COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 500. Effective Date: June 21, 2007

Transcription

1 COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 500 Effective Date: June 21, 2007 This Policy replaces NPP 500 dated August 31, 2006 SUBJECT: ADMINISTRATION OF MEDICATION AND TREATMENTS - GENERAL RULES 1. GENERAL: Only a licensed physician, dentist or podiatrist is authorized to order medications. A Nurse Practitioner, working under Standardized Procedures, may order medications in accordance with written protocols. Only a physician or a pharmacist may dispense medication. Medications are administered by a hospital certified licensed nursing staff, except as follows: 1. A Psychiatric Technician Student may administer medications under the direct supervision of the Nurse Instructor. 2. Individuals may carry nitroglycerine as ordered by a physician. 3. As part of discharge readiness treatment activities, selected Individuals may be allowed, with WR Team approval, to self-administer medications under nursing staff supervision (see Section IV of this procedure). 4. Long-term care diabetic Individuals may draw and/or administer their own insulin after it has been determined they have the knowledge, ability, and the mental faculties to do this responsibly. Before this can commence, the Wellness and Recovery (WR) Team and physician must review the Individual. If approved, a Physician's Order must be obtained. A PT/LVN/RN, certified to administer medications, must directly supervise the Individual and assure that he does not compromise his or other's safety and that all other policies and procedures of medication administration are followed (see NP 513 and NP 523). A physician s order is required before any medication may be administered. 1. Name of medication - as listed in the Hospital Formulary 2. Form oral solid unless otherwise specified. 3. Dose - using metric system. 4. Route oral unless otherwise specified. 5. Frequency four times daily, etc. 6. Duration - x 45 days, x 5 doses, etc. 7. All PRN orders require a minimum number of hours between doses. 8. Psychotropic/neuroleptic PRN orders require a minimum number of hours between doses and may not exceed more than two doses per 24 hour period. -1-

2 A 24-hour period is defined as 0001 to Each unit has a distinct lock for the medication cabinets/cart. Medication room keys are to be kept by the designated med person or the designated relief (i.e. on their person in a secure manner). Medication keys are to be on the unit at all times. The only exception is on the Residential Recovery Units (RRU) which have only one nursing staff member assigned per shift. When these employees are required to go off the unit for necessary errands (e.g. Central Supply, Pharmacy,) the medication keys are to stay with the employee. All other policies and procedures about medications and medication room security and accountability will remain in force on the RRUs. Each time the medication keys change hands all control drugs (including control drugs to be returned to the pharmacy to be wasted) must be counted and accounted for and noted in the unit daybook (change of shift is noted, when signed on the Controlled Drug Count Signature Record).The locksmith must be called if the medication cabinets/carts cannot be opened. The assigned Med Person is responsible for the ordering and stocking of medications and is expected to anticipate the needs of the unit particularly for afterhours, weekends, and holidays. This includes any medical equipment needed e.g. syringes, med cups, lancets and test strips for blood sugar testing, etc. 2. PURPOSE: Medications are administered to aid the body in overcoming an illness, to relieve and to prevent symptoms, and to aid in diagnosis. Use of the following medication practices protects the safety of the Individual as we as the employee assigned to give medications, and provides for the security of the drugs by preventing unauthorized access. 3. EQUIPMENT: Varies according to route of administration (e.g. Oral, Parenteral, Eye, etc.). 4. PROCEDURE: It is the responsibility of the person transcribing an order to ensure that the required information is clearly stated and legibly written. Any confusion or concern over the meaning or appropriateness of any order is to be discussed with the ordering clinician, if possible, or the covering physician (i.e. MOC, PMOC). To clarify the order, have the physician rewrite the order or issue a telephone order prior to administering the medication or treatment (also see NP 514). Orders to prescribe over guidelines shall not be written or administered until a completed consultation is present in the Individual s chart. It is the responsibility of -2-

3 the person transcribing and/or administering an order over hospital guidelines to assure that a consultation is completed and in the chart. All medication orders are to be correctly and completely transcribed to the Medication Administration Record (MAR) and diet orders, daily care flow sheets, lab slip, etc. are to be processed prior to signing off, or "noting" the order. The nursing staff's signature under the order indicates that all transcriptions, processing, notifications, etc. has been completed (also see NP 514). It is the responsibility of each person administering medication to: 1. Review all charts at beginning of each shift to ensure that all orders are noted. 2. Clarify any orders that are improperly written, unclear, or appear to be inappropriate for the Individual at this time. During regular hours of operation, the staff is to contact the physician directly. After hours, weekends, and holidays staff are to contact the NOD. 3. Assess the Individual, prior to administering any medication, for signs and symptoms of possible untoward reactions, including but not limited to: -Allergic reactions -Neuroleptic Malignant Syndrome -Note: If a Individual is suspected of having NMS and if muscle stiffness is present and does not respond to a dose of medication designed to relieve muscle stiffness associated with EPS; do not continue to give additional medication for EPS - report symptoms to the physician. -Atropine overload. Be aware of required VS associated with giving certain medications/treatments (e.g. antihypertensives, beta blockers, antibiotics, etc.). Staff is responsible to assure that the Individual reports to the medication room in a timely manner in order to receive his medications. If necessary, staff will look for the Individual. Recording medication as refused occurs if the Individual has indicated he does not/will not take the prescribed medication. Failure of a Individual to report to the med room does not constitute refusal. Doses shall be administered within one hour of the prescribed time (posted in the Med Room) unless otherwise indicated by the prescriber (as noted in the physician s order) or other circumstances occur which require the med to be given at a later time e.g. if Individual is NPO for lab or medical procedure. Ensure that the expiration date has not been exceeded. Ensure any multidose vial used is dated and initialed when first opened and used within allowable time period (30 DAYS). -3-

4 Only one employee who is currently certified by the hospital to administer medications is to be assigned the primary responsibility to prepare, administer and chart medications at any given time. The Unit Supervisor/designee may assign a 2 nd medication certified nursing staff to assist in the preparation, administration, and documentation of ordered treatments, as necessary. No person may administer medications/treatments prepared by someone else. The person administering medication/treatment must have: 1. Knowledge of the medication/treatment, including the usual dose, route of administration, the expected side effects and any special precautions or contraindications. 2. Knowledge of the Individual, including his identity, diagnosis, disease process and any allergies. 3. The assigned medication person is to have no other assignments that would interfere with the safe preparation, administration, and documentation of medications for that shift. 4. Medicine cabinets/carts are to be kept locked, except while medications are being prepared. Allow sufficient time to follow proper preparation procedures prior to administering medications. At no time are medications to be left unattended unless locked in medication cart. 5. Do not transfer medications from one bottle/box to another. Do not write on any medication label or bottle, with the exception of dating multidose vials as these actions are considered "dispensing". If a label on a container is difficult to read or comes off, return the container to the Pharmacy for relabeling. Do not interchange medication droppers. Do not use medications, dispensed and labeled for an Individual, for any other Individual. 6. After normal Pharmacy operating hours if a unit finds it does not have a control medication or non-control medication available for a Individual and that medication is not available in the night locker, the unit is to contact NOD. Prior to contacting NOD, the unit shall ascertain if another Individual on the unit, or if necessary neighboring units, has the needed medication in stock. NOD will authorize the unit to use this available medication after consulting with the On-Call Pharmacist. Only NOD is authorized to physically transfer the medication from one unit to another. The event will be recorded in the NOD 24-hour report. The event will be recorded in the unit(s) logbook. The unit(s) will contact Pharmacy when it opens for regular operation (also see NP 516). 7. Internal and External products are to be stored on separate shelves in the medication cabinet. -4-

5 8. Whenever the Pharmacy fills an order for "Individual carried" Nitroglycerine sublingual tablets, the Individual and the Unit Supervisor will be given an individual written authorization according to the Pharmacy Formulary and Policy Manual (Section II Number10). NURSING A C T I O N A. Concentrate entire attention on the preparation of medication and avoid all distractions. B. Check all current copies of physician's orders before administering medications. Compare corresponding medication administration record; check the Individual's name, drug, dose, route, frequency and stop date (see III D above). -5- RATIONAL-PRECAUTIONS A. To reduce possibility of medication errors, administration of routine medications should not be interrupted to administer a non-acute PRN. B. An order could be incorrectly transcribed or not noted resulting in the order being omitted or incorrectly given. C. Assemble necessary equipment. C. Organization and planning saves time and effort and minimizes confusion and the possibility of error. D. Perform hand hygiene. D. To avoid spreading pathogenic organisms. E. Oral medications and external treatment meds are set up (opened) when the Individual is present. Read the name of the Individual and the medication from the MAR (no double pouring or pre-pouring ). Note: treatments are never administered in the med room; use of the Exam Room is recommended. F. Compare name of drug and dose with medication administration record, checking it three times. G. If the Individual has several solid medications they may, with due consideration for Individual safety, be put in the same medication cup. H. Do not mix any liquid medications together. E. Medication is not set up in advance ( double pouring or pre-pouring ). This ensures the right medication goes to the right Individual by the right route. F. Continual alertness, purposeful action, and repeated checking enhance concentration and prevent errors. H. Certain liquid meds, when mixed together, may form a precipitate.

6 I. Keep MAR(s), which identifies the Individual and the medication(s) visible at time of administration. J. Ambulatory Individuals come to the Medication Room for their medications at regularly scheduled med. times. Meds may be carried to the Individual when necessary, e.g. illness requiring bed rest or for privacy for an I.M. medication. I. Identifying the Individual and medication is essential to assuring that the right drug will be given to the right Individual. J. Actual time for routine medications (once daily, twice daily, etc.) may differ from unit to unit, allowing sufficient time for correct preparation and procedures to be followed. Standardized times for the unit are posted in the Med Room. 5. PREPARATION: For the procedure to identify and report adverse drug reactions see Pharmacy Formulary and Policy Manual Section II Number 24. STAT and NOW orders take precedence over routine orders and should be carried out immediately. 6. ADMINISTRATION: ACTION A. It is the responsibility of the med person to make a positive identification of each Individual prior to administering meds/treatment. Use picture ID cards for this purpose. If necessary have a second staff member present to help with Individual identification. B. Make appropriate observations and assessments of the Individual for any contraindications to administering the medication. If an allergic reaction, Neuroleptic Malignant Syndrome or other adverse reaction is suspected withhold the medication, provide needed care, and immediately notify M.D., NOD, and supervisor. C. Read MAR to identify medications and Individual then give them their medication. RATIONAL-PRECAUTIONS A. Proper identification is essential to prevent errors in administering a drug. Illness and unfamiliar surroundings often cause a Individual to be confused. Same or similar sounding names, similar appearance or new Individual may cause the med-person to confuse one Individual for another. B. Prevention of adverse drug reactions is the best line of defense. Careful observation is necessary to provide prompt and timely action to prevent serious/life threatening outcomes. Withholding medication is often the most important step. -6-

7 D. Remain with the Individual until medication is swallowed. Check Individual's mouth, if necessary. E. Chart the medications immediately after Individual has swallowed them. Chart treatments promptly after administration. D. To assure Individual is actually taking his meds and receiving properly prescribed treatment. E. For ready indication that medication has been administered. PRN Orders: PRN medication orders not written in accordance with hospital policy will be immediately brought to the physician s attention (after hours MOC or PMOC) for correction (see III A above). PRN Medication orders not written in accordance with Hospital policy, procedure, and protocol will not be noted or given until the order is correctly written as noted in the following procedures. The Pharmacy and Therapeutics Committee (PTC) on an individual case-by-case basis may permit exception to these rules. PTC approval for exceptions will be written on Consultation Forms and filed in the Consultations section of the Individual's chart. In an emergency, PRN doses for psychotropic medications having greater frequency than 2X/24 hr may be given as written without a completed consult, with the understanding that the consult process will be followed in a timely manner, and that the total daily dose will not exceed the accepted upper limits for that medication. PRN orders will clearly specify parameters for administration based on observable conditions and behavior. PRN pain orders should refer to the specific pain syndrome, e.g., low back pain, cephalgia, and migrating arthralgia secondary to rheumatoid arthritis. PRN epigastric distress, GI upset, dyspepsia. PRN fever should be written as PRN temperature greater than N (N=number) degrees. PRN hypoglycemia should be written as PRN blood glucose less than nn (mg/dl). PRN insomnia orders: current hospital Psychotropic Medication Guidelines limit. PRN insomnia orders to a maximum of 14 days per month. Staff must document the Individual's sleep patterns in the IDN's. -7-

8 PRN EPS (extrapyramidal symptoms) should not be written. PRN drooling, tremor, rigidity, or other signs/symptoms of EPS for that Individual should be written in the order. PRN BID, TID, QID etc. Orders must conform to the Approved Acceptable and Unacceptable Abbreviations List (see AD 591). Orders must have a time frequency to indicate the spacing of doses. Orders should not be written PRN BID. The orders must be written: PRN q 12 hours or another specific frequency of administration. The maximum number of doses permitted in a 24-hour period must also be stated. PRN PO/IM should not be written. The circumstances in which IM, as opposed to PO, medications are given need to be specified e.g., "Lorazepam 2 mg PO PRN agitation per protocol (give lorazepam 2 mg IM if PO dose refused) q 2 hr NTE 2 doses/24 hr X 45 days." PRN hallucinations should not be written. If hallucinations are a symptom of agitation, they can be added to a given Individual's agitation protocol as a behavioral symptom, assessed in the same context as the other behavioral and physiological signs and symptoms. PRN anxiety medication may be ordered. The phrase "at Individual's request" may be added to the order. Neuroleptic and Sedative PRN's: Orders shall not be written to authorize more than two doses within 24 hours. Subsequent to an acute phase of illness, administration of any neuroleptic or sedative medication more than 20 doses PRN in one month (per State guidelines) requires review of the regular medication and dosage by the attending psychiatrist. PRN agitation orders must be written per protocol. A generic protocol applicable to all Individuals follows below. This can be modified by the WR Team for a given Individual. PRN medication protocol for agitation Agitation is defined as any three items from the Physiological and Behavioral (nonassaultive, non-threatening lists), with at least one behavioral item, or any one item from the Behavioral (threatening, assaultive) list. The specific items observed needs to be documented on the MAR. IDN s may be utilized to document more detailed observation if required. -8-

9 PRN medication protocol for agitation THREE ITEMS FROM THESE TWO LISTS (At least one being behavioral) Consistent with the Pharmacy Policy Manual (Number II Section 8), time frames shall be established and implemented limiting the duration of new drug orders in the absence of a prescriber s specific indication of duration of therapy. The prescriber shall be contacted for new orders prior to the termination time established by the policy. For purposes of filling, dispensing, and administering medications, if an order is written without a specific duration of therapy, the following automatic stop dates shall apply: 1. Antineoplastic Agents 24 hours 2. DEA Schedule II Drugs 48 hours 1. Injectable Anticoagulants Seven (7) days 2. DEA Schedule III V Drugs Seven (7) days 3. Antibiotics/Anti-Infectives Seven (7) days 4. Oral Anticoagulants Seven (7) days 5. Corticosteroids Seven (7) days 6. All other classes of drugs 45 days If the automatic stop date falls on a holiday, this date shall be extended to the next regular working day, unless otherwise specified by the prescriber. 3. Medication orders are to be recorded on the Physician s Order form. The orders are to be signed and dated by the physician, dentist, podiatrist or Nurse Practitioner. 4. Under urgent or emergency circumstances a phone order may be taken by a registered pharmacist or licensed nursing staff. The ordering clinician is to sign the phone or verbal order within 48 hours or the next business day. 5. There are no "standing" medication orders. 7. SELF ADMINISTRATION PROCEDURE: The Individual must be approved by the unit s WR Team with a current physician s order to self-administer their medications. A Wellness and Recovery Care Plan will also be written for the self-administration of their mediations. -9-

10 The Pharmacy will prepare all medications in their respective containers, labeled for that individual. Medications will be stored in the unit medication room in a locked cabinet when not in use. The licensed nursing staff will assure that the Individual does not compromise his or other's safety and that all other policies and procedures related to medication, medication administration, and infection control procedures are followed, e.g. proper handling and disposal of syringes. Licensed nursing staff assigned to the medication room will be responsible for the direct supervision of the Individuals set up and self-administration of their medication. Nursing staff will chart the medications immediately after the Individual has swallowed/injected them. See NP 523 for detailed information about self-administration. 8. RECORDING/DOCUMENTATION: Forms used: Medication Administration Record (MAR). Diabetic Record. Immunization Record. A. Medication Administration Record (MAR) page Ensure month and year is entered in the appropriate boxes (computerized form should be preprinted). 2. Enter any allergies in the appropriate space at the bottom of the form. If no known allergies, write none known. 3. Spaces bounded horizontally by dark lines are each to be used for one medication/treatment. 4. In the columns on the left side of the form, ensure the following are entered: a. date and time of order b. medication/treatment ordered, dosage, route if other than oral and frequency of administration c. stop date d. in the # box, write the problem number which corresponds to that which appears on the Physician s Orders. e. hrs time of adm column: i. using one row for each hour (to be given), record the hour when the medication/treatment is to be administered. ii. if medications/treatments require more than four administrations in a 24hr. period, use additional rows in the next available space. If all four blocks are not needed, leave the remaining blocks blank. Enter the next medication/treatment in the next available space, below the dark horizontal line. 5. Recording medications/treatments as given: a. Initial the appropriate date/hour box. -10-

11 b. The employee who administers the medication/treatment must sign with their signature (first initial and last name), title and identifying initials in the space at the bottom of page 2 of the form. c. to record site of injection, use site codes printed on the reverse side of the form. Enter site code in date/time box next to/below initials. d. review/assure that pulse and/or blood pressure readings are recorded and taken in conjunction with the medication/treatment. 6. Starting a medication/treatment not at the beginning of the month: a. enter identifying information on the left side of the form (following above procedures). b. draw an arrow from the beginning of the month (day 1) to the date before the date on which the medication/treatment is to begin (e.g. if the medication/treatment starts on the 7 th of the month, draw the arrow from the 1 st to the 6 th ). c. write START over the line drawn for the arrow. d. bracket-in the start time box of the medication/treatment on the appropriate day. e. bracket-in the stop date/time (if available on current MAR) of any medication/treatment that stops prior to 45 days in the same manner. 7. Recording refused/omitted medications/treatments: a. refusal - the appropriate box for that medication/treatment (time and date) will be circled and an R will be placed inside the circle. Additional pertinent, information is to be noted on the reverse side of the form (e.g. Individual says I don t need it anymore ). An IDN may be written to capture more pertinent information if needed or required (e.g. Individual says I hate you and will never take meds if you are in the med room ). Failure of a Individual to report to the medication room is not grounds for refusal. If necessary, staff will track down the Individual. b. omission if a medication/treatment is not given as ordered, the appropriate box for that medication/treatment (time and date) will be circled and an O will be placed inside the circle. A justification must be written on the reverse side of the form (e.g. unacceptable VS). An ID Note may be written to capture more pertinent information. c. refusals/omissions will be brought to the attention of the Medical Clinic physician, psychiatrist, or MOC/PMOC. B. PRN/STAT Documentation on MAR: 1. enter date and time. 2. enter appropriate problem number (must match physician s order). 3. enter the medication, dosage, strength, and route/site. 4. enter the reason for giving the medication/treatment (must match the reason stated in the physician s order and if for pain you must indicate the numerical value of the pain reported from pain scale, 0-10). 5. initial the entry. 6. record the results/effectiveness of the medication/treatment within 1 hour after administration (if for pain you must indicate the new, numerical value of pain relief reported from pain scale, 0-10). If the shift ends, prior to the review of relief (less -11-

12 than an hour since administration) the off-going med person must report this to the on-coming med person to assure completion of this portion of the MAR. 7. Enter initials, then signature (first initial and last name) and title in the space at the bottom of the form to verify the initials on any part of the MAR. 8. PRN, STAT, NOW doses of medication/treatments will be documented in chronological order of administration on the back of the MAR the PRN order is written on (MH 5764). The PRN medication record (CSH-047) should only be used as a continuation page, if the back of the MAR the PRN order is written on is full. 9. PRN will also be initialed on front of medication record as well to see patterns of medication usage. C. Exception to documentation on the MAR. 1. all insulin administration is documented on the Diabetic Record. 2. tuberculin skin testing (TST)/immunizations are documented on the Immunization Record. D. Discontinuing Medications/Treatments on the MAR. 1. discontinuing a medication/treatment prior to stop date: a. place a diagonal line inside the boxes that indicate the start/stop time and name of medication dosage, etc. Place initials and date on the diagonal line. 2. discontinuing a medication/treatment at the stop date: a. complete steps as in D.1-a then draw a diagonal line through the remainder of the empty date/time boxes on the form and write DC, initials and date on the diagonal line. 3. information written on the diagonal lines may go above or below the line depending on space available. 9. AFTER CARE OF INDIVIDUALS AND EQUIPMENT: ACTION A. Report any unusual circumstances involving medications (e.g. toxic signs, refusal of Individual to take medications, etc.) to the Medical Clinic physician, psychiatrist, or MOC/PMOC. Discuss in shift change. B. Clean medication cart after each use and other equipment used as needed with hospital approved cleaner. Return equipment to proper location. RATIONAL-PRECAUTIONS A. The physician needs to be informed in a timely manner to insure continuity of care. B. Prepare for next use. -12-