Safe medication administration requires the Six Rights: right patient, right drug, right dose, right route, right time, and right documentation, with many institutions adding right reason, right response, and right to refuse. The Three Checks occur when reaching for the medication, when comparing it to the medication administration record, and at the bedside before giving the dose. PRN medications require documentation of the indication, time, dose, and patient response within 30 to 60 minutes.
Injection technique varies by route. Intradermal injections use a 5–15 degree angle with the bevel up to produce a wheal of about 0.1 mL, used for tuberculosis and allergy testing. Subcutaneous insulin is absorbed fastest from the abdomen; sites should be rotated within the same anatomical region for one week before moving to a new site, avoiding the umbilicus and scarred tissue. Intramuscular injections are given at 90 degrees, with aspiration required to confirm the needle is not in a blood vessel; if blood returns, the syringe must be discarded and a new injection prepared. The ventrogluteal site is preferred for adults because it avoids major nerves and vessels and accommodates up to 3 mL safely.
Insulin pharmacology guides administration and timing. Regular insulin has an onset of 30–60 minutes, peak of 2–3 hours, and duration of 5–7 hours, and is the only insulin given intravenously in diabetic ketoacidosis. NPH insulin is cloudy, with onset of 1–2 hours, peak of 4–12 hours, and duration of 18–24 hours; it is the only insulin that may be mixed with regular insulin in the same syringe, drawing the clear regular insulin first to prevent contamination. Long-acting glargine has no pronounced peak and must never be mixed with other insulins. Unopened vials are refrigerated, and in-use vials may be kept at room temperature for up to 28 days.
High-alert medications require additional safeguards. Potassium chloride must be diluted and infused via a pump through a central line for high concentrations to prevent lethal arrhythmias. Heparin is administered by continuous infusion rather than IV push, with aPTT monitored at 1.5–2.5 times normal and platelet counts watched for heparin-induced thrombocytopenia. The first action in a suspected transfusion reaction is to stop the transfusion immediately and maintain IV patency with normal saline while notifying the provider; the blood bag and patient sample are sent to the blood bank for analysis. Digoxin is held when the apical pulse is below 60 in adults or below 70 in children, and signs of toxicity include nausea, visual yellow-green halos, bradycardia, and dysrhythmias worsened by hypokalemia.