	Highest risk; check patency, compatibility
Intramuscular	IM	10–30 min	Ventrogluteal site preferred in adults
Subcutaneous	SQ/SC	15–30 min	Rotate sites; 45–90° angle
Transdermal	TD	Hours	Rotate sites; remove old patch before new one
Inhalation	INH	Minutes	Shake MDI; spacer recommended; rinse mouth after corticosteroids

Pharmacokinetics Basics

Pharmacokinetics describes how the body processes drugs — ADME:

• Absorption: movement from administration site into bloodstream (affected by route, food, pH)
• Distribution: spread throughout body tissues (affected by protein binding, lipid solubility, blood-brain barrier)
• Metabolism: chemical transformation, primarily in the liver (CYP450 enzymes)
• Excretion: elimination, primarily via kidneys (monitor renal function for renally-cleared drugs)

Half-life (t½): time for plasma concentration to decrease by 50%. Drugs reach steady state after ~5 half-lives.

Drug Interactions and High-Alert Medications

High-alert medications require special safeguards (double-checks, independent verification):

• Insulin — units cannot be abbreviated; use insulin syringes only
• Heparin/Anticoagulants — monitor aPTT, PT/INR; bleeding precautions
• Opioids — monitor respiratory rate and sedation level
• Concentrated electrolytes (KCl, hypertonic saline) — never administer undiluted IV

Key Checklist

• List all 10 rights of medication administration and give one clinical example of how violating each could cause patient harm
• Compare IV, IM, and SQ routes for onset time, nursing considerations, and appropriate use cases
• Identify four high-alert medications and describe the specific safety precautions required for each