Medication Administration

Philosophy

Mount Auburn Hospital is dedicated to:

1. Developing systems that foster safe medication practice

2. Fostering a culture that encourages the reporting of medical

errors and near misses as a way to:

- identify opportunities within our system for improvement

- define best practice

Medication Occurrence Report /

RL Solutions Report

Developed to encourage reporting of:

• Medication Errors

• Medication Near Misses or Intercepted errors

• Adverse Drug events

(untoward effect)

5 Essentials to Medication

Administration

RIGHT

DRUG

Right

Patient

Right

Dose

Right

Route

Right

Time

Never Guess Again

DOWNTIME

Orders written on paper

Fax to pharmacy

Pharmacy with print downtime eMARs and deliver to unit

Transcript orders onto downtime eMAR

When the system is up

Document medications that were given during downtime

Essentials to safe ordering of

Medications: Complete orders

• Medication full name: no abbreviations

• Dose: strength or concentration; avoid u for

units, 0 before a decimal point (0.125mg)

not .1250

• Route:

• Frequency: be careful with extended release

preparations

DO NOT USE List A b b re v ia t io n /te rm s P o te n t ia l

P ro b le m

P re fe r re d T e rm

U , U . u , u .

( fo r u n it)

M is ta k e n a s z e ro , fo u r

o r c c

W rite " u n it"

IU

(fo r in te rn a tio n a l

u n it )

M is ta k e n a s IV

( in tra v e n o u s o r 1 0 ( te n )

W rite " in te rn a t io n a l u n it "

Q .D ., Q D ,

Q .O .D ., Q O D

M is ta k e n fo r e a c h

o th e r .

W rite "d a ily " o r " e v e ry o th e r d a y "

T ra il in g z e ro

(X .0 m g )

L a c k o f le a d in g z e ro

( .X m g )

D e c im a l p o in t m a y b e

m is s e d

N e v e r w r ite a z e ro b y its e lf a f te r a d e c im a l p o in t

(X m g ) ,

A lw a y s u s e a z e ro b e fo re a d e c im a l p o in t

(0 .X m g )

M S , M g

M S O 4

M g S O 4

C o n fu s e d fo r o n e

a n o th e r

W rite "m o rp h in e s u lfa te " o r "m a g n e s iu m

s u lfa te "

u g M is ta k e n fo r m g

(m illig ra m s )

W rite " m c g "

a m p s o r a m p u le s * D o s e s m a y v a ry fo r th e

s a m e m e d ic a tio n

E x a m p le : W r ite "2 5 g m s D 5 0 W " ra th e r th a n "o n e

a m p D 5 0 W "

v ia ls * D o s e s m a y v a ry fo r th e

s a m e m e d ic a tio n

W rite th e m e d ic a t io n a n d d o s e to b e g iv e n

E x a m p le s o f a m p s o r v ia ls : C a lc iu m c h lo r id e c o m e s in a 1 g ra m v ia l

D 5 0 h a s 2 5 g ra m s o f d e x t ro s e

T h e fo llo w in g ite m s w e re c o n s id e re d b y th e M S E C a n d a re b e in g re c o m m e n d e d to b e

a v o id e d a s w e ll. T h e s e w ill l ik e ly b e a d d e d to th e " d o n o t u s e " lis t in th e fu tu re .

m e d ic a tio n /n u m b e r ,

s u c h a s

In d e ra l 2 0 m g /2

C o n fu s in g W rite " In d e ra l 2 0 m g p o b id "

s u p e rs c r ip ts ,

s u c h a s

In d e ra l 2 0 m g2

C o n fu s in g W rite " In d e ra l 2 0 m g p o b id "

T .I .W . M is ta k e n fo r th re e t im e s a d a y

o r tw ic e w e e k ly

W rite "3 t im e s w e e k ly " o r " th re e t im e s

w e e k ly "

Other considerations with

ordering medications

• Patients name & medical record # on order sheet (2 unique

identifiers)

• Drug allergies on each medication order sheet

• Clinical parameters to HOLD a medication (can’t write

HOLD Digoxin) (can write HOLD Digoxin HR < 60)

• Signature of MD, PRINTED NAME and phone/beeper.

Other activities to promote

medication safety • Check the patient’s ID bracelet. Check 2 identifiers name &

financial # against order sheet, EMAR, or Pyxis paper

• Know why a medication is being prescribed for your patients

and explain to the patient

• Review the patients allergies before administration

• Review pertinent lab values ( chemistries, drug levels, renal

or liver function) before giving medications

• Ensure clear documentation of medications whether they

were given or held

John Smith

Transcribing MD Orders

Place beside each

order as it is transcribed

When order is

transcribed draw a line

Sign, date, and time

when transcription

complete

Person verifying signs

to the left of the order

Transcribing Orders

• Transcribe the order as written onto the MAR

• Place a check mark beside the order as you complete them

• Draw a line under the order

• Sign, date, and time the order to the right of the order

To Verify an order

• Review the transcription on the MAR against the order

• Review that the times for administration are appropriate to

the medication frequency

• Place your initials on the MAR in the date column

• Sign your name to the left of the order

The person who transcribes and the person who verifies

MUST be 2 different people

Daily MAR

DON”T ASS U ME its CORRECT

Initials of verifier go in

the date column

X out days med is not

to be given

If med not given, circle

dose and write reason

If dose changes daily

write in dose given

DM

DM

DM

DM

DM

PRN Record Medications cannot be

ordered with a RANGE in

dose or frequency

If different doses are ordered

they must be specific to a

particular condition (level of

pain

0-3 min pain

4-6 mod pain

7-10 severe pain

Heparin Orders

We have 3 Heparin

Protocols: Cardiac,

DVT and Neuro.

Please make sure the

right protocol is

ordered for your

patient

Dosing based on

patient’s weight in

KILOGRAMS

PTTs Q 6 hours til

patient therapeutic

Heparin Documentation

Dosing adjusted based on PTT by using normogram

All setting of adjustment of Heparin drips must be done by 2

RNs

111

Entering the World of CPOE

Automation of the Medication

Administration Process ORDERING

CPOE

Computerized

Physician

Order

Entry

Transcription

EMAR

Electronic

Medication

Administration

Record DISPENSING

Pyxis

Talyst

Administration

Bar-code Scanning

Smart pumps

Serves as a Springboard to POE, PCI

Admin Data, NUR

Name 1

Name 2

Name 3

Name 4

Name 5

Name 6

INSULIN SLIDING SCALE

Insulin Protocol with Basal – Bolus dosing

PAIN/FEVER ASSESSMENT

Minimal pain or fever? 101

Documenting Infusion Stop Time When the infusion ends

Select your F4 key and then type IV. This will default the

statement IV Infusion stopped at (the current time will default).

If necessary you can edit the time by simply deleting and typing

accurate time.

Click the X to close the text box.

For outpatients

If we don’t document

when fluid went up and

came down. We only get

paid for an IVP med

Then click Edit to save the information

An asterisk will appear indicating there

was a change. Submit and File the

Changes.

Documenting a New Heparin Start

Hanging a New Bag

Documenting a Rate Change

Documenting a Rate Change

Documenting a Critical Test result

Resuming Heparin AFTER a HOLD

CPOE Order or Order Set If you try to order Warfarin for

a patient who has not had an

order for 30 days, you will get

a prompt to ask you to

consider discarding this order

and ordering the Warfarin

initiating protocol

This is the Warfarin

initiation protocol

Processing the Protocol Order

10

/13

/09

Coumadin per

protocol

One time med

sheet

18

Date Medication Time Date Date Date Date Date

IF CPOE Order: place paper order set in MD Order section of

chart so MDs have the nomogram

MD will order subsequent orders as one time meds. Document

dose administration on One Time Medication Sheet and

Coumadin Worksheet

To be placed in Medication

Books and document dose

administered daily

Give to patient at discharge

Date Day of Time PT INR Dose RN

signature

of therapy

10/13

10/14

10/15

1

2

3

1800

1800

1800

1.2 5mg K Murphy RN

1.4 5mg D Morrison RN

2.3 2mg D Devanna RN

Warfarin Protocol Flowsheet

New Patient Education Brochure

New Brochure

from the

Agency for

Healthcare

Research and

Quality

Give to all patients on

Coumadin

Your Guide to your

Blood thinner

Order Management screen will show changes to orders

Verbal Orders

Are only acceptable in an

emergency when a delay

to write the order could

be result in a poor outcome

When taking a Telephone or

Verbal Order

With Telephone orders

Write the order and READ it back to the MD

With Verbal orders:

Before administering REPEAT IT back to the MD

Click on

patient

then

click on

Orders

Check the medication and dose as you

remove the medication from pyxis

Pyxis will tell you which bin to take the

medication from.

Check the medication

against the medication

administration record

Check the medication

label against the

medication administration

record after the

medication has been

dispensed into a cup

Scan the medication

EMAR will notify you

If the medication or dose

Is not a match with the

EMAR screen

Administration Safety

Standard Medication Times

Time Critical Medications ie. Antibiotics

must be given 30 minutes before or after the scheduled

dosing time for a total window of 1 hr

Medications more frequently than daily but not Q4hr

must be given 1 hour before of after the scheduled

doing time for a total window of 2 hours

Daily medications or longer administrative intervals

must be given 2 hours before or after the scheduled

dosing time for a total window of 4 hours

Label admixtures and syringes

Magnesium

1gm

In 500ml D5W

8/8/14 DD

Board of Registration in Nursing

Ruling on IV Solutions

• This recent ruling requires a nurse to:

– see the preparation of IV solutions they are administering

through the process of:

• removing outside wrapping

• removing the seal

• spiking the container

• priming the tubing

• Exceptions:

– IV made by pharmacy

– Emergencies where an RN prepares for another RN in the

same room

See: www.mass.gov/eohhs/licensing/ocupational/nursing/alerts.html for more details

Overwraps

• Do not remove overwraps on IV bags until ready

for use fluid in the bag will evaporate

OVERWRAP NO OVERWRAP BAG IS EMPTY

DRUG CRYSTALIZED OUT

Over time, the volume will decrease as it evaporates

8 Rules to ensure the Sterility of Medications

1. Clean the work surface on which you are preparing meds

2. Wash your hands

3. Swab the vial 3 times and allow to dry

4. Avoid coring

5. Date multidose

vials with expiration

date (28 days out)

6. Store vials at appropriate temperature

7. Questionable vial?? Toss it

8. Never leave a needle in place

Bevel up

Safety Policies Give who??

What??

Those who prepare

a medication

Administer

See the medication enter the

patient

Stay with a patient until they swallow

pills

Pills left at the bedside are a

hazard to many

High Alert Medications

MUST BE CHECKED BY 2 RNs BEFORE ADMINISTERED

Hazardous waste

- Hazardous medications are hazardous to public health or

the environment

- It is regulated by the EPA (Environmental Protection Agency)

P Waste Medications

Hazardous

Waste

Medications Aerosols

“Pyxis” will warn you if

you dispensed a drug

that is a HAZARDOUS

WASTE to the

environment

How do you know if the drug is Hazardous

to the Environment?

If there are any dispensing

instructions, scroll down to see

that the medication is a

hazardous waste medication

The bin you remove

the medication from

will have a black dot

with an HW on it

Black Bucket = Hazardous Waste

Black box has:

• List of drugs that go in

bucket

• Phone #

to call when full

• Container must remain

closed EXCEPT when

adding waste.

• Environmental Service

will inspect containers

weekly and pick up as

needed.

Chemotherapy waste

• If completely used,

discard in yellow

chemotherapy bucket

• If only partially administered and it’s a chemotherapy on the black box label, call Environmental 5084 or Pharmacy 5131 for a new black box to place Chemotherapy bag and tubing for return to pharmacy in black box

New P waste hazardous

medications • Nicotine patch

• Nicotine gum

• Warfarin

• Physostigmine

• These medications will have a return to pharmacy label on them.

• If opened, split and unused, place in a plastic bag and return to Pharmacy

MOUNT AUBURN SPECIFIC

Mount Auburn is considered

a low accumulating hospital

so we need to separate out

this waste stream and measure

it to prove this. This waste stream

may not always be necessary once

to provide our waste amounts to

regulators

A new item on the hazardous

medication list: Insulin vials

• If all insulin in vial is

used, discard in

regular trash

• If any insulin is left in

vial or the vial has

expired, discard in black

box

Insulin drips can be disposed in regular trash and the

diluted concentration is NOT considered hazardous

Aerosol Waste

Combivent Combivent respimat Albuterol Flovent

inhaler inhaler inhaler inhaler

Return to Pharmacy bin

Please only use this bin for the purpose of returning items to pharmacy

Use

Smart Pump

Library

Use your Patient

care area (floor name)

If you can’t find the

drug in your library

Email the pump

distribution list

If you’ve hit a soft limit

you will need to

confirm it, and the

screen will be RED

If you hit a soft or hard

limit double check to

ensure you are setting the

pump correctly

When an error occurs…..

• Notify the patient’s physician and nurse manager

• Complete an on line incident report in RL solutions

• Think about what contributed to the error occuring

• If the patient requires treatment due to the error. State

only the facts in the medical record. What the patient

received, how they reacted, and the treatment measures

taken

• It is the physician’s responsibility to notify the patient of

the error, if the error involved something you did you may

wish to be present during the disclosure

Ensuring patient safety

beyond the hospital

By Patient teaching:

• What is the Drug

• How much to take

• How to take it

• When to take it

• Special instructions: with food /without food

• How long to take it

• Side effects to watch for

• What to do to prevent problems with this medication:

ie. Ways to prevent constipation, do not stop taking medication

I know

what

to do

now

Medications CANNOT be sent home

• We are not licensed as an outpatient pharmacy

• Medications from pharmacy are not labeled with all the

required information needed for patients to take that

medication correctly

• In the event of a recall, we would not know that patient

had that medication

HCAHPS Patient Satisfaction Questions on Medications

Before giving you

Any new medication,

how often did hospital

staff tell you what the

medication was for?

Before giving you any

medication, how often

did hospital staff

describe possible side

effects in a way you

could understand ?

Medication Written Education in Lexicomp

Medication Schedule

Medication Reconciliation

From Nursing Assessment

Pre Admission Medication List

Discharge Medication Reconciliation

When questions arise…..

The only question that is stupid is……

the one not asked.

Resources:

• Medication Books on unit

Betty Garhart

• Pharmacy

• Advanced Clinicians

• Nurse Managers

• Nursing Supervisors

IV Guidelines