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Medication Administration In Nursing Practice Workbook (British Columbia College of Nurses & Midwives)

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Medication
Administration
BCCNM LEARNING MODULE — WORKBOOK
In Nursing Practice
Introduction
This workbook offers activities that allow you to apply ideas presented in the
Learning Module. It is organized in four sections.
• Part 1 includes Workbook Activities that are related to various topic areas
addressed in the Module. As you work through the module, you will
be directed to complete a specific Workbook Activity. Part 1 also includes pages
for you to record your thoughts related to learning in this module. There are
two pages: “Thoughts from Reflection Points” provides a space to jot down your
thoughts related to “Reflection Points” , while “Insights and
affirmations” provides a space to note new insights related to your medication
administration practice. This information will be useful for you in completing your
Growth Plan at the completion of this module.
• Part 2, “Applying My Learning”, includes case scenarios and associated questions.
Completing the questions related to the cases provides an opportunity for you to
apply the information that has been offered in the module in the context of
practice-based scenarios. These cases are organized from relatively straightforward
to more complex. When you have completed the questions, you may wish
to compare your responses with those provided in the “Applying my Learning:
Perspectives” located in Part 4.
• Part 3: This section of the workbook provides an opportunity for you to create a
plan for your continued professional growth. A sample Professional Development
Plan is provided to help you in this process.
• Part 4 presents sample responses to Workbook Activities and the case included
in Part 2: “Applying My Learning”. These responses provide the perspectives of the
course writer and others.
page 2medication administration in nursing practice workbook
Part 1
Workbook Activities
Workbook Activity #1
page 4medication administration in nursing practice workbook
Before you return to the module, take a few moments to reflect on this activity and your conclusions from the
related Reflection Point. What have you learned about your nursing practice related to management of client
information? Were aspects of your nursing practice affirmed by this workbook activity? Or perhaps you gained
some new insights regarding areas that challenge you?
Record these conclusions on the “Affirmations and Insights” page located on page 13 of this Workbook. At the
completion of the module, you will have an opportunity to use the insights and affirmations gained in various
learning activities, as part of your planning for future professional growth and development.
Consider the following questions. Record your responses in the space in your Workbook. These thoughts, ideas,
and responses will help you decide what you would like to focus on in this module. They may also form part of
the basis for your ongoing professional development planning and Quality Assurance requirements of self-
documentation.
1. What are my strengths in relation to medication administration?
2. What aspects of medication administration would I like to know more about?
3. Am I aware of the resources available that can support my practice in relation to medication administration?
1
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Workbook Activity #2
1. Think back to the case scenario, and pretend you are Yvonne. Would you leave the medications for Mrs.
Nemeth to take, and leave to finish medication administration with the rest of your clients? Why or why
not? If not, what would you do? What contextual factors from the scenario are influencing your choices
and decisions? Write your thoughts in the space provided. You may wish to compare your answers with the
discussion in Part #4, Perspectives at the end of this Workbook.
2. Reflection Point
Think of a time in your own practice where you made a decision in relation to medication administration. It
could be anything….you may have decided to hold a medication; you may have decided to give medications in
a different order; you may have decided to have a colleague double check a calculation; you may have called a
physician for an order, etc.
Once you have thought of scenario, think about the contextual factors that influenced your thoughts, decisions,
and actions. Would you have made different decisions, or done other things differently if circumstances, or the
context, were different? How did the context influence you?
Record your thoughts on the “Affirmations and Insights” page of this workbook. At the completion of the
module, you will have an opportunity to use the insights and affirmations gained in various learning activities,
as part of you planning for future professional growth and development.
2
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Workbook Activity #3
This activity provides an opportunity for you to consider the interrelationships between your medication
administration, various directing and influencing factors, and client outcomes.
1. Return to the client situation that you recorded in Workbook Activity #2. Using the conceptual map of
medication administration included in this module, explore your medication administration processes in this
situation.
• What factors provided the most direction for your decision and actions in this situation regarding medication
administration? Was it legal considerations? Professional requirements? Personal knowledge, judgments, and
ethical perspectives?
• How did you administer, or not administer, the medication in this situation? Is the client’s experience reflected
in your process? Did your process include assessment data, evaluation, and client outcomes? Did you document
your process?
• If the situation involved other interacting with other health care professionals, is that evident in your process?
• Does your medication administration process support you and other health care professionals in providing safe,
appropriate, and ethical client care?
3
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Workbook Activity #3 (continued)
2. Reflection Point
Now take a few moments to reflect on this section of the module and the other Workbook activities you have
completed. What have you learned about your medication administration processes in your nursing practice?
Were aspects of your medication administration process affirmed by this discussion and workbook activity? Or
perhaps you have experienced some new insights regarding the extent to which your medication administration
processes fulfills professional responsibilities in the provision of safe, appropriate and ethical client care?
Record these conclusions on the “Affirmations and Insights” page of this Workbook. At the completion of the
module, you will have an opportunity to use the insights and affirmations gained in various learning activities,
as part of your planning and future professional growth and development.
3
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Workbook Activity #4
This activity will give you the opportunity to familiarize yourself with how the Provincial Drug Schedules
specifically relate to your own nursing practice.
1. Click on the BCCNM Medication Resource Link in this module, or download the pdf onto your computer
https://www.bccnm.ca/Documents/learning/modules/MAlearningresources.pdf
Review the 6 categories of drug schedules, and consider how they control your medication administration
practice. You will notice that whether or not you require an order to administer a medication depends on
whether you are treating a nursing diagnosis of a condition, or a medical diagnosis of a disease or disorder. If
you are unsure about the difference between a nursing diagnosis of a condition and a medical diagnosis of a
disease, please first return to the module, and click on the link to the module on UNDERSTANDING THE
SCOPE OF RN PRACTICE (https://www.bccnm.ca/Lists/Learning_modules/rnscope/player.html)to review.
Once you have done so, please fill in the following table with examples from your own practice area. When you
have finished, please return to the module.
RN administers drugs following
nursing diagnosis of a condition
BC Provincial Drug Schedules RN administers drugs following
diagnosis of a disease or disorder
Schedule I drugs require a
prescription from an authorized
health professional.
Schedule IA drugs in the
Controlled Prescriptions Program.
Schedule II drugs do not require
a prescription, but are kept in an
area of the pharmacy where there is
no public access or opportunity for
client self-selection.
Schedule III drugs may be sold
by a pharmacist from the self-
selection area of the pharmacy.
4
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Workbook Activity #5
In this activity you will explore the direction provided within BCCNM regulatory documents for your
medication administration processes in nursing practice. The documents can be accessed by links in the
learning module or directly from
RN: https://www.bccnm.ca/RN/PracticeStandards/Pages/Default.aspx
NP: https://www.bccnm.ca/NP/PracticeStandards/Pages/Default.aspx
Review the BCCNM Professional Standards for Registered Nurses and Nurse Practitioners. As you review
the standards and associated indicators, consider how they relate to your medication administration
processes.
In what ways do the standards and indicators provide direction for competency related to medication
administration in nursing practice? Write your answers below.
5
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Workbook Activity #6
Answer the following questions. Remember, you do not need to share your answers with anyone. This exercise
is intended to assist you to become aware of how you utilize the Practice Standard Principles for medication
administration in your practice, and identify any areas for further learning and growth in your practice.
1. How familiar am I with the Practice Standard Principles for medication administration? Do I regularly
independently apply the principles to my practice? Write these thoughts down in the space below
2. Do these principles offer insights or solutions for areas of medication administration that you are unsure of or
find challenging?
3. What is best practice in receiving verbal or telephone orders in my practice at my place of employment?
4. Does my agency have an official list of approved abbreviations, acronyms and symbols to help eliminate sources
of medication errors? Where can I find this list? Am I familiar with them?
5. What is best nursing practice if I receive an order for an off-label use of a medication?
6
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Workbook Activity #6 (continued)
6. What are the high alert medications? Why are they considered “high alert”?
7. What is one condition that I diagnose and treat in my practice?
8. What medication can I administer without an order to treat this condition?
9. What is one medication that I require an order to administer in my practice setting?
10. Which health professionals can order medications in my practice setting
6
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Workbook Activity #7
In this activity you will explore the direction provided within the BCCNM Scope of Practice Standards for
medication administration in specific circumstances. This document can be accessed by a link in the online learning
module or directly from https://www.bccnm.ca/RN/ScopePractice/Pages/Default.aspx. You will need to access
Sections 6 and 7 in this document.
Begin by reviewing the BCCNM Scope of Practice Standards. Please pay particular attention to Sections 6 and 7. As
you read the Standards, reflect on the direction they provide for your medication administration processes in your
nursing practice. Is any of this information new to you? How do these Standards offer specific direction applicable to
your area of practice? Record your thoughts below. You may find it helpful to review the Provincial Drug
Schedules at this time. The Drug Schedules can be accessed by a link in the online learning module. You may find the
summary of the Drug Schedules that is provided in the BCCNM Medication Resource on useful as well at https://
www.bccnm.ca/Documents/standards_practice/rn/3medications.pdf
7
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Workbook Activity #8
Each agency and employer may have different policies regarding nurses’ practice in relation to medication
administration. This activity will direct you to familiarize yourself with the specific employer policies, and
control on medication administration within your nursing practice. Find out what are the specific employer
policies in your agency that restrict your practice in relation to medication administration. Record these below.
8
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Workbook Activity #9
Reflect on your own practice in terms of medication administration. Here you are considering the top level of
controls on practice. What knowledge, skills, judgement, and attitudes do you hold that may effect your practice
in relation to medication administration? Write these ideas down.
Consider: What do I need to find out, or do, in order to meet any gaps? Think broadly while you do this, and
remember, you do not need to share this with anybody! This learning activity will form part of your learning
plan for ongoing professional development.
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Workbook Activity #10
Here are a number of examples of clinical situations involving medication administration. Choose which level
of control is influencing the process for each situation and place it in the appropriate box in the table following
these scenarios under “Example”. Then try to identify the relevant application to the medication process. The
first one is done for you as an example. You may wish to compare your answers to the ones provided in the Part
#4: Perspectives section at the end of the Workbook.
Situation 1. A surgical RN knows her agency policy requires clients with dopamine drips to be monitored in
the ICU. She consults with the ordering physician and arranges to have the client transferred to ICU as soon as
possible.
Situation 2. A medical RN assesses a diabetic client with low blood glucose, diagnoses hypoglycaemia and gives
D50W IV.
Situation 3. A medical RN follows the BCCNM limits and conditions and uses an established DST when giving
D50W without an order.
Situation 4. An ER nurse gives Diazepam 5 mg IV (Schedule I) to an adult with severe anxiety following a
doctor’s order.
Situation 5. A camp RN assesses a 12 year old with wheezing and shortness of breath after a bee sting, diagnoses
anaphylaxis and gives epinephrine IM.
Situation 6. An RN reviews the BCCNM Standards of Practice and determines if she or he can manage the
intended and unintended outcomes of giving a particular medication.
Situation 7. A Camp RN follows the BCCNM limits and conditions and uses an established DST when giving
epinephrine without an order.
Situation 8. An RN receives an unfamiliar drug order, check the drug formulary and then calls pharmacy for
more information.
Situation 9. A residential care RN gives a nitroglycerin sublingual tablet (Schedule II) to a client who complains
of chest pain
10
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Workbook Activity #10
Application to the Medication
Process
Levels of Control Example
Individual Competence
Employer Policies
Standards, Limits, Conditions
Regulation
RNs are familiar with employer
policies related to medication
1. A surgical RN knows her
agency policy requires clients with
dopamine drips to be monitored
in the ICU. She consults with the
ordering physician and arranges to
have the client transferred to ICU
as soon as possible.
10
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Workbook Activity #11
Please click on the link on the bottom of this page to access the BCCNM Practice Support Medication
Resource. You may wish to download this tool onto your computer, or perhaps even print it out, if you prefer.
Once you have done so, take some time to glance through this tool, then read Mark’s story and use this tool to
help your consideration of his role and actions in this situation.
I was working in an intensive care unit in a large quaternary care teaching hospital caring for a critically
ill young man who was a multi-trauma victim with severe sepsis and multiple organ failure. He was very
unstable, and treatment wasn’t working. During critical care rounds, it was decided to try him on a course
of an experimental drug that was supposed to stabilize cell membranes. The physicians involved received
permission from the agency, and made arrangements for the medication with the pharmacy. However, I
wasn’t sure what my role was, or what to do in regard to giving this experimental drug.
Your Thoughts/Suggestions:
BCCNM Practice Support Medications Resource:
https://www.bccnm.ca/Documents/standards_practice/rn/3medications.pdf
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Workbook Activity #12
Before carrying out a medication order, nurses determine that the order is clear, complete, current legible and
appropriate. Nurses also verify that the order, pharmacy label and/or MAR are complete. Consider the following
questions and jot down your thoughts. You may find it useful to refer to the web page below for standards and
resources that might help you answer these questions.
What should the nurse do if an order is incomplete?
Are there any circumstances in which a pharmacy label can be used as an order?
In what situation can a list of a client’s current prescribed medication be used as an order?
13
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Workbook Activity #13
Read Belinda’s story, and consider how the seven rights “fit” within the situation. Is there anything that could be
done differently? If so how? Record these answers below. You may wish to compare your answers those in Part
#4, Perspectives at the end of this Workbook.
Belinda is a registered nurse working on an orthopedic unit.
I was working nights one shift when Mr. Yao, an elderly gentleman who had just had a hip fracture repaired
two days earlier, appeared to be getting more and more confused. As the evening went on, he progressed
from being a little mixed up about the date and time to being completely confused and agitated. Despite
administering analgesics to control his pain, Mr. Yao repeatedly tried to get out of bed, and tried to physically
fight the nurses. We called the physician, but he was not available. We were getting really worried that Mr.
Yao would hurt himself, or possibly one of us. I had looked in his MAR to see if there was a medication for
agitation ordered for him, but there wasn’t. One of the other nurses working that night also looked at Mr.
Yao’s MAR, and noted that he had Gravol ordered for nausea, as well as the standard narcotic analgesics. She
suggested we try giving him some Gravol, thinking it might work to help sedate him so that he wouldn’t hurt
himself.
Suggest an alternative course of action for Belinda to take in order to help Mr. Yao.
13
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Workbook Activity #14
ROHAN’S STORY
I work in an oncology unit. Recently our health care authority has had problems with one of its main
medication suppliers. We have not been able to obtain enough of the usual medications we use, due to
a factory problem causing a shortage. This has caused many problems for the nurses with medication
administration. Sometimes medications are substituted with different strengths, and sometimes even
different medications. It is very stressful, and we are never sure if the medications we need will even be
available. One evening I was caring for Winnie, who was in the unit for her second round of chemotherapy
for ovarian cancer that had metastasized to her bowel. Winnie was suffering from nausea and vomiting,
and it was time for me to give her more of her anti-nauseant. I went to the medication room with the MAR
to calculate how much antinauseant I needed to reconstitute. I worked out the drug calculation and found
Winnie needed 95 mg. However, there were no large vials of the medication left. The only vials of that
medication were single-dose vials with 10 mg of the medication in each vial, and there were hardly any of
those left. I counted out the 10 vials I would need to draw up the needed amount of medication. It was very
frustrating for me. I needed 95 mg, so I would be wasting half of a vial of medication we were short on!
One of my colleagues was in the medication room with me and suggested I save the rest of the medication
in the partially-used vial for the next dose. I thought about it; the remaining medication was still sterile. If
I saved a few of these, I would have enough for another dose. I know my agency has a policy that single use
medications vials are to be discarded after one use, but in a shortage situation, I worry that I won’t be able to
access any more of the medication for my patients who need it.
Consider Rohan’s situation. This type of dilemma is not uncommon in practice. There are many contextual
factors impacting Rohan’s decision making here. In this learning activity, you will have the opportunity to
utilize BCCNM resources, as well as other resources provided in this module, to outline a process to help
Rohan decide what to do. This learning activity also provides you the opportunity to investigate the resources
and guidance available to you within your own area of practice Some of the resources you may wish to consult
as you complete this activity include the BCCNM Clinical Decision Making Module, the 7 Rs of medication
administration, the BCCNM Medication Administration Practice Standard, the BCCNM Medication Resource.
These links are included in the Resource Section of the Module. You may also want to discuss this with your
clinical nurse educator and review your agency’s policies and procedures.
The decision making process you outline will establish a guiding framework that you can use in the future
in your nursing practice in regard to medication administration, and assist you to meet your Continuing
Competence needs.
14
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Workbook Activity #14 (continued)
To get you started, answer the following key questions. On you have finished please reutrun to the module for
further discussion.
1. Consider Rohan’s situation. What are the contextual factors influencing his medication administration decision?
2. Consider the directives for medication administration. What specific guidance do these provide?
3. Refer to the BCCNM Medication Administration Practice Standard and the BCCNM Medication Resource.
Identify the specific guidance they provide for this situation.
4. Consider the 7 Rs of medication administration. Apply these to Rohan’s medication administration decision.
14
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Workbook Activity #14 (continued)
5. Consider any other resources (if any) that may help you help Rohan come to a medication administration
decision. Identify them here, as well as the guidance they provide.
6. Make a decision for Rohan’s situation, and identify what his course of action should be.
7. Outline the key steps that helped you come to this medication administration decision. This is your own guiding
framework for medication administration decisions
14
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Workbook Activity #15
Think over the last few weeks you have worked, and consider some of the times you needed to perform a drug
calculation. How was that experience for you? How confident are you in your drug calculation skills? Is this
something you find relatively easy, or challenging? What are some strategies you may have to meet any gaps in
this complex skill set?
Use your systematic inquiry skills to seek out sources of drug calculation education. List these here.
15
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Workbook Activity #16 (continued)
Recall the scenario where Teresa gave her client too much insulin. To help you remember the details of the
situation, it is printed here for you to refer to. Review the case, and then analyze it in the table on the next page.
Summarize the error or errors in the left hand column, then for each error, identify which Practice Standard
Principles were not maintained (including the 7 rights, if applicable), the influencing contextual factors and
levels of control, and then suggest some strategies to prevent this type of error from occurring again. Once you
have completed this activity, please return to the module for further discussion with this case
TE RE SA’ S STO RY
I had just started my shift on the cardiac care unit. The unit was extremely busy, and we were short an RN.
It was my first shift after a set of days off. I didn’t know any of the patients, and the unit was chaotic with a
bunch of new admissions. One of the cardiologists had just done rounds and most of my patients had new
orders. Mr. Dyer was one of my patients and he was due for his insulin. I had checked his glucometer and his
glucose was high. I went to look at his sliding scale, but there were new orders. For his current blood glucose
of 9.2, I read the new order the doctor had just handwritten. It said, for blood glucose 8.9-10.0, give Humulog
20 sc. I got the insulin, checked the vial to be sure it was the right insulin, and drew up 20 units of insulin.
I had another nurse check what I had drawn up, then I went to Mr. Dyer’s room. I checked his wristband,
and explained I was going to give him his insulin. He said ok and I prepared his skin and administered the
insulin. I gave him his call bell and told him I would be busy with other patients for the next while, and to
use the call bell if he needed anything. I documented the injection and went to see my next patient. About
half an hour later, I was busy with other patients when Mr. Dyer’s call bell went off. When I went in his room,
his face was pale and diaphoretic. His hand on the call bell was shaking and he had trouble talking to me.
He was clearly confused and drowsy. I immediately thought he was having an insulin reaction, so I grabbed
a glucometer and tested his blood glucose: it was only 1.8! I called for some help and we treated him with
D50W. Fortunately, he was ok. When we reviewed the incident, it turns out that the order had been written
Humulog 2 u, not 20. I mistook the abbreviation “u for units” as a 0. I realize now I should have questioned
the amount of insulin. But I didn’t know the patient, I didn’t know his usual amount of insulin, and I was in a
rush. That was one of the worst moments in my career, realizing I had overdosed him on insulin.
Practice Standard/
Principle Involved
Error Contextual Factors
(temporal, social,
political, physical etc)
Strategies to Prevent the
Error
16
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Workbook Activity #16 (continued)
2. How did you do? Did working through this case study bring up any ideas about your own nursing practice?
Record your thoughts and reflections in the “Affirmations and Insights” page at the end of this section.
Practice Standard/
Principle Involved
Error Contextual Factors
(temporal, social,
political, physical etc)
Strategies to Prevent
the Error
16
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Workbook Activity #17
Below is a list of some common causes of medication errors. Identify some potential strategies to reduce these
errors. These may be systems strategies or personal strategies. You may use any of the module learning resources
to help you with this which may be found in the link below. Suggested resources to consider include the
Medication Administration Practice Standard, the BCCNM Medication Resource Guide, the ISMP website and
your own agency’s practice standards and procedures. Record these answers below. You may wish to compare
your answers those in Part #4, Perspectives at the end of this Workbook.
1. Lack of knowledge about the medication by the person prescribing or administering it.
2. Failure to ensure the 7 Rights of medication administration
3. Miscommunication among professionals
4. Incomplete client information
5. Confusing directions for use
6. Use of error-prone abbreviations.
7. Transitions in care such as meal breaks.
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Workbook Activity #17 (continued)
8. Poor technique.
9. Heavy workload/ inadequate number or type of staff.
10. Errors in transcribing orders.
11. Illegible or erroneous orders.
12. Interruptions during the preparation or administration of medications.
How did you do? Y
ou are probably able to think of many other potential causes of medication errors specific to
your area of practice. In the space below, list as many potential causes of medication errors from your practice
area that have not already been discussed. Once you have done that, jot down some strategies that may reduce
these errors. These may be systems strategies or personal strategies. And remember, the BCCNM has Practice
Support staff to assist you with some of these strategies!
BCCNM Medication Administration Web Page:
RN: https://www.bccnm.ca/RN/PracticeStandards/Pages/medication.aspx
NP: https://www.bccnm.ca/NP/PracticeStandards/Pages/medication.aspx
17
Thoughts from Reflection Points
page 28medication administration in nursing practice workbook
Medication Adminstration
in my Nursing Practice:
Affirmations and Insights
page 29medication administration in nursing practice workbook
Part 2
Applying My Learning
Applying My Learning
Do you want more? In this section, Applying My Learning, there are more complex case scenarios
for you to work through in order to further integrate and apply the understanding you have built
throughout the module. This section is optional for those who want more practice applying what
you have learned to nursing practice. These case scenarios, while fictitious, are based on real-world
cases for your learning. Record these answers below. You may wish to compare your answers those in
Part #4, Perspectives at the end of this Workbook.
CA SE S TU DY # 1
Ed looks over Simone’s shoulder at the computer terminal as she reads over her email. “Looks like
you have an awful lot of email to get through!” he remarks as he reaches for a client chart.
“Yeah, there’s a bunch of notices from pharmacy over the last couple weeks , it looks like.” Simone
responds. “ I haven’t had a chance to read them all. I’m pretty sure it’s about all the medication
substitutions and changes. I don’t have time to go through the all now, either!” Simone shakes her
head as she gets up to attend to one of the three call lights that are on.
Ed nods in agreement. Between the memos from the health authority and the pharmacy the last
while, it was overwhelming.
“Besides, if it’s something really important, I’m sure Lynn will let us know” Simone states as she
logs off the computer.
Ed agreed. He’d worked in this surgical unit for 17 years now, and Lynn had been the manager for
the last 14 of those years. She was really good about letting the staff nurses know whenever there
were practice change decisions made and making sure everyone was informed. He turned and
went back to his charting.
A short time later, Ed goes in to see Mr. Sandover, who has a fractured femur and ankle from a car
accident. He has been scheduled to go in for orthopedic surgery to repair the fractures, but his
surgery has been bumped by an emergent bowel obstruction. Mr. Sandover is clearly in a great
deal of pain when Ed walks into the room: his face is pale and sweaty, his respirations rapid and
low moans escaping from his grimaced lips. After quickly assessing Mr. Sandover, Ed heads over
to the MAR to see when his last dose of analgesic was given. “Whoa…it’s been at least 6 hours
since he had anything for pain!” Ed realizes as he checks the MAR. “Poor guy, I’ve got to get on
that, I didn’t realize from report that it had been so long” as he heads to the narcotics cupboard.
Ed gets the narcotics key from Simone, and open the cupboard. As he reaches in to get the ordered
narcotic, he realizes that the multidose vial looks different than it usually does. Picking it up, he
examines the label. The drug had the same generic name as the usual, but had been provided by
a different manufacturer. Since there had been a problem with one of the health authority’s drug
manufacturer’s production plants, the hospital’s standard stock medications were sometimes
substituted with another medication from another manufacturer. “Probably one of those
pharmacy emails notified us about this change.” Ed thought. “Too bad I didn’t have time to read
them all.”
Ed carefully mixed and drew up the medication in the way he always has for this medication.
He takes it in to Mr. Sandover, and after checking his wristband, administers the intravenous
medication. “There, Mr. Sandover. This should help that pain. Here is your call bell, just press it if
page 31medication administration in nursing practice workbook
Applying My Learning
you need anything. I will be back in a little bit to see if you’re feeling more comfortable,” Ed tells
Mr. Sandover as he ensures the call bell is in reach. Ed leaves to go document the medication, and
carries on with his shift.
About twenty minutes later, Ed notices Mr. Sandover’s call light goes on. He walks into his
room, and looks at Mr. Sandover. He is pale and diaphoretic again. He looks slowly up at Ed and
mumbles semi-coherently, “I feel funny…”. Ed quickly checks Mr. Sandover’s vital signs and finds
his blood pressure very low as well as his level of consciousness decreasing. Calling outside the
room for some help, Ed starts positioning Mr. Sandover flat while he rapidly starts thinking about
what the problem could be….”He doesn’t have a history of diabetes, he hasn’t lost much blood
into that leg where the fracture is, he’s had a standard dose of XXXXXXXX”. Just then Bridgett
rushes into the room to help. Giving her a quick report on the situation, Bridgett asks how much
analgesic Ed administered. “The usual, XXXX mg IV” Ed answered. “It’s a new vial though, from a
different manufacturer”.
“Oh no,” Bridgett exclaims. “That new vial is the latest substitution from pharmacy from the
manufacturer. Those vials are a different strength…you have to dilute them way more than the
usual stock…they are XXXX mg/ml, not XXX mg/ml!”
Ed’s heart sinks to his stomach as he realizes he has overdosed Ms. Sandover with ten times the
ordered amount of narcotic. He immediately starts treatment for a narcotic overdose.
1. Review Ed’s medication administration process. In what ways does it meet the standards for safe,
appropriate, competent and ethical medication administration?
2. What medication error(s) are present? Are these human errors, systems errors, or both?
Identify these.
page 32medication administration in nursing practice workbook
Applying My Learning
3. Consider Ed’s situation. What are the contextual factors influencing his medication administration
decision?
4. Using the guiding framework for medication administration you developed in Workbook Activity
#16, describe how Ed should have proceeded instead. Identify the specific guidance your resources
provide.
5. Consider the contextual factors that influenced Ed, and the systems error(s) that may have happened.
What could be done to address these in a positive way?
Be as specific as possible in identifying strategies.
page 33medication administration in nursing practice workbook
Applying My Learning
CA SE S TU DY # 2
Tuesday 0730
Marnie looked over at the sun streaming in through the windows in the residents’ lounge. It was
going to be another beautiful day summer day. She smiled to herself; some of the residents in the
long term care facility she worked in had an outing planned to go lawn bowling. “Great weather,
isn’t it?” asked Melisa. Marnie looked up at Melisa from the MAR she was about to use to prepare
morning medications for the residents under her care. Melisa was a care aide who had worked
at the lodge since before Marnie had started here. Marnie enjoyed working with her; Melisa was
almost always energetic and cheery, and certainly very chatty. “I’m so glad the weather has worked
out, Mr. Goldstein would have had a fit if we’d had to cancel lawn bowling again! He’s so looking
forward to it!” Melisa laughed. Marnie nodded her head in agreement as she looked over the MAR
again, reading over the list of medications Mrs. Thornley was scheduled to have at 0800. Melisa
chattered on and on while noisily sorting out various pieces of equipment as Marnie prepared
the medications. Marnie frowned as she tried to concentrate on the task at hand. The medication
room was not solely dedicated to medications and preparation, and several other supplies were
stored in there as well.
Marnie reached for the various medications she needed. Mrs. Thornley had a complicated cardiac
history and advanced dementia, and she had many medications scheduled in the mornings. She
resided in the special care unit of the lodge. In the last few months, Mrs. Thornley had been
resistive and uncooperative with taking medications. The nurses had become very creative at
finding ways to encourage her to take her medications. Fortunately, the pharmacy that the lodge
dealt with were able to supply most of her medications in a liquid form. Mrs. Thornley was always
willing to take her medications mixed in with her favorite apple juice. Marnie had called the
pharmacy just a few days ago to request refills of her potassium chloride, and they were able to
bring that in liquid form too. She checked the label on the bottle against the MAR. The pharmacy
had fixed its computer generated label directly onto the bottle, which made it easy to check against
the MAR. As Marnie poured the required 30 mL into a med cup for a dose of 40 mEq, she noted
that the medication seemed to look a bit different. “hmm…” she thought. “This looks darker
than I remember the last bottle; isn’t potassium usually yellow? This looks a little orangey.”
Marnie picked up the bottle to check the label again. The pharmacy label clearly stated the date,
the patient’s name, Potassium Chloride, and the strength. The label was affixed directly over the
bottle’s own labeling, so Marnie picked up another bottle of potassium chloride to compare. The
bottles looked the same. “I wonder if I should call pharmacy..” Marnie mused. It had been a few
shifts since she last gave Mrs. Thornley her medications, and she couldn’t remember exactly.
Just then, a large crash behind her made her jump. Melisa looked at her guiltily, and said “oh,
sorry!”. An entire cupboard full of bedpans and other supplies was emptied out on the floor.
Marnie laughed. Melisa was always knocking something over, just like she was always talking. “I’ll
help you clean that up in a couple minutes, I’ll just give Mrs. Thornley her meds first”. Marnie left
the medication room, hurried to Mrs. Thornley’s room, mixed her medications into the apple
juice, and was successful in convincing her to drink the juice before rushing back to help Melisa
clear up the room so the rest of the residents’ medications could also be administered.
page 34medication administration in nursing practice workbook
Applying My Learning
Tuesday, 1700 hours
Heidi went into the medication room to prepare 1700 medications. The day had worked out really
well. She was glad the manager had decided to stagger the nurses’ shifts in order to have another
RN come in from 1100-1900. The new change in hours worked really well for her life, and it
seemed to really fit the lodge’s needs, too.
Heidi checked the MAR to prepare Mrs. Thornley’s medications. Marnie had told her that all the
meds were now in liquid form, since Mrs. Thornley had become so resistive to taking her pills.
“What a relief!” thought Heidi. “That poor woman couldn’t stand to take those pills no matter
what we tried. It’s just too bad that we have to give her meds more frequently now, since she won’t
swallow the sustained-release pills.” She lifted the bottle labeled Potassium Chloride, checked the
label against the MAR, and poured the required amount into a med cup, mixed it into a cup of
apple juice, and walked up to Mrs. Thornley’s room. She found the resident sitting in her armchair
by the window, dozing. She gently touched Mrs. Thornley’s shoulder to wake her. It took a few
tries before she would wake. “Mrs. Thornley, are you feeling ok?” Heidi asked. Mrs. Thornely just
gazed at Heidi lethargically. Heidi frowned. The feisty resident was typically much more likely to
yell at her when she walked into the room. With a great deal of encouragement, Heidi helped Mrs.
Thornley swallow her juice with her medication in it. She asked if Mrs. Thornley would like to
have a rest, and helped her settle into her bed for a nap. “I’ll need to let nights know how she is this
afternoon, this isn’t usual for her,” Heidi thought. “ I hope she’s not getting the flu or something.”
Wednesday, 1315 hours
Heidi called Melisa to help her in Mrs. Thornely’s room. Cheerful as always, Melisa popped into
the room singing to herself, but stopped as she saw Heidi struggling to help Mrs. Thornley take off
her clothes. “What’s up, ladies?” Melisa asked. This wasn’t a typical scene in Mrs. Thornley’s room,
as she noted Mrs. Thornley barely moving and certainly appearing unaware of Heidi’s efforts.
“I’m glad you are here, Melisa. Mrs Thornley has been incontinent, and I need to clean her up, but
she seems so out of it, she’s almost dead weight here!” Heidi frowned. “I wish I knew what time
Dr. Ko was coming in. I called her this morning and told her about how drowsy Mrs. Thornely has
become. She said she’d come in to see her, but she hasn’t arrived yet. I’m getting really worried.
I’ve called her daughter to let her know, and she is coming. I don’t want her mom to be in a mess
when she gets here.”
“Of course,” answered Melisa. Between the two of them, Heidi and Melisa managed to clean up
and re-dress the elderly lady, who seemed almost completely unaware of her surroundings. Heidi
pulled out a stethoscope as she felt Mrs. Thornley’s radial pulse, which was barely palpable.
“Melisa, I’m having trouble finding her blood pressure, it’s low. Can you see if the daughter is here
yet? Mrs. Thornley has a DNR, but they should know that she’s not well. Can you also ask Marnie
to call Dr.Ko again?” asked Heidi.
The daughter, Esther, was already at the lodge, but had been waiting outside her mother’s door
waiting for Heidi and Melisa to finish. Esther came in and sat with her mother, shocked at the
severe deterioration in her condition. She called other family members, and her two children
arrived to see their grandmother too.
page 35medication administration in nursing practice workbook
Applying My Learning
When Dr. Ko arrived and did her assessment, she asked to see the pharmacy list of medications so
she could review them. Marnie brought it to her. The two women sat down to look it over. “I don’t
see anything here that should cause this type of neurological deterioration,” said Dr. Ko. “I haven’t
changed any of her medications in several months.”
“Oh, right! I meant to ask the pharmacy, but forgot!” Marnie exclaimed suddenly.
“Ask pharmacy what?” responded Dr. Ko, looking puzzled.
“Mrs. Thornley’s potassium chloride…..the pharmacy changed it from pills to liquid because
we were having such a hard time getting her to take her meds. The liquid we can mix in juice and
she’ll drink it. But this one bottle looks different than what I remember it looking like…I meant
to call pharmacy about it, but forgot!” answered.
“It looked different, what do you mean by that?” asked Dr. Ko.
“The color looked darker,” answered Marnie. Dr. Ko frowned. “Why don’t we take a look? Just
in case. I can’t really come up with an explanation for Mrs. Thornley’s condition, unless she is
perhaps having an evolving stroke. “
Together, Dr. Ko and Marnie walked into the med room. Marnie retrieved the bottle of Mrs.
Thornely’s potassium chloride, which was almost empty. She poured some out into a med cup,
and Dr. Ko noted the orange hue. “Whoa, that doesn’t look like potassium to me,” she said. “Let me
see the bottle.” Marnie handed it to her. Dr. Ko noted the pharmacy label clearly stating ‘potassium
chloride’ on it. “That’s odd….” She murmured. “Is there more of this here?” she asked.
Marnie handed her an unopened bottle. The pharmacy label was identical, except on the new
bottle it had been affixed so that it did not completely cover the manufacturer’s label. Just then,
Marnie had a sinking feeling….she grabbed the first bottle, which had been mostly used up, and
pulled a corner of the pharmacy-affixed label off. “What are you doing?” asked Dr. Ko. “Just a
thought….” Marnie’s voice trailed off as she paled. “Dr. Ko!!! This is not potassium chloride!” she
exclaimed.
The bottle that had been almost entirely administered to Mrs. Thornley clearly stated, underneath
the pharmacy label, “Chloral Hydrate”. “Dr. Ko, chloral hydrate is a sedative! We’ve overdosed her
on a sedative!”
1. Review each nurse’s medication administration process (Marnie and Heidi). In what ways do they
meet the standards for safe, appropriate, competent and ethical medication administration?
page 36medication administration in nursing practice workbook
Applying My Learning
2. What medication error(s) are present? Are these human errors, systems errors, or both?
Identify these.
3. Consider this situation. What are the contextual factors that influenced the development of
this situation?
4. Using the guiding framework for medication administration you developed in Workbook Activity
#16, describe how both Marnie and Heidi should have proceeded instead. Identify the specific
guidance your resources provide.
5. Consider the human and systems error(s) that may have happened. What could be done to address
these in a positive way? Be as specific as possible in identifying strategies.
page 37medication administration in nursing practice workbook
Part 3
Growth Planning
page 39medication administration in nursing practice workbook
My plan for growth in
Medication Administration
Goals
1.
2.
3.
Action plan
People or places that I can investigate for learning strategies to help me meet my goals for growth are:
1.
2.
3.
Specific strategies that will help me in meeting my goals are
strategy resources i need
to implement this
strategy
target
completion
date
other thoughts
Reminder: Add your completed action plan to your Quality Assurance Portfolio.
page 40medication administration in nursing practice workbook
Medication Administration:
My Plan for Growth - An Example
Goals
1.
2.
3.
Action plan
People or places that I can investigate for learning strategies to help me meet my goals for growth are:
1.
2.
3.
Specific strategies that will help me in meeting my goals are
strategy resources i need
to implement this
strategy
target
completion
date
other thoughts
Reminder: Add your completed action plan to your Quality Assurance Portfolio.
To become more familiar with dosage calculations
Talk to Clinical Nurse Educator and/or Nurse Leader on Nursing Unit for suggestions about learning resources
Example: detailed plan
1. Review resources available in
my nursing unit
2. Review BCCNM resources
regarding medication
calculations
3. Complete Literature search
using CINAHL
1. None – just look on
the shelves & on the
Intranet at work!
2. Use work or home
computer to do this.
Web site URLs in
Learning resource
section of module
1. During my next set
of scheduled shifts
2. By end of this
month
3. By end of next
month.
Could ask the nurse educator
at work – maybe she can help
me with this?
Part 4
Workbook Activities & Case Perspectives
page 42medication administration in nursing practice workbook
Workbook Activity #2
There are a number of contextual factors that are influencing Yvonne’s decision in this case. Here are some to
consider when you answer this question. You may have other ideas as well.
Macro Level of Context:
• What are the rules, regulations, policies, standards, and guidelines that govern my medication administration?
What, if any, are the exceptions to these?
Meso Level of Context:
• What is my unit’s policy on self-administration of medications?
• How much time will it take for Mrs. Nemeth to be able to take these medications? How much time do I need
to finish medication administration with other clients?
• Would I have my manager’s support for the decision I make?
• Who I am working with today? Is there a coworker who could possibly help me?
Micro Level of Context:
• How well do I know Mrs. Nemeth? Has she self-administered these medications before? Is she aware of what
they are, their indications, expected effects and possible side effects?
• How comfortable am I with the options? What are my beliefs about each?
2
page 43medication administration in nursing practice workbook
Workbook Activity #10
Here are the module developers’ perspectives to this Workbook Activity. We will consider each level of
control, and its application to the medication process, then relate the relevant example to each.
Levels of Control Application to the
Medication Process
Example
Individual Competence RNs know and practise within
their own level of knowledge,
skill, and judgement related to
medications.
8. An RN receives an unfamiliar
drug order, check the drug
formulary and then calls pharmacy
for more information.
Employer Policies RNs are familiar with employer
policies related to medication.
1. A surgical RN knows her
agency policy requires clients with
dopamine drips to be monitored
in the ICU. She consults with the
ordering physician and arranges to
have the client transferred to ICU
as soon as possible.
Standards, Limits, Conditions Parts 2 and 3 in CRNBC’s Scope
of Practice for Registered Nurses:
Standards, Limits and Conditions
BCCNM Practice Standards
Medication Administration,
Dispensing Medications,
Medication Inventory
Management
6. An RN reviews the BCCNM
Standards of Practice and
determines if she or he can manage
the intended and unintended
outcomes of giving a particular
medication.
7. A Camp RN follows the BCCNM
limits and conditions and uses an
established DST when giving
epinephrine without an order.
3. A medical RN follows the
BCCNM limits and conditions
and uses an established DST when
giving D50W without an order.
10
page 44medication administration in nursing practice workbook
Workbook Activity #10 (continued)
Here are the module developers’ perspectives to this Workbook Activity. We will consider each level of
control, and its application to the medication process, then relate the relevant example to each.
Levels of Control Application to the
Medication Process
Example
Regulation RNs may compound, dispense,
or administer by any method a
Schedule I or IA drug with an
order (Section 7).
RNs may compound, dispense
or administer my any method a
Schedule II drug without an order
(Section 6).
RNs may dispense or administer a
Schedule I drug without an order
for the purpose of treating:
-anaphylaxis
-hypoglycemia
4. An ER nurse gives Diazepam
5 mg IV (Schedule I) to an adult
with severe anxiety following a
doctor’s order.
9. A residential care RN gives a
nitroglycerin sublingual tablet
(Schedule II) to a client who
complains of chest pain.
1. A camp RN assesses a 12
year old with wheezing and
shortness of breath after a bee
sting, diagnoses anaphylaxis
and gives epinephrine IM.
1. A medical RN assesses
a diabetic client with low
blood glucose, diagnoses
hypoglycaemia and gives
D50W IV
10
page 45medication administration in nursing practice workbook
Workbook Activity #13
The 7 Rights of medication administration include Right Client, Right Drug, Right Dose, Right Route, Right
time, Right Reason and Right Documentation (slide in points as they are narrated) In this case, Belinda’s
colleague has suggested using a prn dose of Gravol to help sedate Mr. Yao so that he does not hurt himself or
others. Although Belinda’s colleague’s intentions are good, Belinda should not administer the prn gravol to
sedate Mr. Yao. The order for prn Gravol was made to treat nausea, it was not ordered to treat agitation. Giving
prn Gravol to sedate Mr. Yao goes against one of the 7 Rights: Right Reason.
13
page 46medication administration in nursing practice workbook
Workbook Activity #17
1. know the drug
Be aware of look alike and sound alike drugs
Staff education
2. Ensure the 7 Rs
3. Communicate clearly. Use established communication channels for any changes. Double check any orders or
changes you are unsure of.
4. Know the client
Educate and encourage clients to become part of their own “safety net’ by being informed about their
medications.
5. Clarify any confusing directions with the physician and/or pharmacy.
6. Implement a system that reflects medication standards.
Be familiar with common error-prone abbreviations (ISMP)
7. Communicate clearly.
8. ensure 7 Rs.
Request assistance and/or further education if you are unsure.
9. Provide adequate work spaces and human and material resources.
10. educate and encourage clients to become a part of the safety net.
Communicate clearly.
Be aware of common error-prone abbreviations.
11. educate and encourage clients to become a part of the safety net.
Communicate clearly.
Be aware of common error-prone abbreviations.
12. know the client
Know the drug
Provide adequate work spaces and human and material resources.
Ensure the 7 Rs.
Double check medications that have a greater risk of causing significant harm when they are used in error.
17
page 47medication administration in nursing practice workbook
Case Perspectives
CA SE 1 : ED A ND M R. S AN DOV ER
1. Review Ed’s medication administration process. In what ways does it meet the standards for safe, appropriate,
competent and ethical medication administration?
Ed followed 6 of the 7 Rights in administering the medication, but he missed Right Dose. Ed also has not kept
up with the evidence that had been sent to him regarding changes and updates, although he is directed to do
so in both the Professional Standards and the Scope of Practice Standards.
2. What medication error(s) are present? Are these human errors, systems errors, or both? Identify these.
Ed did not recognize the change in the strength of the supplied medication; this is both a human and systems
error. It is a human error because Ed did not follow all 7 Rights, nor did he keep up with practice changes in
his unit. He should have paid closer attention to the dosage rather than assume that only the manufacturer of
the medication was different. It is also a systems error because the notice regarding the change in medication
strength should have been further communicated: ie., there should have been a notice on the narcotic
cupboard and on the medication alerting nurses to the dosage change. There should be a specific system or
process in place for the communication of medication changes to nursing staff.
3. Consider Ed’s situation. What are the contextual factors influencing his medication administration decision?
There are several contextual factors influencing Ed’s medication administration decision, mostly occurring
at the meso and micro level. At the meso level, Ed (and other nurses on the unit) were experiencing an
overload on email information; and they had no set time to review this information. Frequent changes of
manufacturers using different ‘looking’ medications, and the lack of pharmacy alerts on the medication and
the medication cupboard also were contextual factors. At the micro level, the temporal and social contexts
played a role in Ed’s medication administration decision because his client was in severe pain, and Ed was in
a hurry to alleviate it.
4. Using the guiding framework for medication administration you developed in Workbook Activity #16, describe
how Ed should have proceeded instead. Identify the specific guidance your resources provided. (see next page)
page 48medication administration in nursing practice workbook
Case Perspectives
In this case with Ed, one of the problems was at the first stage of the decision making framework: In
terms of context, Ed had not had time to read emails that let him know about the medication changes.
Without this knowledge, and without using his critical thinking skills at the time, Ed missed the change
in medication strength. He should have stopped at this point and recalculated the dosage. At the point
where he did not verify the right dose, he also should have stopped and recalculated. If he was unable to
recalculate for any reason, he should not have administered the medication and instead used one of his
resources for help.




BCCNM







• Rightclient
• Rightdrug
• Rightdose
• Rightroute
• Right1me
• Rightreason
• Rightdocumenta1on





A S S E S S M E N T A N D J U D G E M E N T
• Withinscopeofprac0ce
• Complete/accurateorderordirec0ve?
• Client:Assessment,judgment,needs,consent,etc.?
• Nurse:Assessmentofknowledgeandability
• Context:Systemsinplacetosupportsafemedica0onadministra0on?
YES?
page 49medication administration in nursing practice workbook
Case Perspectives
5. Consider the contextual factors that influenced Ed, and the systems error(s) that may have happened. What
could be done to address these in a positive way? Be as specific as possible in identifying strategies.
Nursing staff need time built into their schedule to keep up with the email notices if this is the approved form
of communication within nursing at the agency. Nurses need to understand their responsibility in keeping
abreast of this information. The employer should have a system in place that puts different alerts on the
narcotic cupboard and the narcotic package to get the nurses’ attention that the dosing had changed. The
employer should also have a specific, consistent process or system for communicating all medication changes
and alerts.
Nurses need to adhere to all 7 rights of medication administration and not short cut these, under any
circumstances. The agency’s educator could provide inservicing or other formal or informal education to re-
emphasize the importance of continuing to follow the 7 Rs, especially in times when there is frequent change.
Education around the importance of critical thinking, using a systematic process, and not doing procedures
out of habit, could be helpful. The previous nurse also should have administered pain medication sooner,
and may require some continuing education to support this.
Ed needs to write an accurate medication error report so that the systems issues as well as human errors can
be addressed and improved upon without blame or shame.
page 50medication administration in nursing practice workbook
Case Perspectives
CA SE 2 : MR S. THORNELY
1. Review each nurse’s medication administration process (Marnie and Heidi). In what ways do they meet the
standards for safe, appropriate, competent and ethical medication administration?
Although at first glance, both Marnie and Heidi followed the 7 Rights of medication administration, there
were some gaps in their administration process. First, Marnie had a suspicion about the medication when she
first poured it, since it was a different color. Nurses need to be aware that their concerns are legitimate and
may be serious, and she should have followed up with the pharmacy immediately.
2. What medication error(s) are present? Are these human errors, systems errors, or both? Identify these.
The medication error here is primarily human. The pharmacy made two errors: the label was attached to the
wrong medication, and it also obstructed the manufacturer’s label when it was placed on the bottle. However,
both Marnie and Heidi administered this medication to Mrs. Thornely. Marnie noted that the medication did
not look the same as usual; this suspicion should have been followed up on. Heidi noted a deterioration in
Mrs. Thornely’s condition, but it is not clear if she noted a difference in the coloration of the medication too.
3. Consider this situation. What are the contextual factors that influenced the development of this situation?
The contextual factors are both meso and micro. At the meso level, the pharmacy that made the error should
have had a system in place to make sure the right medication is labelled in the correct way. At the micro level,
Marnie was distracted by a tray crashing at the time of noting the difference in the color of the medication,
and forgot to followup with pharmacy as a result. She was also in a rush to help clear up the mess so that the
other residents’ medications could be administered. Also at the micro level, Mrs. Thornely was not able to tell
either Marnie or Heidi if she noted something unusual about the medication, such as a different taste.
4. Using the guiding framework for medication administration you developed in Workbook Activity #16,
describe how both Marnie and Heidi should have proceeded instead. Identify the specific guidance your
resources provide. (see next page)
page 51medication administration in nursing practice workbook
Case Perspectives
Decision Making Framework for Medication Administration




BCCNM







• Rightclient
• Rightdrug
• Rightdose
• Rightroute
• Right1me
• Rightreason
• Rightdocumenta1on





A S S E S S M E N T A N D J U D G E M E N T
• Withinscopeofprac0ce
• Complete/accurateorderordirec0ve?
• Client:Assessment,judgment,needs,consent,etc.?
• Nurse:Assessmentofknowledgeandability
• Context:Systemsinplacetosupportsafemedica0onadministra0on?
YES?
page 52medication administration in nursing practice workbook
Case Perspectives
In this situation, Marnie should have stopped at the point where she was feeling uncertain about the
medication that was in the vial. This is at the “nursing action” point on the framework. She should have
contacted the pharmacy and asked for assistance.
5. Consider the human and systems error(s) that may have happened. What could be done to address these in a
positive way? Be as specific as possible in identifying strategies.
The pharmacy needs to have systems in place to ensure that correct labels go on the right medication, and
that no medication label be put over the manufacturer’s label.
The nurse needs to be confident that her observations are important and that if she has questions about a
medication, that these are valid, legitimate and should be followed up on.
The nurse in this case needs to write a thorough and accurate medication error report that helps to identify
the underlying issues that led to this error.
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Medication Administration In Nursing Practice Workbook (British Columbia College of Nurses & Midwives)

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Completed 27 February 2021

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