1. Medication Administration
Subtitle

2. 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

3. 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

4. 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

5. 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

6. 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.

7. 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

8. 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

9. 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

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

11. 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 & 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.

12. 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)

13. 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

14. 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.

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

24. 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)”

25. 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   

26. 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

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

28. 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”

29. 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.

30. 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.