COMMUNITY GENERAL HOSPITAL POLICY AND PROCEDURE

MEDICATION ADMINISTRATION & SAFE HANDLING

PURPOSE: To ensure the safe, appropriate, and accurate administration and handling of medications.

POLICY: Medications are administered to patients by qualified personnel in compliance with federal and state laws and standards of professional practice. Qualified personnel are defined as registered nurses, and licensed practical nurses. Medications are stored, handled and accounted for in a safe manner complying with federal/state laws and standards of professional practice.

RESPONSIBILITIES:

Licensed prescribers prescribe all medications.

Licensed Nurses will:

Accept verbal and telephone orders from Community General Hospital credentialed licensed prescribers.

Fax all medication orders to the Pharmacy.

Transcribe all orders to Medication Administration Record (MAR).

Prepare, administer, and document medication administration.

Ensure safe handling, storage, and security of medications.

Report medication errors and adverse drug reactions.

PROCEDURE:

GENERAL KNOWLEDGE

All medications require an order which is written on the physician’s order form and must contain the name of the medication, dose, time to be administered, route, reason/indication the medication is prescribed, and the specific time the first dose is to be administered. The order must be dated, timed and signed by the prescriber.

Orders will only be accepted or written by licensed prescribers, registered nurses, licensed practical nurses and pharmacists.

Registered nurses and licensed practical nurses may accept verbal or telephone orders from a licensed prescriber credentialed at Community General Hospital. The licensed nurse will:

Repeat the complete order back to the prescriber for verification.

Verify that drug names are spelled correctly.

Confirm the indication with the prescriber to verify that the medication is consistent with the patient’s plan of care, allergies, and other prescribed medications.

Immediately record the order directly onto an order form in the patient’s medical record. Date, time and sign the order.

When orders are incomplete or unclear a nurse or a pharmacist will contact the prescriber who gave the order. If they do not respond or cannot be contacted in a timely manner, clarification should be sought.

All new orders are faxed to the pharmacy and are verified every 24 hours by night shift licensed nurses to ensure accurate transcription to medication administration records (MAR).

Medications are administered according to the following schedule, unless specified differently in the order:

Daily (QD)                           8:00am

Twice daily (BID)                8:00am & 8:00pm

Three times daily (TID)       8:00am, 2:00pm & 8:00pm

Four times daily (QID)        8:00am, 2:00pm, 6:00pm, 10:00pm

Incompatible medications are not mixed. Incompatibility is determined by referencing the incompatibility drug listing in the Medication Manual or the Physician’s Desk Reference or by contacting the pharmacist.

Licensed nurses are responsible for knowing basic information about the medications they administer; i.e. reason medication is prescribed, actions /expected effect and side effects. Medication reference books are available in every Medication Room.

PREPARATION, ADMINISTRATION, & DOCUMENTATION

PREPARATION: All medications are stored in the designated medication room. Prepare medications in medication room.

Wash hands prior to preparing medications

Prepare medications in a clean, uncluttered, well-lit area

Check labels for accuracy and expiration dates

Read label and compare with MAR during preparation. If discrepancies exist, again verify with physicians order.

Medications are prepared not more than one hour prior to the administration time.

Assess and document vital signs and blood sugar values as ordered or indicated prior to the administration of medication.

When preparing the following injectable medications, the prepared dose must be double checked by one other staff prior to administration:

Insulin

Long-acting antipsychotics

Anticoagulants

ADMINISTRATION

Medications are only administered by the licensed nurse who has prepared them.

Medications are administered within one hour (either before or after) the prescribed time.

Accurately identify the patient using picture identification and, when necessary, staff who have accurate knowledge of the patient’s identity.

Document administration of medication on MAR.

DOCUMENTATION

Document on MAR immediately after the administration of each patient’s medication.

MEDICATION ERRORS

All medication errors require the completion of a Medication Error Report and proper notification in accordance with established hospital guidelines.

Medication Administration Policies and Error Reporting Verification

Instructions: In a separate document complete the required components of this assignments.

Review the Medication Administration Policies

Review the hospital’s “Medication Administration and Safe Handling Policy and Procedures” and read the “Interview with Dashia Sampson.”

What parts of the policy do you think may not be followed? Identify at least six (6) areas that are out of compliance, based on the interview with the nurse.

What steps would you take to verify the policy and procedure? For example, would you conduct additional interviews? Anything else? How would you go about seeking to update the policy and procedure? For example, who would be involved? Who would need to approve the updates?

According to the Policy, any medication errors must be documented with the completion of a Medication Error Report. A copy of this report is filed in the patient’s EHR as a Medication Error Incident Report note. Medication error reports for the hospital are generated from the data collected in the Medication Error Incident Report notes.

Review the Medication Error Incident Report template below and list the types of information you will potentially have available for your report.

Keep in mind that data must be structured in order to be stored in the database for including in a report. In other words, radio buttons, pick lists, and combo selections generate reportable information-- free text fields do not. Therefore, which field(s) from the Medication Error Incident Report note will not be able to be included in your report?

What other structured field(s) do you think should be added to this the Medication Error Incident Report template for potential inclusion in a report?