Download Medications - Administration and Documentation

EPHRAIM MCDOWELL HEALTH
PATIENT CARE POLICY
MEDICATION ADMINISTRATION AND DOCUMENTATION
APPROVAL SIGNATURE:
INITIAL DATE:
5/78
APPROVAL DATE:
REVISION DATE:
4/12
4/12
PURPOSE:
Drugs are administered to aid the body in overcoming an illness, to relieve symptoms, to prevent
symptoms, and to aid in diagnosis.
RESPONSIBILITY:
Licensed, Registered, or Certified Clinical Personnel, Pharmacy Associates
POLICY:
These policies apply to the administration of all medications. Standard Precautions will be
maintained and transmission precautions as deemed appropriate for individual patients.
A.
Drugs
1.
Only drugs from containers clearly labeled by a pharmacy will be used. If a label
on a container is difficult to read or accidentally comes off, the container will be
returned to the pharmacy.
2.
The medication dose ordered will be prepared and dispensed via a unit dose system
by the pharmacy. If a liquid form of the medication is available, this will be sent in
preference to a split dosage.
3.
Generic names of drugs are found on the label. If an approved substitute drug is
used, the words “substitute for …” will appear in the label comments on the
Electronic Medication Administration Record (EMAR). Generic names are printed
on the EMAR.
4.
Any abnormal physical characteristic of a drug, i.e. discoloration, precipitation, etc.,
will be reported to the pharmacy. Do not administer dose until approved by
pharmacist.
5.
Medications are to be transferred from one container to another only by a licensed
pharmacist. This does not preclude the transfer of a medication to an IV bag or
syringe in preparation of a prescribed dose for immediate administration of that
dose to the patient by an authorized practitioner.
6.
All medications will be prescribed by a physician or dentist or intermediary or agent
of a physician or licensed practitioner and will be administered to that patient by
qualified hospital staff.
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Associates of respiratory care services, rehabilitation and diagnostic imaging
services may administer those medications, which are required for their respective
scope of practices.
All multi-dose products should be inspected prior to use for visual contamination
and should be discarded when suspected or visible contamination occurs.
Multidose products expire in 28 days from date opened unless otherwise stated by
manufacturer. Multi-dose products should be labeled with the expiration date (date
beyond which the product should not be used). If the multi-dose product has not
been opened by the labeled expiration date, it may be returned to pharmacy and
labeled with a new 28 day expiration date.
Medications are to be labeled with bar codes when dispensed or distributed from
pharmacy.
Medication Order
1.
All medications to be given will be ordered by a physician or LIP. All medication
orders will be electronically entered by the provider, pharmacist or authorized
Associates in a timely, accurate manner. When it is not possible to electronically
enter a medication order, patient care orders will be written, signed, timed and
dated by authorized prescriber acting within their statutory scope of practice, as
allowed by their license and as approved by the medical staff bylaws and rules and
regulations. Written orders are transmitted to pharmacy via facsimile or courier for
processing if there is not a pharmacist on duty on the patient care unit.
2.
Orders for medicines will include:
a.
Date and time ordered.
b.
Drug.
c.
Dose (in metric units).
d.
Route of administration.
e.
Frequency of administration.
f.
Signature of physician or licensed practitioner.
g.
Indication for use if “prn”.
3
Pediatric medication orders will be written on the special Pediatric Physician Order
sheets, order sets or electronically submitted. Pediatric medication orders should be
provided in a weight based (mg/kg) format. The current pediatric patient weight (in
both pounds and kilograms) is required on all pediatric orders. Any pediatric order
that provides the dose but does not provide the weight basis will be double checked
by the pharmacist for appropriateness.
Orders which are dosed outside the
recommended weight based range will be clarified with the ordering physician
before the dose is dispensed. The pharmacist and the administering nurse will
double check all weight based calculations prior to administration of the dose.
4.
A written order is necessary to discontinue a drug. All medication orders (entire
blocks) are to be reevaluated and each order either continued or discontinued after
surgical procedures or when patient’s level of care changes (i.e. transfer to or from
ICU) and upon transfer or discharge. TCU and BMUG transfers are treated as
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discharges or new admissions and require new written orders on the new unit. No
blanket orders to resume all medications or preop orders are accepted.
Medication orders may be taken verbally by licensed personnel if the LIP is out of
the facility or unable to electronically enter or write the order due to unusual
circumstances. The order will be written and read back to physician for
confirmation. The date and time is placed beside the written order on the
Physician's Order Sheet, indicating a verbal order as VO, and write the LIP’s name
with her/his first initial, last name, and title beside it. Such orders will be
countersigned by the ordering physician or licensed practitioner as soon as possible
after the order was given, or in the event that the patient is discharged before the
order is authenticated, the order will be countersigned within 30 days of patient’s
discharge.
If the order is not clear or there appears to be an error, it is the clinician's
responsibility to question the order and to get the order clarified. Assistance will be
requested from the pharmacist, nursing supervisor and/or physician. The
clarification of the order will be documented in the physician’s order section of the
medical records.
A LIP‘s order to (D/C all IV's) will indicate the discontinuation of all intravenous
infusions and medications, including IV piggybacks.
C. Medication Administration
1.
Medications are given according to physician instructions for frequency at adequate
time intervals to provide continuation of therapy. Daily meds are given once in a 24
hour period. BID meds are given two times a day. Orders written as every x hrs or
minutes are scheduled accordingly as orders are received and processed by
pharmacy.
2.
Medication doses are scheduled on the electronic medication administration record
to facilitate proper timing of medications as prescribed. Some medications may be
administered at alternate times to accommodate patient clinical status (N/V)
diagnostic testing schedule (NPO status) or to prevent adverse drug-drug or drugnutrient interactions. With a goal of timely medication administration, time-critical
scheduled medication doses are given +/- 30 minutes from scheduled time.
Medications considered to be time-critical include scheduled pain medications,
antibiotics, and any medication with a dosing schedule more frequent than every 4
hours. All medications not considered time-critical are given +/- 2 hours from
scheduled time. Transitional Care Unit medications are to be administered +/- 30
minutes from scheduled administration time due to CMS regulations.
3.
Nursing may request changes to the MAR administration times assigned based on
the ability or inability to administer multiple drugs via a given route safely (IV
meds, NG tube). Nursing may consult with pharmacist to determine which
medication times should be altered that would not impact continuity of care.
4.
Unless an ordered medication is specified “stat” or “now,” it will not be given until
the next designated time. Once daily meds should be given the day of admission if
the patient has not taken prior to admission that day. Exception: The initial dose of
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some medications which are deemed critical components of care may require an
altered schedule and then may be readjusted to the organized schedule of
administration times. For example, a pneumonia patient who has an order for a
daily dose of IV antibiotic written at 1400 should get a dose as soon as the order can
be processed and delivered and the 2nd dose would be assigned for the designated
daily time on the next day.
Respiratory Therapy Medication and TCU administration times may vary from
standard.
All medications not considered time-critical are given +/- 2 hours from scheduled
time.
All PRN medications will have dose, route and frequency specific by the physician
and indication for usage.
Antibiotic doses will be scheduled on the next hour from the time the order is
received and processed in pharmacy.
Standard default times will not apply to
antibiotic doses. Daily orders are q24hr, twice daily q 12hrs, etc.
First doses administered in the Emergency department or other patient care units
will be documented electronically on the eMAR by the licensed practitioner
administering the dose or by recording the date and time with their initials on a
paper order. If the patient is admitted or transferred to another patient care unit, the
time the last dose of medications administered should be documented on the paper
admission orders so that subsequent doses are scheduled appropriately and duplicate
administration of doses is prevented. The nurse should write “given in ED, date and
time of dose, initials” in margin of paper admission orders for any ordered drug
administered prior to transfer/admission.
Contrast administration is documented in Meditech using the contrast media
administration intervention, by the nurse, technician or clinician administering the
contrast or assisting the physician administration during a procedure. Name of
contrast, volume administered, route and site of administration, manufacturer lot
and expiration date, needle gauge used, central line verification if power injector
used to administer, site monitored for symptoms are documented if applicable.
Medications ordered and administered during an operative procedure,
emergency/code situation, labor and delivery, cardiac cath or other procedure where
the physician is present and providing direct care during the case may be
documented on paper forms or in other electronic charting systems which can
produce a printed report showing all medications administered during the case.
These records are to be included in the patient’s medical record and serve as order
and documentation of medication administration when signed by the physician and
nurse.
Insulin administration should be coordinated with meal availability. The designated
time on the electronic medication administration record is set to default to normal
meal times on the patient care unit but should not supercede clinical judgment by
the nurse as to when to administer in relation to food consumption.
“NPO” (nothing by mouth) order would mean orally administered meds would be
withheld. If a patient has an NPO order, is not eating meals or receiving nutrition
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via tube, but has insulin ordered with meals, the patient’s blood sugar should be
monitored but insulin would be withheld as long as the meals are withheld. Basal
insulins (Lantus, Levemir) would be continued in an NPO patient unless instructed
otherwise by physician. If the patient’s blood sugar is abnormal during the time a
patient is NPO status, the physician should be contacted.
“NPO except meds” order would mean to administer oral medications to the patient
with minimum amount of water for safe administration. If the patient is not eating
meals due to NPO status then they should not receive meal time insulin or oral
hypoglycemic agents until meals are resumed. Basal insulins (Lantus, Levemir)
would be continued in an NPO patient unless instructed otherwise by physician. If
the patient’s blood sugar is abnormal during the time a patient is NPO status, the
physician should be contacted.
Patients who are NPO status but are receiving nutrition through alternative routes
(non-oral, through NG or PEG) should have insulin orders clarified with LIP.
Surgical patients who are NPO or NPO except meds should not receive insulin the
morning of surgery. If the patient’s blood sugar is abnormal during the time a
patient is NPO status, the physician should be contacted
Medications should be administered in the form of oral solutions and other oral
medications must be finely crushed if the medication is to be administered via
enteral feeding tube, in accordance with Enteral Feeding Patient Care Policy.
Pharmacy may make the exchange to an appropriate liquid or immediate release
product when this route of administration is ordered.
Review of Medication Orders
1. Before dispensing or removing medications from floor stock or from an automated
storage and distribution device, a pharmacist reviews all medication orders or
prescriptions unless a licensed independent practitioner (LIP) controls the ordering,
preparation and administration of the medication or when a delay would harm the
patient in an urgent situation (including sudden changes in a patient’s clinical status) in
accordance with law and regulation.
2. Computerized physician order entries for medication orders are verified by a
pharmacist other than when a LIP controls the ordering, preparation and administration
of the medication or when a delay would harm the patient in an urgent situation
(including sudden changes in a patient’s clinical status) in accordance with law and
regulation.
3. As new orders are received in the Pharmacy, the order will be entered into the
computerized Meditech pharmacy profile.
All medication orders are reviewed for the following:
a. patient allergies or potential sensitivities
b. existing or potential interactions between medication ordered and food and
medications the patient currently takes
c. the appropriateness of the medication, dose, frequency and route of administration
d. current or potential impact as indicated by laboratory values
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e. therapeutic duplication
f. other contraindications
g. variation from the hospital’s approved indications for use.
After the medication order has been reviewed, all concerns, issues or questions are
clarified with the LIP before dispensing.
The medication order will be checked against its transcription onto the eMAR by a
licensed nurse, technician or clinician authorized to administer medications. All
orders will be acknowledged via the status board.
LIPs review current medication orders in Meditech during patient rounds. Orders
are evaluated for accuracy, appropriateness and patient response to prescribed
medication regimen as part of this process.
Blanket reinstatement of previous orders for medication is not acceptable. Blanket
statement to continue medications from home is not acceptable. LIP should
evaluate the appropriateness of the medication regimen and elect to continue or
discontinue each medication after surgical procedures, change in level of care, at
admission, transfer or discharge using the transfer or continue from ambulatory
functions in Meditech Physician Order Management system.
Transcription of Medication Orders
1.
Medications are entered into Meditech by the provider/LIP or authorized
Associates, entered or verified by Pharmacists and are available on the eMAR for
end users to review and if correct, administer.
2.
All stat orders will be communicated appropriately. Physicians will flag the chart
tab indicating that a stat order was written. The unit secretary will verbally inform
the nurse of a stat order for the nurse's’ assigned patient. The unit secretary will fax
the written stat order to the designated pharmacy fax number.
3.
A special procedure will be used for a medication that is ordered daily but the
dosage of which is dependent daily upon the patient's condition. For example,
Coumadin is ordered for 6:00 p.m. The LIP, after obtaining the PT/INR result for
that day, orders the dose on a daily basis. The order comments will read “Check
PT/INR” The nurse will check that day's PT/INR value, and if it is within the
therapeutic range, may give the dose. Orders written by the physician to “Hold
Coumadin if INR > 3.5 will also be included in the order comments. If the dose is
held because of an elevated INR value, the non-administered reason should be
documented.
4.
LIPs’ orders for medication to be administered for a designated time (days or hours)
will be converted to total number of doses and entered as such when entered to the
EMAR.
Example:
Kefzol 1 gm IV q6h for 3 days
will appear on the EMAR as
Kefzol 1 gm IV q6h x 12 doses.
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Hold Orders
An order may be placed on “HOLD” if the prescriber indicates a specific number of
doses or period of time. “HOLD” orders without dose or time parameters will be
discontinued by pharmacist. The physician must electronically enter or write a new
order to reinitiate therapy.
Clinicians should avoid using unapproved abbreviations when writing, transcribing
or documenting medication orders. Avoid abbreviating drug names, using trailing
zeros after a decimal (X.0 mg), non metric units of measure or not using a leading
zero before a decimal point (.X mg). Prohibited abbreviations include: U, u, iu, IU,
qd, QD, Q.D., q.d., q.o.d., qod, QOD, Q.O.D, MS, MSO4, MgSO4
Many drug products come in multiple dosage formulations. It is imperative that the
full product description is noted when writing or transcribing medication orders, not
just the generic name, to avoid inadvertent errors that result from omission of a drug
name suffix such as CR, XL, SR, CD .
F. Obtaining medications for administration
1.
2.
3.
Inpatient Care Units without Automated Dispensing Cabinets obtain meds via cart
fill distribution process. The Medication Cartfill will be brought to the Nursing
Unit at designated times. On weekends there will be no cart exchange. When cart
exchange is done on Friday, there will be a three-day supply of medications
dispensed. TCU cart exchange is performed on Monday, Wednesday, Friday at
designated times.
Respiratory medications are labeled for individual patient orders and dispensed
from central pharmacy to the patient care unit approved medication storage area.
Emergency orders for respiratory medications may be obtained from automated
dispensing cabinets.
Inpatient Care Units with Automated Dispensing Cabinets obtain medications as
outlined in the Automated Dispensing Cabinet policy and procedure and below.
a. Access is limited by ID and password to Associates who have authority to
administer medications.
b. The authorized Associate removes all doses needed for that timeframe for a
SINGLE patient, take UD packaged meds in soufflé cup with CHIP (eMAR) to
patient room to administer. The drugs are to remain packaged and labeled up to
the point of barcode scanning and administration.
c. Medications for multiple patients are not to be removed at the same time from
automated dispensing cabinet.
d. Future doses for the same patient are not to be removed from the Automated
Dispensing Cabinet.
e. If the medication is an IV product or a dose that requires extended
administration time, the does should be labeled with the patient chart label so
that the patient identifiers can be checked at a later time.
f. At the bedside, the authorized associate reviews eMAR entry, verifies accuracy
of patient and medication by scanning the patient armband barcode and the
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medication barcode for each dose to be administered, prior to administering the
dose.
Medications removed from Automated Dispensing Cabinets are to be given as
soon as they are removed by the Associate who has removed the medications
from the Automated Dispensing Cabinet and prepared the dose.
If unable to administer the dose immediately, the authorized Associate must
return the dose to the automated dispensing cabinet or waste the dose. The
Associate should not set aside the dose or attempt to store the dose on the unit
or in the medication room for future administration. Medications, which have
been removed from their unit dose packaging, cannot be returned to the
Automated Dispensing Cabinet and should be wasted. The Associate should
“undo” the administration of the medication on the eMAR if unable to
complete administration.
Medications pulled from Automated Dispensing Cabinets and set aside or
found stored in the medication room or unit are to be returned to Pharmacy and
accompanied by an occurrence report.
Medications are to be administered within 30 minutes of scheduled
administration time.
Nurse Directors can request access reports from Automated Dispensing cabinets
to validate time frame for medication administration and documentation
Certain high risk medications, as determined by the Director of Pharmacy, will
not be stored in the Omnicell automated dispensing cabinets or as floorstock.
These medications include chemotherapy medications, concentrated
electrolytes, hypertonic saline (3% NaCl) and intrathecal medications. For
safety reasons, these medications may not be delivered as part of the normal
distribution of IV delivery but are sent to the patient care unit when the clinician
or LIP is ready to administer. The clinician or LIP should call central pharmacy
to request the dose be delivered to the patient care unit when ready to
administer.
G.
Medication Occurrence Reporting
1.
In case of a medication error, the physician will be notified as soon as the error is
noted and the medication given will be recorded on the eMAR as it was
administered.
2.
Action will be taken as ordered by the physician.
3.
An “Occurrence Report” will be filled out and sent to the Department Director.
After the occurrence report has been reviewed by the Department Director, the
report will be forwarded to the Director of Pharmacy if the incident involved
dispensing of medication and then forward the form to Risk Management.
H.
Medication Administration Safety
1.
Before administering any medication, the clinician will know the usual dose and
route of administration, the desired effects, special precautions, side effects, special
handling or waste handling requirements and any contraindications. If the clinician
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is not familiar with the medication or intended action of the medication, additional
clinical staff, resources or references should be consulted prior to administration of
the dose. Drug information is available through Meditech, Pharmacy or approved
Drug Information Service (i.e. Lexicomp). Before administering a new medication,
the patient or family is informed of any potential clinically significant adverse drug
reaction or other concerns regarding administration of a new medication.
Before administration, the individual authorized to administer medications will:
a. verify that the medication selected matches the medication order and product
label
b. visually inspect the medication for particulates, discoloration or other loss of
integrity.
c. verifies the medication has not expired.
d. verifies no contraindications exist.
e. verifies the medication is being administered at the proper time, in the
prescribed dose and by the correct route.
f. discusses any unresolved concerns about the medication with the patient’s
licensed independent practitioner (LIP), prescriber (if different than LIP), and or
staff involved with the patient’s care, treatment and services.
g. verify that the medication can be safely crushed if required to complete
administration. Pharmacy may make the interchange to an appropriate liquid or
immediate release product when the enteral route is ordered and the medication
cannot be crushed. If no appropriate liquid or immediate release product is
available, contact LIP for order change to another formulation or agent.
h. wash hands. Don personal protective equipment if appropriate.
i. refer to current edition of Lippincott’s Nursing Drug Guide for detailed
administration techniques for the specified route.
3. Bedside verification of medications via barcode scanning of patient armband and
medication is required for all medications being administered unless an emergent
situation, intra-procedural orders, patient supply used or self administration of dose by
a patient.
4. The CHIP, medication in intact packaging, and bar code scanner will be taken to the
bedside. At the bedside, before administration of medication, the LIP or health care
professional administering the medication verifies
a. correct identity by comparing the eMAR identified with the patient’s date of
birth and name on the armband prior to administration of the medication or
scanning the barcode on the patient’s armband.
b. Medication selected is correct one based on medication order and label or
by an accepted scan of medication barcode
5. Medication administration should be documented as soon as the administration is
complete, never before the fact, and only by the person who actually administered the
dose. In cases where a LIP or patient administers the dose the nurse will document
dose given with a comment denoting actual person administering the dose. When
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barcode scanning of patient armband barcode and medication is accepted the
administration of that dose is documented on the patient’s eMAR.
6. When discarding the package/container or replacing it to its storage location, the
clinician will read the label again to confirm that the correct drug was administered.
7. The clinician will show the patient the medication which they are about to administer
and give the name and use of the drug. Parents or caregivers of the Pediatric patient
will be shown medications for confirmation. This provides the patient with an
opportunity to confirm or deny that they are familiar with that drug by name or
physical appearance, that they have taken the drug before; that they have a need for the
drug’s intended use and allows the patient to ask additional questions about their
prescribed therapy or plan of care.
8. Prompt and accurate documentation of medication administration is an important
safety mechanism. When barcode scanning of patient armband barcode and
medication is accepted the administration of that dose is documented on the patient’s
eMAR. If a patient is in an area where barcode scanning during medication
administration is not available, documentation of administration date and time should
occur immediately after medication administration is completed by the clinician
administering the dose or assisting in the physician or patient self-administration of the
medication.
9. When medication appears in pink on the eMAR from a prior shift or patient care unit
the nurse should consult with the associate caring for that patient to determine if the
dose was administered or if the dose should be given. Do not assume the medication
was administered on the prior patient care unit (i.e. OR or Recovery).
10. "Allergies” the patient has will be clearly marked on the front of his/her chart and in
Meditech. The clinician administering medications should review recorded allergies
listed on the chart or eMAR prior to administration of any medication.
11. Liquid medications for the pediatric patient will be measured and given via oral
syringe for accuracy.
12. Prepare any unadministered or partial remainder of dose for appropriate waste
disposal. Refer to Patient Care Policies: Administration of Chemotherapy Agents,
Controlled Substance Handling, Dispensing and Control and Organizational Policy
Hazardous Drug Waste Disposal.
13. The patient will be assessed for response to the first dose of a medication new to the
patient while under the direct care of the organization. Monitoring a medication effect
on a patient may include patient’s stated perception about side effects or perceived
efficacy, clinical response or lab tests. Document patient’s response or adverse effects
on the intervention “Effects and Teaching of Medication”. Adverse drug reactions are
to be submitted for review using occurrence report. See Adverse Drug Reaction policy
for more details.
14. Intravenous admixtures are to be administered via Alaris smart pumps equipped with
“guardrails” software to assure appropriate and safe administration.
a. The clinician authorized to administer IV medications should enter the patient
Meditech visit number (M#) when setting up the IV pump initially and select
the appropriate profile based on ordered IV medication.
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IF alerts are given, the nurse should verify the written order in the patient’s
medical record with the eMAR entry.
c. If the order exceeds the recommended administration rate, the clinician should
clarify the order with the prescribing LIP or pharmacist before overriding the
alarm.
d. Administration of an IV medication outside of the “guardrails” limits is
discouraged. Use of the Alaris pump under “basic infusion” is discouraged as
there are not guardrails settings with this setting. The clinician should report
an IV medication which they have to infuse using “basic infusion” setting to
Pharmacy so that the drug can be added or dosing protocol reevaluated for
safety reasons.
15. Opthalmic products
a. If more than one type of eye drop is administered, separate administration time
by 5 minutes
b. If more than one type of eye ointment is administered, separate administration
time by 10 minutes.
16. Administration of Intravenous Medications (See Policy Intravenous Therapy)
a. Intravenous medication will be administered only upon a LIP’s order. Except
for the following which are to be administered by a physician or CRNA.
 Anesthetic Agents (except for nurse anesthetist)
 Diagnostic Agents (according to scope of practice)
 Medications not labeled for IV use
 Intra-arterial Infusions
b. Two (2) IV medications may be administered simultaneously if the following
conditions are met:
 The drug is compatible with the IV solution.
 The drugs are compatible with each other, as indicated in the compatibility
charts.
 The drug does not fall in the category in the restricted drugs listed above.
b.
c. The LPN II may “hang” peripherally administered IV medications which have
been prepared by Pharmacy or the authorized licensed practitioner.
d. A medication label will be completed and attached to the fluid container
including: Patient name, room # and expiration date, medication, dosage,
date& time solution of dose if scheduled, initials of person preparing solution,
bar code for the product.
e. IV additive chambers may be used for infusion of medications.
f. Various systems (Add Vantage, Braun Dual chambers, Baxter minibag plus, IV
admixture to minibag, premixed bags or Frozen) may also be used for
administration of medications via “piggyback.” If controller not in use, lower
primary IV solution.
g. IV PB medications can be added to the secondary line tubing and tubing
changed at the time the primary line tubing is changed.
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h. IV Add-vantage bags require activation prior to administration. This task
involves dislocation of the stopper between the Add-vantage vial and Addvantage mini-bag by grasping the stopper through the minibag and pulling
down. Once the stopper is dislodged, the contents of the vial can mix with the
fluid. The Advantage bag should be mixed by shaking until no particulate
matter can be seen.
i. Baxter Minibag Plus System is used for specific drugs, which are unavailable
as Add-Vantage Vial System and yet have very limited stability. (i.e.
Zithromax) Minibag Plus medication vials also require activation prior to
administration. This process requires the user to flex the neck of bag back and
forth until seal snaps. Squeeze bag of fluid into vial. Shake to mix and then
squeeze bag to allow vial contents to flow back into bag.
j. Braun Dual Chamber IV additive system and Baxter Clinimix TPN bags
require the user to roll the bag to mix the diluent and active ingredient
chambers prior to administration.
k. Manufacturer premixed frozen IVPBs are thawed in the pharmacy prior to
dispensing to patient care units.
l. IV push Medications may be administered via intravenous infusion lines.
m. Parenteral nutrition is administered through a dedicated port via a central
venous catheter. If central access is not available, only those Parenteral
nutrition solutions with a Dextrose concentration less than or equal to 10%
may be delivered via a peripheral IV line.
n. As EMRMC pharmacy offers a 24-hour service, all parenteral products will be
prepared and dispensed from the pharmacy. This does not preclude the
preparation and administration of IV medications in emergency situations or
from authorized stock areas on patient care units.
o. Intrathecal medication preparation and administration is addressed in a separate
policy.
15. Parenteral Medication Administration (Subcutaneous and Intramuscular)
a. Injection sites will be rotated if the patient is receiving repeated injections.
Injection sites used for each dose will be indicated on the eMAR. Avoid any
site that looks inflamed, edematous or irritated. Avoid sites containing moles,
birthmarks, scar tissues or lesions.
b. Dorsogluteal and ventrogluteal muscles are most common muscles for IM
injections. Deltoid muscle can be used if injection is 2ml or less. Vastus
lateralis muscle is used most commonly in children.
c. Subcutaneous injection sites include abdomen, upper arms, thighs, shoulders
and lower back. Rotating site promotes drug absorption and prevents ADRs.
d. Suggested maximum amounts for adult patients’ subcutaneous route, 1 ml;
intramuscular route, 3 ml.
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e. All injectable dosages of selected critical drugs (insulin, heparin, patient
controlled analgesia or epidural orders) will be checked by two licensed
practitioners.
f. Heparin injections will be given subcutaneously at a 90 degree angle in the
abdomen in a rotating pattern unless contraindicated.
g. The injection site will be cleaned with an alcohol prep pad using a circular
motion from the center of the chosen site until all area of about 3 inches has
been prepared.
16. Transdermal Drug Application
a. The old strip/disc will be removed and skin washed with soap and water.
b. The prescribed amount of ointment/gel will be placed on the application strip or
measuring paper.
c. Apply topical product to any dry, hairless, flat surface of the body. Do not rub
the ointment/gel into the skin.
d. Secure the strip/disc with self-adhesive pad or tape. (Note date, time and your
initials on the strip/disc.).
e. Once a medicated transdermal patch is removed from the patient, it should be
folded with adhesive sides together and then discarded into the closest sharps
container to prevent diversion, or inadvertent drug exposure to others.
17. High Risk Medications
a. Specific procedures have been developed to reduce risk of adverse events and
medication errors associated with use of high risk medications and ensure their
safe handling and appropriate administration. Comments on the eMAR or label of
medication orders are designed to assist the clinician in safe administration of the
following high risk medications:
anticoagulants, chemotherapy agents,
concentrated electrolytes (potassium, magnesium, hypertonic 3% sodium
chloride), medications administered intrathecally or epidurals, narcotic/opiods,
insulin, neuromuscular blocking agents, look-alike/sound-alike medications,
concentrated dextrose (> 10%), or pediatric medication orders.
b. A second clinician is required to perform an independent double check of
calculations, ordered dose, route and frequency or programmed infusion rate prior
to administering high risk medications such as heparin, insulin, hypertonic saline
(3% NaCl), concentrated dextrose (> 10%), chemotherapy, PCA pumps or
epidural infusions.
c. A time out is performed at the bedside prior to administration of an intrathecal
dose.
d. A smart infusion pump with Guardrails software is used to administer all
intravenous high risk medications.
e. Bar code scanning of the patient armband and medication is required prior to
administration of any high risk dose in patient care areas where bar code scanning
is available.
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Page 14
f. “Near miss” occurrence, where conditions exist that might lead to medication
errors with high risk (or other medications) are to be filed using the yellow
occurrence report.
g. Hazardous waste drugs are handled, administered and disposed of in designated
waste containers according to established policies and procedures. Refer to
Patient Care Policies Administration of Chemotherapy Agents, Controlled
Substance Handling, Dispensing and Control and Organizational Policy Hazardous Drug
Waste Disposal.
G. Adverse Drug Reaction
1. A suspected adverse drug reaction will be reported immediately to the LIP who
ordered the drug. Significant adverse drug reactions will be reported and trended via
Occurrence reporting mechanism.
2. The EMRMC definition of a significant adverse drug reaction is:
one that results in an increased length of stay or change in level of care
one that requires treatment with a prescription medication or
one that results in temporary or permanent disability or
one that is reported to the Food and Drug Administration or manufacturer or
one that is toxic to the patient or
one that results in death or
any reaction that indicates an antigen/antibody reaction has occurred (hives,
swelling, respiratory involvement). Such reactions may consist of: elevation in
temperature attributable to the drug, changes in blood pressure, appearance of
rash, appearance of edematous area, certain blood dyscrasias, vomiting, and/or
anaphylactic reaction.
3. An entry of the medication given and/or the drug reaction will be properly recorded in
the patient's medical record.
4. Personnel who first notice a reaction to a drug will notify the nurse in charge. The
nurse will notify the prescribing physician of the fact immediately. It is the
responsibility of all clinicians to screen for and report suspected reactions to
medications.
5. Suspected Reactions will be reported by initiation of an Occurrence report. The ADR
box should be checked and a description of the event documented as well as the
response to any prescribed treatment.
6. The event is reviewed by the Pharmacy Director and data collected for trending and
reporting. All ADR reports are summarized and reported to the EMRMC Pharmacy &
Therapeutics (P&T) Committee. The P&T Committee analyzes the data, trends and
recommends actions to minimize recurrence of ADRs to patients of EMRMC.
7. The completed occurrence report is then coded and forwarded to Risk Manager.
H.
Medication Keys/Cart or Cabinet Security
1.
The medication carts or room will be secured with key, proxy card or electronic
keyless entry system, which will be changed at discretion of the Clinical Directors
and Director of Pharmacy. Only authorized Associates should have access to drug
Medication Administration and Documentation
2.
3.
4.
5.
6.
Page 15
storage areas. Authorized Associates include licensed nursing Associates,
technicians or therapists who have medication administration responsibilities as
part of their job description, pharmacists, pharmacy technicians, anesthesia
pharmacy technician, physicians, anesthesiologists or anesthetists who administer
meds to their patients. Access to locked drug storage areas for housekeeping and
maintenance needs are coordinated with the supervisor in the area to assure that
medications remain secure. The organization should limit access to drug storage
areas to prevent potential diversion of medications by unauthorized Associates,
patients and visitors.
OMNICELL Automated Dispensing Cabinets are secured via electronic access
codes and passwords. New Associates who are in positions that require them to
access and distribute or administer medications will be added to the Omnicell User
Dictionary when the Pharmacy is informed of their employment. Access is revoked
as Associates are terminated or their position changes and their job description does
not require them to access, distribute or administer medications. Users may change
their electronic passwords at any time. Omnicell user passwords expire and must be
changed every 60 days.
All medications classified by the Commonwealth of Kentucky as controlled
substances will be stored in double locked carts or storage areas.
The medication key to medication carts or rooms will be carried by the licensed
nurse or clinician responsible for the medications on that unit during his/her shift.
Under no circumstances will a medication cart or room key be taken outside the
hospital. (If such an incident should occur, the Clinical Director of the unit or the
Nursing Supervisor will be notified who will take the necessary action to contact
the responsible associate and retrieve the keys as soon as possible.) If the key has
been taken outside the hospital, the person returning the key will count any
controlled substances stored within the cart or room with the on-duty nurse. The
results will be recorded on the Control Substance Administration Record (CSAR).
For patient care units with Omnicell dispensers, the counts are documented via
Omnicell countback. Pharmacy will be contacted to coordinate replacement locks
and keys with Engineering and BioMed.
Mobile carts used for medication storage are to be kept secure. Associates using
mobile carts are responsible for locking the carts or securing the carts in approved
locations when not in use. Mobile carts used for medication storage are to be
either attended, stored in a locked area or in direct line of sight by Associates to
prevent diversion.
I.
Self Administration of Medications: See Medication Policy, Self-Administration
Doses administered by patient are exempt from bar code scanning process.
J.
Documentation of Medication Administration
1.
Medication administration documentation occurs on the eMAR when the patient
armband and medication barcode are scanned. When barcode scanning is not
completed, the clinician who administered the medication is required to manually
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Page 16
document the administration of the medication on the eMAR or into the approved
medication administration document as promptly as possible.
2.
IV administration documentation is made in the Meditech IV spreadsheet
document. See IV Administration Policy
3.
Special Charting Instructions:
a.
If a dose is not administered for any reason, the nurse or clinician will
document the reason under unadministered function of eMAR.
b.
If a dose is administered by someone other than the nurse or clinician the
dose should be documented as administered on the eMAR and a comment
added to reflect who administered the dose. (Example: intrathecal dose
administered by physician)
c.
The nurse or clinician assigned to the patient must manually denote on the
eMAR the administration of self administered doses or if patient supply of
medications are used.
d.
All PRN medications will be recorded on the eMAR.
Date, time,
medication, dose, and mode of administration, effect will be recorded in the
effects of medication assessment.
e.
All controlled substances will be recorded on the eMAR and for nonOmnicell controlled meds on the Control Substance Administration Record
(CSAR). (See procedure on Controlled Substance Administration Record.)
f.
Medications with varying dosages or 2 different routes ordered will be
documented in eMAR.
g.
Medications given off schedule are documented on eMAR using
“unscheduled med” function on eMAR.
h.
Any pertinent information about the patient's response or adverse effects to
medications given will be charted in the effects and teaching of medications
assessment.
i.
Selected critical medications, (heparin, insulin, patient controlled analgesia or
epidural orders), require another licensed practitioner (LP) to confirm/check
the dose calculation (math) to assure it is consistent with the order, the
measured volume to administer or the programmed pump infusion rate prior
to administration to the patient. The witnessing LP will document the
confirmation via Meditech intervention documentation.
k.
Lot numbers and expiration date of administered vaccines and blood products
are to be documented in Meditech.
l.
The transdermal patch site administration site/location is documented on
eMAR
m.
Injection sites used for each dose will be indicated on the eMAR.
n.
When administering a skin test, appropriate information will be documented
on eMAR.
1. Site of administration: the inner aspect of the forearm will be used (PPD
in left forearm and other antigens in the right forearm.)
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Page 17
2. The test will be read at 48 hours or at time indicated by the
manufacturer.
3. The widest diameter of distinctly palpable induration will be recorded.
4. If not able to read prior to discharge, discharge instructions and sheet
will be given.
REFERENCE:
TJC Standards MM. 1.01.01 thru MM.8.01.01
Date Reviewed:
Date Reviewed:
Date Reviewed:
Date Reviewed:
08/97
04/02
08/02
08/04
Date Reviewed:
Date Reviewed:
Date Reviewed:
Date Reviewed:
02/06
08/06
8/09
6/10
Date Reviewed:
Date Reviewed:
Date Reviewed:
Date Reviewed:
Previously Revised: 8/02, 08/04, 12/06, 12/07, 11/08, 8/10, 1/11, 12/11