Medication administration is one of the highest-risk nursing activities. Errors can occur at any stage — prescribing, transcribing, dispensing, administering, or monitoring — and the nurse is the last safety barrier before the drug reaches the client. The nurse is accountable for knowing each drug's purpose, usual dose, adverse effects, and nursing implications before giving it, and for questioning any order that appears unclear or unsafe.

Rights of medication administration — the classic "5 Rights" are:

1. Right client — use at least two identifiers (e.g., full name and date of birth or medical record number), compared with the medication record and the wristband; never use the room number
2. Right drug
3. Right dose
4. Right route
5. Right time

Most references now add: right documentation, right reason (indication), right response (evaluation), right to refuse, and right education. A "right diagnosis" or "right nurse" is not one of the rights.

Three checks: compare the label with the medication administration record (MAR) when taking the drug from storage, when preparing it, and at the bedside before giving it. Barcode scanning supports but does not replace these checks.

Pharmacokinetic basics that guide route choice

• Oral: convenient, safe, economical; slower onset; affected by food, gastric pH, and first-pass metabolism in the liver
• Sublingual and buccal: absorbed through oral mucosa directly into the circulation — bypass first-pass metabolism, fast onset
• Parenteral: fastest and most predictable, but IV drugs cannot be recalled
• Topical (skin, eye, ear, nose, inhaled, rectal, vaginal): mainly local effect, but systemic absorption and toxicity can occur

Before giving any medication, assess:

• Allergies and the type of prior reaction
• Indication and whether it still applies; relevant vital signs and laboratory values (e.g., apical pulse before digoxin, blood pressure before antihypertensives, glucose before insulin, potassium before diuretics, coagulation tests before anticoagulants)
• Level of consciousness and swallowing ability before any oral drug — risk of aspiration in clients who are drowsy, have dysphagia, or have no gag reflex
• NPO status, vomiting, GI function, enteral tube placement
• Kidney and liver function, weight (weight-based dosing), age, pregnancy and breastfeeding
• Client's knowledge, beliefs, and ability to self-administer after discharge

• Laboratory monitoring: drug levels (e.g., vancomycin, digoxin, lithium, phenytoin), INR or aPTT, serum creatinine, electrolytes
• Dose calculations: always verify units; a calculation that gives an unusual amount (e.g., more than two or three tablets or a very large volume) is a signal to recheck and ask
• Medication reconciliation on admission, transfer, and discharge compares the client's home medications with current orders

Components of a complete order: client name and identifiers, date and time, drug name, dose, route, frequency, indication for PRN orders, and prescriber's signature. The nurse clarifies incomplete, illegible, or unsafe orders with the prescriber before acting.

Verbal and telephone orders are limited to urgent situations; the nurse writes the order down and reads it back to the prescriber for confirmation.

Error-prone abbreviations to avoid (The Joint Commission "Do Not Use" list)

High-alert medications (ISMP) — drugs that cause significant harm when used in error. Examples: insulin, opioids, anticoagulants (heparin, warfarin, direct oral anticoagulants), concentrated electrolytes (potassium chloride or phosphate concentrate, hypertonic sodium chloride, IV magnesium sulfate), neuromuscular blocking agents, chemotherapy, IV sedatives and anesthetics, IV adrenergic agonists and inotropes, oral methotrexate for non-oncologic use. Safeguards: standardized concentrations, smart infusion pumps, independent double checks where required by policy, and restricted storage (e.g., no concentrated potassium chloride stock on nursing units).

Look-alike, sound-alike drugs — use tall-man lettering (e.g., hydrOXYzine vs hydrALAZINE), separate storage, and confirm indication.

Timing — follow facility policy. A common approach (ISMP) separates time-critical medications (give within 30 minutes of the scheduled time, e.g., insulin with meals, antibiotics, anticonvulsants, immunosuppressants, Parkinson drugs) from non-time-critical ones (often within 1–2 hours). "After meals" means shortly after eating so food buffers GI irritation.

Storage: keep drugs in their original labeled containers; never transfer between containers; store per label (light, temperature, refrigeration); keep internal and external preparations separate. Controlled substances are stored in locked, access-controlled systems (automated dispensing cabinets or double-locked storage) with counts and a witness for wasting.

Listed in priority order.

1. Prevent harm before giving: verify the order, allergies, two identifiers, and assessment data; hold the drug and contact the prescriber if parameters are outside limits
2. Oral medications
   • Position the client upright (high-Fowler's if possible); give one pill at a time with water; stay until swallowed
   • Do not crush or open enteric-coated, extended- or sustained-release (ER, XR, SR, CR), sublingual, or buccal products — crushing can cause toxicity or destroy the drug. Check a "do not crush" list and ask the pharmacist for an alternative form
   • Liquids: measure at eye level at the bottom of the meniscus; use an oral syringe for small volumes
   • Enteral tube: verify placement, give each drug separately, flush with water before, between, and after (commonly 15–30 mL in adults)
   • New difficulty swallowing: hold oral medications, keep the client upright, and notify the provider for a swallow evaluation
   • Vomiting soon after a dose: note the time and whether the drug is visible; ask the prescriber before repeating
3. Sublingual nitroglycerin — place under the tongue and let it dissolve; do not chew or swallow; sit the client down. Check blood pressure; do not give within 24 hours of sildenafil or vardenafil, or 48 hours of tadalafil (phosphodiesterase-5 inhibitors) — severe hypotension. Headache and dizziness are common. In the hospital, notify the provider or rapid response team, obtain an ECG, and give up to 3 doses 5 minutes apart per order; outside the hospital, clients call emergency services if pain is not improved 5 minutes after the first dose
4. Eye drops and ointment — tilt the head back, look up, pull down the lower lid, and instill into the lower conjunctival sac (not on the cornea); ointment as a thin ribbon from inner to outer canthus. Close the eyes gently (do not squeeze or rub) and press the inner canthus (nasolacrimal occlusion) for 1–2 minutes to reduce systemic absorption — important for beta-blocker drops such as timolol, which can cause bradycardia and bronchospasm. Wait about 5 minutes between different drops; drops before ointment
5. Ear drops — warm to about body temperature (cold drops cause dizziness and nausea); client lies with the affected ear up; straighten the canal — pull the pinna up and back in adults, down and back in children under about 3 years; remain side-lying for a few minutes
6. Nasal drops and sprays — clear the nose first; tilt the head back (or position for the sinus being treated); remain in position a few minutes and do not blow the nose immediately. Warn that overuse of decongestant sprays causes rebound congestion
7. Metered-dose inhaler — shake, exhale fully, inhale slowly and deeply with actuation (with a spacer or holding chamber, actuate first and start the slow breath within 5 seconds), hold the breath for a slow count of 10, and wait about 15–30 seconds between puffs of a quick-relief bronchodilator (NAEPP; no wait is needed for other medicines). Many product leaflets, such as albuterol HFA, say to wait about 1 minute and shake again before the next puff; follow the leaflet or the prescriber. Use the bronchodilator before the corticosteroid; rinse the mouth and spit after inhaled corticosteroids to prevent oral candidiasis
8. Transdermal patches — remove the old patch, clean and dry the skin, rotate sites, apply to hairless intact skin, write date and time. Do not cut unless labeling allows. Avoid heat (heating pads, hot baths, saunas) — it increases absorption; this is dangerous with fentanyl patches (respiratory depression; only for opioid-tolerant clients) and nitroglycerin (hypotension). Nitroglycerin patches need a daily patch-free interval to prevent tolerance. Remove metal-containing patches before MRI
9. Topical skin preparations — wear gloves; clean the area; apply a thin layer with gloved fingers or an applicator; use sterile technique only for open wounds
10. Rectal suppository — left Sims' position; lubricate; insert past the internal anal sphincter (about 7–10 cm / 3–4 in in adults) along the rectal wall; client stays lying for about 5–15 minutes
11. Vaginal suppository or cream — ideally at bedtime; client voids first, lies in dorsal recumbent position; insert along the posterior vaginal wall about 7.5–10 cm; remain lying 10–30 minutes; offer a perineal pad
12. Refusal: respect the client's right to refuse; explore the reason and provide information; never hide medication in food without a legal basis and informed consent; document and notify the prescriber
13. Medication error: assess the client first and monitor, notify the prescriber promptly, follow orders for treatment, then complete an incident report. Disclose honestly per policy. Document care in the chart but not the incident report itself
14. Document after (never before) giving: drug, dose, route, time, site, client response; for PRN drugs, the reason and effect

• Name, purpose, dose, schedule, and common and serious adverse effects of each drug
• Take drugs exactly as prescribed; do not stop suddenly without advice; never share medications
• Food and timing instructions (empty stomach vs with food); drug–drug and drug–food interactions
• Carry an up-to-date medication list and allergy information; use one pharmacy
• Store drugs as labeled, away from children; dispose of unused drugs through take-back programs
• Use teach-back to confirm understanding, especially for inhalers, eye drops, and patches

• 5 Rights: client, drug, dose, route, time (plus documentation, reason, response, refusal, education)
• Two identifiers, never the room number; three label checks
• Check swallowing and consciousness before oral drugs; position upright
• Do not crush enteric-coated, extended-release, or sublingual products
• Sublingual nitroglycerin: dissolve under the tongue; no sildenafil or vardenafil within 24 h, tadalafil within 48 h
• Eye drops into the lower conjunctival sac, then nasolacrimal pressure 1–2 minutes
• Ear drops: affected ear up; adults pinna up and back, young children down and back
• Inhaled corticosteroid: rinse and spit; hold breath about 10 seconds
• Patches: rotate sites, remove old patch, avoid heat
• Error: assess the client first, then notify, then report
• Client may refuse; never disguise drugs; document and notify
• No trailing zeros; always a leading zero