NNA E5 AF5.

NATIONAL NURSING AUDIT MINISTRY OF HEALTH MALAYSIA

ELEMENT 5: CONTINUUM OF CARE

5.1 ADMINISTRATION OF ORAL MEDICATION

1. INTRODUCTION
The leading cause of patient harm is medication error, which accounts for
almost 6 percent of medical injuries.
(Annual Report Pharmacy Program, MOH, 2017)

“First, do no harm” is the ethical imperative for every patient safety effort. In
working towards reducing the frequency of medication errors, priority should
be given to prevent errors which contribute any potential for harm.

The definition of a medication error as approved by the National

Coordinating Council for Medication Error and Prevention is:

". . .any preventable event that may cause or lead to inappropriate

medication use or patient harm, while the medication is in the control of the
health care professional, patient, or consumer. Such events may be related
to professional practice, health care products, procedures, and systems
including: prescribing, order communication, product labeling, packaging
and nomenclature, compounding, dispensing, distribution, administration,
education, monitoring, and use."
(https://www.nccmerp.org/about-medication-errors, Retrieved 16 April 2019)

Administering oral medications is a core function of nurses. Their

responsibility is to comply with safe medication use processes and
practices in order to prevent occurrence of medication errors /
misadventures.

National Nursing Audit, Ministry of Health Malaysia : Version 6 / April 2019, Nursing Division, MOH Malaysia
Page 1
 NNA E5 AF5.1

2. STANDARD
2.1. Patient does not experience medication errors during hospitalization.

3. OBJECTIVES
3.1 All medications are served according to the 7 R’s of medication
administration.
 Right patient
 Right drug
 Right dose
 Right route
 Right time
 Right documentation
 Right to refuse

3.2 Nurses exhibit the caring component during the administration of

oral medication.
3.3. Nurses document the medication administered accurately and
completely.

National Nursing Audit, Ministry of Health Malaysia : Version 6 / April 2019, Nursing Division, MOH Malaysia
Page 2
 NNA E5 AF5.1

4. CRITERIA
Structure

1. Each patient has current written prescription / medication profile.

2. There is a Standard Operating Procedure (SOP) for administration of oral

medication.

3. The nurse is competent in serving medication, has knowledge on the

effect, adverse drug reaction and the appropriate measures to be taken when
there is an adverse reaction.

Process

1. Greet / acknowledge patient.

2. Identify right patient.

3. Verify prescription.

4. Assess patient, take appropriate nursing measures and document accurately.

5. Dish out the correct medication using 3 CHECKS:

5.1 Before dishing out
5.2 During preparation
5.3 After preparation

6. Explain and inform patient.

7. Listen/Responds promptly and politely to patient’s /carer‘s questions.

8. Serve and ensure patient consume the medication.

9. Document medication served / omitted.

10. Monitor patient’s response and document.

11. Take appropriate measure if adverse reaction is identified.

National Nursing Audit, Ministry of Health Malaysia : Version 6 / April 2019, Nursing Division, MOH Malaysia
Page 3
 NNA E5 AF5.1

Outcome

1. Patient received safe medication administration during hospital stay.

2. Patient was informed of his/her medication.

3. All medications are served according to 7 Rights (7Rs) of medication

administration.

4. Medication errors are detected early and appropriate measures taken

accordingly.

5. Accurate and complete documentation.

5. METHODOLOGY

5.1 Design : Direct observation of nurse administering oral

medication and also gather information from
documents
5.2 Setting : All wards
5.3 Inclusion criteria : Medication served to all in-patient
5.4 Exclusion criteria : Medication served to out-patient/ unconscious/
mentally challenged patients
5.5 Population : Registered Nurse
5.6 Sample Design : Convenient sampling
5.7 Sample size : 30% of registered nurse working in patient
area
5.8 Time frame : 6 weeks
5.9 Instrument : Audit Form (E5 AF 5.1) -– one audit form for
one observation

National Nursing Audit, Ministry of Health Malaysia : Version 6 / April 2019, Nursing Division, MOH Malaysia
Page 4
 NNA E5 AF5.1

6. DEFINITION OF OPERATIONAL TERMS

6.1. WRITTEN PRESCRIPTION

Any legal orders of oral medication endorsed in patient’s medication
profile and patient’s case notes.

6.2. MEDICATION PROFILE

Legal document where the doctor prescribes and the nurse endorse
the administration of the medication.

6.3. IDENTIFY RIGHT PATIENT

6.3.1 Confirm patient’s identity by 2 identifier:
6.3.1.1 patient’s full name
6.3.1.2 registration or identification number

6.3.2. Ask patient to verbalize his/her name and cross check:

6.3.2.1 with patient’s wrist band for name and registration
number or identification number .
6.3.2.2 verify accuracy of identifier with patient’s medication
profile/Hospital Information System.

6.4. VERIFY WRITTEN PRESCRIPTION BY CHECKING FOR :

6.4.1. Correct patient’s name and registration number
6.4.2 Drug – generic name, dose, frequency, route, duration
6.4.3 Prescribing doctor – name, signature, and date ordered

6.5. ASSESSMENT OF PATIENT PRIOR TO ADMINISTRATION OF

ORAL MEDICATION
6.5.1. Nurses need to determine the patient’s current status prior to
administration of selected medication to confirm its continuity
by interviewing the patient and from observation charts e.g.
Anti-hypertensive drugs, oral hypoglycemic agents, digitalis,
analgesics, antipyretics and beta-blockers.
6.5.2 Nurses when assessing the patient will exhibit the caring

National Nursing Audit, Ministry of Health Malaysia : Version 6 / April 2019, Nursing Division, MOH Malaysia
Page 5
 NNA E5 AF5.1

component by explaining the intended procedure in a

respectful manner.

6.6. DISH OUT MEDICATION ACCURATELY

6.6.1. Read patient’s medication profile (right patient).
6.6.2. Select required medication (right medication).
6.6.3. Calculate dosage before dishing out (right dosage).

6.7. RIGHT TIME

6.7.1. An allowance of ± 1 hour (according to priority)
6.7.2. Initial dose served within a maximum of 1 hour upon
prescription / acquisition of medication and subsequent
doses according to time as stated in SOP of the unit / ward.

6.8. RIGHT ROUTE

Correct method of consuming various type of oral medication, example:
I. Tab. Magnesium Trisilicate - chewable
II. Tab. Glyceryl Trinitrate - sublingual
III. Lugol’s Iodine – straw

6.9 RIGHT TO REFUSE

Patient has the right to refuse the medication prescribed. When patient
verbalize refusal, the following nursing action shall be taken:
6.9.1 Identify reason for refusal and reinforce on importance of consuming
the drug.
6.9.2 If patient still refuse, inform doctor and document.

National Nursing Audit, Ministry of Health Malaysia : Version 6 / April 2019, Nursing Division, MOH Malaysia
Page 6
 NNA E5 AF5.1

6.10. SERVE MEDICATION

Nurses ensure patient consume their medication upon administration.
However, for medications that need to be consumed after / with meal, clear
explanation must be provided. The nurse needs to follow up to ensure those
medications are taken accordingly before documentation.

6.11. RIGHT DOCUMENTATION

Accurate and complete documentation of the following:
6.11.1 Record assessment findings if applicable.
6.11.2 Date and time of administration must be indicated in the medication
profile.
6.11.3 Signature of nurse who served medication endorsed in the
appropriate column.
6.11.4 All drugs omitted/refused, indicated in the medication profile.
6.11.5 Document explanation of any omitted dose / medication refused in
patient’s case notes.

7. RATING SYSTEM
7.1 TECHNICAL COMPONENT
Medication compliance to technical component includes all of the
following:

7.1.1 Identify right patient.

7.1.2 Verify written prescription.
7.1.3 Perform assessment, if applicable.
7.1.4 Read patient’s medication profile.
7.1.5 Select required medication from patient’s drawer of medication
cart.
7.1.6 Calculate dosage before dishing out medication.
7.1.7 Re-verify identity of right patient.
7.1.8 Serve medication.
7.1.9 When patient refuse to take the medication, the nurse need to
inform doctor and document omission for refusal.
[ if applicable ]

National Nursing Audit, Ministry of Health Malaysia : Version 6 / April 2019, Nursing Division, MOH Malaysia
Page 7
 NNA E5 AF5.1

7.2 SOFT SKILL COMPONENT

Conformance is verified by direct observation and listening to the nurse
7.2.1 Greet / acknowledge patient – verbal / non verbal.
7.2.2 Explanation prior assessment, if applicable.
7.2.3 Respond promptly and politely to patient’s / carer’s questions.

7.3 DOCUMENTATION COMPONENT

Accurate and complete documentation compliance included all of the
following for D9 (Checklist):
7.3.1 Document assessment findings, where applicable.
7.3.2 Document medication served/omitted - date, time and signature.
7.3.3 Document omission for refusal, where applicable.
7.3.4 Document communication with doctor, where applicable.

7.4 SCORE
7.4.1 Conformance Standard : 100% which include:-
 Technical skill : 100%
 Documentation : 100%
 Soft skill : 100%
7.4.2 Non – conformance : 0%

** Overall marks (% of Technical skill + % documentation + % soft skill ÷ 3)

National Nursing Audit, Ministry of Health Malaysia : Version 6 / April 2019, Nursing Division, MOH Malaysia
Page 8
 NNA E5 AF5.1

8. AUDIT FORM

NATIONAL NURSING AUDIT MINISTRY OF

VERSION 6/2019
HEALTH MALAYSIA

ELEMENT 5 : CONTINUUM OF CARE

TOPIC : 5.1 ADMINISTRATION OF ORAL

MEDICATION DATE : 11 April 2019

DOCUMENT NO : E5 AF 5.1 PAGE No. 1/4

8.1 STANDARD:
Patient does not experience medication errors/misadventures during
hospitalization.

8.2. OBJECTIVES:
8.1 All medication served according to 7 Rights (7R’s) medication
administration.
8.2 Nurses exhibit the caring component during the administration of
oral medication.
8.3. Nurses document accurately and completely the medication
administered.

Date of Audit :

Locality :

Auditors: 1. …………………………………...

2.……………………………………

National Nursing Audit, Ministry of Health Malaysia : Version 6 / April 2019, Nursing Division, MOH Malaysia
Page 9
 NNA E5 AF5.1

N.B. Instructions for Auditors

1. To tick [√] at appropriate column.
2. S / T/ D indicate soft skill / technical skill / documentation respectively.
3. Item 5, is rated as N/A if no specific nursing measures required.
4. Item D 8.1, is rated as N/A if patient does not refuse medication.

S/N ITEM SOURCE OF INFORMATION YES NO N/A

S1. Greet/ Acknowledge Listen / Observe nurse.

patient
T2. Identify right patient. Listen / Observe nurse.

T3. Verify written prescription Observe nurse.

4. Assess patient.
S4.1 Explain prior to Observe nurse and listen to
conversation
assessment
T4.2 Perform Observe nurse and verify
finding
assessment
T5. Dish out correct medication :
T5.1. Read patient’s Observe nurse and verify right
medication profile patient and right time.

T5.2. Select required Observe nurse and verify

medication from findings for the right
patient’s drawer of medication
medication cart
(3 CHECKs)
T5.3. Calculate dosage Observe nurse and verify
before dishing out findings for the right dose
(Optional for unit of
dose drugs)
S6. Respond promptly and Listen / Observe nurse.
politely to patient’s / carer’s
questions.

National Nursing Audit, Ministry of Health Malaysia : Version 6 / April 2019, Nursing Division, MOH Malaysia
Page 10
 NNA E5 AF5.1

S/N ITEM YES NO N/A

SOURCE OF INFORMATION

T7. Administer medication:

T7.1 Re-verify identity Listen and observe nurse.

of right patient.
T7.2 Serve medication Listen and observe
medication serve via the
right route.
D8 When patient refuse to take medication, the nurse need to
take the following actions:

D8.1 Document omission Verify findings

reasons for refusal
D9 Accurate and completeness Check document
of documentation

AUDIT REPORT

(please [√] the appropriate box)

Rating:
Non
Criteria Item Conformance N/A
conformance
Technical 8
Documentation 2
Soft skill 3
Total
13

REMARKS:

Auditor 1 (name and signature): ………………………………………….

Auditor 2 (name and signature): ………………………………………….

**Calculation: Item conformance X 100

Total item – item N/A

National Nursing Audit, Ministry of Health Malaysia : Version 6 / April 2019, Nursing Division, MOH Malaysia
Page 11
 NNA E5 AF5.1

Example:
**Calculation: Item conformance X 100
Total item – item N/A

Technical: _6 X 100 = 600 = 100%

8- 2 6

Documentation: _2 X 100 = 200 = 100%

2-0 2

Soft skill: 1_ X 100 = 100 = 33.3%

3-0 3

Criteria Item Conformance Non conformance N/A

Technical 8 100% 0 2

Documentation 2 100% 0 0

Soft skill 3 33.33% 66.67% 0

(0+0+66.67= 66.67
Total (100 + 100 + 33.33 = (2 + 0 + 0 = 2
13
233.33 ÷ 3) = 77.78% ÷ 3) = 22.22% ÷ 3) = 0.67%

Note: To minimize N/A as much as possible. The nurse can be lead to answer if
situation arises.

National Nursing Audit, Ministry of Health Malaysia : Version 6 / April 2019, Nursing Division, MOH Malaysia
Page 12