1. March 2010 Medication Administration Record (MAR)

2. Describe the Medication Administration Record –Steps to implementation –Menu Options –Medication Order Challenges –Tools Identify common pharmacy issues Course Objectives

3. Why implement computerized MARs? Forces adoption of inpatient med order entry (IOE) and configuration of inpatient system parameters Foundation for implementation of CPOE in EHR Benefits of computer-generated MAR Reduces or eliminates transcription by hand Legibility Allows all staff to view inpatient’s meds on-line Allows use of multiple tools & reports Overview

4. Overview - continued Impacts all disciplines Ward Clerks Providers Nurses Pharmacists/Technicians Respiratory Therapists Requires multi-disciplinary cooperation

5. Types of Printers and Terminal Types Newer printers preferred –Very Challenging - need IT help. –Printer requirement: 132 columns Terminal Type Examples

6. Types of Labels Labels Company: TimeMed Phone Number: 1-800-323-4840 Item Number: DPS15-32A

7. DAPO Discontinue All of a Patient's Orders EUP Edit Inpatient User Parameters ESD Edit Patient's Default Stop Date HAPO Hold All of a Patient's Orders IOE Inpatient Order Entry IPF Inpatient Profile INQ INQuiries Menu... LPUD Label Print/Reprint NV Non-Verified/Pending Orders OE Order Entry PICK PIck List Menu... PPUD PAtient Profile (Unit Dose) REPM Reports Menu... SUPM Supervisor's Menu... RPMS MAR Options

8. MAR Parameters Ward Group Set up Inpatient User Inpatient Ward Systems Parameter

9. New Workflow MAR Labels –Who prints and who sticks? –Can be configured to print automatically This may generate unnecessary labels May be advisable to print “on demand” MAR Sheets –Who prints and who manages?

10. The MAR consists of 2 types of sheets: –Continuous MAR sheet (aka “Scheduled” meds) –PRN/One-time MAR sheet Shows meds given prn, one-time, and on-call The schedule type for each order determines which MAR the order will print on MAR Sheets

11. Schedule Types Not the same as the Schedule –e.g. schedules are “qid”, “qhs prn”, “now”, etc. Schedule types –O = One-time (e.g. “stat” or “now” doses) –OC = On-call (e.g. pre-op dose) –P = PRN (no set administration times) –C = Continuous (aka “Scheduled”) Usually set administration times –R = Fill on Request (e.g. creams, inhalers, etc.) Can be continuous or prn

12. Schedule Types (cont) Inpatient EHR Drug File Prep: Default for schedule type is “continuous” Sometimes this will be changed during POE (Provider Order Entry) –Benadryl ordered PRN in EHR by provider (Q8H PRN), so PRN is now the “schedule type” –Benadryl ordered continuous in EHR by provider (QHS), so continuous is now the “schedule type”

13. Does the pharmacy staff enter these? –Should be entered for complete profile –MUST be entered if drug cannot be overridden Should MAR be updated with MAR label? –If urgent need, RN might override Pyxis before the label is applied to MAR –This can lead to“extra dose” errors Should nursing staff handwrite these onto the MAR? One-Time Orders

14. Order Verification Verification on MAR sheet –Designated space for RN initials on each order Verification in RPMS or EHR –RN should also verify in computer –Skip teaching RN verification in RPMS –Go straight to verification in EHR

15. Verification of Orders

16. Printing MAR Sheets Can print through two menu options –From Inpatient Order Entry for 1 patient, e.g. after entering or finishing all orders for a new admission –From the Unit Dose Menu, Reports Option Printing of MARs for multiple patients or for an entire ward Option to print Blank, Non-blank, or Both –Blank sheets are used to apply MAR labels for orders subsequent to admission –If short stay or few med changes, blank sheets go unused & waste paper (e.g. OB, nursery)

17. 24 hour vs 7 or 14* day MAR 24 hour7 or 14 day Pros -New “clean” copy each day -May eliminate need for stickers -Standard at most community hospitals -No need to print MARs daily -Saves paper -Can look at trends easily, e.g. pain meds past 3 days -Can re-print “prn” Cons -Volume of paper -More difficult to look at med admin over time -Who will print MARs each day (or night)? -Updating of MARs with stickers is time/labor intensive -MARs become “messy” due to changes, discontinuations *14 day MAR same as 7-day except boxes for documenting are smaller

18. 24 Hour MAR - Continuous

19. 7 Day MAR – Continuous

20. 24 Hour MAR – PRN/One-Time

21. 7 day MAR – PRN/One-time Sheet ONE-TIME/PRN SHEET 7 DAY MAR 06/28/2009 through 07/04/2009 SITE: PHOENIX INDIAN MED CTR (606601) Name: PATIENT,ANY Weight (kg): 127.47 06/26/2009 Ward: ICU PID: XXXXXX DOB: 06/23/1963 (46) Height (cm): 156.85 01/24/2005 Room-Bed: ICU-5 Sex: FEMALE Dx: LEFT CHEST ABCESS Admitted: 06/26/2009 19:00 Allergies: NKA ADR: Order Start Stop Order Start Stop ------------------------------------------------------------------------------------------------------------------------------------ | | | | | | 06/28 |06/28 10:17 |10/06/09 15:00 (P) | | 06/26 |06/26 21:00 |10/04/09 15:00 (P) BISACODYL TAB,EC P | | PROMETHAZINE INJ,SOLN P Give: 10MG PO QDAY PRN | | Give: 12.5MG (IV-MIX W/ 10ML NS) IV Q3H PRN FOR CONSTIPATION | | FOR NAUSEA WS RPH: reg RN: _____ | | WS RPH: SMD RN: RNM ------------------------------------------------------------------------------------------------------------------------------------ | | | | | | 06/26 |06/26 21:00 |10/04/09 15:00 (P) | | MORPHINE INJ P | | Give: 2-8 MG IV Q1H PRN | | FOR PAIN | | WS RPH: SMD RN: RNM | | ------------------------------------------------------------------------------------------------------------------------------------ | | | | | | 06/26 |06/26 21:00 |10/04/09 15:00 (P) | | PERCOCET 325/5 U/D TAB P | | Give: 1 TO 2 TABLETS PO Q4H PRN | | FOR PAIN | | WS RPH: SMD RN: RNM | | ------------------------------------------------------------------------------------------------------------------------------------ |DATE|TIME | MEDICATION/DOSE/ROUTE|INIT| REASON | RESULTS |TIME |INIT| |--------|--------|-----------------------------------------|------|-----------------------|-----------------------|--------|------|

22. Reports Menu Options From Unit Dose Menu, Reports Option –MARs (already discussed) –Action Profiles –Medications Due Worksheet –Inpatient Stop Order Notices

23. Reports: Action Profiles Action profiles (AP1 and AP2) –Prints all active inpatient meds for a pt –Provider can “take action” on orders Renew, Discontinue, or No Change –Useful for medication reconciliation at patient transfer, post-op, and discharge –Saves a lot of writing for providers –With E.H.R. these will no longer have any utility

24. Action Profile #1

25. Reports: Medications Due Worksheet Used by nurses Prints medications due in a selected time frame (e.g. during that nurses shift) Allows nurse to meet Joint Commission requirement without having to take MAR to patients room “Work Copy”, discard at end of shift

26. Medications Due Worksheet

27. Reports: Inpatient Stop Order Notices Prints list of medications that are going to expire in a defined time frame Can print Unit Dose orders, IV orders, or both Useful if your site policy specifies automatic stop order durations

28. Inpatient Stop Order Notice

29. Accu-checks & Sliding Scale Insulin Premixed maintenance IV Fluids –Plain and with KCl Titrated IV drips (e.g. dopamine) Wound dressing orders Immunizations Difficult/Oddball Med Orders

30. Difficult Med Orders: Sliding Scale Insulin and Accu-cheks MAR requires multiple blanks for each time of administration, i.e. –Accu-chek result, dosage of insulin, RN initials Requires set up of special standard schedules Special schedule is then used in entry of order

31. Difficult/Oddball Med Orders: Maintenance IV Fluids Will these be placed on MAR? If so, quick orders are built as “IV Medications” –Appears as an IV “Admixture” in the pharmacy package –Adjust the number of labels needed each day for Pre-Mix IV Solutions

32. Difficult/Oddball Med Orders: Titrated IV Drips Entered in IV package as Admixture Rates of administration often change In Admin Rate field, enter “TITRATE@3” –On label, admin rate prints as “TITRATE” –When scheduled labels are run, three labels will print with “dose due” times spaced 8 hours apart In Other Print Info field, can enter special info e.g. Start at 5mcg/kg/min. Titrate by 2-4 mcg/kg/min q10min to keep SBP > 90. This information prints both on the label and on the MAR

33. Difficult/Oddball Med Orders: Immunizations Often ordered to be given once “at discharge” One-time order dilemma –Default Auto stop time for all one-time orders must be defined (min 1 day, max 100 days) –If defined as 1 day, order will auto d/c before pt disch –If defined as longer, all one time orders will continue to show for that duration (even if already given) Solution –during order entry, change stop date to 7 or 10 days in the future

34. Recommendations for Implementation Develop strategy based on site specific variables –Workload / census, staffing, hours of operation, etc. Secure consensus with nurse leadership Communicate plans to all disciplines that are going to be affected Nursing Providers Pharmacists Ward Clerks RT’s

35. Recommendations for Implementation (cont) Start in a controlled environment –Pilot on one ward, ideally one with Flexible, enthusiastic staff Limited number of med orders Limited number of complex med orders Evaluate issues and make changes Communicate to all parties involved Expand to other wards

36. Training of Staff/ Competency Attend departmental staff meetings –Show MAR examples, explain general use Train nurse educators or nurse managers –Delegate one-on-one training with staff nurses if possible Integrate review of MARs into nurse and provider orientation for new employees

37. Questions?

38. Nursing Perspective: MAR Nursing Procedures (Daytime) –Medication Administration –Medications Due Worksheet –MAR Kardex Nursing Procedures (Evening) –Pharmacy Closed –Pending MAR Labels

39. Nursing Perspective: MAR Nursing Department Involvement –7 Day/14 Day MAR vs 24 Hour MAR Which one? Location of MAR Label Printer and MAR Laser Printer –Verbal/Telephone Order(s) Process

40. Questions?