Download CMS Clarifications 11/2/2012

CMS Clarifications
11/2/2012
Medication errors
Medication administration practices
Medication review for short stays less than 30 days and/or changes
in condition
Faculty: Diane Atchinson, RN-BC, MSN, ANP, RAC-CT
President, DPA Associates, Inc
Kansas City, MO e mail: [email protected]
Medication errors
• Administration of medications via a feeding tube
F425-facility with the consultant pharmacist must provide procedures
for the accurate administration of all medications
• Must reflect best practices
• Types of medications that may safely administered via a feeding tube
• Appropriate dose forms
• Techniques to ensure that the feeding tube is in the right location before
administering medications
• Preparing drugs for administration
• Administering drugs separately
• Diluting drugs appropriately
• Flushing the tube before, between and after drug administration and
• That drugs with know incompatibilities are not given at the same time
•
Survey implications: F 322
• Placement checked prior to medication administration
• Amount of water to be used as flush noted via an MD order
for medication administration
• Standard of Practice (American Society for Parenteral and
Enteral Nutrition) Enteral Nutrition Handbook, 2010.
• Administer each medication separately followed by flushing the
tube
• Exception: MD order that specifies a different flush schedule
• Failure to flush will constitute 1 medication error
• Surveyor will review your facility policy (F425)
• Surveyor will also review F 520-QA to review for monitoring for
safe administration practice including TF medications
Enteral Nutrition Handbook (p
309-329)
• Drug interactions
• Compatibility
• Stability
• When a drug formulation is altered, by pulverizing, adding to fluid,
or combining it with other substances, drug stability may be
compromised
• TF should be held when giving medications. IE medications should
not be added to the TF.
• Recommendations
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Do not combine liquid medications
Do not combine crushed medications
Sustained release medications should never be crushed
Do not pucture liquid filled gel capsules
Crush each medication separately and dissolve in a small amount of
water to prevent occlusion of the tube
• Liquid medications can also cause problems-consult with pharmacist
Interdisciplinary team review
• Develop
• Guidelines
• Nurse education
• Pharmacist recommendations
• This reduces tube obstruction and drug errors
Drug/Nutrient Interactions
• Dilantin
• Hold TF for 1-2 hours before and after dose is given or
• Adjust the dose based on therapeutic drug levels
• Diluting is recommended to avoid tube obstruction
• Consistency of procedures used should be well documented
• Carbamazepine
• Hold TF for 1 hour before and after dose
• Monitor serum levels closely
• Dilute 1/1 with water
• Fluoroquinolones
• Separate doses from food, dietary supplements, or other drugs containing
calcium, MG (antacids) or iron.
• Hold TF for 1 hour before and 2 hours after dosing
• Warfarin (Coumadin)
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Separate the drug from the formula
Increasing the dosage via monitoring
Hold the TF 1 hour before and after dosing
Interactions with Warfarin can be life threatening
Medication Administration
Technique
• Basics-verify placement ,turn off feeding if running and do not
add medications to formula
• Flush the tube with at least 15cc of water
• Do not mix medications together but do dilute them
• Each medication administered separately
• Liquid dose forms used if available and diluted
• Pulverize tablets and mix with water.
• Open hard capsules and dilute powder with water
• Flush with at least 15cc of water between each medication
administered
• Restart TF as per resident specific medication needs
Metered Dose Inhalers
• If more than 1 puff is needed (same or different medication)
there should be at least 1 minute between each puff except
for:
• Short acting beta agonists such as albuterol-15-30 seconds is
acceptable
• Ensure the device is administered correctly
• Examples of education sites include:
• http://nhlbi.nih.gov/health/prof/lung/asthma/nurs_gde.pdf
• http://aafa-md.org/thumbdrive.htm (under pharmacy filehandouts
• You tube video: http://www.youtube.com/watch?v=Z_95ni8DJwU
Proton Pump Inhibitors (PPI)
• Facility has policies related to medications and food
consumption
• PPI’s given on an empty stomach at least 30-60 minutes
before a meal
• Use greater than 1 year-higher risk of fractures, pneumonia
and C diff. This should be reviewed by DRR.
Borrowing medications
• Not consistent with best practices
• Leads to medication errors
• Recommendations:
• Use of an E kit
• Contents decided by pharmacist and DON
• P and P for medication ordering and reordering of medications
• Monitoring that medications are delivered as ordered
• What to do if medication is not available for administration
• MD aware
• Use of Medical Director
Fentanyl patches
• Polies to address:
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Safe and secure storage
Limited access
Reconciliation
Safe handling, distribution and disposition
• Disposal
• Same manner as wasting of any controlled substance
• Must be safe and secure
• Where kept until destroyed
• Control and accountability
• Documentation if destruction for both full dose and partial doses
• Timely indentification and removal lf medications from current
supply
Medication reviews for stays less than
30 days and changes of condition
• Reviews might need to occur more frequently than monthly depending on:
• Resident’s condition
• Risk for adverse affects related to current medications
• Review applies to all residents including:
• Respite
• Residents at end of life or are using hospice
• Residents with stays less than 30 days or
• Residents who have experienced a change in condition
• Complex residents in the transition from hospital to SNF
• This review prevents errors due to drug/drug, omissions, duplication of therapy
or miscommunication between providers and care givers
• Recommendations
• Facility has p and p on who needs a more frequent review (define complex resident),
and risk for consequences for residents with stays of less than 30 days
• How will the need for this consult be communicated
• How the review will be handled if the pharmacist is off site
• How the results of the report will be communicated to the provider
• Expectations for the provider’s response and follow up
• How and where this information will be documented