Medication Administration Subtitle

Drug References Micromedex Drug Reference Medication Pyxis Computer access Click on “icon Internet Explorer” Type in “gcweb” on address line Select “Departments J-Q”, then “Pharmacy” Click on” Microdedex Drug Reference” Nursing Medication References Found on every unit Pharmacy Unit based pharmacist M-F 7a-3:30p Ext. 4401

Guidelines for Medication Administration Policy Overview No medication is to be given without a physician’s order. Always remember the five rights: 1. Right patient 2. Right medication 3. Right dose 4. Right route 5. Right time Medications must be taken to the bedside in the unit dose packages & opened at the bedside. Remain with the patient until all medications have been taken Medications are not to be left at the bedside

Right Patient Garden City Hospital policy ensures that all patients are properly identified prior to any care, treatment or services are provided. Wristband Color Communication RED ALLERGY YELLOW FALL RISK PURPLE DNR GREEN PACEMAKER/ICD WHITE PATIENT ID CLEAR THIN PEDIATRIC TYPENEX BLOOD BANK BAND BLUE PICC ORANGE NO BP/LAB

A violation of any of the five patient rights Medication Errors A violation of any of the five patient rights constitutes an error Notify nursing management Notify physician Document occurrence in the integrated notes Fill out a Medication Quality Improvement form Send completed form to pharmacy

Allergies and Follow Through Verify any medications contraindicated according to the patient’s stated allergies Chart flagged Red Allergy bracelet on patient Documentation of Allergies will appear in MAK on the EMAR (Electronic Medical Record). Follow through: The nurse who prepares the medication is to give the medication. Administration of medication prepared by another Nurse constitutes unsafe practice.

Therapeutic Substitution The replacement of one drug by another drug of equal therapeutic value Drugs have been approved by P&T Committee Does not require additional notification to the Dr. Nursing Notification Therapeutic Substitution List Pharmacy will automatically change EMAR will come with the named medication substitution given with a note under the medication stating “This is a substitution for “_____________” Drug Ordered Drug Dispensed Benazepril (Lotensin ®) Lisinopril Zestril ®, Prinivil ® given once daily on a milligram for milligram basis Maalox ®, Mylanta ®, Gelusil ®, Maalox Plus ® Candesartsan (Atacand ®) 8mg Losartan (Cozaar ®)25 mg

Stop Orders Schedule II narcotics Injectable medications-3 days Oral medications-5 days Antibiotics-10days IV antibiotics will not be placed on surgical hold-send pre-op antibiotics to OR Oxytoxics injectables-single dose only Chemotherapeutics-3 days Exception-specific doses ordered per the physician The RN is to communicate with the physician regarding “Stop Order medications” during Rounding

Standard Administration Times Abbreviation Administration Times QHS 9PM AC 7AM-11AM-4PM ACHS 7AM-11AM-4PM- 9PM Q AM 9AM Q PM QID 6AM-12N-6PM-12MN TID 6AM-2PM-10PM BID 9AM-9PM Q 4H 2AM-6AM-10AM-2PM-6PM-10PM Q 8H Q 6H Q 12H 9AM- 9PM Q 4H x5 7AM-11AM-3PM-7PM-11PM

Midnight Dose Any medications to be administered at midnight will be shown as follows: INVISION: Timed at 2400 hours MAK: Timed at 0000 hours

Standard Administration Times All medications will be administrated at standard times unless specifically ordered with the exception of the following specific drugs: Diuretics given BID at 6AM-6PM Coumadin QD at 6PM (check INR – daily order) Digoxin QD at 2PM (record apical rate, call the physician if the apical rate is less than 60 bpm, if digoxin level is greater than 2 or the drug is held for any reason Oral Hypoglycemics (Daily dose at 0700 and BID dose at 0700 & 1600) STAT medication within 10 minutes NOW medication within 60 minutes Medication administration may start 60 minutes prior to the hour and finish 60 minutes after the hour. Time critical scheduled medications must be given within 30 minutes before or after their scheduled time (examples include antibiotics, anticoagulants, insulin, anticonvulsants, immunosuppressive agents, pain medications) The nurse is responsible for all medication administration up to including 15 minutes prior to the end of their shift.

Pre-Drawn Syringes Pre-drawn syringes will be labeled with 1) the name of the medication, 2) strength of concentration, 3) date & time of the draw, 4) the initials of the person who drew the medication into the syringe, 5) expire in most cases in 24 hours (always check with pharmacy)

Verification of Calculated Drugs Two nurses are to check Insulin, heparin infusion, IVPB magnesium & chemotherapeutic agents Verifying nurse will scan their badge at the patient’s bedside after independently verifying the medication Insulin Document on the EMAR and DM flow sheet the time, amount, glucose level, site of injection All insulin will be held prior to diagnostic test while the patient is NPO: Blood Glucose testing should continue If the blood glucose is greater than 200, call the physician Administer the ordered dose of insulin when the procedure is complete If held NPO past noon, contact the physician for orders Contact the physician for insulin dosing related to stress testing

Standard Administration Times Phenytoin (Dilantin) When administered via feeding tube-stop the enteral feeding 1 hour prior to the dose & resume 1 hour after dose given Post-operative medications Medications are ordered after surgery via Post-operative Medication Reconciliation Restock of medications in MAK If restocking a medication for a patient is required (e.g. Maalox bottle), highlight the medication, click on Rx message and it will attach the name of the drug to the message. Pharmacy will directly receive the message.

Standard Administration Times Hold Orders Doses of medications can be held for a specific number or time period Document on the EMAR the reason for holding any medication NPO Includes all oral medication unless specified Crushing Medications Refer to “Oral Dosage Forms that Should Not be Crushed” found in the policy and Pharmacy Manual on all units

Loading Doses of Antibiotics Standard Administration Times Patients given pain medication must stay on the unit for 2 hours after the medication is given or if the off of the unit must be escorted to & from supervised procedures Alternate Routes Each route must be documented-a separate drop down box will appear on the EMAR for site administered Loading Doses of Antibiotics Pharmacy will address the dosing consult within 24 hours

Frequency Conversion Examples Range Orders Medication orders that express the dose and/or dosing interval with a lower and upper limit are commonly referred to as “range orders.” All physician orders that contain a range of frequencies (e.g., “every 4 to 6 hours”) will be processed at the most frequent range of the order…automatically. Frequency Conversion Examples All physician orders that contain a range of dosage (e.g., “1mg - 2mg”, “1-2 tablets”, “2mg - 4mg”) will be processed as multiple orders… Range Dosage Orders AS ORDERED PROCESSED AS 1-2mg 1mg (order #1) 2mg (order #2) 1-2 tablets 1 tablet (order #1) 2 tablet (order #2) AS ORDERED PROCESSED AS Q3-4 hours Q3 hours Q4-6 hours Q4 hours

Dispensing Medications Document patient response to PRN medications Wasting Medications Narcotics-waste the amount given & the amount wasted Waste when removed Requires another nurse to co-sign Return unopened doses All return items must go to the RETURN BIN in the Medication Pyxis

Discrepancies Must be checked at change of shift Resolved when they occur or within the shift they are detected Unresolved or invalid reasons are violations of DEA requirements

Override Medications Used only for medications on the override list Override list is unit specific Limited to emergency or STAT medication use only NOT REVIEWED BY A PHARMACIST-can be completed in the pharmacy pending review section of MAK PYXIS

Controlled Substance Administration Record (Proof of Use Sheet) Identifies the drug and amount dispensed if not in the medication pyxis After verifying the medication the nurse must sign the “Proof of Use Receipt” –return this to the pharmacy tech Completed and signed by the nurse initiating therapy Must be signed by the nurse discontinuing therapy Record returned to Pharmacy not in the patient’s medical record

MAK Downtime Procedures If Pharmacy & Invision downtime: *Less than 2 hours: Snapshot MAR *Exceeds 2 hours- Pharmacy will print MARs The nurse will verify the orders on the MAR against the chart New orders will be written on the MAR and scanned to pharmacy When the system is operational-pharmacy will enter new orders into the system All meds & IVs administered during downtime are to be charted in MAK by the RN Medication administration should be up to date by the end of the shift The nurse will override the barcode to chart the med after downtime using the reason “MAK Downtime” If downtime occurs over a shift change or pharmacy is unable to complete entry of all new meds and IVs by shift change the paper MAR will become a permanent record and placed in the patient’s chart and the oncoming RN documents medication administration from previous shift and adds a comment, “Administered by ____ RN (Downtime)”

Dispensing Medications Identify patient Scan the wristband and ask the patient to state their name & birth date Check the allergy bracelet Compare the information on MAK Dispense medications to one patient at a time (obtain medications from medication pyxis) Documentation - Downtime MAR is a legal document After the medication has been administered draw a single line through the designated administration time Sign your initials adjacent to each medication Place your initials & signature at the bottom of the page If a medication is not administered circle the designated administration time State reason for omission in space provided Note: “Not on Floor” or “Not Up From Pharmacy” are not legitimate reasons to omit a medication   

Medication Administration Record (Downtime) RN Documents Order Validation Here RN Documents Explanation of Medications Given to Patient RN Initials Each Dose Next to Time Given

Medication Administration Record (Downtime) Scheduled IV’s Scheduled Meds Also Separate MAR’s For PRN’s

If the wrong patient is accidentally discharged from the computer: Additional Notes If the wrong patient is accidentally discharged from the computer: Call the registrar at extension 4400 to readmit the patient Call pharmacy to enter the patient’s medication orders back into the computer Upon discharge should the patient be sent home with any unused medication(s)? (e.g. inhalers) All medications dispensed must be properly labeled as required by “State Law”: Pharmacy name and address Prescription number Patient’s name Date the prescription was dispensed Prescriber’s name Directions for use Name of the medication unless the prescriber indicates “do not label”

PLEASE CONTINUE TO CONFIRM ALL HEPARIN DOSES CAREFULLY. HEPARIN SUPPLY We are working to transition to a single concentration of heparin, but depending on availability, DIFFERENT CONCENTRATIONS OF HEPARIN MAY BE DISPENSED. The following concentrations are currently being utilized for subcutaneous administration at Garden City Hospital: Heparin 5,000 units/1 mL Heparin may be supplied in syringes or vials. Heparin may also be supplied: Heparin 100 units/1ML in a 5 mL syringe PLEASE CONTINUE TO CONFIRM ALL HEPARIN DOSES CAREFULLY.

Medications of Any Kind Remember It is a violation to leave medications & or sharps on any dietary tray at the patient’s bedside. This includes: Needles Jelcos IV bags Syringes IV tubing Syringe caps Medications of Any Kind If this occurs the Manager or Director of that area will be asked to come to Nutritional Services to properly dispose of the items.