Medication Check off Chart Medication Safety A Brief Overview of

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					         Medication Safety




A Brief Overview of the Policies & Procedures
Medication: Procurement of Pharmaceuticals
    Purpose: To adhere to the national accepted standards
            for procurement of pharmaceuticals




  Chambersburg Hospital has a Pharmacy and Therapeutics
    Committee. They review which medicines should be
     included on the formulary. Pharmaceuticals on the
      formulary are kept in stock for our inpatient use.
                  What happens if patient medicine
                     is not on the formulary?


•The pharmacist will call the physician and offer a
formulary alternative.

• In the event that the physician does not feel that the
alternative is appropriate the pharmacy will have 48
hours to obtain the non-formulary medication.
       Can a patient use his own
    medication while in the hospital?

Yes. Home medications can
be used, but they are not to
be administered until an
order for the med is written
by the attending physician,
and the medications are
labeled by the Pharmacy.
                  Home Medications

                      • Medications should be placed in a
                        specially marked bag with a label
                        that reads, “Patient’s own med, do
Pt. own med—
do not discard.         not discard”
                      • Send the bag to the Pharmacy with
                        a note asking Pharmacy to label.
  Are medications ever sent home with the patient?




If the physician orders medications ( inhalers,
topicals, suppositories, and vaginal preparations) to be
continued after discharge, the nurse may send the
medication home after proper labeling.by pharmacy
Medication: Ordering and Prescribing
               Policy
 • It is the policy of the Chambersburg hospital
   that the healthcare provider has a duty to follow
   the physician’s order (s).

 • The healthcare provider has a duty to question
   the appropriateness, accuracy, and applicability
   of the orders received.

 • The healthcare provider will clarify orders that
   are unclear, illegible or incomplete
What does a complete medication
order consist of?

The medication, including any dose designations
     (i.e. XL, XR,CD)
Strength of medication

Route of administration

Frequency of administration

Absence of forbidden abbreviations
                      PRN medications: If staff is going to
                      administer a medication, “as needed” and
                      the medication has more than one
                      indication, the ordering prescriber must
                      include the intended indication with the
                      order.

                      For example: Tylenol 1000 mg po q 6
                      hours prn for fever greater than 101 F
                      (Fever as the indication needs to be specified since
                      Tylenol can be also given for pain.)


Generic or Brand names are acceptable for all medication orders.
                    “Rx” Each Medication order

Prior to scanning the Physician Order sheet to the
Pharmacy, the RN, LPN, or Unit Secretary:
• must check that the medication order is complete.
• must write “Rx” in front of the medication order –
  remember IVs, and Respiratory Therapy orders are
  also medications.
Verifying Correct Medication Orders
                  See P&P Medication: Transcription of Orders (Inpatient)


The RN, LPN (according to scope of practice), or other healthcare
provider will verify the correct medication orders are on the MAR
by using the following process.
                                        The RN, LPN, or other health care
                                        provider will review
                                        the medication order (s)
                                        with the original physician order (s),
                                        if all the information is correct the
                                        RN, LPN, or other healthcare
          provider will “Acknowledge’ (ACK) the medication order(s) on
          the EMAR. Then the health care provider will sign off the
          physician order(s) This will indicate that the correct medication
          order has been ordered on the correct patient’s Medication
          Administration Record.
Verifying Correct Medication Orders
             See P&P Medication: Transcription of Orders (Inpatient)




    If the medication order (s) are not correct the RN,
    LPN, or other health care provider will Reject (REJ)
    the order. Pharmacy will review the original order
    sheet and correct the order. When the order is
    correct, the RN, LPN, or other health care provider
    will ACK the corrected order, and sign off the
    original order.

    The RN, LPN, or other healthcare provider will need
    to communicate the REJ in report or follow up with
    correction prior to leaving.
    Oral and Telephone Orders
           see Medical Staff Rules and Regulations

RNs can take verbal orders when necessary. LPNs (can
take verbal orders when necessary for actions within their
scope of practice).

Nurses write the verbal order, and read them back to the
practitioner for verification of accuracy, and review the
patient’s allergies with the physician.

Documentation on the order sheet consists of the date, time
of the oral order, practitioner's name, and credentials, as
well as the nurse’s signature who took the order.

The verbal order stamp is used. The nurse checks off that
allergies were reviewed for medication orders, the verbal
order read back was completed, and signs.
•Hold orders:      If a medication is written “hold”,
 place on hold on the e-MAR, through POM.

•It is permissible to write to hold medications for specific
doses without having to re-write the order. Medications
can also be held for specific parameters, i.e. “hold for
SBP less than 120”, by writing in comment field.
       A blanket reinstatement
   of previous orders for medications
            is not acceptable,
         all medications will be
re-ordered upon change in level of care.
     Orders such as, “same meds”
          or “meds per home”
         will not be acceptable.
At discharge, each discharge medication
should be written as a complete order.
Blanket re-instatements of medication
orders are not permissible.
Questioning an order: What steps do I take if an order is
incomplete or the appropriateness of it is questionable?

Call the prescribing physician
•   If still unresolved, call the attending physician
•   If still unresolved, notify immediate supervisor or house
    supervisor
•   If still unresolved, notify Department chair or Department
    Medical Director (Refer to Chain of Command Policy).
                    Chart Check Each Shift


All patient care records will be checked for all physician
orders prior to the end of each shift to assure a Registerd
Nurse has signed them off.

This check may be performed by a RN, LPN III, or Unit
Secretary.
                  24-hour Chart Checks:


1. New medication orders written since the last 24-hour
   Chart Check will be reviewed every night by an RN or
   LPN.

   a. The original order will be compared to the current
      e-MAR for accuracy.
   a. All orders written since the last 24 hour chart check
      will be checked to be sure an RN has signed them off.
                   24 hour Chart Checks:
2. If a transcription error is found, the order will be corrected by
   copying the original physician order and handwriting the
   correction on the order sheet, then scan the corrections to
   Pharmacy.
3. An ERF will be completed for all medication transcription
   errors that have reached the patient.
4. The RN or LPN III who performs the 24 hour chart check
   will date, time, and sign after the last physician order is
   written and then highlight with a green highlighter under
   your signature.
                   Pain Medications:


One of 3 pain rating scales is to be utilized, each time pain
is assessed.
1. The Verbal Analog Scale (1-10)
2. FLACC - Face, Legs, Activity, Cry and Consolability
3. Wong-Baker Faces
           Medication Orders: Range Orders


Policy:     To allow range orders for medications to be
written for dose and frequency designations.

The dose should not vary by more than a factor of 4.
(To explain: 10-40 is acceptable, but 10-50 is not)

                         For example:
Morphine sulfate 2-8 mg IV q 4 hours prn pain=acceptable
Morphine sulfate 1-10 mg IV q 4 hours prn pain=NOT acceptable
                          Range Orders
So, I have an order for Percocet 1-2 tablets, po, q 4 hrs prn
for pain. My patient is requesting pain meds. What dose
should I administer?

A pain score of 1-4= Mild to moderate pain
   Staff should start with the lower dose of the range order

A pain score of 5-10= Severe pain
   Staff should start with the higher dose of the range order


*Subsequent doses are based on the initial response.
*This rating can also be applied to other range
orders that the pain scales do not apply to.

The order is for Phenergan 12.5-25 mg IV q 6hrs prn for nausea.
What dose should I give to my patient?
If the patient rates the nausea as mild to moderate—
            start with the lower dose

If the patient rates the nausea as severe—
            start with the higher dose

*Subsequent doses are based on the initial response.
Reassess and document the patient’s pain score
 No more than 60 minutes after administration
               for effectiveness.
        Medication: Distribution




This procedure establishes written procedures for the
correct receipt, filling, checking, and delivery of
medications.
                 In non-emergent situations, prior to
                 dispensing any medication, a
                 pharmacist will review the order for:
                 •the appropriateness of the drug
                 •dose
                 •frequency
                 •route of administration
*If the allergy information is not entered, medication orders shall not
be entered.
         Administration of Medication:
                              Observe the 6 rights:
                         1.   Right Medication/Drug
                         2.   Right Dosage
                         3.   Right Route
                         4.   Right Time
                         5.   Right Patient
                         6.   *Right Healthcare Provider
* Nurses only administer medications to their assigned patients.
     Labeling of medications



Any time one or more medications are
 prepared but are not administered
 immediately, the medication container
 must be appropriately labeled.
Appropriate Labeling includes
Drug name, strength and amount (if not
apparent from the container).
Date and time (expiration time is within 24
hours of initial date/time unless otherwise
stated). Note: if IV not mixed in pharmacy, the
IV solution can only hang for 12 hours.
(example: Nipride & Insulin).
Intravenous fluids will be labeled with
Patient’s Identification label and rate of
administration.
•A physician order is necessary for patients to keep
medications at the bedside and for self-administration.

•Medications brought in from home must be sent to
Pharmacy for identification and labeling before being
placed at the bedside.
Examples of medications that the physician may order for
the patient to self administer include: inhalers, insulin
pumps, etc.

Remember: You must have an order for the patient to self
administer the medication.
Scan the medication to verify on
the e-MAR prior to administering
                                 Document in PCS under
                        “Self Medication Competency”

The competency only needs
to be completed once during
the hospitalization, prior to
the first self administration.

     You will receive a reminder that a physician’s orders needs
     to be obtained prior to administration.
Complete the competency and click save.
             High Alert Medications:


•Nearly all drugs have a wide safety margin, but a few
drugs have a higher risk of causing harm when an
error involving these agents occurs.

•Although errors made with these drugs may not be
more common, the consequences of the errors may be
more devastating.
   Examples of High Alert
       Medications:


      •Insulin
   •Heparin Drips
      •PCA’s
•Epidural Medication
  •Chemotherapy
         High risk medications require an
           INDEPENDENT DOUBLE CHECK
to be completed by Two (2) licensed nursing personnel for
times of initiation, bag or dose change, pump setting
changes, or receipt of the patient on a new clinical area

An independent double check requires that two nurses
independently (not together) check calculations, pump
checks, or whatever is involved for the specific medication.

•Independent double checks will include the 6 rights and
 pump set up.
Medication: Education and Monitoring

 It is the policy of Chambersburg
 Hospital that patients are monitored
 during the medication process and
 are educated on their medication
 regimen.
  Medication education is a component of the medication
administration process.
  The healthcare provider will educate patients on their
complete medication profile.
  Ongoing reinforcement of the education should be
done.
  The education should be appropriate in relation to the
patient’s condition and educational level.
Medication Education Components should consist of:
          The purpose/indication of the medication
                           Dose
                        Frequency
                   Potential side effects
  Where do I document that medication
      education was completed?




Medication teaching documentation is documented in
PCS under the “Teaching Records Packet,” Medication
                     Teaching.
     Education may also be provided to the
family/significant other/caregiver, as applicable
to the individual patient’s current learning needs
                   and abilities.
After administering a medication, the patient
 should be continuously monitored for side
  effects or adverse reactions according to
  his/her clinical needs. This includes first
            and subsequent doses.
Any patient who receives a first dose of
a new medication will be monitored for
a minimum of 30 minutes prior to
discharging them from the facility

                   or

will be provided appropriate discharge
instructions for signs and symptoms to
report of an adverse/allergic reaction as
related to the medication administered.
Respiratory Therapy Medication Orders




What do I, as a nurse, need to know?
Respiratory Therapy medication orders can
  be written in 2 ways according to
  physician's preference:

1. By drug, dose, route, freq, etc.
   i.e. Advair 2 puffs po bid

2. Respiratory Per Protocol
            RT Orders
RT orders are handled differently than
other medications. RT is triggered that
an order was written.
RT will review the chart and enter their
own orders.
The physician writes an order for Respiratory
Protocol
              Now what do I do?

Is this an incomplete order---NO.

Respiratory will evaluate the patient and per their
protocols and evidence based research findings
determine the patient’s needs.
  Nursing will perform the 24 hour chart
check.

  MDI’s and Med Nebs are medications,
and will be treated as such, this is why
Nursing will complete the 24 hour chart
check.
         Resources to Help You
Click on Internet Explorer, and you will be at our home page.
Check out all of the wonderful resources you have available to you.
Radiology Grid




      Want to find
      Prep for a test?
      Radiology Grid
      is the place to go.
safemedication.com
                 Want drug
                 info to send
                  home with
                  a patient?
                      Safe
                 Medication
                 is the place
                     to go.
Are you familiar with Micromedex?
A great place to go to learn side effects, interactions, etc. -
right on your computer.
Chambersburg Medication Grid
                     Check out all of
                     the help this site
                       can give you.
We hope this CBT has helped orient you to some of
 our medication policies.

You are now finished viewing Safe Medication
  Administration. Remember to sign off on your
  CBTs/Videos for New Employees check list.

If you have any questions, do not hesitate to ask
   your preceptor, manager, or pharmacist.

				
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