Long-Term Care Nursing: Medication Pass

Ensuring that the correct medication is given to the correct patient and for the right reason is the first step in safe medication administration. This is done by comparing the individual and the prescribed medication to the resident’s medication administration record (MAR).  This ensures that the nurse has correctly verified the individual. Nurses are often required to carry heavy patient loads, so patient verification is key. This is best done by asking the patient their first and last name and their date of birth. Utilizing two patient identifiers is a double check that the right individual is receiving the medication. A room number is not considered a means of identification because residents can move rooms; it is not tied directly to the individual. Many facilities utilize a wristband with a barcode assigned to each individual. Computer-assisted medication administration can significantly help reduce medication errors and notify nurses of discrepancies. It is also important to recognize that residents can have the same first or last name, so proper verification is mandatory.

Residents with certain medical conditions may be unable to speak or understand what is being asked of them. This can pertain to residents with dementia, Alzheimer’s Disease, cognitive impairments, or mental health diagnoses. In some memory care facilities, patients may be unable to verbally identify themselves or remember their name or birthdate. Following facility guidelines in such instances is important to properly identify residents before medication administration.

Medication errors can occur when the incorrect medication is given to a patient. The medication being given must match the medication prescribed. Many factors can lead to the administration of an incorrect medication.

• Similar names: Some medications have names that sound or look alike and can easily be confused. Other medications may have a similar physical appearance to those with a different indication.
• Similar packaging: Packaging that looks similar amongst medications can result in misidentification.
• Poor handwriting: Illegible writing or writing in abbreviations can cause a medication to be administered incorrectly. It is recommended that prescribers write out the full medication name when writing orders and use the generic name to decrease the risk of confusion with other medications that may have similar names. A nurse taking a verbal order should also avoid abbreviations.

To prevent such errors, medications must be thoroughly checked before they are pulled from the pharmacy or dispensing cart, after they have been prepared, and again before they are given to the resident at the bedside.

Nurses must also remember that careful attention to detail is required when multiple medications are due simultaneously for the same resident. Always double-check the medication being given before drawing up, crushing, or pushing it. Check that the correct medication is being handled in each step of medication preparation and administration. If there is any hesitation or question regarding which medication is prescribed, provided, or ordered, the best practice is to verify with the prescribing healthcare professional and/or pharmacist.

Verifying that the correct dose is being administered is extremely important for patient safety; administering too much or too little of a medication can be detrimental. There are many factors to consider when confirming that the correct dose is given to a resident. The dose of the medication itself is important. Additionally, it is important to realize that medication errors can occur when an incorrect concentration of a drug is mixed or prepared. Some medications and situations require conversions, increasing the opportunities for error. Utilize measuring devices such as syringes and measuring cups to ensure the exact dose is prepared.

Many medications have standard dosing for adults based on the severity of the disease or comorbidity being treated. Other medications, such as Warfarin, are dosed based on therapeutic levels. These medication dosages can be adjusted because treatment can change based on the patient's status, the advancement or improvement of a condition, and how much the body can tolerate.

Some individuals in long-term care may have medical conditions that make it difficult to swallow pills by mouth. If this is the case, some medications may be crushed and mixed into food, such as applesauce. Always check your MAR, label, or with your pharmacist to confirm if a medication can be crushed or split because some medications are not meant to be split or crushed, such as extended-release medications. If you mix medications in food, always confirm that all the food has been consumed. If not all the food is consumed, medication may be left behind, resulting in only a partial dose being administered. Never leave a resident’s room until you know the medication has been taken.

There are many routes for medication administration that nurses need to understand and feel confident with. Varying routes allow for different absorption rates. These varying absorption rates alter how quickly a medication is utilized within the body. Some medications are meant to be absorbed quickly, while others are made to have a delayed release or be processed over an extended time frame. Common routes for medication administration in long-term care include intravenous (IV), intramuscular (IM), inhalation, subcutaneous (SQ), oral (PO), sublingual, buccal, topical, intravaginal, intraocular, otic, intranasal, rectal, and transdermal. This course will discuss some of these methods and their indications and benefits. Certain medications are only indicated for certain routes because of their composition or mechanism of action, and administering medications through an improper route can cause bodily harm or life-threatening complications.

Timing is critical to ensure that medications work to their maximum benefit. Administering a medication too often or too early can result in accidental medication overdose. If a medication is not given frequently enough or too late, complications can arise from the delayed administration. Medication orders include a specific time or times that the medication must be administered. Pay careful attention and administer medications as close to the prescribed time as possible. Important items to remember include the following.

• Typically, in long-term care, routine orders have a window of one hour before and one hour after the prescribed time to administer the medication.
• Time-sensitive medications must always be given as soon as possible. Many medications are given at specific intervals to ensure that the medications are processed and can be utilized before the previous dose wears off.  This is imperative with certain medications, such as cardiac, psychiatric, and blood-thinning medications.
• Some medications are given on a PRN (as needed) basis, such as analgesics, sleeping medications, and anxiety medications.  Nurse discretion can be utilized to support and care for the resident.
• In pain management, administering the medication when directed can help regulate pain control before the previous dose of the medication wears off and the pain becomes more intense. Always document when medications are given so that the next dose can be given at the correct time.

The right time also includes administering medications at the correct rate. This pertains to medications given via a pump or administered by hand, such as intravenous (IV) push medication.

• Some medications must be administered over a set period of time to reduce side effects and harm. For example, IV pain analgesics, like morphine, are to be administered over 4-5 minutes to prevent side effects and to allow the body to absorb it (Medscape, 2025).
• Nurses also need to be aware that some medications need to be administered slowly to prevent severe injury. Potassium, for instance, can cause severe tissue damage if infiltrated.
• Some medications have an extremely short half-life, such as Adenosine. Adenosine has a half-life of approximately 10 seconds, which requires nurses to quickly push the medication and follow with a saline flush to allow the body to process the medication before it is depleted.
• Some medications that are taken orally are an extended-release version, meaning that the tablet or capsule dissolves slowly so that the body absorbs the necessary amount over a period of time. These medications should not be crushed or altered.
• While nurses are most often the ones giving medications to patients, there are some instances in which a patient has control over how much medication is received, such as with patient-controlled analgesics (PCA) pumps. In this scenario, nurses oversee medication administration and have orders to follow. However, the patient can push a button to deliver more medication as needed, while still having a limit

Paying careful attention to drug administration orders ensures that medications are given at the correct time and rate, which prevents medication errors and bodily harm, and maintains patient safety.

Expiration dates of medications are another aspect of time in proper medication administration. Always check for the expiration date to confirm that the medication you are administering has not expired. Expired medications are not safe and may not be as effective, which can have negative impacts on the individual who needs a specific amount of medication for treatment. Additionally, be aware of expiration dates on food used during medication administration, such as when crushed medications are added to applesauce.

Oral medications are extremely common and routine in long-term care facilities. Oral medications are taken through the mouth and absorbed into the bloodstream. The benefits of the oral route are that a wide variety of medications can be administered this way, and it is painless. Oral medications can be difficult for some residents with cognitive impairments who may not want to take the medication or may not understand why they are being asked to consume it. Oral medications may also be a problem for patients with dysphagia or digestive issues. Depending on the medication, oral medications can be tablets, capsules, or liquids. Many healthcare providers prescribe medications through this route because it requires little intervention or invasive means.

Medications administered through an enteral tube are also administered through the digestive tract, bypassing the mouth. Before administering medications through a feeding tube, always check for placement. Feeding tubes can become dislodged because of movement, coughing, and sneezing. Improper placement can lead to food being administered into the lungs, causing life-threatening aspiration pneumonia. Placement of a feeding tube can be confirmed by imaging, observing incremental markings on the tube itself, aspirating stomach contents, and checking the pH of stomach contents (Ernstmeyer & Christman, 2023). Maintain a patent tube by flushing it after medication administration so that no medication stays in the tube and is not delivered to the individual when not intended. Utilize oral syringes for oral medications so they are not confused with IV syringes.

One of the most common routes for medication administration is intravenous. This is commonly used in a hospital setting, but can also be used in a long-term care facility. Medications administered intravenously are given through a vein; thus, they are directly delivered to the circulatory system and carried throughout the body. Various medications can be given intravenously, including antibiotics, blood pressure medications, TPN and lipids, pain medications, potassium, fluids, etc. These IV entry points are often found in the hand or arm, but can also be accessed in the feet or jugular vein. Because of the direct access to the bloodstream, medication absorption occurs quickly. An IV can be used many times if properly cared for. The intravenous route is more invasive than the oral route. Disadvantages include the fact that some people do not tolerate the pain of placing the IV well, the IV must be maintained properly to prevent clotting and damage, and it increases the risk for infection due to the direct access to the bloodstream and the penetration of the skin.

Central venous catheters are used for patients who may require longer medication treatment and need a more stable venous access than a regular IV. These may also be indicated for specific medications or substances, such as TPN or lipids, or when long-term medication administration is required, as can be the case with some antibiotic treatments. Peripherally inserted central catheters (PICC) are one example of a central venous catheter. Due to the proximity to the heart and the direct access to the circulatory system, central lines are treated with extreme caution and care. Sterile and routine dressing changes are required to maintain a healthy site and prolong the central line's usage. Many other forms of central lines are used in healthcare settings and are not discussed in this course. It is important to know central lines, their indications, and how to care for them.

Intramuscular (IM) refers to medications given into the muscle. IM injections are given in thick muscle tissue, such as the buttocks, thighs, or biceps. The IM route is often used for analgesics, epinephrine, naloxone, antibiotics, and vaccines. The medication is injected into the muscle through this route, where it is absorbed and transferred into the bloodstream. It is effective when venous access is not required or there isn’t time to obtain venous access (administering epinephrine during an anaphylactic reaction), when oral medications are not tolerated, or in a situation where a patient needs a medication but is not compliant (such as with an agitated and confused patient needing haloperidol)(Kim & De Jesus O, 2023). There are varying gauges of needles used in IM injections based on the size of the patient and the muscle, as well as the thickness of the substance being injected. This route is commonly used in outpatient settings and has relatively low risks.

SQ stands for the subcutaneous route. Subcutaneous refers to the fatty tissue found between the skin and the muscle. This injection form is less common, but is used in specific medication administration, such as insulin, monoclonal antibodies, and blood thinners like heparin. The most common places for a subcutaneous injection are in the fatty tissue of the stomach, the front of the thigh, or the underarm. If administering the medication in the stomach, avoid the 2 inches around the navel (Kim & De Jesus O, 2023). Such injections are given by pinching the skin to gather the subcutaneous tissue and inserting a small needle to deliver the medication. The subcutaneous route is used when a medication needs a faster absorption/bioavailability than the oral route can provide, or when the intestinal tract can’t effectively absorb the drug due to its molecular size (Kim & De Jesus O, 2023).

Types of Injections

Inhalation is an effective route for medication administration because the lungs have a large surface area, which allows for increased absorption. Additionally, the lungs are in close proximity to blood flow (Kim & De Jesus O, 2023). Inhaled medications are most commonly used for respiratory conditions or infections, such as asthma, COPD, or bronchitis. Steroids for respiratory conditions are commonly administered through inhalation. Administering medications through this route requires careful monitoring and proper training so that the individual receives the right amount of medication within a specific time frame. Specialized equipment to dispense the medication is required for administering these medications (Le, 2024). This may include an inhaler device or a nebulizer. Inhaling medication allows for direct dispersion to the lungs and, thus, is extremely effective for individuals who require this type of medical treatment.

Sublingual means “under the tongue”, and buccal means “cheek.” Medications taken by these routes dissolve and do not require chewing or swallowing. Medications administered through these routes are absorbed more quickly than when taking medications orally (PO) because they are absorbed through the tissue under the tongue or between the gum and the cheek, and are transferred into the bloodstream. Medications absorbed via the sublingual or buccal route bypass the liver, which is beneficial in some instances. For example, Nitroglycerin is administered sublingually. If it were to be taken by mouth, the liver would clear approximately 90% of the medication, which decreases its effectiveness significantly (Kim & De Jesus O, 2023). This route is quick, painless, convenient, and has a low risk of infection.

There are many other routes for medication administration, many of which target the area, organ, or tissue directly affected. Examples that are common in a long-term care setting include:

• Intravaginal: Hormonal medications are commonly administered intravaginally. These medications may be a cream, gel, ring, suppository, solution, or tablet. During menopause, estrogen is often given vaginally to relieve uncomfortable symptoms associated with menopause (Le, 2024).
• Rectal: This route allows for quick absorption, can be used in emergencies, has low risk factors, and can administer large amounts of medication. It is also often used for patients with digestive tract complications that may interfere with the absorption of oral medications (Kim & De Jesus O, 2023). The disadvantage is that it can be embarrassing or uncomfortable for some patients.
• Intraocular: Medications used to treat local eye conditions, such as dry eyes, glaucoma, conjunctivitis, or even injuries, are often administered through the eye (Le, 2024). Medication delivery through this route is effective but can be stressful for the patient. For intraocular medication, it is important to use gloves and not touch the eye with the dropper.
• Topical: These medications are administered on the skin and can target the specific part of the skin affected by a condition, infection, or disease. They are in the form of gels, lotions, ointments, powders, solutions, or creams. Examples include antifungals, antibacterials, or steroids (Le, 2024).
• Transdermal: Medication is delivered through the skin and enters the bloodstream. This can include gels, ointments, and transdermal patches, such as fentanyl patches (Kim & De Jesus O, 2023)
• Otic: Medication is delivered through the ear, typically through the outer ear canal. This route treats ear issues, such as infection or inflammation. Examples of medications that are administered in the ear are hydrocortisone (to relieve inflammation), ciprofloxacin (to treat infection), and benzocaine (to numb the ear) (Le, 2024).
• Intranasal: Medication is delivered through the nose. Medications given through this route are typically decongestants for allergies or colds. Recently, the FDA approved an epinephrine nasal spray for the treatment of anaphylaxis (US Food & Drug Administration, 2024). Other medications that can be given through this route are used for treating diabetes insipidus or osteoporosis. These medications are absorbed in approximately 30 minutes and are easy to administer. The nasal mucosa also has increased permeability compared to the gastrointestinal mucosa (Kim & De Jesus O, 2023).

Medication preparation can be a potential source for spreading bacteria and viruses if it is not done with caution.

• Maintain a clean medication cart or station free from clutter and mess.
• Always disinfect the area.
• Always wash your hands and use gloves to prepare medications. Washing hands with soap and water is the most effective way of cleaning your hands. Hand sanitizer is appropriate in many instances, but hand washing should always be done when hands are visibly soiled.
• Always use hand hygiene when entering and exiting patient rooms to prevent the spread of disease.
• Place medications directly in a medication cup or syringe.
• If you use a syringe, always cap it.
• If using a pill cutter or crusher, ensure it has been cleaned.
• If you drop a pill, throw it away.

Creating a distraction- and interruption-free preparation space can improve medication administration and reduce the chances of errors during preparation.

• Keep the medication cart or station organized without any personal items.
• Limit distractions by informing others in your facility that you are preparing medications.
• Medications must also be prepared for one individual at a time. Preparing multiple medications for multiple individuals can lead to confusion and accidental medication errors.

Reviewing resident allergies is one of the duties of a nurse and an essential step in medication preparation. Allergies to medications, foods, and the environment should be documented in a resident’s chart in an obvious location. Reviewing allergies can help prevent dangerous medication errors. Residents should never be prescribed a medication they are allergic to. However, reviewing allergies before medication administration is a way to catch errors and maintain the safety of those within the facility.

An important aspect of medication administration is understanding why a medication is being given, how the medication works, and assessing the patient before medication administration. Pre-administration vitals should be assessed for some medications, such as blood pressure and pain medications. For instance, if a patient is experiencing a fever and PRN acetaminophen is appropriate, assess the individual’s temperature before administration and after the acetaminophen has had a chance to take effect. Assess pain scores before administering an analgesic, and again post administration. Many other medications require pre-administration assessments. Nurses must use critical thinking skills to recognize what assessments must be completed. Nurses are trained to recognize abnormalities, and it is their duty to respond appropriately in terms of medication administration, which, at times, may include withholding a medication if it is deemed unsafe to administer. In such a situation, notify the prescribing provider immediately and document. Assess the resident and the situation; don’t just pass the medication.

The Institute for Safe Medication Practices (ISMP) defines high-alert medications as “drugs that bear a heightened risk of causing significant patient or resident harm when they are used in error (wrong drug, wrong dose, wrong route, wrong resident)(2021).” Nurses should be aware of such medications to promote resident safety.

Another tool to aid in safe medication administration is the Beers Criteria. The American Geriatrics Society created “The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults” to help providers safely prescribe medications to people 65+ (Cleveland Clinic, 2023). These criteria can be helpful for nurses to reference when caring for residents in long-term care.

The Beers Criteria includes (Cleveland Clinic, 2023):

• Medications to avoid if you’re over 65 years old and not in a hospice or palliative care setting
• Medications to avoid among those with certain health conditions
• Medications to avoid that can cause drug-drug interactions
• Medications to avoid because of harmful side effects that outweigh the benefits
• Medications that should be used at limited doses or avoided because of their impact on kidney function

“The Beers List” contains almost 100 medications. The Cleveland Clinic has provided a list of some of the medications that are on that list and why they are dangerous (Cleveland Clinic, 2023):

Click here for the most updated American Geriatric Society Beers Criteria(AGS, 2023).

Recognizing which medications have higher risks and why they can harm individuals is essential to medication administration. Knowing how high alert medications work, why and when they are prescribed, and what precautions must be taken will improve patient safety and prevent inappropriate medication administration. Having reference lists on medication carts can be a resource for nurses preparing medications. Thorough training on high-alert medications must be prioritized. This will improve patient care.