11.2 Medication and Injection Reference Checklist
Key Takeaways
- Run every drug question through the rights of medication administration and stop on any failed right.
- Memorize injection angles, gauges, and maximum volumes, and convert pounds to kilograms before any mg/kg math.
- An order that is illegible, impossible, or conflicts with a documented allergy is clarified before any action.
Medication and Injection Reference
Medication items are dangerous when treated as arithmetic only. The stem may bury an allergy, an expired label, or an impossible dose that makes the math irrelevant. CCMAs support medication workflow only within state law, employer policy, training, and a provider's order.
Rights and Stop Conditions
| Right | Verify | Stop condition |
|---|---|---|
| Patient | Two identifiers + allergy history | Wrong/unverified patient, documented allergy |
| Drug | Label, expiration, appearance, storage | Unknown, expired, or damaged product |
| Dose | Ordered vs available, units | Illegible, impossible, or unsafe dose |
| Route | PO, topical, IM, subcut, ID as authorized | Route conflict or no authorization |
| Time | Schedule, last dose | Duplicate or missed-dose concern |
| Documentation | Name, dose, route, site, time, lot | Chart mismatch or missing data |
Many sources expand to nine rights by adding reason, response, and right to refuse. A documented allergy to a prescribed drug is an automatic stop: notify the provider, never "give it and watch."
Injection Anchors (Memorize)
| Type | Angle | Common gauge / length | Max volume (adult) |
|---|---|---|---|
| Intradermal (ID) | 5-15 deg | 25-27 G, 3/8-5/8 in | 0.1 mL (wheal/bleb) |
| Subcutaneous (subcut) | 45-90 deg | 25-27 G, 5/8 in | ~1 mL |
| Intramuscular (IM) | 90 deg | 22-25 G, 1-1.5 in | 1-3 mL (deltoid up to ~1 mL) |
Common IM sites: deltoid, ventrogluteal, vastus lateralis (preferred for infants). The vastus lateralis is the safest pediatric site; the dorsogluteal site is avoided due to sciatic nerve risk. Activate the needle's safety device and drop it directly into a sharps container; never recap a used needle.
Dosage Math
Write the target unit first, then convert: 1 kg = 2.2 lb, 1 g = 1000 mg, 1 mg = 1000 mcg, 1 L = 1000 mL, 1 tsp = 5 mL, 1 tbsp = 15 mL. Core formula: (Desired dose / Have on hand) x quantity.
Worked example: Order is 250 mg; stock is 125 mg per 5 mL. (250 / 125) x 5 mL = 10 mL. A child weighs 44 lb; order is 10 mg/kg. 44 / 2.2 = 20 kg; 20 x 10 = 200 mg. If the arithmetic yields an absurd number (e.g., 14 tablets), suspect an unsafe order and clarify.
Last-Minute Self-Test
| Cue | Decision habit |
|---|---|
| Dose problem | Convert units, calculate, then sanity-check safety |
| ID injection | 5-15 deg, raise a wheal, 0.1 mL |
| Allergy on chart | Stop and notify the provider |
| Used needle | Sharps container, no recapping |
Routes, Storage, and Patient Teaching
Route knowledge separates safe answers from plausible-sounding wrong ones. Sublingual (under the tongue, e.g., nitroglycerin) and buccal (between cheek and gum) tablets must dissolve and are never swallowed or chewed. Ophthalmic drops go into the conjunctival sac with the patient looking up, and the CCMA avoids touching the dropper to the eye; otic drops are warmed to body temperature and the pinna is pulled up and back for adults, down and back for children under three. Enteric-coated and extended-release tablets are never crushed because crushing destroys the timed-release mechanism and can cause an overdose.
Storage rules are high yield: many vaccines and insulins require refrigeration at roughly 2-8 C (36-46 F) and must never be frozen, while reconstituted multi-dose vials carry a beyond-use date that the CCMA must label and honor. A medication that has been frozen, left at room temperature too long, or stored past its date is discarded, not given.
Adverse Reactions and the Five-Minute Rule
After any injection, especially vaccines, watch for an allergic or anaphylactic reaction. Mild reactions include local redness, swelling, or soreness; serious reactions include hives, wheezing, facial or throat swelling, dizziness, and a drop in blood pressure. Anaphylaxis is a medical emergency: the provider may order intramuscular epinephrine, and the CCMA activates the office emergency protocol and stays with the patient. Best practice is to observe a patient for roughly 15 minutes after a vaccination so a reaction is caught while help is immediately available.
Document the site, lot number, expiration, the patient's response, and any reaction, because vaccine records are legally required to capture the manufacturer and lot.
Reconstitution, Z-Track, and Insulin Pitfalls
Some injectables arrive as a powder that must be reconstituted with a specific diluent and volume; using the wrong diluent or volume changes the concentration and the delivered dose, so follow the package insert exactly and label the vial with the time and your initials. The Z-track technique - pulling the skin laterally before an intramuscular injection and releasing it after withdrawal - seals irritating medications such as iron in the muscle and prevents tracking back into subcutaneous tissue.
Insulin is measured only in an insulin syringe marked in units, never a tuberculin or standard syringe, because reading units off the wrong scale is a classic and dangerous dosing error. When two insulins are mixed, draw clear (regular) before cloudy (NPH) so the rapid-acting insulin is not contaminated by the longer-acting one. Across all of these, the constant exam theme is that a calculation alone never authorizes administration: the order must be legible, the dose plausible, the allergy history clear, and the technique correct before the medication ever reaches the patient.
An order reads 250 mg of a medication available as 125 mg per 5 mL. How many milliliters should be drawn up?
Which technique correctly describes an intradermal injection such as a TB skin test?
The chart documents a penicillin allergy, but the provider's order lists amoxicillin. What is the safest first action?