Nursing Workbook 1: Safe Medication Practices and Responsibilities

This nursing workbook provides a comprehensive overview of key concepts in medication management and patient care. It begins by outlining the four phases of clinical trials, emphasizing the importance of efficacy and safety testing. The workbook then delves into the role of the Therapeutic Goods Administration (TGA) in regulating medications in Australia, detailing the registration and listing processes. Pharmacokinetics and pharmacodynamics are defined, with a specific focus on the hepatic first-pass effect and its implications for oral medications. The correct administration of Glyceryl Trinitrate is explained, along with essential patient education points. Furthermore, the roles and responsibilities of Registered Nurses (RNs), doctors, and pharmacists in ensuring medication safety are discussed. The workbook also explores different types of medication errors, their potential causes, and the difference between person-centered and system-centered approaches to human error. Finally, the Swiss Cheese Model is introduced to illustrate how defenses, barriers, and safeguards can prevent medication errors from occurring, providing a well-rounded understanding of medication safety practices for nursing students.

Nursing Workbook 1
Nursing Workbook
Student's Name:
Instructor's Name:
Date:

Nursing Workbook 2
Q. 1. Pharmaceutical companies conduct clinical trials to determine the efficacy
(effectiveness) and safety of a medication. Briefly outline the FOUR (4) phases of clinical
trials.
Answer:
The clinical trials are spread out in four phases and each step has a definite goal to perform:
Phase – 1:
The first step involves testing the drug on the volunteers. Usually, the number of volunteers
ranges from a minimum of 20 to a maximum of 80. The testing at this phase is to check how the
drug is metabolized and excreted and also to monitor the side-effects, if any.
Phase – II:
This phase lasts from several months to two years and is used to test the efficacy of the drug on
volunteers. Mostly blinded trial phase, where two groups of participants are involved, one being
administered with the drug tested and the other group with a placebo or standard available
medicine. The safety of the drug to the patients is also tested.
Phase – III:
Further efficacy, safety and the effect of drugs on the patients is tested in this phase. The number
of volunteers increases to thousands.
Phase – IV:
This phase is done as a ‘Post marketing surveillance’ of the drug, to further test its effectiveness,
safety features and the quality of health endured by the patients who are administered with the

Nursing Workbook 3
drug. The comparisons with other drugs present in the market are also done at this stage.
(Overview of Clinical trials)
Q. 2 a) Briefly outline the main responsibility of the Therapeutic Goods
Administration (TGA)
Answer: TGA is the regulatory authority for therapeutic goods including drugs, medical devices,
and other related products. It is the responsibility of the TGA to ascertain if the drugs available in
the market are up to the standards specified. The TGA is also responsible for import, export of
drugs, advertisements for therapeutic goods in Australia. (Australian Government Department of
Health)
b) Describe TWO (2) ways medications are regulated by the TGA for
Use in Australia
Answer:
Since all therapeutic products carry some amount of risk and benefits, the TGA tests them with
scientific and clinical expertise to assess if the benefits of a drug outweigh its side effects.
Accordingly, medicines are tested in two ways:
1. Identifying, evaluating and assessing any risks that the drugs might pose on usage.
2. Applying any corrective measures to reduce the risk or eradicate it
3. Monitoring the progress after the corrective measures are taken to ascertain the safety of
the drugs.

Nursing Workbook 4
After such processes, the medicines are awarded two numbers depending upon the type of drug
under certification:
a. The Australian Register of Therapeutic Goods registers all the high risk medicines by
evaluating the quality of the drug, its safety and effectiveness. After the clinical trials,
they get awarded the AUST R number.
b. The Listed medicines, such as vitamin and herbal medications, which contain pre-
approved as well as low risk ingredients get an AUST L number and can be purchased in
supermarkets, or health shops. (Australian Government Department of Health. TGA,
2013)
Q. 3 Briefly define the terms pharmacokinetics and pharmacodynamics.
Answer:
The pharmacokinetics are defined as “ the study of the movement of drugs in the body, including
the processes of absorption, distribution, localization, bio-transformation and excretion.“
(Pharmacokinetics-Medical Dictionary)
The four phases of pharmacokinetics are:
1. Absorption- This is a phase which defines the course which the drug takes from the time
it is administered to when it enters the blood stream.
2. Distribution – This phase is when the drug is transported through the blood stream to the
intended site. The distribution of each drug differs depending upon its action.
3. Metabolism (bio-transformation) is a stage where the drug is metabolized and the drug
becomes inactive. It happens in the liver.

Nursing Workbook 5
4. Excretion is when the drug, after metabolism, is eliminated from the body, through the
kidneys (The Free Dictionary, 2017).
Pharmacodynamics:
It is a branch of pharmacology which studies the effect of drug and its biochemical,
molecular and physiological effects of drugs on the human body. This study acts as a
deciding factor for dosage of a drug and also helps in predicting the response to a particular
illness. Pharmacodynamics of a drug can be affected, by any disorder, age, and involvement
of other drugs within the system. (Farinde, 2016)
Q 4: In relation to oral medications, explain the phenomenon known as the
‘Hepatic first pass effect’
Answer:
The hepatic first pass effect or the first pass metabolism is a process where some of the active
substance present in the drug is removed or metabolized from the blood stream before it
enters the general circulation system. The concentration of drug, is reduced through the first
pass effect. It is called the Hepatic First pass effect, since the site of metabolism of the drug
is liver. This effect is a process which happens during the absorption and transfer of drugs
from the administration site to the site of action. The gut wall and the liver are the possible
metabolism sites (Study.com, 2017)
Process:
A drug, when it is administered orally, passes through the digestive tract and enters the
hepatic system. The portal veins from the hepatic system carry the drug to the liver. The

Nursing Workbook 6
liver, with its potential enzymes metabolizes the drug, (any active ingredient present) and
thus, only some of the potentially active ingredients of the drug manages to escape into the
circulatory system. The bio-availability of a drug is greatly reduced by the hepatic first pass
effect. The enzymes present in the liver, gut wall, hepatic system and the gastrointestinal
lumen, act on the active ingredients of the drug to metabolize it.
Thus, the drugs which have a high hepatic first pass effect are usually given in higher oral
doses, to allow at least a substantial amount of active ingredients to reach the potential
site(and the circulatory system), after its passage through the liver. Examples of such drugs
are morphine and diazepam (Encyclopedia.com, 2016)
Q.5: Briefly describe why Glyceryl Trinitrate 600 microgram tablets must only be
administered sublingually.
Answer:
The area below the tongue and cheek has a lot of capillaries (tiny blood vessels). This helps in
absorption of medication immediately into the bloodstream, instead of taking the long route of
the digestive system, and the liver.
Glyceryl Trinitrate is a drug usually administered to help improve the working of the heart. Since
it needs to be absorbed instantly, in case of seizures and heart attacks, it is administered
sublingually (Marshall, 2015).
b) List TWO (2) specific areas of education you should deliver to the patient that only
relate to the medication Glyceryl Trinitrate
Answer:

Nursing Workbook 7
Glyceryl Trinitrate needs to be used carefully and the following instructions have to be
adhered strictly:
a. Do not chew or suck the tablets. They are to be placed under the tongue and allowed to
dissolve slowly.
b. One should always sit down and rest while taking the tablet, to avoid dizziness.
c. The tablet should be placed under the tongue in case of heart pain and a repeat dose can
be given in case the chest pain does not ease. However, if the pain persists for longer than
15 minutes, medical intervention is required.
Q. 6: Outline FIVE (5) different roles and/or responsibilities of the RNs, doctors and
Pharmacists involved in the safe use of medications
a) Registered Nurse
Registered nurses or RNs have a great many support role in clinics, hospitals and healthcare
units. The place they work decides upon the duties of a nurse, and their active involvement in
diagnosis and treatment of patients.
The duties of a registered nurse include:
1. Monitor, register and record patients' conditions (changes, stability, and so on)
2. Maintain detailed and accurate reports about the conditions and changes
3. Educate patients on drugs to be taken, with prescribed dosage and timings
4. Evaluate diagnostic tests and interpret the reports to make changes in medications
5. Prepare the patients for examination and assist the consultants during physical
examination (Greenwood, 2017).

Nursing Workbook 8
b) Doctor
Doctors or consultants have a significant role to play in hospitals and clinics.
Depending upon their specialization, the doctors:
1. Diagnose and prescribe medicines, order diagnostic tests depending upon the conditions
of the patients.
2. Perform surgeries, including emergency surgeries where and when required.
3. Neurologists, cardiologists and aesthetics have their own specific role as surgeons, in
major operations.
4. Doctors make important decisions in patient care and instruct the health care workers and
nurses as to how and what medications needs to be administered or what instructions to
be given to the primary caregivers.
5. Doctors have the authority to make any changes in medication, increase dosages or
introduce new drugs to improve patient’s conditions.
c) Pharmacist
A pharmacist should be:
1. Be able to provide appropriate and prescribed medications to the patients. Should have
managerial and computer skills to handle emergency situations with panache.
2. Collaborate with the physicians and health care workers to deliver medications as the
prescription demands and whenever the necessity arises.

Nursing Workbook 9
3. Have in depth knowledge of the medications, their use, any side effects and interactions
with other drugs.
4. Supervise the pharmacy store and counsel and advise patients on health and nutrition.
5. Specialize in dispensing medications appropriate for a specific purpose, such as heart
condition, cancer, and so on.
Q. 7 Describe FIVE (5) different types of medication error AND a possible cause for each
Answer:
The possible errors and the causes can be as follows:
1. Error in prescribing, includes wrong dose, wrong route of administration, wrong
frequency, wrong drug and wrong time.
2. Dispensing errors, including incorrect preparation of an infusion solution, dispensing of
an expired drug, equipment failures (syringe defect), IV fluid leak or the line struck,
dispensing a drug too late, and so on.
3. Infusion pump – forgetting to set the infusion line, no written communication or non-
compliance failure (Allard et al., 2008).
4. Fragmented care errors, such as lack of proper communication between the physician and
health care professional.
5. Wrong drug preparation error, where the medicines to be administered intravenously is
done orally or vice versa.
Causes of errors:

Nursing Workbook
10
1. Lapse in memory, where a nurse might just forget that a patient is allergic to a drug. This
happens due to distraction. Not remembering the maximum daily dose and administering
more than required or less than necessary can also be the cause of memory lapse.
2. Problems with systems, such as not labelling the drugs categorically, medicines of similar
names placed nearby or lack of bar coding can cause the errors.
3. Lack of understanding or proper knowledge in health workers can lead to errors in
remembering or administering drugs with generic name.
4. No proper patient information or lack necessary information such as previous history or
allergies can lead to errors.
5. An overworked nurse or health care worker might, due to exhaustion, causes errors.
Q. 8 Explain the difference between the person-centered approach and the system-
approach to human error
Answer:
A person-centered approach is where the whole system, from care to drug administration
revolves around the patient (a person). The person here is at the center, and he is educated to
administer the dosage of drug prescribed. The problem here is that since the patient is not
knowledgeable enough, he or she might take excess, less or can time the drug intake wrong, to
create the error.
In a system centered approach, the system is in the middle, and the system involves everyone,
from doctors, nurse to health care workers. Here, the error arises due to several factors, such as

Nursing Workbook
11
no proper communication, overworked staff, no proper lighting in the area, negligence and lapse
of memory.
b) Defences, barriers, and safeguards are components of James
Reason’s (1990) ‘Swiss Cheese Model’. Briefly explain how these factors can prevent a
medication error from occurring (4 marks)
Answer:
The Swiss cheese model described defence layer as a prevention of errors. The high-
technological operations in many hospitals have alarm systems and physical barriers for
‘defence’, which might prevent an error from occurring.
The barriers might come up in the form of ‘holes’ not aligned with each other- where a health
worker might be required to report to the nurse on the drug administered, and they might
pinpoint the error. Hence, one point failure might not lead to complete error, where there are
‘safeguards’ in the system in the form of several layers.
Doctors- Nurse- health care workers- patient- This whole sequence may become impenetrable,
since ‘holes’ or ‘errors’ can be reverted due to non-alignment, as per the Swiss cheese model.
As the model predicts, having one system over the other, or having ‘defenses in place (in line)
can save the errors from occurring. If one in the line fail, (say, a health care worker has mislaid
information), the nurse who is monitoring can revert the error immediately. Thus, Swiss Cheese
model can help in error defection (Duke University School of Medicine, 2016).

Nursing Workbook
12
c) Holes in the defences arise because of active failures and latent conditions. In relation to
medication errors identify:
i. THREE (3) possible Latent conditions
Answer:
Latent or dormant conditions, are, within the system, and sometimes, becomes
inevitable.
They include:
1. Time-pressure of the nurses and health workers
2. Overworking, understaffing conditions and no proper equipment in place
3. No alarms or efficient indicators, no standard procedures in place or design
deficiencies in the equipments.
The latent failures, may or may not cause an error, because, the other person who is
monitoring, or in charge, might prevent the error from happening. However, latent
conditions, if persistent, can cause a long lasting holes within the system (Reason,
2000)
ii. THREE (3) possible Active failures (3 marks)
Answer:
Active failures are unavoidable.
They include:

Nursing Workbook
13
1. Violations caused by nurses and health care workers (who are in direct contact with the
patient), such as slips in care, mistakes in drug administration, and violations in
procedure.
2. Instructions not read properly or not understood or simply ignored.
3. Mistakes due to negligence, while administering infusions, or IV fluids or potent drugs
and not reading the patients' allergy reports.
Q. 9 Describe FIVE (5) factors that contribute to medication error AND a
Possible cause for each (10 marks)
Answer:
Errors occur in every system, and the medical field is no less immune to it.
There are several factors which contribute to medication errors.
1. Mistakes in drug administration – giving wrong dosages, wrong drug or not noting
down the allergy symptoms.
Causes: Look-alike drugs and should –like medicines can cause confusion in health care
workers, no proper system to convey information, no proper knowledge to administer
drugs or understand instructions. Medical abbreviations used by professionals might lead
to confusion, and as a result, can cause serious errors (Medcom Trainex, 2017)
2. Errors in prescription of drugs by nurses and doctors, wherein the patient condition was
not monitored properly and thereby making the mistake of giving wrong medication.

Nursing Workbook
14
Causes: Poor communication - Poor communication in the system- between nurses and
health care workers, doctors and nurses, patients and nurses, and patients and doctors.
The allergic symptoms not noted clearly.
3. Way of administering a drug: An IV fluid administered orally or through infusion, can
cause serious error.
Causes: Here again, the cause may be due to improper communication, no knowledge of
the drug or its administration techniques.
4. Inaccurate or incomplete diagnosis of a disease or illness
Causes: No proper knowledge about the disease or its cause, communication error
between the patients and the doctor, the patient not able to relate the problems clearly,
error in the diagnosis report.
5. Errors in nursing care due to negligence.
Causes: Overworked staff, poor knowledge of conditions, uncooperative patients or no
systems in place for essential information to be passed between consultants and care
takers.

Nursing Workbook
15
References:
U.S. Food and Drug Administration Commissioner (2017). The Drug Development Process -
Step 3: Clinical Research. Retrieved from
https://www.fda.gov/forpatients/approvals/drugs/ucm405622.htm [Accessed on 21st Aug
2017]
Center Watch (2017). Overview of Clinical Trials. Retrieved from
http://www.centerwatch.com/clinical-trials/overview.aspx [Accessed on 21st Aug 2017]
Australian Government Department of Health. Therapeutic Goods Administration. (n.d.). About
the TGA. Retrieved from https://www.tga.gov.au/about-tga [Accessed on 21st Aug 2017]
Australian Government Department of Health. Therapeutic Goods Administration. (2013). Listed
medicines: The role of Australia's medicines regulator. Retrieved from
https://www.tga.gov.au/community-qa/listed-medicines-role-australias-medicines-
regulator [Accessed on 21st Aug 2017]
Australian Government Department of Health. Therapeutic Goods Administration. (n.d.).
Medicines and TGA classifications. Retrieved from https://www.tga.gov.au/medicines-
and-tga-classifications [Accessed on 21st Aug 2017]
Duke University School of Medicine (2016). Swiss Cheese Model. Retrieved from
http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html [Accessed on 21st Aug
2017]
The Free Dictionary (2017). Pharmacokinetics. Retrieved from http://medical-
dictionary.thefreedictionary.com/pharmacokinetics [Accessed on 21st Aug 2017]

Nursing Workbook
16
Farinde, A. (2016). Overview of Pharmacodynamics - Clinical Pharmacology. Retrieved from
https://www.msdmanuals.com/professional/clinical-pharmacology/pharmacodynamics/
overview-of-pharmacodynamics [Accessed on 21st Aug 2017]
Study.com (2017). The First Pass Effect in Pharmacology. Retrieved from
http://study.com/academy/lesson/the-first-pass-effect-in-pharmacology.html [Accessed
on 21st Aug 2017]
Encyclopedia.com (2016). First-pass metabolism. Retrieved from
http://www.encyclopedia.com/caregiving/dictionaries-thesauruses-pictures-and-press-
releases/first-pass-metabolism [Accessed on 21st Aug 2017]
Marshall, H. (2015). GTN sublingual tablets (glyceryl trinitrate). Retrieved from
http://www.netdoctor.co.uk/medicines/heart-and-blood/a6820/gtn-sublingual-tablets-
glyceryl-trinitrate/ [Accessed on 21st Aug 2017]
Greenwood, B. (2017). Role of a Nurse in Health Care. Retrieved from
http://work.chron.com/role-nurse-health-care-6967.html [Accessed on 21st Aug 2017]
Learn.org (2017). What are the duties of a Pharmacist? Retrieved from
http://learn.org/articles/What_are_the_Job_Duties_of_a_Pharmacist.html [Accessed on
21st Aug 2017]
Allard, J., Carthey, J., Cope, J., Pitt, M., & Woodward, S. (2008). Medication Errors: Causes,
Prevention and Reduction. Retrieved from
http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2141.2002.03272.x/full [Accessed on
21st Aug 2017]

Nursing Workbook
17
Medcom Trainex (2017). Medication Errors in Nursing: Common Types, Causes, and
Prevention. Retrieved from https://www.medcomrn.com/index.php/articles/common-
nursing-medication-errors-types-causes-prevention/ [Accessed on 21st Aug 2017]
Terry's Post (2013). Describe Person-Centred ways of Administering Medicines whilst adhering
to Administration. Retrieved from http://pensbyterry.com/describe-person-centred-ways-
administering-medicines-whilst-adhering-administration/ [Accessed on 21st Aug 2017]
Reason, J. (2000). Human error: models and management. West J Med., 172(6), 393-396.