AREAS OF RESPONSIBILITY

Transcription

1 Page 1 of 17 Applies To: All UNM Hospitals Responsible Department: Pharmacy Title Medication Orders & Administration Procedure Patient Age Group: ( ) N/A ( X) All Ages ( ) Newborns ( ) Pediatric ( ) Adult DESCRIPTION/OVERVIEW This procedure standardizes medication ordering and administration practices in an effort to maintain safe, clear, and consistent administration of prescribed medications. REFERENCES New Mexico Board of Pharmacy (NMBOP) Rules and Laws The Joint Commission Standards: MM MM MM MM MM MM MM MM MM PC PC USP<797> Pharmaceutical Compounding Sterile Preparations CDC Vaccine Storage Handling and Toolkit State of New Mexico Statutes: New Mexico Statutes Annotated 1978; Chapter 61 Professional and Occupational Licenses AREAS OF RESPONSIBILITY This document applies to health care providers who order or administer medication within their scope of practice, as determined by licensure and education. PROCEDURE 1. Establishing the Profile 1.1. The patient s registration information will be entered into the medical record system, which is integrated with the inpatient pharmacy information system All patient information, including the patient s name, telephone number, address, birth date, sex, pertinent problems/diagnosis, lab values, height, weight, pregnancy/lactation status, allergies, and sensitivities will be available to all appropriate healthcare providers, including pharmacists Once the information has been received, a pharmacist will review all information The medication profile is available to staff responsible for the patient s care. 2. Recording of Orders

2 Page 2 of The pharmacist is responsible for all medication order entry or verification for inclusion into inpatient pharmacy information system The inpatient medication profile will reflect current medication therapy and individual medical history. 3. Purging of Records 3.1. Patient medication profiles are kept on file for 3 years These records are readily retrievable in accordance with the rules and regulations of the NMBOP. 4. Medication Orders: Medications must be properly ordered by an authorized prescriber prior to administration All valid medication orders will contain the patient name, medical record number, date, time, medication name, dose, route, and frequency. The order must be electronically or physically signed by the prescriber. The authorized prescriber s provider number and pager number must be readily available. Verbal and telephone orders must contain the same information Medication orders for pediatric and neonatal patients should have normalized doses (e.g., doses written as mg/kg) w appropriate. The final dose should be calculated and provided on the order form or the Electronic Medication Record (EMR). The weight of the patient should be on the order form or entered in the patient's EMR. Doses cannot be written in milliliters except for combination products w appropriate Outpatient prescriptions must be written using the EMR as available 4.4. In the event of a computer failure, the downtime procedure will be initiated When ordering medications the use of generic names is preferred, with the exception of combination medications which are commonly known by brand name, or medications for which using the brand name will prevent medication errors All PRN medication orders require an indication Radiology will use manufacturer-provided contrast dosing charts or approved protocols for contrasted imaging as ordered by an authorized prescribing Radiologist Additional elements are required when ordering If possible, the following time frames will be honored for medication delivery and administration: STAT: 30 Minutes NOW: 2 hours Routine: The next scheduled dose Titration orders -- The dose is either progressively increased or decreased in response to the patient's status. Clinical parameters are required Taper orders -- The dose is decreased by a particular amount with each dosing interval Orders for compounded drugs or drug mixtures not commercially available must state the medications and the concentrations required. If the order is not clear, and no clarification is provided, the pharmacy will not fill the order. The pharmacist will call the prescriber to clarify the order Orders for investigational medications should have the UNMHSC protocol number on the order The pharmacy department does not provide complementary and alternative medications (CAM) for inpatients unless the product is on the formulary Orders for medications at discharge or upon transfer to another healthcare facility will be communicated in written or electronic format.

3 Page 3 of Range Orders Orders in which the dose or dosing interval varies over a prescribed range will be aligned with clear objective clinical parameters Standing Orders (non-patient specific orders) are not allowed Orders for medication-related devices should specify the device and include all the information needed to ensure they are used appropriately and safely Blanket reinstatement of previous orders a summary order to resume all previous orders for medications are not acceptable Pre-printed medication order forms are reviewed by the Medication Safety Committee or Pharmacy & Therapeutics Committee initially. Subsequent reviews occur every 5 years or sooner if necessary, based on current evidence and practice. Unapproved preprinted order forms are not valid orders Medication Renewal It is the responsibility of the authorized prescriber to renew or change expiring medication orders Inpatient Departments All medications must be renewed by the authorized prescriber at least every 30 days Medication orders must be reauthorized upon patient transfer to a different level of care or for patients requiring surgery Outpatient Departments All medication orders for administration in the ambulatory setting will expire in 1 year, or sooner if indicated. 5. Review of Medication Orders 5.1. Before dispensing from pharmacy or removal of medications from floor stock or from an automated storage and distribution device, a pharmacist shall review all medication orders or prescriptions unless an authorized prescriber controls the ordering, preparation, and administration of the medication or when a delay would harm the patient in an urgent situation All medication orders are reviewed for existing or potential interactions between the medication ordered and food and medications the patient is currently taking The appropriateness of the medication, dose, frequency, and route of administration are evaluated for each medication order 5.4. Orders which are unclear, lacking the necessary elements of a medication order, or not appropriate for the patient will be clarified by the pharmacist. The pharmacist will contact the provider who is responsible for the care of the patient and clarify or change the order Previous orders for the same medication and route may be discontinued by the pharmacist upon review and verification of the new order. 6. Medication Administration 6.1. Personnel administering medication should not give any medication when the authorized prescriber's order is unclear, or in the case of written orders, illegible, or contains an unapproved abbreviation. If this is the case, the prescriber should be contacted to clarify the order It is the responsibility of the person administering a medication to check all medications prior to administration to verify the Rights of Basic Medication Administration All medications will be documented at the time of administration The personnel who will administer the medication may acquire only one patient s medications at a time.

4 Page 4 of Medication will be administered in accordance with the employee s scope of practice, licensure, and education as defined by the appropriate professional licensing board and the New Mexico Statutes Annotated 1978; Chapter 61 Professional and Occupational Licenses (see Attachment A for examples) Standard medication administration times are used at University Hospitals whenever possible (adult & pediatric: Attachment B; Newborn ICU: Attachment C; CPC: Attachment F; Mental Health: Attachment G) Medication administration times may be rescheduled by pharmacy to reflect the patient s home schedule Critical care or special needs patients may have medications rescheduled to be administered at nonstandard times Reasons for nonstandard administration times will be communicated to the pharmacist via the Med Request option on the EMAR with a selection of Time Change Request Medications prescribed between standard dosing times will be initiated based on the order priority (STAT, NOW, or ROUTINE) designated by the prescriber Actual medication administration for most medications should occur between 60 minutes before and 60 minutes after the scheduled administration time. Exceptions to this rule are as follows: Medications that must be administered when prescribed: STAT doses First time doses requiring a large initial dose of a medication to bring blood, tissue or fluid levels to an effective concentration quickly Loading doses requiring a large initial dose of a medication to bring blood, tissue or fluid levels to an effective concentration quickly One-time doses; doses specifically timed for procedures Time-sequenced doses; doses timed for serum drug levels Investigational doses Medications prescribed on an as needed basis (PRN doses) Medications that must be administered between 30 minutes before and 30 minutes after the scheduled administration time: Medications prescribed more frequently than every 4 hours Short or intermediate acting insulin 6.7. Prior to administration, all medications must be checked for expiration date, physical damage, and deterioration Prior to first dose administration, the patient will be assessed for potential food/drug interactions, drug/drug interactions, and drug/drug class allergies Medications not administered within the appropriate time window may be administered if not more than half of the dosing interval has passed. If more than half the dosing interval has passed the provider responsible for the patient should be contacted to determine if the dose should be administered and/or if the dosing schedule should be changed If a medication dose is not given, or missed, it will be documented on the EMAR as not given. The provider will be notified if the patient has missed a dose.

5 Page 5 of Late administration or missed doses of medication should be considered medication errors and the hospital s Medication Error, Potential Adverse Drug Events and Adverse Drug Reaction Reporting Procedure should be followed Pediatric oral liquids that are not available in doses prepackaged by the manufacturer should be administered using an oral syringe. The pharmacy will dispense oral liquids in patient specific, single use oral medication syringes when possible. Oral syringes will be in all pediatric areas for nurses to administer oral medications that cannot be prepared in advance by the pharmacy For medications that need to be cut or crushed before administration, a disposable tablet cutter and tablet crusher can be obtained from the unit s supply Pyxis Before cutting or crushing any tablet, visit Pharmacy Department Services web page at UNM Hospitals Intranet Department Pharmacy Inpatient Pharmacy Resources- Resources DO Not Crush list: Tablet cutter and tablet crusher are for patient specific use. Patient s identification sticker will be applied to them at all times. They will be stored in the patient s medication bin in Pyxis when not in use Healthcare providers will wash their hands and wear gloves before splitting or crushing tablets Tablet crushers will be used to pulverize tablets to a fine powder. Tablet splitters will be used to accurately cut tablets into multiple doses Each tablet will be split and/or crushed individually Tablet cutter and/or tablet crusher will be wiped clean with a damp paper towel before and after each use Upon discharge, patient will be provided with the tablet cutter and/or tablet crusher, if still needed for home use Some transdermal patches contain metal. To prevent burns, a patient medicated with a transdermal patch who is undergoing Magnetic Resonance Imaging (MRI) should have certain patches removed prior to the procedure. Nurses should contact Pharmacy for transdermal patch information and replacement Before medications can be left at the bedside for non-staff member administration (patient self-administration), an order must be obtained from an authorized prescriber. This includes medications brought from home. Notation of a medication as at bedside is written by the provider, verified by the pharmacist reviewing the order, and will appear on the MAR as such. Administration is documented on the MAR by the nurse as per patient or appropriate non-staff member Nursing must determine the competency of non-staff members who wish to administer medications, such as parents, family members, or patients, before they are allowed to administer medications. The nurse should document these findings in the education teaching record Non-staff members who will be administering medications will receive information and training from the nurse, who documents the training in the nurse education tool, regarding: -The nature of the medication to be administered.

6 Page 6 of 17 -How to administer medication, such as frequency, route of administration, and dose. -The expected actions and side effects of the medications. -How to monitor the effects of the medications on the patient Medications should be stored in a cabinet or drawer, not on a table or countertop, to ensure that only the patient and authorized staff have reasonable access Controlled substances cannot be left at the bedside. 7. Medication Administration Record (MAR) Reconciliation 7.1. Nursing staff will compare MAR with the authorized prescriber s orders Nursing staff will notify Pharmacy of discrepancies between the MAR and the order, as well as requests to reschedule medication administration times, by use of Med Request option on the EMAR or by contacting the pharmacy. During downtime procedures the 24 Hour MAR Reconciliation Form (Attachment D) may be used to request changes 7.3. A pharmacist may change medication orders for oral dosage forms with similar release characteristics for ease of administration upon request by the nurse or provider (ex. tablet to suspension) A pharmacist may change the ordered route of administration for oral medications to an equivalent route upon request by the nurse or provider (ex. by mouth to NG tube ) When contrast is administered by radiology, the radiologic technologist will document this on the approved screening tool Oral contrast medications for nursing administration to inpatients will be ordered via CPOE and charted on the EMAR. 8. Missing Medications 8.1. Upon discovery of a missing medication, personnel will request the missing medication using the Med Request option on the EMAR. During downtime, a Medication Request Form (Attachment E) may be used Unit specific trends in missing medications will be evaluated as needed. 9. Returning and wasting medications 9.1. Expired or discontinued medications will be returned to the Pharmacy. The medication may be placed in the Return to Pharmacy container in the medication room Damaged or partially used medications will be appropriately disposed of on the unit 10. Labeling of medications in perioperative and procedural settings The person preparing the medication is responsible for labeling the medication Label each medication or solution as soon as it is prepared, unless it is immediately administered. An immediately administered medication is one that an authorized staff member prepares or obtains, takes directly to a patient, and administers to that patient without any break in the process Medication or solution labels will include: -the medication name -strength -quantity -diluent and volume (if not apparent from the container) -expiration date and time Medications and solutions both on and off the sterile field are labeled even if t is only one medication being used All medication or solution labels are verified both verbally and visually by two qualified individuals whenever the person preparing the medication or solution is not the person who will be administering it.

7 Page 7 of No more than one medication or solution is labeled at one time Any medications or solutions found unlabeled are immediately discarded All original containers from medications or solutions remain available for reference in the perioperative or procedural area until the conclusion of the procedure All labeled containers on the sterile field are discarded at the conclusion of the procedure At shift change or break relief, all medications and solutions both on and off the sterile field and their labels are reviewed by entering and exiting personnel. 11. Labeling of medications in non-procedural settings The person preparing the medication is responsible for labeling the medication Medication containers are labeled whenever medications are prepared but not immediately administered. An immediately administered medication is one that an authorized staff member prepares or obtains, takes directly to a patient, and administers to that patient without any break in the process Medication or solution labels will include: -the patient s name -medical record number -medication name, strength, and amount (if not apparent from the container) -diluent and volume (if not apparent from container) -expiration date and time -preparation date and diluent for all compounded intravenous admixtures or parenteral nutrition formulas -the initials of the person preparing the medication -applicable warnings -location w medication is to be delivered 12. Intravenous Medication Preparation Emergency medications may be prepared in patient care areas by healthcare professionals operating within their scope of practice. All other medications must be prepared in the pharmacy IV contrast agents for imaging studies will be prepared by a Licensed Radiologic Technologist Medications must be prepared utilizing aseptic technique A filtered needle must be utilized to draw a medication from a glass ampoule Medications prepared in patient care areas must be initiated within 1 hour of preparation Medications prepared in patient care areas must be replaced with a pharmacy prepared product as soon as possible and no later than 10 hours after the medication was started Medications prepared must be labeled according to above labeling procedure Medication may not be added to an IV bag/bottle that is already being administered to the patient. 13. Expiration Dating Multi-dose vials will be discarded 28 days after opening or on the expiration date, whichever is earliest. Vials require a beyond use or expiration date and the initials of the person who opened the vial. Vaccines may follow current CDC guidelines for expiration dating. (CDC Vaccine Storage and Handling Toolkit) Opened or needle-punctured single-dose containers, such as bags, bottles, syringes, and vials of sterile products must be used within one hour and the remaining contents must be discarded Topical and oral multi-use containers expire on the manufacturer s date and do not

8 require date, time, and initials IV solutions expire a maximum of 24 hours after being hung. Exceptions to expiration dating can be made if supported by evidence based practices. Page 8 of 17 DEFINITIONS Emergency Medication: Medication which becomes necessary when a patient experiences a sudden change in clinical status or when a delay in administration would potentially harm the patient. Medication Administration: A process wby a prescribed drug or biological agent is given to a patient/client by a person licensed or certified to administer medications. The administration of medications is a procedure that requires knowledge of anatomy, physiology, pathophysiology, and pharmacology. When administering a medication, the licensed person is required to assess the patient s health status and disease process before and after the administration of the medication and to evaluate the patient s response to the medication. Rights of Basic Medication Administration: Right drug, right dose, right time, right route, right patient, right indication, and right documentation; IN ADDITION, right concentration, right method, right position, right site, right sequence and other considerations may apply SUMMARY OF CHANGES Tablet Cutter and Tablet Crusher Added references Expanded labeling and administration requirements GPC Range Orders Decision-Making for Medications procedure was been withdrawn tfore language has been amended Added section 6.13: An overview of the proper use of tablet cutters and tablet crushers ONCE A DAY administration times was added to CPH Included an exception clause for IV solution expiration dating RESOURCES/TRAINING N/A

9 Page 9 of 17 DOCUMENT APPROVAL & TRACKING Item Contact Date Approval Owner Medication Safety Committee Consultant(s) Executive Director of Pharmacy, Director of Pharmacy Operations, Medication Safety/Compliance Manager, Pediatric Pharmacy Manager Committee(s) Medication Safety Committee, PP&G Committee Nursing Officer Chief Nursing Officer Y Medical Director/Officer Chief Medical Officer, UNM Hospitals Y Official Approver Administrator, Professional & Support Services Y Official Signature On SharePoint 05/24/2018 Effective Date 05/24/2018 Y ATTACHMENTS: Attachment A: EXAMPLES OF PROFESSIONAL SCOPE OF PRACTICE & EDUCATION Title Scope Examples Graduate Nurse LPN II / Under the supervision of an RN Per UNMH LPN Scope of Practice Guidelines Medications within the scope of an RN Preceptor

10 Page 10 of 17 MA II MA IIs may administer selected medications under the supervision of a physician in an ambulatory setting. Including: -routine vaccinations (excluding Pneumovax) - medroxyprogesterone acetate - vitamin B12 - erythropoietin Nurse Intern Under the supervision of an RN Medications within the scope of an RN Nurse Extern Cannot administer medications None Radiology Technologist: CT Fluoroscopic Interventional MRI Nuclear Medicine Unlicensed Assistive - Personnel (UAP): Medical Assistant Nurse Technician Nursing Assistant / CWA Tech Mental Health I CWA Tech Mental Health II CWA Tech Mental Health III Respiratory Care Practitioner Administration of contrast agents or radiopharmaceuticals Nurses (including Advanced Practice Nurses) cannot delegate IV therapy or medication administration to UAP. Observation of a client taking their medications. Limited to Milagro Residential program only. IV therapy and IV medications with UNMH education and competency completion. Retrograde, Anterograde (Fluoroscopy, IR), Stomal (Fluoroscopy) Intravenous (CT, MRI, Nuclear Medicine), IM or subcutaneous injection (Nuclear Medicine), Oral (CT, MRI, Fluoroscopy, Nuclear Medicine) None Limited to Milagro Residential program Including conscious sedation Anesthesia Techs / OB Techs /013800/ CDU techs / Patient Care Techs / Housekeeping Under the supervision of an Anesthesiologist/CRNA. Under the supervision of the RN Supervisor, stocking only. In view of Nurse while in med room Stocking medications, transport of non-narcotic anesthesia drugs from pharmacy and/or Pyxis. Stocking medications in ORs for nursing use. Stocking supplies or cleaning only.

11 Page 11 of 17 Attachment B: Adult and Pediatric Standard Medication Administration Times ADULT AND PEDIATRIC STANDARDIZED MEDICATION ADMINISTRATION TIMES 5 x day awake 0700, 1100, 1500, 1900, x day 1000, 1500, 2000, 0100, 0500 AC & HS 0700, 1200, 1700, 2100 BID 0900, 2100 BID AC 0700, 1700 BID PC 0900, 1800 Bedtime 2100 Three times per week 0900 PC & HS 0900, 1400, 1800, 2100 Q12 H 0900, 2100 Q12 H alternate 0600, 1800 Q12 H RT 0800, 2000 Q2 H Odd hours Q3 H 0900, 1200, 1500, 1800, 2100, 2400, 0300, 0600 Q3 H RT 0700, 1000, 1300, 1600, 1900, 2200, 0100, 0400 Q4 H 1000, 1400, 1800, 2200, 0200, 0600 Q4 H RT 0800, 1200, 1600, 2000, 2400, 0400 Q6 H 0900, 1500, 2100, 0300 Q6 H alternate 1200, 1800, 2400, 0600 Q8 H 1000, 1800, 0200 Q8 H alternate 1400, 2200, 0600 Q8 H RT 0800, 1600, 2400 QAM 0900 Once Daily 0900 Once Daily before meals 0700 QID 0900, 1300, 1700, 2100 QID RT 0800, 1200, 1600, 2000 TID 0900, 1400, 2100 TID AC 0700, 1200, 1700 TID PC 0900, 1400, 1800 TID RT 0900, 1500, 2200 Warfarin 2100 Daily Steroid doses 0900 Three times daily 0900, 1400, 2100 Isosorbide doses True Interval Dosing Parenteral Products *all times standard unless otherwise noted. AC Thirty minutes before meals PC Thirty minutes after meals Pharmacist may change times based on clinical parameters of individual medications.

12 Page 12 of 17 Attachment C: NBICU Standardized Medication Times Scheduled Hours of Administration Q1H 2400, 0100, 0200, 0300, 0400, etc. Q2H 2400, 0200, 0400, 0600, 0800,etc. Q3H 2400, 0300, 0600, 0900, 1200,etc. Q4H 2400, 0400, 0800, 1200, 1600, 2000 Q6H 0400, 1000, 1600, 2200 Q8H 2400, 0800, 1600 Q12H 0900, 2100 Q24H 0900 True Interval Dosing Parenteral Products Standard times apply to ALL medications. IV antibiotics will be administered as soon as possible with subsequent doses adjusted to standard times using the half-way rule: a. If the first dose is administered before the half-way point of the standard time, administer next dose as scheduled. b. If the first dose is administered after the half-way point of the standard time, skip the next dose, then resume the scheduled times. Oral medications will be administered at the next regularly scheduled time unless the order specifies a NOW or STAT dose. Drugs ordered to be given once daily will be administered on the day of the order unless t are fewer than 12 hours until the next dose. Orders written after 2100 will be started at 0900 the following day Pharmacist may change times based on clinical parameters of individual medications

13 Page 13 of 17 Attachment D 24 Hour Nursing/Pharmacy MAR Reconciliation Form PATIENT LABELS MEDICATION DOSE ROUTE FREQ Date: Unit OTHER CORRECTIONS/COMMENTS INITIALS & TIME

14 Page 14 of 17 Attachment E Missing Medication Request Form Scan to Pharmacy, for non-emergent medications allow for a 2-hour turn-around. Medication Date: Unit: Time: RN requesting: Reason for request: Pyxis restock Not on unit Not in patient profile Other Needed: Within 2 hours ASAP Follow up by Pharmacy: Medication Found: Tube Refrigerator Envelope Other NotFound: Other dose sent Date: Time: Initials: Comments:

15 Page 15 of 17 Attachment F: Children s Psychiatric Center (CPC) Standard Medication Administration Times CPH STANDARDIZED MEDICATION ADMINISTRATION TIMES All Cottages except as noted. QAM 0700 QAM & Noon 0700, 1200 BID 0700, 2000 BID, C , 1900 Q Noon and HS 1200, 2000 Q Noon and HS C , 1900 TID 0700, 1300, 2000 TID C , 1300, 1900 QID 0700,1200,1600,2000 QID C ,1100, 1500, 1900 QEVE 1700 QHS 2000 QHS C ONCE A DAY 0900 AC Thirty minutes before meals PC True Interval Dosing Thirty minutes after meals Parenteral Products *All times standard unless otherwise noted *Pharmacist may change times based on clinical parameters of individual medications.

16 Page 16 of 17 Attachment G: Adult Mental Health standardized medication administration times 5 x day awake 1000, 1400, 1600, 1800, x day 1000, 1500, 2000, 0100, 0500 AC & HS 0700, 1200, 1700, 2100 BID 0700, 1800 BID AC 0700, 1700 BID PC 0900, 1800 Bedtime 2100 Three times per week 0900 PC & HS 0900, 1400, 1800, 2100 Q12 H 0700, 1900 Q12 H alternate 0600, 1800 Q12 H RT 0800, 2000 Q2 H Odd hours Q3 H 0300, 0600, 0900, 1200, 1500, 1800, 2100, 2400 Q3 H RT 0700, 1000, 1300, 1600, 1900, 2200, 0100, 0400 Q4 H 0400, 0800, 1200, 1600, 2000, 2400 Q4 H RT 0800, 1200, 1600, 2000, 2400, 0400 Q6 H 0600, 1200, 1800, 2400 Q6 H alternate 1200, 1800, 2400, 0600 Q8 H 0600, 1400, 2200 Q8 H alternate 1400, 2200, 0600 Q8 H RT 0800, 1600, 2400 QAM 0700 Once Daily 0700 Once Daily before meals 0700 QID 0700, 1200, 1800, 2100 QID RT 0800, 1200, 1600, 2000 TID 0700, 1200, 1800 TID AC 0700, 1100, 1630 TID PC 0900, 1400, 1800 TID RT 0900, 1500, 2200 Warfarin 2100 Daily Steroid doses 0900 Three times daily 0900, 1400, 2100 Isosorbide doses True Interval Dosing Parenteral Products *all times standard unless otherwise noted. AC PC Thirty minutes before meals Thirty minutes after meals Pharmacist may change times based on clinical parameters of individual medications.

17 Page 17 of 17 Attachment H: Sample Radiologic contrast dosing chart BY BODY WEIGHT DOSE AND DURATION OF MAGNEVIST INJECTION BODY WEIGHT Total Volume, ml* lb kg