8.17 Administration of Medications
Category: UWHC Administrative Policy Print
Policy Number: 8.17
Effective Date: June 23, 2017
Section: Patient Care (Hospital Administrative
To define the control and administration of medications and to define personnel authorized to administer
1. Medications are administered as directed by a prescriber's order or protocol as described in
Hospital Administrative Policy 8.16-Patient Care Orders.
2. The person administering the medication is responsible for ensuring documentation of
administration in the patient's medical record has occurred. See also Nursing Patient Care
Departmental Policy 10.19-Medication Administration Using Scanning Technology.
3. Available safety-designed sharp devices must be used, activated and discarded into a sharps
disposal container immediately after use. See Hospital Administrative Policy 13.07-Standard
Precautions and Transmission-based Precautions (Isolation) for Inpatient Settings.
B. Personnel Authorized to Administer Medications. (See procedure section III. A for additional detail.)
1. Administration of medications is the responsibility of licensed health care professional treating the
patient, but may be performed by the specified, qualified personnel identified in section III. A
2. A clinical service may restrict the administration of selected medications to physicians or to
specified, qualified personnel with approval of the Pharmacy and Therapeutics (P&T) committee.
C. Ensuring Safe Medication Administration. (See procedure section D for additional detail.)
1. Those administering medications are responsible for assuring appropriateness and accuracy of
medications and treatments they administer under prescribers' orders.
2. Emergency medications and resuscitative equipment are stored on all units where medications
3. Medication syringes must only be used for one patient. Syringes which may contain unused
medication must be discarded and may not be used for additional patients.
D. Administration of Sample Drugs. Sample drugs are not to be administered to inpatients in the hospital. In
the event that sample drugs are found in the inpatient care area, they should immediately be given to the
unit pharmacist for disposition. See Hospital Administrative Policy 8.36-Control of Trial Supplies of
Prescription Medication Samples for information on the use and administration of sample drugs in non-
E. Administration of Investigational Drugs. (See Hospital Administrative Policy 4.11 for information on
administration of investigational drugs.) Investigational drugs and devices must receive approval of the
UW Health Sciences Institutional Review Board prior to their use.
F. Administration of IV Medications. (See Hospital Administrative Policy 8.31 for guidelines on hospital
location-specific administration of IV medications.)
G. Administration of High Alert Medications. (See Hospital Administrative Policy 8.33 for information on
administration of high alert medications.)
H. Administration of Chemotherapy. (See Hospital Administrative Policy 8.59 for information on
administration of chemotherapy.)
I. Administration of Medications expressed as Range Orders. A range order is a medication order where the
dose to be administered is expressed as a range rather than a specific amount. Use of range orders is a
clinical practice designed to provide flexibility in dosing to meet an individual's unique needs. A range
order requires nursing staff to exercise judgment in determining the most appropriate dose to be
administered for a given clinical situation. The scope of permitted range orders is limited by Hospital
Administrative Policy 8.16(III)(C)(2)(Y). Clarification from the prescriber should always be sought if the
intent of an order is not clear.
J. Administration of medications using a patient's own delivery device should be limited to times when a
UWHC device is not optimal to meet the patient's needs. The benefits of using the patient's own device
must outweigh the risks based on the collaborative decision of a nurse manager, pharmacy manager,
attending physician, and the patient (if applicable) or their respective designee(s). (See Nursing Patient
Care Policy 10.25AP-Use of a Subcutaneous Insulin Pump (Patient's Own) in the Hospital Setting and
Nursing Patient Care Policy 10.26AP-Use of a Patient's Own Medication Delivery Device.)
K. Medications must be administered using the route that is specified in the order. Pharmacists have the
delegated authority to change the route of selected medications identified in the clinical practice guideline
for route interchange.
A. Personnel Authorized to Administer Medications. Unless administration of the medication is restricted by
policy, the following categories of individuals may administer medications: i) as permitted within the scope
of their license, education and training, and clinical privileges (if applicable) or ii) according to a written
delegation protocol if the individual is not licensed. Supervision of the medication administration is the
responsibility of the licensed health care professional who made the delegation.
1. Registered nurses
2. Advanced Practice Providers (e.g., CRNAs, Nurse Practitioners, Clinical Nurse Specialists, and
Physician Assistants )
4. Pharmacists, pharmacy interns and pharmacy residents.
5. Respiratory Therapists
6. Students in disciplines normally authorized to administer medications
8. Medical assistants
9. Radiologic technologists
10. Occupational therapists, occupational therapy assistants, physical therapists, and physical
11. Athletic trainers
12. Nuclear medicine technologists
When the above acts of administration are not within the licensed scope of practice of the designated
individuals, the administration is a delegated act of a physician. When the medications are prescribed by a
licensed physician, the prescribing physician is the delegating physician. When the medications are not
prescribed by a licensed physician, the delegating physician shall be:
1. For inpatients and emergency department patients, the attending physician;
2. For registered clinic patients, the physician director of the clinic; and
3. For other ambulatory patients who are not registered as clinic patients, the physician director of
the laboratory, radiology, or other ancillary service.
This delegation shall occur automatically upon the entering of the order for the procedure or
medication, unless the designated delegating physician has directed in writing that the delegation
B. Self-administration by Inpatients and Medications Stored at Bedside.
1. The decision that an inpatient should be responsible for self-administration of medications or
treatment is made jointly by the physician, nurse, pharmacist, respiratory therapist when
appropriate and the patient. The physician or designee must enter this order in Health Link.
a. There are two types of medication self-administration programs:
i. Those medications taken under nursing supervision.
Under the nursing supervision program, patients are learning to self-
administer medications with direct nursing supervision. All doses are
documented in the medication administration record.
ii. Those taken independently.
Under the independent self-administration program, the patient takes
the medications independently. The nurse verifies with the patient that
the medications due are taken and documents the administration in
the medication administration record.
b. Prior to the initiation of the self-administration program an assessment of the patient's
competency and ability to safely, accurately and independently take the medications will
be completed and documented. Patient instruction on safe self-administration of each
medication should include the following:
i. The nature of the medication.
ii. Correct administration including the appropriate frequency, route of
administration, and dose.
iii. The expected actions and side effects.
iv. Appropriate monitoring technique.
c. Documentation of the education/training and competency assessment will be performed
in the medication administration record and in the patient education documentation. For
each order or set of self- administration orders, pharmacy will enter a note to chart for
the nurse in the medication administration record. The note to chart will read as follows:
Patient/Care Giver assessed to be knowledgeable, competent and aware of expected
actions and side effects with all medications identified as self-administered.
2. Prescription medications for self-administration (excluding patients' own medications where
procedures are outlined below) are issued from the Pharmacy labeled with the name of the
patient and physician. The instructions for administration as stated in the physician's order, and
the name, strength, and quantity issued must be placed on the label.
3. Self-administered medications shall be stored in a secured location (either locked or under
supervision by the patient). See also Pharmacy Departmental Policy 1.43-Storage, Handling,
Security and Disposition of Medications
4. Respiratory therapists may determine the need to store multi-dose aerosolized medications at the
bedside regardless of whether approved for self-administration. Such orders must be documented
in patient care orders and do not require a counter signature. Aerosolized medications stored at
the bedside will be maintained in a secure manner.
5. The Regulatory, Accreditation and External Reporting Committee has approved an exception list
of "low risk" medications that may be stored at bedside without a physician's order. This
approved "low risk" medication list applies to all patient care settings (inpatient, clinics,
procedure and perioperative areas):
a. Sterile water in pour bottles/vials
b. Normal saline in pour bottles/vials
c. Desitin cream
d. Carmex lip balm
e. Cepastat lozenges
f. Artificial tears
h. Saline and sterile water unit dose containers for nebulization
i. Nystatin power and cream
j. Oral care products
k. Petroleum jelly
l. All wound and skin creams (e.g. proshield, aloevesta, double/triple ointment packets)
C. Administration of Patients' Own Medication.
1. Use of personal medication supplies while hospitalized is discouraged and should be ordered only
when an equivalent formulary product is not available.
2. While hospitalized, patients' own medication should be given to the unit pharmacist for
identification and storage.
3. While hospitalized, use of a patient's own medication is permitted based on a physician order if
the following standards are followed:
a. The patient, guardian or the patient's legal representative must give verbal consent
allowing personal medications to be administered by hospital personnel.
b. The unit pharmacist must positively identify the patient's medication for content and
integrity, and store the medications appropriately.
An exception is made for patient's own implantable or subcutaneous pumps for
medication delivery (e.g., baclofen, insulin, treprostinil, morphine.) because the
pharmacist is unable to positively verify the contents of the pump. The patient is
responsible for identifying the contents of the pump to the hospital staff. An order must
be written to continue the use of the patient's own pump and medications during
c. For an inpatient, the medication should be stored in the patient's medication drawer or,
when the medication is a schedule II or III controlled substance, in an automated
dispensing cabinet. The medication will remain in the patient's medication drawer unless
there is a written order for the patient to self-administer their medication or to store the
medication at bedside. Schedule II and III controlled substances may not be stored at
the patient's bedside.
d. Within 24 hours of the physician's order for a non-formulary patient's own
medication, the pharmacist will document the number of days' supply received based on
the current dosage regimen. The pharmacist will document the days' supply in the
Pharmacy computer system using the notation "enough through (date)". This notation
will appear on the patient's medication profile. The supply of the non-formulary
medications will be monitored by the pharmacist on a daily basis via a report generated
from the Pharmacy. If the pharmacy does not receive the patient's own supply of
medication within 24 hours from the time it was ordered, a new order will be obtained
from the physician for a formulary alternative, or the special order process will be
initiated for the non-formulary medications.
e. The patient's own supply will concurrently be monitored during daily administration of
the medication by the nurse or designee, who will re-assess the current supply and
communicate any apparent discrepancies to the unit pharmacist immediately.
f. The medications should be profiled, administered, and charted by the same procedures
governing all other medications given to patients at UWHC. The order should note it is
the patient's own medication.
g. Seventy-two hours before the patient's own medication supply is depleted, the
pharmacist will contact the resident or attending physician regarding the need for the
patient's own medication. At that point the options will include:
i. Order the medication via the special order process,
ii. Change the medication order to a formulary alternative or,
iii. Request that the patient acquire a refill of the medication. The determination
must be made 48 hours before the current supply of medication is exhausted.
h. If the patient has been determined capable of self-administration of their medications
(via physician's order), the patient then becomes solely responsible for timely
notification of pharmacy or nursing personnel regarding medication supply. See also
Pharmacy Departmental Policy 3.5-Patients Own Medications Storage and Use.
4. Emergency department (ED).
a. Staff notification: The triage nurse, primary nurse or emergency room physician may be
informed of patient's own medications upon patient's arrival in the emergency
department. ED staff will notify the pharmacist, when present in the ED, of any
medications the patient, or the patient's guardian, has in their possession. ED staff or
the pharmacist will document the patient's own medications within the electronic
b. Use of the patient's personal supply of medication is permitted based on a physician
order for "patient may take own supply" in the patient's electronic medical record.
c. Patient's may self-administer medications only if the physician enters an order for self
administration in the patient's electronic medical record.
d. Patient's own medications should be profiled, administered, and charted by the same
procedures governing all other medications given to patients within the ED.
5. For other non-inpatient and preoperative areas: When the provider caring for the patient is aware
of self administration and/or use of patient's own medications, every attempt should be made to
record the medication, dose, and time of self-administration if the medication may have an effect
on the procedure, therapy or other medications administered by the provider during the course of
D. Ensuring Safe Medication Administration.
1. To ensure safe and accurate administration of medications to patients, a pharmacist reviews all
non-emergent inpatient medication orders against the medication profile prior to medication
dispensing and administration, unless the absolute necessity of patient clinical needs or safety
does not permit such a review. Nurses and physicians are responsible for judging whether the
patient's clinical condition warrants bypassing the pharmacist review.
2. Review of an order by a pharmacist prior to administration is not required in settings where a
physician controls the ordering, preparation and administration of the medication.
3. Each person administering medications or treatment is required to check the medication against
the medication administration record (MAR) or original written order, verify patient allergy status,
and verify identification of the patient using two patient identifiers (excluding patient location)
prior to medication administration. If urgency necessitates administration of a scheduled
medication to an inpatient prior to it reaching the profile, a nurse will check the medication label
against the original order to verify accuracy prior to administration.
4. Prior to administration, the person administering the medication must do the following:
a. Verifies that the medication selected matches the medication order and labeling
b. Visually inspects the medication for particulates, discoloration or loss of integrity (e.g.,
changes in proper storage conditions, temperature, light, protective and/or tamper-proof
c. Verifies the medication has not expired
d. Verifies no known contraindications exist
e. Verifies the medication is being administered at the proper time, in the prescribed dose,
and by the correct route
5. On patient care areas where the point of care bar code medication administration scanning
system is used, the patient's wrist band bar code (and medication bar code when applicable)
must be scanned to confirm accurate patient (and medication) identity prior to administering
non-emergency doses of medications. (See Nursing Patient Care Departmental Policy 10.19-
Medication Administration for more information on administering medications utilizing bar code
6. Medications must be stored in the patient's medication cassette drawer or the AcuDose unless an
order exists to store at the bedside for self-administration.
7. Access to patient-specific medication in non-patient-specific storage areas (pharmacy delivery
bins) is limited to pharmacists, pharmacy technicians, and nurses. Medications preparations for
chemotherapy and parental nutrition should not be removed from delivery bins prior to a
8. In emergency situations, all drug therapy should be announced to another health-care provider
immediately before administration - saying, for example, "I am now giving heparin 2,000 units
9. Whenever possible an explanation of purpose of each new medication and potential clinically
significant adverse reaction or other concerns about administering a new medication are to be
provided to the patient or patient's family prior to administration. The patient's perceptions about
side effects will be gathered as part of medication monitoring.
10. Nurses or others administering medications shall remain with the patient until medications are
taken. The patient's response to the first dose(s) of a new medication while they are under the
direct care of the hospital will be monitored jointly by the pharmacist, nurses, physician and
other pertinent care providers. Adverse drug reactions will be documented via the hospital's
adverse drug reaction reporting system.
11. Medications should be administered within sixty minutes of their scheduled time of
administration. Acceptable reasons for administering medications outside this time frame do exist
and should be documented (e.g., nursing clinical judgment, scheduled procedure, etc.). In
addition, Hospital Administrative Policy 7.08-Management of Stat Medications defines when
medications are expected to be given within this time frame.
12. Errors and other significant incidents related to the administration of medications are to be
reported verbally to the employee's immediate supervisor and via the Patient Safety Net on-line
occurrence reporting system.
13. Medications that are drawn up for future administration must be labeled with drug name and
dose at the point of preparation. Any time one or more medications are drawn up or prepared for
later use, the container (syringe, bottle) must be appropriately labeled. In addition, every drug
must be labeled during any intermediate step of the preparation process, if the medication could
possibly be confused or mistaken for another. Any time the medication leaves the hand of the
clinician who has prepared it, it must be labeled, even if that clinician intends to administer or
use it immediately.
14. If a question arises about the intent of a medication order or whether a medication should be
held, the prescriber should be consulted prior to administration.
IV. RELATED POLICIES
There are a number of related procedures which are developed, coordinated and maintained by the utilizing
services and which are available in the appropriate manuals.
Hospital Administrative Policy 8.16-Patient Care Orders
Hospital Administrative Policy 8.33-High Alert Medication Administration
Hospital Administrative Policy 8.59-Chemotherapy Process: Informed Consent, Ordering, Verification,
Administration, Documentation and Education
Hospital Administrative Policy 7.08-Management of Stat Medications for Inpatient Units
Hospital Administrative Policy 7.27-Management of Patient Belongings
Hospital Administrative Policy 8.37-Use of a Subcutaneous Insulin Pump (Patient's Own) in the Hospital Setting
Hospital Administrative Policy 7.80-Medication and Solution Labeling
Hospital Administrative Policy 13.07-Standard Precautions and Transmission-Based Precautions (Isolation) for
Hospital Administrative Policy 8.36-Control of Trial Supplies of Prescription Medication Samples
Hospital Administrative Policy 4.11-Investigational and Study Drug Control
Hospital Administrative Policy 8.31-Guidelines for Hospital Location Specific Administration of IV Medications
Hospital Administrative Policy 8.75—Credentialing & Professional Privileging of Advanced Practice Providers
Hospital Administrative Policy 8.93-UW Health Patient Care Delegation Protocols
Nursing Patient Care Departmental Policy 10.19-Medication Administration Using Scanning Technology
Nursing Patient Care Departmental Policy 10.21AP-IV Epoprostinil Administration
Nursing Patient Care Departmental Policy 10.25AP-Use of a Subcutaneous Insulin Pump (Patient’s Own)
Nursing Patient Care Departmental Policy 10.26AP-Use of a Patient’s Own Medication Delivery Device
Pharmacy Departmental Policy 1.43-Storage, Handling, Security and Disposition of Medications
Pharmacy Departmental Policy 3.5-Patient’s Own Medication for Storage and Use
Sr. Management Sponsor: VP Professional Services
Author: Pharmacy Manager, Regulatory Compliance
Review/Approval Committee(s): Associate General Counsel; Nursing Practice Council; Nursing Executive Council;
Pharmacy and Therapeutics Committee; Patient Care Policy and Procedure Committee
VI. SIGNED BY
President and CEO
Scott McMurray, MD
Chair, Patient Care Policy and Procedure Committee