No Slide Title - Beth Israel Deaconess Medical Center · Transcribing Orders • Transcribe the...
Transcript of No Slide Title - Beth Israel Deaconess Medical Center · Transcribing Orders • Transcribe the...
Medication Administration
Philosophy
Mount Auburn Hospital is dedicated to:
1. Developing systems that foster safe medication practice
2. Fostering a culture that encourages the reporting of medical
errors and near misses as a way to:
- identify opportunities within our system for improvement
- define best practice
Medication Occurrence Report /
RL Solutions Report
Developed to encourage reporting of:
• Medication Errors
• Medication Near Misses or Intercepted errors
• Adverse Drug events
(untoward effect)
5 Essentials to Medication
Administration
RIGHT
DRUG
Right
Patient
Right
Dose
Right
Route
Right
Time
Never Guess Again
DOWNTIME
Orders written on paper
Fax to pharmacy
Pharmacy with print downtime eMARs and deliver to unit
Transcript orders onto downtime eMAR
When the system is up
Document medications that were given during downtime
Essentials to safe ordering of
Medications: Complete orders
• Medication full name: no abbreviations
• Dose: strength or concentration; avoid u for
units, 0 before a decimal point (0.125mg)
not .1250
• Route:
• Frequency: be careful with extended release
preparations
DO NOT USE List A b b re v ia t io n /te rm s P o te n t ia l
P ro b le m
P re fe r re d T e rm
U , U . u , u .
( fo r u n it)
M is ta k e n a s z e ro , fo u r
o r c c
W rite " u n it"
IU
(fo r in te rn a tio n a l
u n it )
M is ta k e n a s IV
( in tra v e n o u s o r 1 0 ( te n )
W rite " in te rn a t io n a l u n it "
Q .D ., Q D ,
Q .O .D ., Q O D
M is ta k e n fo r e a c h
o th e r .
W rite "d a ily " o r " e v e ry o th e r d a y "
T ra il in g z e ro
(X .0 m g )
L a c k o f le a d in g z e ro
( .X m g )
D e c im a l p o in t m a y b e
m is s e d
N e v e r w r ite a z e ro b y its e lf a f te r a d e c im a l p o in t
(X m g ) ,
A lw a y s u s e a z e ro b e fo re a d e c im a l p o in t
(0 .X m g )
M S , M g
M S O 4
M g S O 4
C o n fu s e d fo r o n e
a n o th e r
W rite "m o rp h in e s u lfa te " o r "m a g n e s iu m
s u lfa te "
u g M is ta k e n fo r m g
(m illig ra m s )
W rite " m c g "
a m p s o r a m p u le s * D o s e s m a y v a ry fo r th e
s a m e m e d ic a tio n
E x a m p le : W r ite "2 5 g m s D 5 0 W " ra th e r th a n "o n e
a m p D 5 0 W "
v ia ls * D o s e s m a y v a ry fo r th e
s a m e m e d ic a tio n
W rite th e m e d ic a t io n a n d d o s e to b e g iv e n
E x a m p le s o f a m p s o r v ia ls : C a lc iu m c h lo r id e c o m e s in a 1 g ra m v ia l
D 5 0 h a s 2 5 g ra m s o f d e x t ro s e
T h e fo llo w in g ite m s w e re c o n s id e re d b y th e M S E C a n d a re b e in g re c o m m e n d e d to b e
a v o id e d a s w e ll. T h e s e w ill l ik e ly b e a d d e d to th e " d o n o t u s e " lis t in th e fu tu re .
m e d ic a tio n /n u m b e r ,
s u c h a s
In d e ra l 2 0 m g /2
C o n fu s in g W rite " In d e ra l 2 0 m g p o b id "
s u p e rs c r ip ts ,
s u c h a s
In d e ra l 2 0 m g2
C o n fu s in g W rite " In d e ra l 2 0 m g p o b id "
T .I .W . M is ta k e n fo r th re e t im e s a d a y
o r tw ic e w e e k ly
W rite "3 t im e s w e e k ly " o r " th re e t im e s
w e e k ly "
Other considerations with
ordering medications
• Patients name & medical record # on order sheet (2 unique
identifiers)
• Drug allergies on each medication order sheet
• Clinical parameters to HOLD a medication (can’t write
HOLD Digoxin) (can write HOLD Digoxin HR < 60)
• Signature of MD, PRINTED NAME and phone/beeper.
Other activities to promote
medication safety • Check the patient’s ID bracelet. Check 2 identifiers name &
financial # against order sheet, EMAR, or Pyxis paper
• Know why a medication is being prescribed for your patients
and explain to the patient
• Review the patients allergies before administration
• Review pertinent lab values ( chemistries, drug levels, renal
or liver function) before giving medications
• Ensure clear documentation of medications whether they
were given or held
John Smith
Transcribing MD Orders
Place beside each
order as it is transcribed
When order is
transcribed draw a line
Sign, date, and time
when transcription
complete
Person verifying signs
to the left of the order
Transcribing Orders
• Transcribe the order as written onto the MAR
• Place a check mark beside the order as you complete them
• Draw a line under the order
• Sign, date, and time the order to the right of the order
To Verify an order
• Review the transcription on the MAR against the order
• Review that the times for administration are appropriate to
the medication frequency
• Place your initials on the MAR in the date column
• Sign your name to the left of the order
The person who transcribes and the person who verifies
MUST be 2 different people
Daily MAR
DON”T ASS U ME its CORRECT
Initials of verifier go in
the date column
X out days med is not
to be given
If med not given, circle
dose and write reason
If dose changes daily
write in dose given
DM
DM
DM
DM
DM
PRN Record Medications cannot be
ordered with a RANGE in
dose or frequency
If different doses are ordered
they must be specific to a
particular condition (level of
pain
0-3 min pain
4-6 mod pain
7-10 severe pain
Heparin Orders
We have 3 Heparin
Protocols: Cardiac,
DVT and Neuro.
Please make sure the
right protocol is
ordered for your
patient
Dosing based on
patient’s weight in
KILOGRAMS
PTTs Q 6 hours til
patient therapeutic
Heparin Documentation
Dosing adjusted based on PTT by using normogram
All setting of adjustment of Heparin drips must be done by 2
RNs
111
Entering the World of CPOE
Automation of the Medication
Administration Process ORDERING
CPOE
Computerized
Physician
Order
Entry
Transcription
EMAR
Electronic
Medication
Administration
Record DISPENSING
Pyxis
Talyst
Administration
Bar-code Scanning
Smart pumps
Serves as a Springboard to POE, PCI
Admin Data, NUR
Name 1
Name 2
Name 3
Name 4
Name 5
Name 6
INSULIN SLIDING SCALE
Insulin Protocol with Basal – Bolus dosing
PAIN/FEVER ASSESSMENT
Minimal pain or fever? 101
Documenting Infusion Stop Time When the infusion ends
Select your F4 key and then type IV. This will default the
statement IV Infusion stopped at (the current time will default).
If necessary you can edit the time by simply deleting and typing
accurate time.
Click the X to close the text box.
For outpatients
If we don’t document
when fluid went up and
came down. We only get
paid for an IVP med
Then click Edit to save the information
An asterisk will appear indicating there
was a change. Submit and File the
Changes.
Documenting a New Heparin Start
Hanging a New Bag
Documenting a Rate Change
Documenting a Rate Change
Documenting a Critical Test result
Resuming Heparin AFTER a HOLD
CPOE Order or Order Set If you try to order Warfarin for
a patient who has not had an
order for 30 days, you will get
a prompt to ask you to
consider discarding this order
and ordering the Warfarin
initiating protocol
This is the Warfarin
initiation protocol
Processing the Protocol Order
10
/13
/09
Coumadin per
protocol
One time med
sheet
18
Date Medication Time Date Date Date Date Date
IF CPOE Order: place paper order set in MD Order section of
chart so MDs have the nomogram
MD will order subsequent orders as one time meds. Document
dose administration on One Time Medication Sheet and
Coumadin Worksheet
To be placed in Medication
Books and document dose
administered daily
Give to patient at discharge
Date Day of Time PT INR Dose RN
signature
of therapy
10/13
10/14
10/15
1
2
3
1800
1800
1800
1.2 5mg K Murphy RN
1.4 5mg D Morrison RN
2.3 2mg D Devanna RN
Warfarin Protocol Flowsheet
New Patient Education Brochure
New Brochure
from the
Agency for
Healthcare
Research and
Quality
Give to all patients on
Coumadin
Your Guide to your
Blood thinner
Order Management screen will show changes to orders
Verbal Orders
Are only acceptable in an
emergency when a delay
to write the order could
be result in a poor outcome
When taking a Telephone or
Verbal Order
With Telephone orders
Write the order and READ it back to the MD
With Verbal orders:
Before administering REPEAT IT back to the MD
Click on
patient
then
click on
Orders
Check the medication and dose as you
remove the medication from pyxis
Pyxis will tell you which bin to take the
medication from.
Check the medication
against the medication
administration record
Check the medication
label against the
medication administration
record after the
medication has been
dispensed into a cup
Scan the medication
EMAR will notify you
If the medication or dose
Is not a match with the
EMAR screen
Administration Safety
Standard Medication Times
Time Critical Medications ie. Antibiotics
must be given 30 minutes before or after the scheduled
dosing time for a total window of 1 hr
Medications more frequently than daily but not Q4hr
must be given 1 hour before of after the scheduled
doing time for a total window of 2 hours
Daily medications or longer administrative intervals
must be given 2 hours before or after the scheduled
dosing time for a total window of 4 hours
Label admixtures and syringes
Magnesium
1gm
In 500ml D5W
8/8/14 DD
Board of Registration in Nursing
Ruling on IV Solutions
• This recent ruling requires a nurse to:
– see the preparation of IV solutions they are administering
through the process of:
• removing outside wrapping
• removing the seal
• spiking the container
• priming the tubing
• Exceptions:
– IV made by pharmacy
– Emergencies where an RN prepares for another RN in the
same room
See: www.mass.gov/eohhs/licensing/ocupational/nursing/alerts.html for more details
Overwraps
• Do not remove overwraps on IV bags until ready
for use fluid in the bag will evaporate
OVERWRAP NO OVERWRAP BAG IS EMPTY
DRUG CRYSTALIZED OUT
Over time, the volume will decrease as it evaporates
8 Rules to ensure the Sterility of Medications
1. Clean the work surface on which you are preparing meds
2. Wash your hands
3. Swab the vial 3 times and allow to dry
4. Avoid coring
5. Date multidose
vials with expiration
date (28 days out)
6. Store vials at appropriate temperature
7. Questionable vial?? Toss it
8. Never leave a needle in place
Bevel up
Safety Policies Give who??
What??
Those who prepare
a medication
Administer
See the medication enter the
patient
Stay with a patient until they swallow
pills
Pills left at the bedside are a
hazard to many
High Alert Medications
MUST BE CHECKED BY 2 RNs BEFORE ADMINISTERED
Hazardous waste
- Hazardous medications are hazardous to public health or
the environment
- It is regulated by the EPA (Environmental Protection Agency)
P Waste Medications
Hazardous
Waste
Medications Aerosols
“Pyxis” will warn you if
you dispensed a drug
that is a HAZARDOUS
WASTE to the
environment
How do you know if the drug is Hazardous
to the Environment?
If there are any dispensing
instructions, scroll down to see
that the medication is a
hazardous waste medication
The bin you remove
the medication from
will have a black dot
with an HW on it
Black Bucket = Hazardous Waste
Black box has:
• List of drugs that go in
bucket
• Phone #
to call when full
• Container must remain
closed EXCEPT when
adding waste.
• Environmental Service
will inspect containers
weekly and pick up as
needed.
Chemotherapy waste
• If completely used,
discard in yellow
chemotherapy bucket
• If only partially administered and it’s a chemotherapy on the black box label, call Environmental 5084 or Pharmacy 5131 for a new black box to place Chemotherapy bag and tubing for return to pharmacy in black box
New P waste hazardous
medications • Nicotine patch
• Nicotine gum
• Warfarin
• Physostigmine
• These medications will have a return to pharmacy label on them.
• If opened, split and unused, place in a plastic bag and return to Pharmacy
MOUNT AUBURN SPECIFIC
Mount Auburn is considered
a low accumulating hospital
so we need to separate out
this waste stream and measure
it to prove this. This waste stream
may not always be necessary once
to provide our waste amounts to
regulators
A new item on the hazardous
medication list: Insulin vials
• If all insulin in vial is
used, discard in
regular trash
• If any insulin is left in
vial or the vial has
expired, discard in black
box
Insulin drips can be disposed in regular trash and the
diluted concentration is NOT considered hazardous
Aerosol Waste
Combivent Combivent respimat Albuterol Flovent
inhaler inhaler inhaler inhaler
Return to Pharmacy bin
Please only use this bin for the purpose of returning items to pharmacy
Use
Smart Pump
Library
Use your Patient
care area (floor name)
If you can’t find the
drug in your library
Email the pump
distribution list
If you’ve hit a soft limit
you will need to
confirm it, and the
screen will be RED
If you hit a soft or hard
limit double check to
ensure you are setting the
pump correctly
When an error occurs…..
• Notify the patient’s physician and nurse manager
• Complete an on line incident report in RL solutions
• Think about what contributed to the error occuring
• If the patient requires treatment due to the error. State
only the facts in the medical record. What the patient
received, how they reacted, and the treatment measures
taken
• It is the physician’s responsibility to notify the patient of
the error, if the error involved something you did you may
wish to be present during the disclosure
Ensuring patient safety
beyond the hospital
By Patient teaching:
• What is the Drug
• How much to take
• How to take it
• When to take it
• Special instructions: with food /without food
• How long to take it
• Side effects to watch for
• What to do to prevent problems with this medication:
ie. Ways to prevent constipation, do not stop taking medication
I know
what
to do
now
Medications CANNOT be sent home
• We are not licensed as an outpatient pharmacy
• Medications from pharmacy are not labeled with all the
required information needed for patients to take that
medication correctly
• In the event of a recall, we would not know that patient
had that medication
HCAHPS Patient Satisfaction Questions on Medications
Before giving you
Any new medication,
how often did hospital
staff tell you what the
medication was for?
Before giving you any
medication, how often
did hospital staff
describe possible side
effects in a way you
could understand ?
Medication Written Education in Lexicomp
Medication Schedule
Medication Reconciliation
From Nursing Assessment
Pre Admission Medication List
Discharge Medication Reconciliation
When questions arise…..
The only question that is stupid is……
the one not asked.
Resources:
• Medication Books on unit
Betty Garhart
• Pharmacy
• Advanced Clinicians
• Nurse Managers
• Nursing Supervisors
IV Guidelines