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Learning to prepare and administer medications safely and accurately is an essential component of your nursing practice. Determining that you have the right drug involves checking the medication label against the medication administration record (MAR) at least three times before you administer the drug. When administering oral medications, it is sometimes necessary to give only a portion of a tablet. If a patient is unable to swallow pills, you might have to crush a medication and mix it with food or a beverage before administering it.
Whenever you cut or crush a medication, clean the pill cutter or mortar and pestle before and after use. Medications are usually ordered to be given at certain frequencies, intervals, or times of day (such as “hour of sleep”). In certain situations, medications must be administered at times other than those indicated by the facility’s time schedule. Accurate documentation must be available before and after a drug is administered to ensure that it is prepared and administered safely.
Following the six rights of medication administration and checking the medication label against the MAR three times each time you prepare and administer a medication might seem redundant and unnecessary. We will be provided with an authorization token (please note: passwords are not shared with us) and will sync your accounts for you.
Objective: Medication adherence is extremely important in preventing relapse and lowering symptoms in schizophrenic patients.
Results: Forty-six percent of patients were deemed to be non-adherent with antipsychotic medication.
Clinicians can increase medication adherence in schizophrenia patients via prescription of long-acting injectable antipsychotics or non-pharmacological interventions as cognitive behavioral therapy, psychoeducation, family intervention, and motivational approaches (Zhornitsky and Stip, 2012).
In summary, non-adherence is a core problem in schizophrenia, but there is no validated tool to quantify implementation of drug regimen in real time, and there is a lack of effective tool to improve management of adherence in these patients. In the present randomized trial, we used the DoPill® to provide estimates of AAR in FEP patients as well as to quantify implementation in real time. DoPill® is an electronic dispenser with 28 compartments covered by a dynamic membrane which allows events detection (Figure 1). Study protocol consisted of three visits: one baseline, one at 6 weeks, and one at 8 weeks. The DoPill® software calculated AAR for all patients, and computed the mean adherence rate of antipsychotics in the experimental group. The results in the BARS did not follow a normal distribution since most scores fell toward 100% adherence. In the data set, extracted for each patient, we noticed that some patients did not take all the medication prescribed by the psychiatrist and choose or selected only some of the pills from the dispenser.
This randomized trial revealed that the DoPill® is a well-designed, technologically sophisticated, and highly functional electronic pill dispenser. Universal design is a term which refers to accessible, comprehensible, and intuitive design solutions for all, regardless of age, ability, or status, but also solutions that avoid stigmatization and digital exclusion. Overall, results from this randomized study indicate that DoPill® is a valid tool to quantify adherence. The exact times you perform these three checks depend on how the drug is stored and your facility’s policy, but in most situations you would check as you remove each drug from the storage area, as you prepare each drug, and at the patient’s bedside before you administer each drug. However, if your facility does not have a unit-dose system or you must prepare a medication from a larger volume or a different strength, you must perform conversions and dosage calculations. It is a good practice to check with a pharmacist or a drug guide before cutting or crushing a medication. If this information is missing or the specified route is not the recommended route, notify the prescriber and ask for clarification. Become familiar with the medications you are giving, why they are ordered for certain times, and whether or not the time schedule is flexible. For example, a preoperative medication might be ordered to be given “stat” (immediately) or “on call” (right before a procedure). Medication orders should clearly state the patient’s first and last name, the name of the drug ordered, the dose, the route, the time the drug is to be administered, and the signature of the prescriber. However, taking shortcuts and not following procedures greatly increases your chances of making a medication error.
This means that you will not need to remember your user name and password in the future and you will be able to login with the account you choose to sync, with the click of a button.
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Each of its 28 compartments is covered by a plastic lamina that, when taken off, sends a signal to the pharmacist. Recently, technologically sophisticated electronic reminder devices and electronic pill dispensers have been developed (Diaz et al., 2001). In their systematic review of assessments tools of antipsychotic adherence, Velligan et al. Recently, an electronic, smart, 7-days pill dispenser named DoPill® was developed by Domedic in Quebec to simultaneously quantify and help patients with implementation.

We hypothesized that this smart pill dispenser would provide objective and direct measures of implementation comparable with those found with the BARS, and that the reminders would help patients improve their management implementation of the drug regimen. Group sizes differ because of chance in the randomization process, and the sample size is modest because of time restrictions related to academia and human resources.
No significant differences were noted for age, education, illness duration or PANSS positive, negative and general scores between patients randomized to the DoPill® and the TAU groups.
As illustrated in Table 3, we can see that for instance in subject EET-20 venlafaxine was 38% taken versus 43% for procyclidine. Additionally, when treated as a dichotomous variable (<70% criteria), 46% of patients were found to be non-adherent using the device. We found that the most popular devices are simple alarm clocks with vibration, and the most sophisticated are alarms that also dispense the medication and can call a caregiver if forgotten.
The imbalance between the two groups as well as the low completion rate have to be considered. In addition to checking the label against the MAR to make sure you have the right drug, check also that you have the right dose, are planning to give it by the right route, and that it is the right time.
When you are new to practice or if you rarely perform calculations or are at all unsure about the dose, have another nurse double-check your work before you give the drug.
If the tablet does not break evenly, discard it, if your facility’s policy allows it, and cut another tablet.
Some medications, such as sublingual, enteric-coated, and timed-release preparations, must not be cut or crushed. When giving an injection, verify that the preparation of the drug is intended for parenteral use. When medications are ordered on a PRN (as needed) basis, use your clinical judgment to determine the right time. The Brief Adherence Rating Scale (BARS) seems to be the most reliable tool assessing adherence in schizophrenia and shows that the antipsychotic adherence ratio (AAR) is about 49.5% in schizophrenia. DoPill® recorded better AAR than some of those found in the literature and were lower than the BARS estimate we found.
When we learned its existence, we immediately wondered if its potential could help our patients suffering from schizophrenia. The patient’s pharmacist is responsible for programming the device, doing the usual safety checks, and dispending the medication as prescribed. The patient and clinician-rated measure of drug adherence by the BARS is separated in two steps.
Mean adherence rate was also compared numerally with AAR found in the literature using MEMS®.
On the other hand, a repeated measures ANOVA revealed an interaction between group and visit for the BARS clinician rating (P = 0.01).
This can also be explained if the patient forgot most often morning drugs but not evening ones because of environmental or time factors.
By contrast, BARS scores were overly optimistic (86–99%) for adherent and non-adherent patients across visits. However, MEMS® excluded, there are no other device that integrates the pharmacist in the process, and no other device that were studied in a clinical trial. Results could have been different with a bigger sample size, a fully functional DoPill®, and longer duration of the trial.
Today more than ever, designers are sensitive to the need for simple and meaningful products, especially considering the complexity and continuously changing nature of digital products and devices. Although policies differ from facility to facility, many require double-checking of doses of some medications, such as insulin and anticoagulants.
Because medications can alter the taste of food, avoid mixing it with the patient’s favorite foods and beverages as this might diminish the patient’s desire to eat or drink them. Other drugs should be given during the patient’s waking hours to allow uninterrupted sleep. For example, when a pain medication is ordered q4-6h, assess your patient’s pain level to determine whether your patient needs another dose after 4 hours or can comfortably wait longer.
In some facilities, an electronic scanner will be used to match the patient’s medication administration record with the identification band. After you give a medication, place your initials in the designated space by the medication as soon as possible to indicate that you gave the dose. The aim of the study was to test if an electronic pill dispenser named DoPill® improved AAR of schizophrenic patients. It consists of a cap containing an electronic chip that records openings of the bottle; the cap contains a liquid crystal display (LCD) screen that shows the number of times the bottle has been opened in the day and hours since its last opening. Although it provides indirect and self-rated measures, the Brief Adherence Rating Scale (BARS) is a reliable tool to detect sub-optimal implementation of the dosing regimen in schizophrenic patients. Visual and sound alarms alert the user when it’s time to take medication and the compartment from which it must be taken. The level of significance for two-sided hypothesis tests was set at a P-value less than 0.05.
Although the patients were recruited from a FEP program, mean age and duration of illness were 38 and 11 years, respectively, in the DoPill® group, and 35 and 9 years, respectively, in the TAU group.

Contrast tests allowed us to verify that this difference is present between both baseline and visits 1 and visits 2.
Although we did not compare them directly, we believe they are technically comparable for measurement because they both record the opening of the pill compartments. This professional is the most important to ensure that drug regimens are safe and effective, and it’s critical that he validates the final disposition and identification of drugs before administration. Unfortunately, every trial or study in technology or device development can be confronted with time restrictions to complete the study due to the evolution of the device. Keep in mind that it is difficult to confirm that you are giving the correct dose after you divide a tablet, so this is a practice best avoided if at all possible. Most drug manufacturers label parenteral medications “for injectable use only” to help prevent errors, so check the label carefully.
Most facilities recommend a time schedule for administering medications ordered at specific intervals (q4h, q6h, q8h).
If the patient is confused or unresponsive, your two identifiers can consist of comparing the medical record number and the birth date on the MAR with the information on the patient’s identification band. Failure to document or incorrect documentation can be considered a medication error in itself and can cause an error as well. However, in our study the scale was filled by a nurse, an ergotherapist or a specialized educator, but not by the psychiatrist of the patients. Despite the cues, we found comparable rates of non-adherence using both devices at the <70% threshold. For many people who suffer from reduced cognitive and intellectual capacity, the complexity of user interfaces, their logic and configuration appear to be the biggest challenge, but many designers and manufacturers still overlook these problems. It is presently used in clinical practice, because physical and psychological barriers have been reduced, and its user interface is intuitive and decipherable.
Policies about this practice vary widely, so be sure you understand what your facility requires should this situation arise.
Most facilities also have a policy indicating how soon before or how long after the scheduled time a drug can be administered.
If your patient is a child, ask the parents or legal guardian to identify the patient, in addition to comparing the information on the MAR with the information on the patient’s identification band.
In the TAU group, antipsychotic prescriptions were as follows (eight patients were on antipsychotic polypharmacy): olanzapine (n = 8), clozapine (n = 6), risperidone (n = 5), quetiapine (n = 3), ziprasidone (n = 2), haloperidol (n = 2), perphenazine (n = 2), aripiprazole (n = 1), fluphenazine (n = 1). Our results suggest that the BARS is more reliable if filled by the psychiatrist of the patient.
All this is integrated seamlessly in the pharmacy software, with the usual security checks. Some might allow this practice only in the pharmacy, for example, or might prohibit nurses from dividing unscored tablets. For routinely ordered medications, such as antibiotics, 30 minutes before or after the scheduled time is commonly acceptable. No matter how long you have been caring for the patient or how well you know the patient, each time you enter the room to administer a medication, you must use a minimum of two identifiers to confirm that you have the right patient. However, recovery and long-term outcomes were not correlated with adherence in a recent well-designed discontinuation FEP study (Wunderink et al., 2009).
Concomitant medications were allowed and dispensed in the DoPill® by the pharmacist as usual. Recently, another group from Montreal evaluated how much agreement exists between self-reports of adherence to antipsychotic medication and objective or derived measures of adherence in FEP (Lepage et al., 2010).
In support, the BARS clinician ratings showed that adherent patients evidenced significantly greater improvement in adherence, relative to non-adherent patients over the 6 weeks.
MEMS® remains the most studied device to monitor adherence, but it does not include reminders, and every dosage of a drug needs a separate device. For example, if a medication is to be given at 0700, you can give it between 0630 and 0730 and still be administering it at the right time.
Moreover, administering antipsychotics every other day was not associated with higher relapse rate or lower side effects in a randomized controlled trial on 35 stable patients (Remington et al., 2011), suggesting that in some patients sub-optimal implementation of prescriptions might represent a form of lay dosage optimization. Adherence was measured in 81 FEP subjects on a monthly basis by reports from patients, clinicians, family, and pill counting. Taken together, these preliminary findings suggest that there may be a limit on the benefit that electronic aids can have for increasing the implementation of the drug regimen in non-adherent schizophrenia patients. DoPill® has the potential to replace it, because it includes reminders, monitors opening in real time, can communicate with a provider, and can dispense multiple drugs at a time.
Adherence (74%) as measured by patient report, pill count, and clinician reports were in good agreement with each other and all of these measures were highly correlated to consensus adherence.
The authors showed that patient or clinician reports gave a reasonable estimate of medication adherence in FEP, and that introducing pill counting was a better accurate measurement. This is compatible with a model of five patient prototypes of adherence: patients with (1) good adherence for the right reasons, (2) with good adherence for the wrong reasons, (3) with passive adherence, (4) with reluctant and tenuous adherence, and (5) with unwillingness to take medications (Freudenreich and Tranulis, 2009).

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