SaskHealth - Medication Assistance Module. Part I Introductory Information. Part II Licensing Requirements for Personal Care Homes

Transcription

1 Member Log Out Student Learner Log Out Table of Contents SaskHealth - Medication Assistance Module Module Status Last Accessed Personal Information Welcome, student Last Visit: Date: 2/23/14 Time: 11:29 PM Learning Object Status: Available: 18 Visited: 1 Part I Introductory Information 2/23/14 11:29 PM Part II Licensing Requirements for Personal Care Homes 2/23/14 11:29 PM Part III Course Content - Module 1: Medications 2/23/14 11:29 PM A. Medication Benefits, Risks, and Unwanted Side Effects Not Accessed B. Common Medication Terminology, Abbreviations, Labels and Packaging Not Accessed C. Roles and Responsibilities for Medication in Personal Care Homes Not Accessed D. Types of Medication Frequently Found in Personal Care Homes Not Accessed E. Non-Prescription and Over-The-Counter Medication, Vitamins, Supplements, and Herbs Not Accessed F. Safe Medication Storage, Transport, and Disposal for Personal Care Homes Not Accessed G. Consulting With the Residents' Physician/Nurse Practitioner Not Accessed H. Pharmacists: Your Medication Support Experts Not Accessed I. Assisting Residents to Take Their Medication Safely Not Accessed J. Medication Safety, Infection Control, and Staff Training Not Accessed K. Training for People Working in personal care homes Who Assist with Medications Not Accessed L. The 6 Rights When Assisting With Medication Not Accessed M. Resident Rights Not Accessed N. Medication Errors Not Accessed O. Questions for General Overview of Module 1: Medications Not Accessed Bibliography Not Accessed User Profile Member Name Courses Role Last Log On Learner, Student (student) 1 / 1 Learner 2/23/14 11:29 PM 1

2 A. Who is this course designed for? This course is designed for 3 main groups of people: 1. Personal Care Home Staff - who are paid to work with the residents in personal care homes, and may be providing personal care, medication assistance, recreation, meal preparation and/or other services. 2. Operators - who are employed to manage or administrate personal care homes, and are required to carry out all the duties of the licensee, including assisting with medication and supervising staff who assist. The operators are required to carry out their responsibilities in accordance with The Personal Care Homes Act, The Personal Care Homes Regulations, and the Licensees' Handbook for Personal Care Homes. 3. Licensees - who own or sit on a board of directors of a personal care home, have applied for, met the conditions set out by The Ministry of Health, and have been granted a license by the Ministry of Health to open or administrate a personal care home. Licensees are ultimately responsible for the provision of safe and appropriate care to the residents. This includes the proper assistance to residents with medication in personal care homes, and ensuring the home operates according to the standards under The Personal Care Homes Act and The Personal Care Homes Regulations. An important responsibility of the staff, operators, and licensees in personal care homes is to ensure the safe storage and documentation of medication, and to ensure that anyone who is assisting residents with medication is knowledgeable and trained, and capable of assisting residents in a safe manner. If you have any questions about the course content please call a personal care home consultant at

3 Learning Objectives Upon completion of Medication Assistance Module, as evidenced by attaining a minimum 95% score on the accompanying review questions, the Learner will: recognize the benefits as well as the dangers of medication develop an awareness of how resident medications are managed in personal care home environments identify and apply the "6 Rights" for safely assisting residents with their medication demonstrate awareness of the various routes with which medication are taken, and the principles which are required to be followed for each of these routes understand the rights of the residents with respect to medication understand and apply the medication procedures which will most effectively assist residents with taking their medication, while preserving their independence and dignity understand how and when to report medication errors or concerns identify and adhere to safe medication labeling, transport, storage, and disposal practices be aware of and follow best practices and the requirements under The Personal Care Homes Act with all handling of medications in the personal care home develop an understanding of the role of the pharmacist, physician, and nurse practitioner, with respect to resident medication identify which medications require specialized care procedures or special considerations 3

4 What are the requirements for medication assistance in personal care homes? Licensees are responsible to operate personal care homes in accordance with all requirements under The Personal Care Homes Act. All staff in personal care homes, operators, and licensees, are required to be aware of and follow these requirements regarding medication. These requirements are outlined in the following documents from the Ministry of Health: The Personal Care Homes Act The Personal Care Homes Regulations The Licensee's Handbook for Personal Care Homes This training module The Personal Care Homes Orientation Workshop Manual for Licensees and Operators The staff, operators, and licensees in personal care homes are responsible to ensure that residents' medication is stored securely. They are also responsible to ensure that anyone who is assisting residents with medication in personal care homes has the necessary knowledge and training to do so. This course will provide a comprehensive overview of the expectations with regard to medication in the above documents. It will also educate learners about the responsibilities of staff, operators, and licensees about medication assistance in personal care homes. Some of the information contained in this document was adapted from the above Ministry of Health publications. Full credit is acknowledged for those who assisted in the development of the preceding Ministry documents. 4

5 A1. Why do residents in personal care homes take medication? Many residents of personal care homes take medication on a regular basis to: treat a disease or illness promote or maintain health treat unwanted symptoms Medications can have many benefits for residents in personal care homes, however, they can also cause severe illness and even death if they are stored carelessly, taken improperly, or taken by the wrong person. Due to the potential for harm to residents, there are many important rules about medication in personal care homes which are required to be followed. The basis for these rules is The Personal Care Homes Act. This Act originated to protect personal care home residents by establishing guidelines for all personal care homes in Saskatchewan. When it comes to an issue such as medication, which has such great potential to harm residents, there are definite requirements about how residents in personal care homes are required to be assisted with their medication. 5

6 A2. How are elderly people affected by medications? The majority of personal care home residents are elderly people. Medication therapy in the elderly is complicated by many factors unique to this age group. Multiple disease processes and environmental influences combine with the physical effects of aging to alter the response of elderly to medication. The Canadian version of the Resident Assessment Instrument (RAI) Minimum Data Set (MDS)-Home Care Manual explains the physical changes which occur with aging and which also alter the response of the elderly to medication and contribute to possible complications: There is a reduction in body size, with a decrease in lean body mass and an increase in body fat, thereby altering the distribution and availability of some medication in the body Absorption (passage from the gastro-intestinal tract to blood) may be marginally slower in older persons as compared to young individuals for some compounds (although it is not usually a major factor) The rate of metabolism by the liver of some compounds decreases The rate of processing the waste of some medication is diminished by the kidneys The responsiveness of some tissues to a medication may be different in elderly persons than in those who are young Additionally, many acute and chronic illnesses may alter the response of elderly residents to medication. For example, dehydration associated with a fever may decrease the urine output and thereby increase the amount of a medication in the body. This might result in toxic levels of the medication being achieved. Some illnesses affect the absorption of some medication (diarrhea, etc.) Other illnesses result in alterations in the way some medication are distributed in the body (example: kidney or liver failure). Diseases can also affect the metabolism of a medication (example: thyroid disease, viral infections). 1 1 Baumann, Brandeis, Resnick, Resident Assessment Instrument - Home Care (RAI-HC), (Washington, DC, 1994, 1996, 1997)

7 A3. What kinds of medication do seniors take which could create problems? All medication have the potential to affect seniors in unwanted ways. "Since the elderly frequently suffer from a multitude of disorders, they are likely to be taking multiple medication. 60% to 80% use prescription medication and 50% to 75% use nonprescription medication." 2 It is the responsibility of licensees, operators, and personal care home staff to be watchful for changes in the residents and for unwanted side effects or problems from medication. 2 Baumann, Brandeis, Resnick,

8 A4. What else can we do to protect residents from unwanted medication side effects? Personal care home licensees, operators, and staff are required to be aware of common problems and side effects that may be connected to any existing and new medication the residents take. Some resources where you can get information about various medication are: read the material that comes from the pharmacy with the medication ask a pharmacist check a medication reference guide ask a nurse if your personal care home employs a nurse, or if a nurse visits the home check reliable sources on the internet *Remember...even if you believe a medication prescribed for a resident is causing unwanted side effects, you can NOT make changes to medication without a physician's/nurse practitioner's, or in specific circumstances, a pharmacist's order. Unwanted side effects are required to be reported to the physician/nurse practitioner. 8

9 A5. How do medication sensitivities and allergies affect elderly people? Elderly individuals with pre-existing health conditions can have extreme reactions if they take medication to which they are sensitive or allergic. For example, skin rashes and breathing difficulties can be the results of taking a medication to which one is sensitive or allergic. Younger, healthy people may be able to tolerate skin reactions (hives, rashes, etc.) or even breathing problems after accidentally taking an allergy-trigger medication. However, elderly peoples' skin is thinner and more fragile and a rash or hives could cause open sores, or an infection. Breathing problems in a healthy adult may be experienced as breathing emergencies in elderly people. Elderly people do not have the ability to recover as well after an allergy is triggered, causing their body systems to be compromised. 9

10 A6. What is poly-pharmacy? Poly means many. Pharmacy refers to preparing and dispensing medication. Poly-pharmacy is when multiple medications are prescribed and taken by the same person during the same period of time. Multiple medications increase the risk of unwanted side effects and interactions between medication. herbs. NOTE: It is best practice to have a pharmacist, physician or nurse practitioner review new residents' prescription and non-prescrition medication. In personal care homes, physicians'/nurse practitioners', and in specific circumstances, a pharmacist's orders are required for all prescription and non-prescription vitamins, supplements, and Based on data from the 1996/1997 (institutional component) and 1998/1999 (household component) National Population Health Survey, seniors were major consumers of prescription medications, over-the-counter (OTC) products, and natural and alternative medicines. Almost all (97%) seniors living in long-term health care institutions were current medication users. Over half (53%) of seniors in institutions used multiple medications (currently taking five or more different medications). Both medication and multiple medication use were associated with morbidity (illness or death) 3 3 Statistics Canada, "National Population Health Survey", , (September 2011) 10

11 A7. How do we identify and avoid medication sensitivities, allergic reactions, and unwanted medication side effects? Unwanted side effects will occur in some residents regardless of what the staff do; the important part is that licensees, operators, and staff are able to identify when a resident is experiencing an unwanted side effect, and to work with the resident's pharmacist, physician/nurse practitioner to determine whether it is serious and needs medical attention or is one that will resolve over time. The keys to identifying and avoiding unwanted side effects and dangerous consequences when assisting residents with medication include: documentation, observation, and evaluation. Documentation ensure the proper documentation regarding the type, time, frequency, and dose of ALL medication is listed on a medication records sheet for all residents all prescription or non-prescription medication, as well as vitamins, supplements, and herbs are required to be ordered by the physician/nurse practitioner, or in specific circumstances a pharmacist information about what each medication is used for and possible side effects are required to be available to anyone assisting residents with medication information about ALL individual residents' medication sensitivities and allergies is required to be listed on the medication records sheet medication sensitivities and allergies are required to be documented in the residents' care plans All of the previous documented information is required to be reviewed at least every 6-12 months, as well as anytime medication changes are made. Whenever a new medication is introduced to a resident, it is required to be checked against the list of medication sensitivities and allergies by both the person from the personal care home and also the pharmacist. Observation good observation and ongoing monitoring are important whenever a change occurs with a resident's medication residents are required to be watched carefully for any changes in their behaviors, how they feel, and their physical appearance any recent change is required to be considered a possible unwanted medication side effect; common conditions to be observed are: confusion falls depression incontinence constipation restlessness tremors loss of memory involuntary movements of lips, tongue, face and body nausea dry mouth rashes, itching dizziness bruising diarrhea tiredness anxiousness all observations are required to be documented in the resident's progress notes Evaluation follow up is an essential part of medication changes for residents 11

12 residents must be carefully observed for the intended benefits of a medication change as well as any unwanted side effects a good follow up plan is required to be in place to evaluate medication changes. The plan should include daily observation for the first few days after the change, then in 1 week, 2 weeks, 1 month, 3 months, and then every 6-12 months as required medication records are required to be part of a resident's care plan; When the care plan is reviewed, review the medication the resident is currently taking When reviewing the medications, consider: What is the medication for? Is it doing what it is intended to do? Can it be improved upon? The Personal Care Homes Regulations state, "A complete review of each resident's care plan is carried out at least annually" 15(3)c Asking the physician/nurse practitioner and/or the pharmacist to review residents' medications on an annual or semi-annual basis is best practice, it is a pro-active way to monitor residents' medications needs. 12

13 A8. Review Questions for Elderly People and Medication The following multiple choice questions are based on situations that might be encountered in a personal care home. Which of the following is NOT a reason why residents should take medication? To treat a disease or illness To keep them quiet at night so that the overnight staff can do their work To promote or maintain health To treat unwanted symptoms Hint Tries Remaining: 2 Which of the following is NOT a true statement about medication? They have both benefits and risks They can reverse the aging process They require care and attention on the part of staff in personal care homes They can cause death Tries Remaining: 2 Why do medications affect some elderly people differently than young people? Elderly people's families often interfere with their medication Elderly people do not go to their physician/nurse practitioner often enough Elderly people's metabolisms interact differently with medication Elderly people usually take their medication incorrectly Tries Remaining: 2 13

14 Which other factor generally does NOT influence how effectively medications work for seniors? Their chronic disease and/or short term sickness Their age Their physical condition (frail vs. strong) Their marital status Tries Remaining: 2 Why are we required to know the reason the residents' medications were prescribed, and why must we know information about those medications? It will help us know what days of the week the residents' laundry should be done It will help us know what to watch for regarding unwanted side effects of the medication It will help us know which medication to tell the physician/nurse practitioner to prescribe It will help us know which medication we should decide to stop giving to the resident Tries Remaining: 2 A resident in your personal care home takes medication to reduce blood clotting (anticoagulant). It would be important to know what this medication does because: You will know when to give extra tablets of the medication, and when to give fewer tablets, and will be able to decide this whenever a dosage change is needed You will know that the resident's dentist needs to be made aware of the anticoagulant medication when the resident goes to have dental work done You will impress the resident's family You will look very knowledgeable to your friends 14

15 Tries Remaining: 2 The physician has just ordered a new medication for a resident. You are required to: Ensure you check the resident's care plan and medication record sheet to ensure the resident is not allergic to the new medication Call the pharmacy to ask for enough copies of the new medication's information sheet for all the other residents in the care home Ensure you document the resident's meal and liquids intake for the next 7 days Call the physician/nurse practitioner, and in specific circumstances, a pharmacist to double check whether he or she ordered the correct dosage of the medication Tries Remaining: 2 A resident has been taking her new medication for approximately 1 week. She has complained of nausea for the past 2 days. You are required to: Assume that the new medication is the logical reason for the nausea, and stop giving the new medication until the physician can switch her to a different one Document the nausea and hope it goes away Inform your supervisor or pharmacist about the nausea, mention the resident just started a new medication, and document your observation and your conversation in the resident's record Go to the store and get her some over-the-counter anti-nausea pills Tries Remaining: 2 15

16 B1. What are some common medication terminologies and abbreviations? Many medication terms are shortened or abbreviated when they are in frequent use. The following terms may be seen in communications between health professionals and/or personal care home personnel. They may also appear in the residents' records and on the medication information sheet. Beside each term or abbreviation is its meaning, so that if you encounter this term you will know what it means. Note: These terms and their abbreviations listed below can be used interchangeably. BID= twice daily IM= into-the-muscle injections (Vitamin B12, flu shots) IV= intravenous (into the vein) NKA= no known allergies OTC= over-the-counter medication PO= per/by mouth (for food and oral medication) q2h= every 2 hours QID= 4 times per day DOB= date of birth Sub-q/SC= under-the-skin injection (Insulin) Med= medication NPO= nothing by mouth (no food or drinks) PRN= as needed (as directed by the physician/nurse practitioner) PR= per/by rectum (for enemas and suppositories) q5h= every 5 hours RX= prescription 16

17 s/l= sublingual (oral medication placed under the tongue) TX= treatment TID= three times daily Note: For a complete list of abbreviations which should not be used due to the possibility of medication errors, visit the Institute for Safe Medication Practices website at 17

18 B2. Review Question for Medical Terminology and Abbreviations Translate the following case study, changing the abbreviations (underlined) to their full terminology equivalents in the blanks provided. Each terminology word or phrase can only be used once: Mr. Jackson is an elderly male, DOB Feb 1, 1925, with an RX for pain med. Sometimes his legs ache, so he takes a pain medication BID, PRN. Our goal is to ensure Mr. Jackson remains pain-free with the above TX. Each evening, the staff is to ask Mr. Jackson whether he has pain. Note: Do not include words in parenthesis ( ) from the abbreviation chart in your answers in the following quiz questions. BID= twice daily IM= into-the-muscle injections (Vitamin B12, flu shots) IV= intravenous (into the vein) NKA= no known allergies OTC= over-the-counter medication PO= per/by mouth (for food and oral medication) q2h= every 2 hours QID= 4 times per day s/l= sublingual (oral medication placed under the tongue) TX= treatment DOB= date of birth Sub-q/SC= under-the-skin injection (Insulin) Med= medication NPO= nothing by mouth (no food or drinks) PRN= as needed (as directed by the physician/nurse practitioner) PR= per/by rectum (for enemas and suppositories) q5h= every 5 hours RX= prescription TID= three times daily For the following questions, select the correct translation for the underlined abbreviation. Mr. Jackson is an elderly male, DOB Feb 1, 1925 Daily operating bulletin Date of business Date of burial Date of birth 18

19 Tries Remaining: 3 Mr. Jackson is... Feb 1, 1925, with an RX for pain... Prescription Reaction Recipe Reserve Tries Remaining: 1 Mr. Jackson is... Feb 1, 1925, with an RX for pain med. Medical payments Multiple Epiphyseal Dysplasia Minimal effective dose Medications Tries Remaining: 3 Sometimes his legs ache, so he takes a pain medication BID, PRN. Three times daily Once daily Four times daily Twice daily 19

20 Tries Remaining: 3 Sometimes his legs ache, so he takes a pain medication BID, PRN. Physicians Research Network As needed As little as possible As much as possible Tries Remaining: 3 Our goal is to ensure Mr. Jackson remains pain-free with the above TX. Each evening, the staff is to ask Mr. Jackson whether he has pain. Treatment Transplant Transfusion Therapy Tries Remaining: 3 20

21 B3. How are medications labeled in personal care homes? Medications may come in a variety of packages, all of which are to be filled by a pharmacist and properly labeled. If a medication is not in its original container, it is required to be in a container that has been filled and properly labeled by a pharmacist or nurse. Below is a medication label which has all the required information on it: Explore the different areas of the medication label. You can click the SHOW ALL button to reveal every area. The PRINT button will send a copy of the revealed label to your printer. It makes a handy reference guide! 21

22 B4. Exercise: Medication Labeling Using the sample label provided, answer the following questions in the blanks provided to determine what important information is to be included on a prescription drug label. If you are stumped, you can use the following link to review the interactive version. What is the name of the pharmacy? Dilweg's Drug Store Dilweg's Drugstore Dr. Paul Moreau Tries Remaining: 3 What is the address of the pharmacy? 39 Ruby Lane Rouleau SK Dilweg's Drug Store Ruby Lane Rouleau SK Tries Remaining: 3 What is the phone number of the pharmacy? 22

23 (306) (306) Tries Remaining: 3 What is the prescription number? mcg Tries Remaining: 3 What is the physician's name? Dr. Jane Smith Dr. Paul Moreau Dr. Dilweg Dr. Paul Tries Remaining: 3 What is the date that the prescription was filled? Sep 19,

24 Sept 18, 2011 Sep 19, 2011 Sep Tries Remaining: 3 What is the name of the person for whom the medication is prescribed? (Note: Prescription medications are to be used only by the person for whom the medication was prescribed.) Dilweg Paul Moreau Jane Moreau Jane Smith Tries Remaining: 3 What is the quantity of the medication? 1 puff daily 50mcg Tries Remaining: 3 How many repeats/refills are remaining? 24

25 Tries Remaining: 3 What are the directions or instructions for taking the medication? Inhale 2 puffs once daily Inhale 1 puff twice daily Inhale 1 puff once daily Inhale 2 puffs twice daily Tries Remaining: 3 What is the drug identification number (DIN)? (306) Tries Remaining: 3 25

26 B5. How are medications packaged? Other than in pill bottles or vials, medications are usually packaged in 3 other ways: bubble packs, pack-med packets, or dosettes. Bubble Packs This type of medication packaging is made of foil and is sometimes placed in an outer plastic or cardboard frame. The pharmacist fills the foil packets, then uses heat to seal them. Bubble packs can hold single or multiple medications in each bubble. The medication information is often inscribed on the back of the foil bubbles Pack-med Packets This type of medications packaging is made of labeled plastic packets into which the medications are placed. A large machine is required to do this and once the resident's name and medication specifics are entered the machine does all the packaging and labeling at the pharmacy. 26

27 Dosettes This type of medications packaging is not recommended, but is sometimes used in special circumstances. It is generally made of plastic and has separate compartments in which to place the medications. Dosettes can only be filled by the pharmacist (or a nurse) with the medications for a particular day, times of the day, or a particular week. Medications packaging such as bubble packs and pack-med packets which pharmacists prepare and seal at the pharmacy are a preferred manner of packaging medications in personal care homes. These methods are superior to medications kept in individual original containers or dosettes. Multiple individual medication containers can sometimes lead to confusion and errors, and dosettes are prone to sliding open and/or meds falling into the wrong compartments in the dosettes. Dosette problems can cause medication errors. 27

28 Who is Responsible? The Physician The Nurse Practitioner The Pharmacist The Licensee / Operator The Resident The Staff C1. Who is responsible for medications in personal care homes? Contrary to popular belief, there most certainly is an I in team. It is the same I that appears three times in responsibility. ~ Amber Harding In personal care homes, the licensee, operator, and staff are responsible to ensure that medications are taken by the residents exactly as their physicians/nurse practitioners, and in specific circumstances, a pharmacist have ordered. Only a physician/nurse practitioner, and in specific circumstances, a pharmacist can order a medication or decide to alter or withhold regularly scheduled medications. The only exception to this is PRN medications. PRN stands for?pro re nata? in Latin, and means the medication is to be given as needed. PRN medications are ordered by a physician/nurse practitioner to be given when the resident needs them. However, the PRN medication order needs to specify why the resident might need the medication, how much can be taken, what to try before taking, and how often. Each of the people involved with assisting residents with their medications in personal care homes has specific roles and responsibilities. The physician/nurse practitioner, the pharmacist, the licensee and operator, the resident, and the staff all have their respective responsibilities. 28

29 Who is Responsible? The Physician The Nurse Practitioner The Pharmacist The Licensee / Operator The Resident The Staff The Physician: is responsible to prescribe the appropriate medications to the residents, and provide ongoing monitoring of their health. The physician is responsible to indicate in writing to the personal care home whether the resident is capable of self-administering his or her own medications. The physician will provide the personal care home and/or the pharmacy with: Medication names for all medications the resident is to take The dosages of all medications the resident is to take The times of day when the resident is to take the medications If there is a concern about the residents' medications that is not an emergency, the physician/nurse practitioner or pharmacist is the person to contact. In an emergency, call an ambulance. 29

30 Who is Responsible? The Physician The Nurse Practitioner The Pharmacist The Licensee / Operator The Resident The Staff The Nurse Practitioner: is responsible to prescribe the appropriate medications to the residents for common medical disorders in their scope of practice, and provide ongoing monitoring of the resident's health. The nurse practitioner is responsible to provide, in writing, the resident's ability to self administer medication or the level of assistance required. The nurse practitioner shall provide the personal care home and/or pharmacy with: A list of all medications the resident is to take The dosage, route and times to take each medication The nurse practitioner is to refer/consult with the physician as required. If there is a concern about the resident's medication that is not an emergency, the nurse practitioner, physician or pharmacist is the person who should be contacted. 30

31 Who is Responsible? The Physician The Nurse Practitioner The Pharmacist The Licensee / Operator The Resident The Staff The Pharmacist: is responsible to provide the residents' medications as prescribed by their physicians/nurse practitioners, and provide information about medication changes. The pharmacist is responsible to provide medications in properly labeled containers, a medications record sheet which lists all the medications to be taken by a particular resident, as well as the dosage, amounts and times. Pharmacists are responsible to provide information about the effects and potential unwanted side effects of medications. The pharmacist is an excellent source of information and will welcome questions and/or concerns you may have with residents medications. 31

32 Who is Responsible? The Physician The Nurse Practitioner The Pharmacist The Licensee / Operator The Resident The Staff The Licensee and Operator: are ultimately responsible for the safe and secure storage, transportation, and disposal of all medications in the home, and ensuring all residents are assisted with their medications according to the requirements under The Personal Care Homes Regulations and best practices. If residents are managing their medications independently, the licensee/operator is responsible to: ensure the residents' physician/nurse practitioner have documented that the residents have the ability to self-manage their medications periodically check to ensure the residents maintain their ability to manage their own medications; should there be concerns about this they are required to document their concerns and report them to the physician/nurse practitioner immediately have a medication records sheet which lists the medications and their doses and times for all residents, including those who are managing their own medications ensure all medications are stored in a manner which is safe for all the residents in the home (a lockbox in the resident's room or a lock on the resident's door are strategies that may provide a secure place for the resident who is self-managing medications to store the medication) assist the resident to order medications from the pharmacy as required If staff will be assisting residents with medication, the licensee/operator is responsible to ensure that the staff have received medication training, completed an orientation in the personal care home, and understand how to carry out these duties safely. 32

33 Who is Responsible? The Physician The Nurse Practitioner The Pharmacist The Licensee / Operator The Resident The Staff The Resident: is responsible to advocate for their own health as much as possible. If they are able, residents should notify caregivers if feeling unwell, pain, dizziness, or any unusual symptoms. Residents in personal care homes who are considered by their physician/nurse practitioner to be physically and cognitively able to manage their own medications should be encouraged to do so in a manner which is safe. Residents who manage their own medications When residents have been deemed by their physician/nurse practitioner to be capable of managing their own medications: The physician/nurse practitioner is responsible to document in the residents' records that the residents have the ability to manage their medications independently. The independence with medications is required to be documented in the residents' care plan and on the medications record sheet. The responsibility for medications management then rests with the resident and as long as the resident demonstrates the ability to manage their medications, the personal care home is not responsible for assisting with medications or documenting that the medications are taken daily. The personal care home is required to periodically check to ensure the resident maintains their ability to manage their own medications; should the care home staff have concerns about this they must document their concerns and report them to the physician/nurse practitioner immediately. The residents hold the responsibility for ensuring they follow their physician's/nurse practitioner's instructions concerning their medications. The personal care home is required to have a medication record sheet which lists the medications and their doses and times. The residents' medications are required to be stored in a manner which is safe for all the residents in the home. Residents who require assistance with their medication Residents who are not considered able to manage their own medication may require various levels of assistance from personal care home staff. Their need for assistance is required to be documented by the residents' physician/nurse practitioner in the resident records. It is required to also state the type of medication assistance needed on the care plan and the medication record sheet. When a staff member is assisting with medication, residents have the right to refuse the medication and also to ask questions about their medication. Residents have the responsibility to follow the physician's/nurse practitioner's instructions concerning their medication. 33

34 Who is Responsible? The Physician The Nurse Practitioner The Pharmacist The Licensee / Operator The Resident The Staff The Staff: are responsible to ensure they are provided with medications training that is both clientspecific Which medications does Mrs. Smith take and how should we help her to take them? and also general How should all the residents' medications be stored and documented? The staff have the responsibility to carry out all safety, storage, disposal, and assistance policies regarding the residents' medications. Safety Storage Disposal Assistance 34

35 D1. What kinds of medications are commonly taken by some residents of personal care homes? The most commonly prescribed kinds of medications are: cardiovascular agents and anti-hypertensives: to prevent blood clots, control blood pressure and regulate the heart pain medications: to reduce pain anti-arthritis preparations: to reduce swelling, pain, and stiffness in the joints sedatives and tranquilizers: to induce sleep and relaxation gastro-intestinal preparations such as laxatives and antacids: to promote digestions and regulate bowels thyroid and hormone preparations such as hormone replacement therapy and blood sugar medications: to regulate hormone and blood sugar levels The overall incidence of unwanted medication side effects is estimated to be at least two to three times that found in young adults. Unwanted medication side effects are often less readily recognized by the elderly as they may believe the signs and symptoms are just a part of aging. 4 4 Baumann, Brandeis, Resnick,

36 D2. What medications require special considerations? Narcotics/Opiates Narcotics/opiates are powerful medications. Special storage, disposal, and tracking procedures are required to be in place to track the usage of all narcotics/opiates. These medications are required to be accounted for whenever they are taken by a resident. Narcotics/opiates are to be used with caution for severe pain due to their strength and the possibility of a wide range of serious side effects such as hallucinations, changes in breathing and heartrate, nausea, constipation, and dependence. Specialized Procedures Some medications require assistance which is considered to be a "specialized procedure." These are methods of assisting with medications which are usually only performed by health care professionals (physicians/nurse practitioners, Registered Nurses, Registered Psychiatric Nurses, and Licensed Practical Nurses). The type of specialized procedure will determine what kind of health professional is required. The type of specialized procedure will also help the health care professional to determine if the procedure can be delegated to the licensee, operator, or care home staff. Delegation only ocurrs in certain circumstances and requires that specific steps be followed by the health care professional and the personal care home staff. A common kind of medication which requires specialized procedures in personal care homes is medication which is injected, such as Insulin used to treat Diabetes. Residents who require oxygen from a concentrator or canister also require Specialized Procedures. Oxygen therapy is to be treated as a medication. Controlled Drugs and Substances Some categories of controlled drugs and substances may be prescribed for resident's living in Personal Care Homes includes: Selected narcotics often used to treat pain, such as Codeine, Morphine, Hydrocodone, Methadone, Fentanyl, and Demerol. Benzodiazepines typically used for sedation, anxiety, agitation and insomnia such as Alprazolam, Clonazepam, Lorazepam, Oxazepam or Temazepam. Note: the above lists are not exhaustive. 36

37 Controlled drugs and substances are treated with extra care and caution related to their potential for risk and harm (serious side effects, dependence and abuse). All controlled drugs and substances require a written order. A verbal/telephone order cannot be accepted. Personal Care Home staff receiving new medication should always ask the pharmacist if the medication require any specific considerations. Ensure the drug information sheets accompany the new medication. Review the information sheets and comply with all of the pharmacists directions. Controlled drugs and substances cannot be transported without an accompanying prescription (the label on the medication package provided by the pharmacist serves as a prescription). This is also important to consider when medication is being packaged for a resident who is leaving the personal care home for a short period of time. The pharmacist prepares all prescriptions. When the pharmacist releases the prescription to staff it is expected that the staff will assist the resident with the medication according to the pharmacist's directions. All medication including controlled drugs and substances are required to be stored in a secured drawer/cabinet. 37

38 E1. What are "over-the-counter" medications? "Over-the-counter" (OTC) medications are those which can be purchased in any pharmacy or store without a prescription from a physician/nurse practitioner. In personal care homes, over-the-counter medication (OTC), vitamins, herbs, and supplements are subject to the same safety precautions as prescription medication. This is due to the possibility of interactions or unwanted side effects between the OTC medication, vitamins, or herbs and the prescription medication a resident may be taking. Examples of over-the-counter medication which are available without a prescription: vitamins and supplements herbal treatments such as St. John's Wort Pain medication such as Advil, Tylenol, Aspirin or Motrin Laxatives such as Metamucil, or Dulcolax Anti-nauseas such as Gravol 38

39 E2. What requirements exist for non-prescription and OTC medications, vitamins, supplements, and herbs? In personal care homes, any OTC medications are required to have written physician's/nurse practitioner's, and in certain circumstances a pharmacist's orders that specify: the name of the OTC medication or preparation the name of the resident instructions about when and how much and how often it should be taken 39

40 F1. Why are safe medication storage, transport, and disposal so important for personal care homes? Due to the potential for medication errors and incidents, there are strict guidelines regarding the storage, labeling, transport, and disposal of medication. In personal care homes, these guidelines apply to prescription medication, non-prescription (OTC) medication, vitamins, supplements, and herbs. 40

41 Storage Labeling Transportation Disposal Storage Storage of medications in personal care homes is required to be: Secure Secure Appropriate for all residents in the home According to medication directives Confined to the container packed by a pharmacist (or nurse) The medications are required to be stored in a place where people who may be unsafe with the medications do not have access to the medications. Appropriate for all residents in the home If the storage is not appropriate for the person in the personal care home who is most at risk, then it is in fact not safe and secure for everyone who lives in the home. This is an important issue when residents are able to manage their medications independently. Even though they may be managing when and how to take the medications on their own, the storage of those medications is required to be safe and secure for ALL residents in that personal care home. Personal care homes which house residents with mental (cognitive) problems, or higher numbers of residents, are required to be more careful and more watchful about how medications are stored, regardless of the medication independence of individual residents. A locked medication box in the bedrooms of the residents who are independent with medications or a locked door on a resident's room may provide sufficient safety and security for the medication storage. All situations regarding medication storage are required to be approached on an individual basis to ensure the residents have their needs for independence met while also providing safe storage for their medications in terms of all other residents in the personal care home. Residents who have dementia or mental health issues, poor eyesight, or poor hearing, etc. may ingest other residents' medications if these are not stored properly. Residents who take someone else's medication, or the wrong amount of their own medication, are at risk for unwanted side effects and even death. Medications are required to be secure for visitors to the home, such as small children. According to medication directives Instructions from the pharmacy about the physical environment where the medication is stored are required to be carefully followed to protect the effectiveness and safety of medications. For example, some medications are required to be kept cold and are stored in the refrigerator (insulin), others are required to be stored away from bright light and are stored in a box or cupboard. Moisture affects some medications, so they are required to be stored in a dry place. 41

42 Age also affects the safety and effectiveness of medications; expiry dates on medication boxes or containers are required to be checked regularly. Medications are required to be stored safely regardless of where they are stored; a small lockbox may be required in the refrigerator, a cabinet may require a locking mechanism, etc. In the container packed by a pharmacist bubble packs, dosettes, etc. are required to be packed by a pharmacist and cannot be tampered with by a non-medical professional. 42

43 Storage Labeling Transportation Disposal Labeling Labeling of each medication stored in a personal care home is required to include: Each resident's full name The name and strength of the medication Directions for giving the medication The physician's/nurse practitioner's name The pharmacy's name and contact information Over-the-counter medications, vitamins, supplements, and herbs require only the name and strength of the medication, recommended dose, frequency, and expiry date on the label. In personal care homes over-the-counter medications, vitamins, supplements, and herbs are required to be treated like prescription medications and require physician's, nurse practitioner's or in specific circumstances a pharmacist's order. 43

44 Storage Labeling Transportation Disposal Transportation Transportation of medications may occur when residents and/or their medications leave the personal care home for a period of time. There are several options for ensuring their medications are transported properly: Medications can be sent with the resident or transported in their original containers with directions for how the medications are to be taken A pharmacist or nurse can package the medications in a dosette or vial that can be sent with a resident who is going to be temporarily absent from the personal care home The licensee, operator, or staff from the personal care home can supervise a family member or supporter to put the appropriate medications for the specified period of time into a container or envelope on which the following is written: the resident's name the date(s) during the resident's absence from the personal care home indicating when the medication is going to be taken the names and dosage of medications enclosed when the medication is to be taken If a resident is leaving the personal care home permanently, record the amounts of each medication before handing them over to the family members, supporters, or government officials (police officers, coroner, etc) who are going to be transporting the medications. Document the full name of the person who took possession of the medications, and have the person, along with you, sign and date the record of medications taken. 44

45 Storage Labeling Transportation Disposal Disposal Disposal of medication is required to be done responsibly and safely. When medications need to be disposed of, they should never be thrown in the garbage or flushed down a sink or toilet, as these practices carry risks of medication getting into the wrong hands, or medication polluting the environment Medication should never be replaced into another pill bottle for disposal unless that bottle is marked for disposal Take all expired or discontinued medication to a pharmacy for safe disposal If a pharmacy is not available to you for disposal of medication, there are private companies that provide this service in some areas Safe disposal is also required for any potentially hazardous tools that may be used by residents to take their medication (used needles, etc.) 45

46 F3. Review Questions for Safe Medication Storage, Transport, and Disposal Fill in the blanks with the words below the following excerpt with the BEST answer for each blank. There is one extra word that will remain unused at the completion of this exercise. Note: Do not include words in parenthesis ( ) in your answers to the following quiz questions. non-prescription/otc ("over-thecounter") pharmacist drug interactions Words to Use family member dosage licensee resident's name contact information flushed Medications are required to be stored in bubble packs, dosettes, or containers prepared by a (1). Medication labels are required to contain the resident's name, the prescribing physician's/nurse practitioner's name, the name and strength of the medication, the (2) as well as the pharmacist's name and pharmacist's (3). (4) medications also are required to be labeled in personal care homes, and are required to have written orders by the resident's physician before they are taken. This is due to the potential for (5). When residents leave the personal care home they may need to take their medications with them. One option for transporting their medications is to send them in an envelope in which their family member has placed the medications, and labeled with the (6), the date, type, dosage, and time of the medication. If a resident is leaving the home permanently, their medications should be given to their (7 ) for safe-keeping. If medications need to be disposed of, they should never be (8) returned to the pharmacy. Tries Remaining: 3, but instead 46

47 G1. What kind of written documentation is required from the residents' physicians/nurse practitioners? Prior to residents moving into the personal care home, written instructions are required to be obtained from their physicians/nurse practitioners regarding what kind of assistance the residents require in order to ensure that they receive their medication as ordered. Some residents' physicians/nurse practitioners may document that they are capable of managing their own medication; other residents' physicians/nurse practitioners may document that they require assistance with medication. These instructions are required to be included in the residents' care plans and medication records. All prescription and over-the-counter medication are required to be ordered, in writing, by the residents' physicians/nurse practitioner. These written orders must include: The resident's name The name of the medication, The amount of medication, The times of day the medication is to be taken The frequency with which the medication is to be taken *All medication instructions from the physician/nurse practitioner/pharmacist are required to be included on the pharmacy's labels which are placed on all medication. 47

48 G2. How do staff and physicians/nurse practitioners work together? As staff, if you are present for the exchanges between physicians/nurse practitioners and residents, it is your goal to act as an advocate for the resident, and to ask questions as needed, or explain what the physician/nurse practitioner has said to the resident if they require additional explanation. The physician/nurse practitioner is required to be notified whenever you have a medication or health concern about a resident. The physician's/nurse practitioner's instructions are required to be documented immediately and accurately, and the pharmacy is required to be notified (preferably by the physician/nurse practitioner) of any medication changes. 48

49 H1. What role do pharmacists play in personal care homes? Pharmacists spend many years receiving university training regarding all aspects of medications and their effects on the human body. Licensees, operators, and staff in personal care homes should look to pharmacists for medication support in caring for residents. Pharmacists are a source of information about any issues that arise about residents' medications. Pharmacists are very knowledgeable about the different kinds of medications, desired effects, side effects, and interactions. Some pharmacists are available 24 hours/day. Both pharmacists and nurses have studied the human body and how medications affect the body, and both can be a good source of suggestions and assistance with medications questions. Pharmacists provide packaged, properly labeled medications for the residents Pharmacists provide medication record sheets for use in tracking residents' medications Pharmacists provide printed medication information sheets for medications prescribed to the residents that explain how the medications work and unwanted side effects to watch for Some pharmacists can order and re-order some medication such as in the "Warfarin Program" 49

50 H2. How must physicians'/nurse practitioners' medication orders be dealt with? Ensure you have the physician's/nurse practitioner's orders in place, and preferably the medication newly packaged and labeled by the pharmacy, before instituting any medication changes that have been ordered by the physician/nurse practitioner. Example: It is not BEST practice to accept verbal/telephone orders for medications. In an emergency situation the physician/nurse practitioner can give verbal/telephone orders to a non-professional who is properly trained and competent, in a situation where sufficient quality assurance measures are in place, such as supervision/checking/double checking. The verbal orders are required to be followed by written orders from a physician/nurse practitioner as soon as possible. The person receiving the verbal/telephone order from the physician/nurse practitioner is required to document the order. The documentation of a verbal/telephone physician's/nurse practitioner's order should include the medication name, dosage, and frequency, the date, the name of the physician/nurse practitioner, and signature of the person receiving the order. The best practice is for the physician/nurse practitioner to speak directly to the pharmacist, so if possible, have the phone number available, and ask the physician/nurse practitioner to call the pharmacy for new medication orders for a resident. If there is no emergency and you receive a verbal or telephone order for medication, ask the physician/nurse practitioner to write the order down and get it to you or the pharmacy as soon as possible If a resident arrives at the personal care home with prescription medication or over-thecounter medications, vitamins, herbs, or supplements, take the medication to the pharmacy and ask the pharmacist to contact the resident's physician/nurse practitioner to obtain written orders and provide the required labeling for the medication. If a medication arrives from the pharmacy and you receive it, you are required to check to ensure: the medication label matches the medication record sheet from the pharmacy the resident and medication names match what is on the medication record sheet the dose and instructions on the container and label match what is on the medication record sheet If you note errors between the medications/labels from the pharmacy and the medication record sheet, contact the pharmacy immediately. the care plan and medication record sheet for information about medication sensitivities or allergies whenever medication arrives from the pharmacy. It is important to identify any new medications or changes, to draw attention to them for anyone assisting with medications in the personal care home so that the changes are not overlooked. 50

51 H3. What is a medication record sheet? You are required to obtain a medication record sheet for each resident, which contains the "instructions" for all of a resident's medication. This is usually provided by the pharmacy. Every medication the residents take should be on this sheet, along with the residents' name, dose, time, frequency, and a description of the medication. Here is an example of a medication record sheet: The sample medication records sheet includes: Pictures of each of the medications (a description is also acceptable) Physician/nurse practitioner, resident, and pharmacy name and contact information Names for each medication, strength of medication, and directions for medication Times of day each medication is to be taken by the resident Dates and space for initials. The person who assisted with each medication is required to initial as soon as possible after the resident has taken it A key which provides several codes that can be used to explain why a medication was not taken a pharmacist, or physician/nurse practitioner is required to be notified if a resident has not taken prescribed medication if a pharmacist or physician/nurse practitioner is not available, there are other resources you may access: Saskatchewan Drug Information Line: Saskatchewan Health Line:

52 Your local emergency department or the nearest hospital or treatment centre medication should never be crushed or dissolved (tablets) or opened (capsules) unless the physician/nurse practitioner has indicated in written orders to do so and the pharmacist has indicated it can be crushed it is best practice to consult with a pharmacist before crushing, dissolving, or opening any medication if for some reason the physician/nurse practitioner has asked for a medication to be crushed, the pharmacist is responsible to indicate on the medication records sheet that it is safe to crush that medication 52

53 H4. Review Questions for Pharmacists: Your Medication Support Experts Answer the following questions by selecting True or False after reading the statement about pharmacists: Pharmacists can answer questions you may have about a medication's side effects True False Tries Remaining: 1 Pharmacists can assist you with knowing whether a medication is doing what it is supposed to do for a resident in your personal care home. True False Tries Remaining: 1 Pharmacists are available 24 hours per day, 7 days per week at some pharmacies. True False Tries Remaining: 1 Pharmacists may be a resource to call in the event of a medication error. True 53

54 Tries Remaining: 1 Pharmacists can make suggestions to a resident or family member about OTC and prescription medications, and adjust or alter a physicians'/nurse practitioner's orders under specific circumstances. True False Tries Remaining: 1 Pharmacists are sometimes available to personal care homes to provide information seminars and staff education. True False Tries Remaining: 1 Pharmacists provide labels and medications record sheets to the personal care home so medications can be checked and documented correctly. True False Tries Remaining: 1 Pharmacists are the best choice for who should receive physicians'/nurse practitioner's orders for new medications or changes to current medications for residents. 54

55 True False Tries Remaining: 1 55

56 I1. How are residents in personal care homes assisted with their medication? Various levels of medication assistance may be provided in personal care homes. The assistance provided will depend on the written instructions you receive from the resident's physicians/nurse practitioner and in specific circumstances a pharmacist, regarding the resident's ability to manage their medication, and also on the policies of the personal care homes. Residents with mental (cognitive) problems will typically require higher levels of medication assistance. Residents with physical ailments only and without cognitive problems may be able to be more independent with their medication. Each resident's physician/nurse practitioner is responsible to indicate in writing the type of medication assistance that person requires in the personal care home. 56

57 I2. How do we determine what is safe medication assistance? How residents are assisted with their medications, and how medications are tracked once they are taken is determined by: the number of residents in the Personal Care Home personal care homes with an authorized capacity of 11 or more residents require a medication record sheet which has each resident's name, list of medications, directions for the medications, and a place to initial once the medication has been taken the number of people assisting residents with medication in the Personal Care Home if more than 1 person is assisting residents with medications, the personal care home requires a medication record sheet which has each resident's name, list of medications, directions for the medications, and a place to initial once the medication has been taken the abilities of the residents It is best practice to maintain a medication record sheet which documents who assisted which resident with which medication, regardless of the number of residents in the home, the number of people assisting with medications, or the level of assistance required by the resident. 57

58 I3. What are some examples of how medication assistance is provided in different situations? Read the following case studies, paying attention to the differences between the following personal care homes. Case Study A- Mrs. Jones is 78, has Arthritis, and her joints are stiff most of the time. This limits her mobility when she gets in and out of chairs and moves around the personal care home. Her mind is very clear and she effectively manages all her own personal financial affairs without help from her family. Mrs. Jones is one of 3 residents in the care home; the other residents have minor heart conditions and are frail due to their advanced age, but they have no other physical or cognitive ailments. Case Study B- Mr. Smith is 61, and has dementia (memory and cognitive problems), which affects his ability to think and use reasoning to determine what is safe and what is not. There is one other resident in the care home where Mr. Smith lives who also has dementia which affects his thinking abilities. Case Study C- Mrs. Carson lives in a large personal care home which houses 25 residents, all of whom have different physical and cognitive challenges. Mrs. Jones, Mr. Smith, and Mrs. Carson live in personal care homes which could potentially all have very different policies and rules about how medication is stored and how their residents are assisted with medication. The Personal Care Homes Regulations state that medication is required to be stored safely in a secure cabinet within the home. However, what is safe in one personal care home may not be safe in another. Residents with very few health or cognitive problems may only require occasional reminders about when to take their medication, or a secure place to store them. Residents with many health or cognitive problems may need extensive assistance to take their medication. It is important for licensees, operators, and staff in personal care homes to put careful thought and effort into their medication policies, and to review them regularly. It is their responsibility to ensure the safety of every resident in the home, and ensure that they receive safe, appropriate assistance with their medication. 58

59 I4. Review Questions for Assisting Residents with Medications Answer the following True / False questions. Click the button to check your answer. It is the residents' families' responsibility to ensure that residents in personal care homes take their medications as prescribed by their physician/nurse practitioner. True False Tries Remaining: 1 If it is very obvious that a medication is not helping a resident, it is fine for the licensee of the personal care home to stop giving the medication. True False Tries Remaining: 1 If a medication is helping a resident a little bit, it is ok for a personal care home staff member to double the dose so that the resident's health improves even more. True False Tries Remaining: 1 It is fine to keep medications in a drawer under the bathroom counter in a personal care home if that is what you normally do at your own home. True False 59

60 Tries Remaining: 1 If there are only 1 or 2 residents in a personal care home, there is no need to list their medications anywhere because1 or 2 people's medications is easy enough for staff to remember. True False Tries Remaining: 1 If a staff member is assisting residents to take their medications in a 15-bed personal care home, it is sufficient to document in a note for the staff coming for the next shift that says All residents took their prescribed medications. True False Tries Remaining: 1 60

61 J1. How do we provide assistance with medications in personal care homes which is safe for the residents and the people assisting them, while minimizing the spread of infection and illness? Many of the rules that apply to assisting with medications are very standardized and these rules are in place for the safety of all residents and for the people assisting them with medications. It is the licensee's responsibility to ensure that if staff are assisting with medications, these staff are properly trained about all safety measures and procedures for assisting with medications. Hands are required to be washed immediately before and after helping a resident with their medication *Hand washing is THE SINGLE most effective way of decreasing the spread of bacteria and illness. Gloves are required to be worn: When assisting residents with any medications that involve mucous membranes, blood, or body fluids; all body fluids can contain illness and/or disease-spreading agents. mucous membranes and body fluids are found in our eyes, ears, nose, mouth, rectum, and on any weeping or open sores or cuts blood is potentially present whenever a resident receives an injection When assisting residents with medications that come in cream, ointment, or transdermal patch (patch on the skin) forms. This prevents the medication from being absorbed into the skin of the person assisting with the medication. Assistance with nebulizer and inhaler medications is required to be provided utilizing methods which promote the best absorption of the medication into the resident's lungs. When assisting a resident with eye or ear drops, the drops are required to be placed into the eyes or ears with a time lapse between drops to enhance absorption When oral medications are prepared for a resident, ensure the supplies and environment which that particular resident needs or prefers are present. Examples: Glass of water/milk/tea/etc or a small amount of food to help the resident swallow the oral medication Resident sitting upright to allow gravity to help the resident swallow oral medication and also to reduce the risk of choking and/or the risk of fluid or food in the resident's airway Place oral medication into a spoon or medication cup - Avoid handling medications with your hands if possible; instead, pop from bubble packs right into the medication cup, or utilize the lid of the bottle to take medications out of the 61

62 container Quiet setting without distractions Medications which are required to be taken by injection require that a nurse perform the injection, teach the injection to the resident, or train and delegate the injection to a person working in the personal care home. Residents who require injectable medications are required to have access to a nurse who can supply the care they require. 62

63 K1. What training should people who assist with medications in personal care homes receive? All personal care homes are required to have a written training plan for medications assistance which includes: 1. Teaching the importance of "The 6 Rights" for assisting residents with medication The 6 rights are required to be followed by all staff members every time they assist a resident with medication. The 6 Rights: Right Resident Right Medication Right Dose Right Time Right Route 63

64 Right Documentation 2. Information about: all the residents' health conditions what medication they receive what the medications are for which medication are PRN (only to be taken as needed) and what conditions should cause the resident to take that PRN medication (examples-sleeplessness, pain, etc) instruction about how to evaluate and document the effectiveness of PRN medication after they are given special considerations such as required blood tests or heart rate or blood pressure monitoring with certain medication possible side effects or food/medication interactions with medication when to alert the physician/nurse practitioner or hospital and the importance of alerting the physician/nurse practitioner to any changes in the resident how to notify a physician/nurse practitioner when a resident has refused to take the medication, and how to document the physician's/nurse practitioner's instructions 3. How to document the medication assistance, including documentation of PRN medication and their effects on the resident 4. What to do in the event of an error when giving the medication In the event of a medication error you are required to: Report the error to the resident's physician/nurse practitioner, the physician/nurse practitioner on call, or the pharmacist and ask for direction on what to do Carry out the instructions given by the physician/nurse practitioner or pharmacist Record the error as well as what direction the physician/nurse practitioner or pharmacist gave to you in the resident's progress notes Identify and take corrective action to prevent the error from occurring again and to prevent further harm to the resident Report the error to your personal care homes consultant, as it is a "Serious Incident" as per section 13 of The Personal Care Homes Regulations 5 The licensee and/or operator are responsible to ensure that anyone assisting residents with medication is confident and knowledgeable in this role. Staff who are asked to assist residents with their medication in a personal care home are responsible to alert the licensee or operator if they are not confident in this role and/or desire more medication training. Staff are also responsible to ensure they are aware of all the rules and policies about any medication for which they are providing assistance. 5 Personal Care Homes Regulations

65 K2. What are the responsibilities of the licensee with regard to an instruction and evaluation plan for medications assistance? The licensees of personal care homes are responsible for ensuring that safe medications assistance is taught and carried out in a consistent manner. Having a clearly organized, consistent training program in place for all staff is essential. The program is required to be written, visible to all staff, and implemented in the same way every time a staff member is trained. The program is required to also have built-in steps for: 1. Teaching 2. Practice with Supervision 3. Observation & ing in 4. Independence 5. Evaluation Teaching The same methods are required to be taught in the same manner for all staff and must be documented and presented by a trainer who is assigned to ensure consistent medications assistance training takes place. The licensee is required to have written training materials. the training materials must include important information about: the training process the residents their health issues the medications they take and why the home's policies about medication preparation, assistance, and documentation the need for 100% accuracy what to do if you have a question or concern what to do if a medication error occurs the training program is required to include the 6 Rights: Right Resident Right Medication Right Dose Right Time Right Route Right Documentation the training program is required to be documented (trainer and trainee names, dates of training, material covered, etc) it is best to introduce the Medication Assistance Module and other medication training until newly hired staff has had an opportunity to absorb other personal care home information. Do not let staff assist residents with medications until they are fully orientated to medication assistance and have demonstrated competency. Caregivers have the right to receive appropriate orientation, training, and to understand their responsibilities in terms of medication assistance in personal care homes. They have the right to refuse to assist residents with medication if they feel unprepared or without confidence in doing so. If a caregiver is not confident assisting with medication, they are required to inform a supervisor in advance to ensure that residents receive their medication on time. 65

66 Practice with Supervision * the methods taught are required to be demonstrated the licensee or trainer may verbally "talk the staff through" preparing and assisting residents with medication, while reinforcing all of the training information Observation and ing in * the staff trainee will prepare and assist residents with medications while being observed and corrected if needed by the training supervisor the licensee is required to double check all medication before residents take them the licensee may decide that after a certain period of time, depending on an individual's ability, the staff if confident and knowledgeable, may assist with medication independently Independence * this step cannot be reached until the trainer and the staff member being trained are confident in the staff's ability to assist all residents in the home with their medication it is important to reinforce that the staff "err on the side of caution" and ask questions if unsure about anything; all questions and concerns are worth bringing up to the trainer at any point in time Evaluation (after initial training, and periodically) as needed, or as scheduled all staff are required to be periodically re-evaluated to ensure they are following the best practices which were taught in their training the licensee is responsible to ensure that checks of medication records and documentation are conducted by experienced staff the licensee is responsible to ensure that medication assistance is critically observed periodically to ensure that the 6 Rights are implemented when residents are assisted with medication if a medication error is discovered, the reasons behind the error are required to be investigated, and the causes addressed to prevent the error from being repeated if a medication error occurs, it may be appropriate to have the staff go through the Medication Assistance Module again 66

67 K3. What should be observed when staff are being evaluated for their medication assistance? When staff in personal care homes assist residents with their medication, they are subject to evaluation of their medication assistance at any time. The licensee is responsible to evaluate initially after the staff have been newly trained, and then periodically to ensure that best practices for medication assistance continue to be followed. Below is a table that outlines a possible evaluation process that licensees, operators, and/or senior staff can utilize to check whether the 6 Rights are being followed by staff when they assist residents with medication: Right Resident Right Medication Right Dose Right Time Right Route Right Documentation Demonstrates knowledge of resident's identity Appears to check name on medication and ensure it matches with resident's name who is to be assisted Appears to read label on medication packaging Verbally states name on medication packaging and medication records sheet If pre-pouring for the next medication time, containers are labeled with resident name and time of dose Verbally states dosage of medication as printed on medication record sheet and ensures dose is the same on medication packaging Counts tablets once removed from packaging to ensure correct number are present for that medication time Capsules are not opened, or directions to do so are provided by the pharmacy. A pill crusher is required to be cleansed between using it with medications for different residents. Liquid medications are measured properly by pouring at eye level in medication cup marked with measurements Resident is assisted with medication within the time frame of 30 min before to 30 min after the designated medication time PRN medication time between doses is observed and documented PRN medication is documented Resident's medication is assisted utilizing appropriate route Trans-dermal patch placement is correct and follows a site rotation plan Gloves are worn to assist with creams, gels, ointments, Eye drops are assisted with correct amount of time between multiple drops Creams and ointments are assisted in correct place on body Proper technique demonstrated when assisting with suppositories Medication information sheet and medication record sheet are present Medications are initialed for on the medication record sheet after the resident is assisted PRN medication times taken, reasons and results are documented 67

68 K4. Review Questions Place the following steps in the correct time order from first step to last to illustrate how medications assistance skills and procedures should be taught to people who work with residents in personal care homes. Number the steps from 1-8. New staff member comes to work at the personal care home The trainer or other supervisor will periodically check the new staff's medications preparations and medications assistance New staff get to know the personal care home and its residents and their needs The trainee/new staff is able to independently assist residents with their medications The trainer goes through the medications assistance steps and procedures with the new staff using written policy materials Medications assistance training begins, with the trainer demonstrating and talking the trainee/new staff through each step of the medications preparation and assistance process The trainee/new staff has completed a number of days of medications assistance without making any errors, and feels confident with the procedures The trainee/new staff practices preparing medications and/or assisting residents to take medications while being advised and supervised by the trainer Tries Remaining: 3 68

69 L1. What are the 6 Rights and why are they important? Medications ordered by a physician/nurse practitioner may be ineffective, harmful, or cause death if they are not taken according to the physician's/nurse practitioner's orders. To help ensure that medications do what they are supposed to do for residents in personal care homes, the residents require assistance from staff who know the 6 Rights and follow them at all times. The 6 Rights: 1. Right Resident 2. Right Medication 3. Right Dose 4. Right Time 5. Right Route 6. Right Documentation 1. Right Resident 1.1 When assisting residents with medication, the residents' identity is required to first be verified before they take the medication, either by photograph, or by asking their names. Note: DON'T SAY "You're John Smith, right?" DO SAY "Can you please tell me your name?" 1.2 Instances of residents taking medication which has not been prescribed for them is required to be prevented; therefore the names on the medication orders are required to match the names of the resident being assisted to take the medication. 2. Right Medication 2.1 The name of the medication on the bubble pack or medication container packaging is required to match the name of the medication on the physician's/nurse practitioner's orders or on the medication record sheet from the pharmacy. 2.2 The appearance of the medication and any markings, etc. on the medication are required to be consistent with any descriptions provided by the pharmacy. 2.3 If there are any discrepancies between the names or the appearance of the medication, question a supervisor and call the pharmacy to confirm that the medication is correct. 3. Right Dose 3.1 The dose of the medication is required to match the dose indicated on the physician's/nurse practitioner's medication orders/medication label and on the medication record sheet provided by the pharmacy. There are 2 factors associated with correct dose: strength, and quantity. i. Strength: this refers to the amount of active ingredient contained in a medication, or how much active medicinal ingredient is present in the tablet, liquid, ointment, etc. Medication strength can be indicated by: markings on the tablet colour of tablet or packaging 69

70 numbers on the tablet *always ensure that the description of the medication that is provided by the pharmacy matches the medication that has been packaged by the pharmacy. ii. Quantity: this refers to the number of tablets or amount of medication that must be given to arrive at the correct dose ordered. Usually quantity is measured by counting the number of tablets in the case of pills, or puffs in the case of inhaled medication, or by measuring the amount of liquid, etc. (example: if the resident's physician orders 4mg of a medication, and the tablets available are 2mg tablets, then 2 of the 2mg tablets are required to be taken) ing for the correct dose involves ensuring that the correct amount of medicinal ingredient (strength) is in the medication, as well as ensuring the number of tablets, capsules, etc. is matched with the physician's medication orders for dosage. Medication colour and markings as well as number of tablets are required to be considered when checking that a resident is being assisted with the right dose of a medication. 3.2 Inform a supervisor and contact the pharmacy before assisting with any medication if there are any discrepancies between the medication and the physician's/nurse practitioner's orders. Compare the dose, the number of tablets and the appearance of the medication. 4.1 Right Time 4.1 Residents should always be assisted with their medication at the time indicated by the physician/nurse practitioner. However, in the event of unavoidable circumstances it is acceptable to assist a resident with medication anytime within 30 minutes before the medication's scheduled time, to 30 minutes after the medication's scheduled time. (example: a 1pm medication can be given anytime between 12:30pm and 1:30pm) 4.2 Medication orders are sometimes written using the 24 hour, or military clock (example: 1300 means 1pm, 1800 means 6pm, 0100 means 1am, etc). If this method is used by the pharmacy on labels or on the medication records sheets, then anyone assisting residents with medication are required to receive training on how to interpret these times. Below is the entire list of military time/24 hour clock and the equivalent am/pm conversions: 1:00 AM hrs 1:00 PM hrs 2:00 AM hrs 2:00 PM hrs 3:00 AM hrs 3:00 PM hrs 4:00 AM hrs 4:00 PM hrs 5:00 AM hrs 5:00 PM hrs 6:00 AM hrs 6:00 PM hrs 7:00 AM hrs 7:00 PM hrs 8:00 AM hrs 8:00 PM hrs 9:00 AM hrs 9:00 PM hrs 10:00 AM hrs 10:00 PM hrs 11:00 AM hrs 11:00 PM hrs 12:00 PM hrs 12:00 AM hrs Helpful Hint: Add 12 to any of the AM times to determine the equivalent PM military time. Example: to determine how to write 7pm, add 12 hours to 7am (7+12) = 19 so 7pm=1900hrs 70

71 5. Right Route 5.1 A medication "route" is the pathway by which that medication enters a person's body. There are various routes for medication, and each medication should only be taken according to its specific route. 5.2 Many different medications are to be taken in specific ways, therefore anyone who assists a resident to take a medication must ensure that they are knowledgeable about how that medication must be taken. For example: Some kinds of anti-nausea medication are to be taken rectally. The route or method is "per rectum". It would therefore be a serious error for the resident to swallow this medication. In some special circumstances, a physician/nurse practitioner and pharmacist will provide written orders and instructions about crushing or dissolving medication for residents. There are some instances where a physician/nurse practitioner or pharmacist will advise that a certain medication is most easily taken when mixed with liquid or crushed and added to applesauce, ice cream, etc. However, some medication may become harmful if crushed or mixed with other liquids or foods. Therefore, it is very important to only crush or mix medication with documented instructions from a physician/nurse practitioner or a pharmacist. In addition, this is only to be done with residents' knowledge for the purpose of assisting them to take their prescribed medication. No medication should ever be crushed or mixed with anything without the advice of the pharmacist or physician/nurse practitioner and without the consent of the resident. *written physician's/nurse practitioner's orders must be present if crushing or dissolving a medication to assist a resident to take the medication *it is best practice to place written instructions from the pharmacist on the medication record sheet indicating if a medication is to be crushed or dissolved 5.3 The most common route for medication taken by residents of personal care homes is oral (swallowed). Examples of other medication routes commonly seen in personal care homes are: creams or patches applied to the skin ("transdermal" route) *note: the site on the skin where a transdermal patch is applied is to be rotated each time a new patch is applied to prevent damage to the skin; best practice is to include a map or schedule for the rotation sites as part of the resident's medication record sheet eye drops, ear drops, and nose sprays ("transmucosal" route) Example: ear drops for an ear infection nebulizer mists and inhalers ("pulmonary/lung" route) Example: inhaler for treating Asthma liquids that need to be injected just under the skin ("subcutaneous/sub-q" route) and into the muscle ("intramuscular/im" route)*note: all injections are Specialized Procedures and are required to be managed by a physician/nurse practitioner or nurse gel capsules or suppositories that are placed into the rectum ("rectal" route) Examples: suppositories to treat hemorrhoids or to treat constipation 6. Right Documentation 71

72 6.1 Medication is to be given when proper documentation is supplied by a physician/nurse practitioner or pharmacy regarding the medication. This information is required to include: The resident's name A list of the medication The amount or dose of each medication that is to be taken The time the medication is required to be taken A medication record that tracks who has assisted with each medication in the form of initials on the medication record sheet 6.2 When staff in personal care homes assist residents with medication, there are documentation requirements: Documentation for assisting residents to take their medication is required to be recorded by staff initials on the medication record sheet indicating which medication the resident was assisted with, as well as the date and time Documentation of all PRN medication should also be recorded on the medication record sheet; record: why the PRN medication was taken by the resident when it was taken the amount that was taken the results approximately 30 to 60 minutes after it has been taken (Example: Was the resident able to sleep after taking her PRN sleep medication? Did the resident's pain subside after he took his pain medication?) Results documentation will depend on the purpose of the PRN medication 72

73 L2. Review Questions for The 6 Rights The following multiple choice questions are based on true-to-life situations that might be encountered in a personal care home. Choose the BEST answer for each question by selecting the bullet next to the answer, then click the button to check your answer. Question 1 John is a new staff member who isn't familiar with all of the residents yet. He is to assist with some of the medications today. When it comes time for Mr. Pierce to take his pills, John is unsure about which resident is the correct person. He should: a) Ask the gentleman whom he believes might be the correct person "Is your name Mr. Pierce?" b) Trust his instinct and give the pills to the gentleman he believes is the right person c) the picture of Mr. Pierce that is attached to his medication information sheet, and then to be sure he has the correct person, say to the gentleman whom he believes to be Mr. Pierce, "I am sorry, but I have forgotten your name; could you please remind me what it is?" d) Tell the operator just before he is scheduled to assist with the medication that he does not want to help with the medication today and go do something else instead. Tries Remaining: 2 Question 2 What is the best way to assist residents with their medications? a) Ask the residents what pills they take and when, then help them as they request. b) Ask another staff member what medications each resident takes then follow his or her directions. c) Call the physician/nurse practitioner to ask what medications the resident is supposed to take. d) the resident's medication record sheet and assist the residents with their medications as directed. Tries Remaining: 2 Question 3 Mrs. Towney takes medication to reduce the swelling in her feet and legs. When 73

74 you notice that her legs and feet are extremely swollen, much more than what is normal for Mrs. Towney. What should you do? a) Help her with the medication as directed but notify your supervisor right away so that he or she can contact the physician/nurse practitioner b) Don't give the medication at all. It is obviously not helping. c) Write a note to Mrs. Towney's family about the swelling and leave it in her room so they will know about the swelling the next time they visit. d) Give double the usual dose of the medication so that the extra amount will work to decrease the swelling. Tries Remaining: 2 Question 4 The medication record sheet for Mr. Johnson, a resident in your personal care home, says that he is supposed to take 250 mg of pain medication each day at 12:00pm. When you begin to get the medication ready you notice that the bottle says 500mg on it. You should: a) with a supervisor and/or pharmacist to see if you should cut the pill in half to ensure Mr. Johnson takes only the 250 mg dose as ordered. b) Assume a mistake has been made and that Mr. Johnson is actually supposed to be taking 500 mg of medication. Give the medication as you found it in the bottle. c) Tell Mr. Johnson that his medication is the wrong dose, and he will have to wait until the correct dose comes from the pharmacy to take his medication. d) Ask Mr. Johnson what the other staff have been doing with the pain medication and follow whatever he says. Tries Remaining: 2 Question 5 Mrs. Dauncy is supposed to get her medication at 1:00pm; however you were busy, so you forgot and it is now 1:20pm. You should: d) Ask Mrs. Dauncy if she still wants to take the medication even though it's 1:20pm. b) Go ahead and give the usual dosage of the 1:00pm medication even though it is 20 minutes late. c) Call the physician/nurse practitioner and ask if you should wait until 74

75 a) Encourage Mrs. Dauncy to take double her usual dose, as the medication is late. Tries Remaining: 2 Question 6 A resident has just moved into your personal care home and he takes Insulin for his Diabetes. The subcutaneous injection to give insulin is required to be managed by a nurse. How should you ensure the resident is able to get his Insulin medication safely? a) Get a staff member who has given Insulin in the past to teach you how to do it properly b) Ask your supervisor if he or she will explain to you how to safely give Insulin c) Leave the Insulin medication for someone else to help the resident with. d) Ask your supervisor to arrange for a nurse to come into the personal care home to give the Insulin. Tries Remaining: 2 Question 7 Ensuring that proper safety measures are followed is an important part of assisting residents with their medications. Which of the following would NOT be considered a safety measure with regard to assisting with medications? a) Wearing a mask over your mouth and nose if you have a cold while you are responsible for giving residents their medications b) Wearing gloves when putting medicated cream on a resident's sore c) Ensuring the resident has all the items he or she needs for an outing such as a change of clothes, and her purse d) Ensuring a glass of water is present and the resident is sitting upright while a he or she swallows pills Tries Remaining: 2 Question 8 75

76 It is time for Mr. Kistner, a resident with dementia, to take his bedtime medication which is used to treat overactive bladder (you know this because you looked the medication up in the book provided at your personal care home). However, when you bring the medication to him, he states, "You can just throw those away and save yourself some trouble because I am not going to be taking them." Your next action should be: a) Reply, "Mr. Kistner, I certainly can't make you take these, but your physician/nurse practitioner wants you to take them so that you don't have to go to the bathroom so much in the night." b) Take the medication away and discard it as Mr. Kistner requested. c) Wait until he is sleeping, then try to gently wake Mr. Kistner and get him to take the medication while he is disoriented and not really aware of what is happening. d) Leave the medication with Mr. Kistner and hopefully he will take the medication later. Tries Remaining: 2 Question 9 ing the documentation and recording your own documentation is an important step when assisting residents with medications. Which of the following is NOT an example of appropriate medication documentation? a) Comparing the names of the medications in the resident's bubble pack with the names of the medications on that resident's medication record sheet. b) Initialing the medication record sheet for the remainder of the day when you arrive for your shift so that you can save time later and leave for home earlier. c) Writing down the results of a PRN medication about minutes after a resident has taken the medication in order to evaluate how well it's working. d) Noticing that a medication a resident is supposed to be taking has not been initialed on the medication record sheet for the past few days, and alerting your supervisor. Tries Remaining: 2 Question 10 Personal care homes which have more than 1 person assisting the residents with medications are required to have a medications training plan in place which teaches: a) The residents' conditions,why they are taking each medication, and how to document whether or not the residents have taken their medication 76

77 ) y g g denominations c) The residents' personal goals regarding mobility d) The residents' preferred clothing choices Tries Remaining: 2 77

78 Review Questions for Medication Routes/Safety/Infection Control Below are 2 columns with medication routes terms which are lettered a-j. Below the medication routes terms is a list of descriptive phrases. Place the letter of each medication routes term in the blank beside the phrase which BEST describes that term. Medication routes terms: a) Gloves f) Route b) Suppositories g) Hand washing c) Specialized Procedures h) Subcutaneous d) Inhalants i) Medications Assistance Module e) Oral j) Transdermal Medication routes descriptive phrases: Safety precaution taken before and after all medications assistance To be worn whenever a medication will come into contact with blood or body fluids Medication that enters the body through the skin Required in personal care homes where more than 1 person will be assisting residents with medications The most common medication route in personal care homes The term that means "a pathway by which medication enters the body" A type of medication which enters the body in the rectum A medication or treatment which is required to be administered by a health care professional, such as a Registered Nurse, or which the health professional may teach to the resident or delegate to the staff member(s) of the personal care home Medications which are breathed into the residents' lungs, such as with treatments for asthma A medication route which requires an injection under the skin, and which is considered a Specialized Procedure Tries Remaining: 3 78

79 M1. What rights do residents have regarding their medications in personal care homes? Residents of personal care homes have the same rights with respect to all aspects of their daily lives as anyone living in their own home does. This also applies to taking medications. No one is legally allowed to come into your home and force you to take medications that you don't want to take, nor are they allowed to hide it in your food or drinks to trick you into taking it. The personal care home is the home of the residents who live there. People who work in personal care homes cannot force or trick residents to take their medications. It is important that people who assist residents to take medications in personal care homes take the time to do so in a straightforward, honest manner. 79

80 M2. How do I assist residents with their medications in ways which preserve their rights, independence, and dignity? Anyone assisting residents with medication is required to: learn for what purpose each medication is taken by each resident provide privacy when assisting with a medication if you are explaining the purpose of the medication ask the residents if they would like to take their medication now don't demand or tell them that they must take it explain to the residents what the medication does, and why it's important for them to take that medication if they refuse to take the medication, take the time to politely ask if there is a reason for not wanting to take it; perhaps there is a reason for the refusal which you can resolve for the resident provide an opportunity for the resident to be as independent as possible with taking his or her medication don't spoon-feed pills to residents who can take medication from their own hands encourage independence with medication as specified by the physician/nurse practitioner give residents as much control as possible over how they take their medication offer a slight choice of timing when appropriate "would you like to take your pills before lunch or afterwards?" ask what kind of drink the resident would like to take the medication with be discreet when ensuring residents have taken their medication move away and busy yourself with another task while keeping a close eye on the 80

81 person taking the medication rather than standing in front of them staring and looking directly at their face if you are unsure whether the medication was swallowed, talk to the resident for awhile after helping them take medication and see if there is difficulty with talking ask the resident if everything is ok preserve the dignity of residents at all times make conversation while helping residents with medication rather than give the impression that the only reason for your interaction with them is to hand them pills approach medication times with friendliness and respect not as a task you are trying to finish quickly do not loudly announce "time to take your pills!!!" when approaching residents with medication ask the residents if this is a good time to take their medication ensure that to your knowledge it is in fact a good time for the resident (they are not in the middle of a conversation with a visitor, etc) 81

82 M3. Review Questions Approaching residents with respect and dignity are key components of assisting them with their medications True False Tries Remaining: 1 If confused residents say they won't take their liquid medications, it is ok to add the medication to their juice or tea True False Tries Remaining: 1 You are required to check with a pharmacist before crushing a medication True False Tries Remaining: 1 When it is time for residents to take their medications, it is very important that they stop whatever they are doing and take them immediately True False Tries Remaining: 1 82

83 "Just please take your pills I have a lot to do in the next half hour!" is a fair response for a person working in a busy personal care home to say to a resident who refuses his or her medication True False Tries Remaining: 1 83

84 N1. Medication Errors Memories of a medication error... "When I was a senior nursing student, I neglected to check a patient's heart rate before giving him a dose of [heart medication]. I was devastated. As soon as I saw him swallow the pill, it hit me that I hadn't taken his pulse [this medication is not to be given if the pulse is less than 60]. I panicked and grabbed his wrist. His pulse was 62; above the "Hold for heart rate less than 60" but not by much. I hadn't thought about this incident for a long time, but now thinking back, I can remember this clinical day so vividly. My first concern, of course, was for the well-being of the patient and fortunately, his vital signs remained stable. My own feelings of self-doubt and failure, however, stayed with me for quite some time. How could I have forgotten something so important and yet so simple?" By Lisa Bonsall, MSN, RN, CRNP 6 This memory, so disturbing for Lisa, even years later, shows the long-lasting effects on staff when they make a medication error. Luckily, there were no consequences for the patient. However, in Lisa's mind she had serious doubts about her ability and her skills. This is something that no one ever wants to feel. And even worse would be the feelings of being responsible for the illness or death of a resident if you made an error with medications in a personal care home. 6 Bonsall, Lisa, "Memories of a Medication Error" June 7, 2010, (October, 2012) Causes for Medication Errors (adapted from Cohen, 2007) 84