ARTIGO DE REVISÃO / REVIEW ARTICLE Data de recepção / Received in: 17/09/2010 Data de aceitação / Accepted for publication in: 10/11/2010 Marta Salgado, Rute Reis, António Vinhas de Sousa, Elza Tomaz, Irina Dydenko, Andreia Ferrão, Fátima Ferreira, Filipe Inácio Serviço de Imunoalergologia / Immunoallergology Department – Hospital de São Bernardo, Setúbal
RESIDENTS OF SPECTRUM #
ADMINISTRATION OF MEDICATION - RULES MATERIALS USED FOR DAILY OPERATIONS THE MEDICATION CARD, ITS LABELLING AND USE ADMINISTRATION OF MEDICATION ORAL DRUGS THAT SHOULD NOT BE CRUSHED OR CHEWED SPECIAL MEDICATION - DIGOXIN, LITHIUM STORAGE AND EXPIRY OF NITROGLYCERIN MEDICATION ORDERS CHANGE OF MEDICATION ORDERS PHYSICIAN ORDER FORM DOCUMENTATION OF TELEPHONE ORDERS H. PATIENT'S OWN SUPPLY I. HERBALS, HOMEOPATHICS ALTERNATIVE MEDS MEDICATION ADMINISTRATION RECORD (MAR) MONTHLY CHECKING-MARS AND MEDICATION CARDS RESIDENT SELF-ADMINISTRATION PHYSICIAN RELEASE FOR SELF-ADMINISTRATION 20 XIII CHARTING MEDICATIONS DISCONTINUED MEDICATIONS MEDICATION STORAGE AND SECURITY XVIII RETURN MEDICATION DISCHARGE MEDICATION HOSPITALIZATION MEDICATION MEDICATION RELATED INCIDENT REPORTS ADVERSE DRUG REACTION REPORTS ADVERSE DRUG REACTION REPORTING FORM XXIII NEW ADMISSIONS XXIV COMMONLY USED ABBREVIATIONS XXV STRAIGHT NARCOTICS THAT REQUIRE A WRITTEN ORDER XXVII PHARMACY HOURS AND EMERGENCY SERVICES Revised: 4 ‘02 ADMINISTRATION OF MEDICATION - RULES
To provide a written routine for the staff to follow to ensure that
medication is given to residents as ordered by physicians, in a prompt,
efficient and safe manner.
Observe the six RIGHTS in administering medication:
give the RIGHT medication, in the RIGHT manner, at the RIGHT time, to the RIGHT resident, by the RIGHT method, with the RIGHT documentation. Read the label three times; when locating medication, once before punching or pouring it, and once again when returning it to the proper storage place. Always read and understand the physician's order, the action and side effects of any drug administered. Administer medication only on a valid order of the attending physician. The order must include dosage, frequency, and route of administration. When in doubt about drug or dosage, check with drug reference, Pharmacy, Facility Administration, or the physician before administering the medication. Document this action on the Interdisciplinary Progress Notes of the resident's Clinical If regularly scheduled medication is withheld for 24 hours, contact the physician. If any medication is withheld for more than one dose, inform the physician, as necessary. Check the medication card and correctly identify the resident. Have another staff member accompany you to correctly identify resident if you are unable to identify residents yourself. Medication charts, carts, or cards are not to be left unattended. Once the seal on a medication card has been broken, the medication must be discarded if not being administered to the resident immediately. A replacement dose can be ordered from pharmacy to be send with the next scheduled delivery if required. A dose from the highest numbered pouch containing medication should be used until the replacement dose is received from pharmacy. Do not tape medication back into the card for any reason whatsoever. 10. A new prescription written in connection with the same previously ordered medication cancels the previous medication order. 11. Medication orders are to be automatically cancelled when a resident is hospitalized for more than 10 days. New orders for medication are required on re-admission. 12. Medications on hold for seven days are considered discontinued and require a new order if they are to be started again. If the medication is on hold, mark the card hold and date it. Place in storage in the selected area. Return to pharmacy if not reordered. 13. If drugs are brought in by a new resident on admission, forward them to the pharmacist for disposal once replacement medication has been received from pharmacy. The resident is to be advised by staff to come to admission with the least amount of medication as is feasible. MATERIALS USED FOR DAILY OPERATIONS:
Medication room, cart or cupboard
Lockable room, vehicle or cupboard in which medication is stored and transferred.
Unit dose storage packaging which can house up to 34 doses for one pass. The reorder
section (pouches 1-9 indicates time for reordering medication used on a PRN basis only.
(Note: medications administered on a regular basis are delivered automatically once a
This card may be used as a flag for medication that cannot be placed in a card but is
given on a regular basis, that is:
solid dosage forms not suitable for cards (example: antacid tablets which are too large for the card pouches) refrigerator items MAR (Medication Administration Record)
This record lists current medications for each resident and is also the charting record for
each month's administration. MARs are printed by the computer once a month and are
put into use on the first day of each month. These records should be kept on file for a
minimum period of seven years. An MAR should be kept for each resident at the
facility, even though a resident may not be taking medications at the time.
The book that houses the MAR in the order of administration for the period of time they
are in use. A staff signature and initial sheet will be kept in the front of the MAR book
and replaced annually (January of each year).
Device used to crush medication for administration to residents who are unable to
swallow. (Tablet crusher should be cleaned thoroughly after each use).
Exception: See list of oral drugs that should not be crushed or chewed. III THE MEDICATION CARD, ITS LABELLING AND USE
Hand written notation on the unit dose card next to the label indicates: D Din (drug identity number) L Lot number The prescription label contains information printed in the following format: Home number-Rx number Prescribing physician (Date of 1st fill) (current fill date) No of labels printed Directions for administration Quantity dispensed Drug name ROOM and/or TABLE # This House is Spectrum Home # All resident's medications shall be labelled with the non-proprietary (generic) and/or brand name, strength and quantity of medication, name of manufacturer. The name of the resident, name of physician, the directions for use, the date dispensed and the prescription number shall also be included. When appropriate, auxiliary and cautionary labels shall be added, indicating storage requirements and/or additional handling or administration procedures. Medication containers which have soiled, damaged, or incomplete or illegible labels shall be returned to the pharmacy for relabeling or disposal. When a resident's medication is ordered on a "when needed" (PRN) basis, the prescription, the resident's MAR, and the medication container prescription label shall clearly indicate the following: (a) the minimal interval of time between doses, or (b) the maximum number of doses to be administered daily (c) the specific indication for which the medication shall be given (d) lot number and expiry date Non-specific directions stating "as directed", "as before" or "when needed" shall be clarified prior to dispensing. Begin administration from the 30th or highest number pouch containing medication for all PRN (as needed) medication orders. Unit dose medications given regularly are dispensed from pouch number according to the day of the month (i.e. on the 1st- use pouch number 1, on the 15th-use pouch number 15). The medication administration system is based on the concept that the majority of medications are administered during four basic times of the day: Morning (0800 hrs, 8 am) *Yellow (1200 hrs, 12 n) (1700 hrs, 5 pm) *Red (2000 hrs, 8 pm) *Blue NOTE: Each card for a regular pass time or PRN use is marked to make for easier identification of the pass with a small coloured sticker) Medications ordered AC (on an empty stomach) should be administered 1 hour before meals and will be labelled 700, 1100, 1600 and 2000 unless indicated otherwise. AC passes and any other passes to be administered outside the four regular pass times will have administration times underlined in red for easier identification. ADMINISTRATION OF MEDICATION:
Unlock the medication room, cupboard or cart. Make sure appropriate time pass medication is available. Check Locator Cards; if you see any coloured locator cards check to be sure that all medication (eg insulin, refrigerated items) that may not normally be housed in the medication cart is secured before starting out on the medication pass. Check that there are sufficient stock of supplies you may need such as water cups, pill cups, cotton balls etc. Fill water and juice container. Take MAR book with the MARs for charting. Take the med cart or pass to the appropriate location to begin pass. Open the MAR book to the first page corresponding to the first resident (meds to be racked alphabetically and/or by room). Flip to the resident's pill cards and locator cards on the rack. 10. Check pill cards against the MAR for accuracy 11. Punch out the medication directly into the med cup, according to the day of the month (exception PRNs start with the highest numbered bubble). To do this, hold the card directly over a med cup and press down on the plastic bubble with your thumb. The tablet or capsule will pop through the foil backing and into the cup. If a pill must be crushed, a pill crusher is available (CLEAN CRUSHER THOROUGHLY AFTER EACH USE with a cotton swab which is then discarded). If a liquid is to be given, it should be poured into a calibrated cup. Non-carded medications are to be given at this time. 12. Do not put medication in food or coffee. Crushed medication may be given in jam or applesauce (assess suitability of crushing medication with pharmacy before administration). 13. Never approach the resident until all doses, solids and liquids have been prepared. 14. Pour water into water cups. 15. Identify the appropriate resident. Administer medication to the resident. Give medications to the resident yourself and watch carefully to make sure he/she swallows it. Never
leave the resident's side until you are sure that the medication has been taken. You must
never leave medications at the table/bedside, or ask another person to administer them. If
a resident refuses medication, flush down the sink or water closet and made suitable
notation on the MAR sheet. DO NOT TAPE medication back into the card.
Note: Administer medication with meals unless contraindicated by the nature of the medication, eg., antibiotic, appetizers, etc. 16. Dispose of paper, water cup, med cup and excess water. 17. Immediately chart the medication that has been given on the resident's MAR by initialling the appropriate block. Your initials indicate that the resident received the specific medication at the specific time. See charting (page XV ) for charting procedures for doses that are missed, refused or destroyed. No white out (liquid paper) is to be used on the MAR. 18. This procedure is repeated for the remaining residents. If a resident is not available at the time of medication administration, a clip should be used to flag any doses that might have been omitted. When individual doses of medication are prepared and subsequently cannot be given they should be flushed down the sink or toilet and charted as destroyed on the MAR. 19. When the medication card is empty, it is clipped as a reminder for staff to restock.
The following may be used as a guideline for late administration of missed doses (if no personal protocol exists for the resident): * If a medication is given once or twice a day, a dose may be given up to three hours late. * If a medication is given three or four times a day, a dose may be given up up to one hour late. The actual times of administration should be documented on the MAR for doses of medication administered late. ORAL DRUGS THAT SHOULD NOT BE CRUSHED OR CHEWED ***
lansoprazole (Prevacid) Belladenal Spacetab Bellergal Spacetab potassium chloride (Micro K, Slow K) buproprion (Wellbutrin, Zyban) carbamazepine CR (Tegretol CR) diltiazem CD (Tiazac, Cardizem CD, SR) Carters Liver Pills Cefuroxime (Ceftin) tab * morphine tab/cap (M-Eslon, MS Contin) chloral hydrate Cap * valproic acid (Depakene Tab) nitroglycerin sl diclofenac tab (Voltaren SR) Dimetapp Extentab divalproic acid (Epival) Donnatal Extentab Ponderal Extentab omeprazole (Losec) pantoloprazole (Pantolac) 40mg Slow Fe, Slow Fe Folic sumatriptam tab (Imitrex) Fe sulphate (ECT) theophylline tab (Theodur, Theolair, Uniphyl) Felopidine (Renedil, Plendil) finasteride (Proscar)** drugs that have bitter taste, are irritating to or could stain teeth or oral tissues exposure to powder may pose risk to fetus during pregnancy. Brand names begin with a capital letter, generic names with a lower case letter. *** Staff should consult with pharmacy before crushing any medication that should not be SPECIAL MEDICATION - DIGOXIN
Check pulse rate for 60 seconds before administering any digoxin preparation. If the pulse is below 60 notify the physician and request further instructions. Chart the pulse on the top of the medication sheet. Recognizing that the therapeutic window for lithium is small and the risks of toxicity are severe, staff will hold a lithium dose until they are able to contact the physician if a resident on lithium is unable to eat or drink, or exhibits any of the following symptoms: * insatiable thirst * persistent diarrhea * blurred vision * slurred speech * severe trembling of hands * difficulty concentrating * buzzing, ringing or whistling in the ears STORAGE AND EXPIRY OF NITROGLYCERIN
The first time the seal is broken on the medication container staff should note the date on the prescription label in the space provided. Nitroglycerin should be replaced one year after the date of opening.
VIII MEDICATION ORDERS:
Only medication ordered by a physician shall be administered to a resident. All
alcohol orders should be charted on the Medication Administration Record (MAR) and
should be the result of a physician's order.
Telephone, verbal or written orders from prescribers to facility staff should be
documented on the Physician Order Form(POF) and phoned, delivered or faxed to
pharmacy. For written orders by physicians origional written prescription should be sent
to pharmacy on the next scheduled delivery, along with the top copy of the Physician
The prescriber should be asked by staff to phone the pharmacist directly when making medication orders or changes of order. This will save time and trouble for all members of the health care team. Pharmacy will notify staff by phone and by written note of all new orders or order changes or discontinuations that are not initiated through facility staff. All medication orders/order changes (new orders, whether telephone or written, direction changes, discontinuation of medication) should be documented on the Physician Order Form (POF). New orders should include dosage, direction (specifying frequency or interval or maximum daily dose), indication and assessment date. Prescriptions for topical treatments should specify area to be treated. If appropriate, prescriptions for analgesics should specify acute condition or injury. It is the responsibility of staff to obtain a written order for "straight" narcotic and control drugs (see page 30 for a list of medication that require a written prescription). Written orders for narcotic and control drugs must contain the date, resident's name, the name of the drug, quantity or duration of use (eg 30 tablets or for 7 days), strength, indication, directions for use (minimum interval and/or maximum daily doses) and physician signature. NOTE: Use of a triplicate prescription form is NOT required in LONG TERM
Any medication received from residents (brought in on admission or obtained from another pharmacy) should be immediately reported to pharmacy so that this medication can be assessed for verification of need, as well as possible interaction, and be reviewed with relation to currently administered medication. Where appropriate, pharmacy will replace the patient supply with a new supply of medication in the unit dose packaging. New orders sent from pharmacy will be flagged with a "ATTENTION STAFF" tag which will alert staff to the need to make the appropriate notation on the resident's Medication In addition, any medication indicated to have been "replaced" should be discontinued on the MAR and the remaining supply of this medication should be pulled and be made ready for return to pharmacy. A diagonal line should be drawn through the box containing the Rx on the MAR for any discontinued orders and the notation D/C with the date added near the box. In addition, a diagonal line should also be drawn from the date of discontinuation to the end of the month on the dose administration charting area of the MAR. Typed notes from pharmacy should be filed in the communication book. The assessment date on new orders marked (assess) should be calendarized for review with pharmacy on the date indicated. Refill Orders
Medications which are suitable for unit dose administration and are given on a regular basis (with the exception of orders marked "ASSESS") are dispensed and delivered automatically once a month. Orders given on a regular basis marked "ASSESS" should be reviewed with pharmacy when there is a need for reorder. Please provide any pertinent details (eg. B.P. for hypertensive medications) at this time so that pharmacy may relay this information to the physician at the time of request for refill authorization. Assessment medication should be calenderized so that appropriate assessment information may be relayed to pharmacy on the date of assessment. NOTE: Date of assessment will be noted on the Rx label and/or on the "Attention Staff" form in the field marked "Assess". PRN (as needed) medications, liquids and topical medications should be ordered as needed by Rx number, full resident name and drug name by phone or Fax. Because regularly administered orders are dispensed automatically, it is important to notify Pharmacy as soon as possible if a patient is deceased, hospitalized or discharged; and when an order is on hold, is being refused by the resident, or has been discontinued. Changes of Medication Orders
Please notify pharmacy by fax or telephone promptly when the physician changes a resident's medication order. The pharmacist shall, following receipt of any required confirmation, initiate a new prescription. No handwritten direction changes shall be made on the prescription label on the container.
A pink "PLEASE NOTE DIRECTION CHANGE" pink slip (see sample below) should be
attached to current stock which indicates any altered direction until the new
Rx is received from pharmacy after an assessment of a maximum of 10 days.
Insert samples of Pink slip And Attention Staff Order Slip Changes shall be promptly recorded on the Physician Order Form and charted on the resident's MAR on receipt of medication from pharmacy or initiation of the order. As soon as the new prescription is received, be sure that all details as seen on the prescription label (Rx number, date of fill, physician name, drug name and directions for use) are recorded in the appropriate space on the MAR. In addition, any medication indicated to have been "replaced" should be discontinued on the MAR and the remaining supply of this medication should be pulled and made ready for return to pharmacy.
Typed notes from pharmacy should be placed in the communication book so that
all staff can review at the beginning of their next shift.
Physician Order Form (POF)
All new orders, order changes and discontinuation of orders should be recorded on the Physician Order Form. Written prescriptions from physicians should also be recorded on the Physician Order Form. The typed notes from pharmacy outlining new orders, change of orders or discontinuation of orders or assessment dates should be posted in the communication book for staff review. It is the responsibility of the staff member who receives a telephone order from physician or pharmacy to record that order on the Physician Order Form. A copy of all written orders should be faxed to pharmacy with the daily fax order.
All original written order from a physician should be sent to pharmacy (use Zip-lock
bags provided for transport) at the time of the next scheduled delivery along with the
top copy of the Physician Order Form.
Documentation of Telephone Orders
When new or changed drug orders are phoned to staff by pharmacist or physician, the orders should be transcribed onto the Physician Order Form (POF) in the following manner: (a) Presciber t/o Pharmacist t/o staff signature (b) Prescriber t/o staff signature Note: pharmacy notified Please note the name of the pharmacist (first name/last name initial/CV) phoning staff regarding telephone orders received by pharmacy directly from the physician eg. SusanT/CV Dispensing Pharmacists at Crestview:
Connie Chu Jencinne Chan Jasvinder Sandhu Stop Orders
a) Orders for short term use/acute conditions
In order to reduce the number of treatments which are unnecessarily continued for long periods of time, an automatic stop policy (ASP) after 10 days of use will be implemented on the following medications: * antibiotic ear/eye drops or ointments * antibiotic topical preparations * decongestants and antihistamines * topical steroid preparations for acute conditions * cough syrups * oral antibiotics if duration not specified * analgesics for an acute condition At the time of fill, the order will be marked with an assessment date on the "ATTENTION
STAFF" tag which accompanies the new order. On receipt of a new order, should
calendarize the assessment date and review with the pharmacist on that date. If the
condition is not resolved at the end of this period, pharmacy will notify the physician. If the
condition has resolved, the drug will be discontinued.
b) PRN orders
An automatic stop policy (ASP) will also be implemented for all PRN (as needs) medications unused for 90 days. These PRN medications should be reviewed by the
pharmacist and staff, be documented on the medication flow sheet and MAR, and
rema ining stock of medication be returned to pharmacy. PRN medication orders used occasionally but needed on a long term basis will be marked "Chronic use" in the direction field on the prescription label after consultation with
Medications placed "on hold" will be discontinued automatically after 7 days of no use.
Documentation of Automatic Stop:
The following notation should be used for documentation ASP on thePhysician Order Form:
" _" DC by ASP on
Drug Name/Rx # Date
When a resident is going away for three days or less, staff should prepare holiday supplies by putting the correct number of doses of medication in zip-lock bag and labelling the bags with the total details as seen on the prescription label * patient name, * physician, * quantity, * name of medication given, * date, * complete directions for use One zip- lock should be used for each different medication taken, unless the resident is out for 12 hours or less. When medications are prepared for one pass (one dose only), all medication may be dispensed in one zip- lock that should contain: * the resident's name, * the date, * a detailed description of all medications enclosed and the directions "take the entire contents of this zip- lock bag today at HRS/with (eg.Supper)." When a resident is going away for more than three days, pharmacy will prepare the holiday supply if given at least 24 hours notice. If "as needed" (PRN) medications are required, they should be ordered as needed after review with pharmacy at the time social leave medications are ordered. A pocket profile which contains a complete list of the resident's medications, as well as directions for use, is available on request from Pharmacy. This profile may be useful for residents going on extended social leave. When a resident goes on social leave and staff prepares the holiday supply of medication, the
staff member should mark code 4 (social leave) along with their initials in the appropriate boxes on the MAR for doses given to a resident. If the resident is out for the day and has not taken medication along, the dose will not be administered and code 4 should be placed in the appropriate boxes without initial, to indicate the dose was missed due to social leave. If the resident is going on extended social leave and medication supplies have been prepared by pharmacy, mark the MAR with a vertical line to indicate the beginning of social leave, along with the notation "social leave". A vertical line may be used again to indicate the beginning of administration. The staff should check the holiday supply sent by pharmacy, before giving this supply to the resident/care giver. Make an appropriate notation on the PRN ADMINISTRATION area on the back of the MAR (indicate number of doses given to the resident/care giver, together with the time and date given and staff's initials). H. "Patient Own" Medication Supply
By-law B 38 of the Pharmacists Act requires that all medication administered to a resident be dispensed to a resident on the prescription of a practitioner. The act of dispensing includes " the preparation and release of a drug prescribed in a prescription and the taking of steps to ensure the pharmaceutical and therapeutic suitability of a drug for its intended use."
There is no way for pharmacy to ensure the pharmaceutical and therapeutic suitability for a resident's supply of medication which has been outside the pharmacist's control. Because of concerns about storage, stability, liability and resident safety, a new supply of medication will be dispensed by pharmacy for medication prescribed by the residents physician. During the pre-admission interview, residents should be asked to bring a minimum of medication to the facility on admission and be told that all future supplies of medication (including vitamins and OTC drugs) will be provided by the designated pharmacy. Patient's supply of medication should be send to pharmacy for destruction after a new supply is obtained for administration from pharmacy.
An exception to use a resident's own supply of medication may be made following
approved by the Medication Safety and Advisory Committee and on written release from
the resident's Physician. Such medication will be charted on the MAR as "patient supply".
I. HERBAL, HOMEOPATHIC, ALTERNATIVE/COMPLEMENTARY
PURPOSE: To allow herbal, homeopathic and alternative medications desired by resident/
contact person to be administered after receiving an order from the resident's medical practitioner. To ensure contact person provides a continuous supply of medication to pharmacy if pharmacy cannot access through regular channels. To provide accurate information on each medication to medical practitioner, pharmacist and facility staff if such information not easily accessible. To provide accurate documentation of all medications administered to resident. The Director of Resident Care must be informed when a resident/contact person wishes to initiate such therapy. The Director will provide a copy of this policy to such person. It is the responsibility of such person to:
1. Provide current, brand specific literature regarding the product to the medical practitioner. This literature must contain accurate, quantitative list of ingredients, aim of treatment, side effects, contraindications. 2. Obtain prescription from medical practitioner, indicating drug name, dosing maximum/24 hours, indication, duration of treatment. If product has been recommended by an alternative health provider it must be authorized by resident's medical practitioner. 3. Provide medication if contract pharmacy unable to obtain. 4. Take literature and unopened medication to pharmacy 5. Be willing to pay carding/repack/re-label fee to pharmacy 6. Supply copy of mediation literature to facility staff 7. Continue to supply medication to pharmacy when contacted by facility to It is the responsibility of pharmacy to:
1. Follow normal practices regarding mediation safety for resident. If the pharmacist decides therapy is not appropriate for resident he/she has the right to refuse to fill. The pharmacist will document reasons for refusal and communicate with appropriate parties. 2. Card/label all supplied medication (entire bottle) and send to facility. 3. Print such medication on MAR chart for positive dose charting by facility.
Such medications will be administered at this facility only if the above policies are followed.
MEDICATION ADMINISTRATION RECORD (MAR)
A medication administration record (MAR) must be maintained for each resident. It is a chronological record of all medication in current use for a resident and a record of all doses of medication administered, refused, omitted or destroyed. The current MAR should be stored in the MAR binder until month end, then stored in the resident's clinical record for a minimum of 6 months. MAR must be kept on hand at the facility for seven (7) years. Weights, blood pressures, temperature, pulse and blood sugar reading must be recorded on the MAR before placement into the resident's clinical record. The resident's MAR shall indicate all medications administered, refused, omitted or
destroyed, utilizing positive charting. The administration record will be kept current
and should be completed by the professional staff administering the medication at the
time of administration of the medication.
Each dose of medication ordered and given on a "when needed" (PRN) basis, shall be recorded in the MAR. The PRN ADMINISTRATION record on the back of the MAR should be completed at this time. Note time and date next to pouch for all PRN doses administered from med cards. X MONTHLY CHECKING - COMPUTERIZED MARS AND MEDICATION CARDS
MONTHLY CHANGE OF PASS
To ensure that medications appearing on the MAR and in the medication rack are accurate; and to ensure that the resident actually receives what the physician has ordered. Three to five days before the month end, pharmacy produces computerized MARs for each resident and delivers them with the next months regular pass medication. In the following order staff will:
a) check all new MARs with the previous months. Any medication ordered within the last month, including PRNs, liquids,topicals, must also be checked with the Physicians Orders and/or Medication Review. b) check all medication cards and indicator cards with MARs. c) rack and check new medication cards against current cards for completeness. d) check all medication in PRN bin. PRN medication which is outdated or has not been used in 90 days is evaluated and/or discontinued. e) check expiry dates of all medication in stock including PRN, liquids, IMs topicals, refrigerated medication, contingency supplies, f) place new MARs in the binders, g) check old MARs for missed signatures, etc., and draw this to the attention of the Director of Resident Care so there is follow up. h) leave old medication sheets for staff to file in the resident's Clinical Record, i) inform pharmacy at least one working day before beginning of the new pass on the first day of the month of any deficiencies on the MARs, missing medication for new passes, and expired medication in stock that needs replacement before beginning use of the new pass on the first day of the new month. j) inform pharmacy using the MONTHLY MAR CHECKING SHEET if:
medication at bedside is not marked (ROOM) on MAR resident medications that are crushed are not identified "MEDS CRUSHED" AT THE BOTTOM OF THE MAR medication on the MAR are no longer being used or are no longer needed medication on the MAR are no longer being used as ordered (eg. cream labelled BID is needed prn only) medication is marked "ASSESS" past the date of assessment if room/bed # where appropriate, family physician, allergies, diagnosis are noted incorrectly or missing from the bottom of the MAR. k) Before beginning administration of medication from the new pass on the first day of the month, each pass should be checked once again with the medication cards from the previous month's pass and the MAR as a double-check to ensure the new pass is complete and correct. XI RESIDENT SELF-ADMINISTRATION OF MEDICATION
All medication will be administered by staff unless self-administration is authorized in writing by the
resident's physician and approved by the Medication, Safety and Advisory Committee.
When a letter of authorization for self-administration is on file (see sample) staff should notify pharmacy by fax so that the notation (ROOM) will be noted in the direction field on the MAR and label to indicate that the resident is authorized for self-administration. The time of administration for each dose should be inserted in the space provided and any medication which is being self- administered by a resident should be appropriately indicated on the MAR (the notation (room) found at the end of the direction section of any medication will indicate that the medication is at the bedside and is being self-administered). NOTE: A current letter of release is required to be on hand at the facility to cover any medications which are self- administered. This release is renewable every year or more frequently if there is concern about the resident's ability to self-administer medication. A lockable storage area in the resident's room is required before a resident may self administer medication All medication to be self administered must be ordered by a physician and be supplied by the designated pharmacy. The resident must be aware of the indication, side effects and full directions for use of each medication to be self administered. Staff are responsible for on- going monitoring (at least monthly) of self-administration use by resident to confirm that the resident is coping with self- medication. This monitoring should be documented in the residents file monthly. When a supply of medication is given to the resident for self-administration: ! the date and time, ! drug, ! quantity ! staff initials should be charted in the PRN ADMINISTRATION area on the back XII Self-Medication Release for Residents (sample)
Resident's Name: _ Date of Admission: Care Level: _ Is the resident physically and mentally competent to administer their own medication Does the resident understand the following: (a) use of the medication (b) medication side effects (c) times of administration Is there a secure (locked) area in the resident's roomor medication? Has the resident been informed that "self administration plans" are reviewed and renewed yearly or as necessary by their physician and by theMedication Safety Committee (MSC)? Approved by: Date: Director of Resident Care (on behalf of the MSC) Approved by: Date: Resident's Physician Date for Next Review: _ Please return this form to the above address or fax to Crestview Pharmacy: 879-8809 Thank You. CHARTING MEDICATIONS
To ensure that all medication administered is recorded in an appropriate manner.
1. The resident's medication administration record (MAR):
a) are generated monthly by the pharmacist for each resident receiving medication; b) any medications started after this printing must be written on the MAR by staff; and c) are routinely checked by staff See "Routine Checking - Computerized MARs and Medication Cards, Monthly
Change Of Pass" procedure.
2. All Staff administering medication must sign name and initials on the Staff Signature
3. On the MAR, initial for medications given in proper time slot, immediately after
4. Use the codes at the top of the MAR when indicated:
a ) code 8 (other), when using code 8 an explanation must be made on the back of
b) code 4 (social leave) indicate on the back of the MAR:
ii) the hours of medication passes that were sent on leave, and iii) initials of staff member preparing social leave medication iv) numbers days supply if prepared by pharmacy v) name of caregiver who received the medication if resident is not capable of self-administration See page 14 for details of charting medications given for Social Leave.
5. PRN Medication - chart the following
a) Front of the MAR i) time of administration, and ii) initials. i) indicate the reason for and the results of administering the medication for all PRN medications Note: when a dose is requested by a resident for PRN medication, their MAR should be checked before drug administration. Be sure to chart the "quantity given" on orders with a variable dose (eg. 15-30ml, 1 or 2 tablets). Discontinued Medications a) write D/C by each medication which has been discontinued, b) draw a line to the end of the sheet. See "Discontinued Medications" procedure. 7. When a charting error is made, do not use liquid paper to correct charting errors.
Circle the error and note "ERROR". The appropriate correction may be made where
possible (again the back of the MAR may be used if there is not sufficient room to
chart on the front).
Chart the pulse on the top of the medication administration record (MAR). DISCONTINUED MEDICATIONS
A. When medications are discontinued write D/C on the label on medication cards and return to pharmacy by the delivery person each day, Monday to Friday. B. Write D/C on the Medication Administration Record. Draw a line to the end of the C. Be sure all D/C orders are documented on the Physician Order Form. Exception: Order for short term use for defined period of time e.g. antibiotics fo r 7 days. MEDICATION STORAGE AND SECURITY
Resident's medication should be kept in an area solely designated for medication storage. The storage area shall be clean, well lit, at the right temperature ( 20 Celsius), and secure. The medication area should be kept locked when not in use and should be accessible only to authorized personnel. Internal and external medications should be stored separately. Refrigeration must be available if required for certain medications. All resident's medication shall be kept in the original labelled containers provided by the pharmacist until immediately prior to administration. NOTE : No unlabelled medications (including OTC's and medications received from residents or their family members) should be kept on hand at the facility.
All medication shall be returned by the facility and recovered by the pharmacist: upon discontinuation, strength change, resident discharge from the facility, adverse reaction No medication shall be kept in the facility in anticipation of a future medication
Please be sure to return all discontinued medications, blister cards containing missed doses, empty medication cards and any written prescriptions via the delivery person on the next scheduled delivery. DISCHARGE MEDICATION
When a resident is discharged to another long term care facility, all medications and a photocopy of the current MAR should accompany the resident. When a resident is to be discharged home, pharmacy will consult with the prescribing physician and a discharge supply will be dispensed. It is the responsibility of the nurse to notify pharmacy by fax of all resident
When a resident is sent to hospital, a photocopy of the current MAR should be sent with the resident. No medication should be sent. On hospitalization, pull all medication cards and non carded medications, and keep on
hold until the resident is discharged from the hospital.
When a resident is admitted to hospital for more than 10 days, all medications including
ointments, liquids, eyedrops, injections, etc., shall be discontinued and promptly
returned to pharmacy. No medications are to be placed "into stock" in the medication
When a resident returns from hospital after a short stay (eg for elective surgery) all
previous orders must be confirmed with the resident's physician.
When a resident returns from hospital after 10 days or less, all previous orders and any
hospital discharge orders will be assessed by pharmacy with the physician. Pharmacy
will then notify regarding any previous orders which should be discontinued.
It is the responsibility of the staff to notify pharmacy by phone or fax when a
resident is admitted to hospital.
MEDICATION RELATED INCIDENT REPORTS
An incident report should be filled out by staff using an incident report form for the following: Dispensing errors Administration errors * To wrong resident * In wrong dose/ wrong time * Inappropriate route * Extra dose given * Incorrect administration technique * Outdated drug * Discontinued drug given Incorrect Narcotic Count/Missing doses of Narcotic Charting or Documentation Error Discovery of hoarded meds or meds in the room Unprocessed Doctor's Order Incorrectly processed order The staff who first discovers the error: 1. Complete the Medication Incident Report in ink. a) the appropriate categories should be ticked. A brief factual description should be given only if pertinent information has not been covered. b) the name and dosage of the drug/s should be listed under the factual description. c) record the number of doses resident received/missed in the appropriate area. 2. Notify the attending physician, (if applicable). 3. Notify the pharmacist. 4. Notify Director of Resident Care B Disposition of Report A copy of all medication related incident reports should be forwarded to pharmacy (see sample). A copy of all medication related incident reports will be reviewed by the Medication Safety and Advisory Committee.
1. The Director of Resident Care is responsible to see that all possible steps are taken to avoid a recurrence of the error by staff. 2. The pharmacist is responsible to see that all possible steps are taken to avoid a recurrence of pharmacy dispensing errors. REPORTING OF ADVERSE DRUG REACTION OR DRUG ALLERGY
In the event of a suspected adverse drug reaction or allergic reaction to medication administered, and after consultation with the resident's physician and pharmacy, a "Report of Adverse Drug Reaction or Drug Allergy" form will be completed (see example). Staff should complete the sections of the form marked with (*). Approximate weight and height are adequate. Keep the description of the adverse reaction brief (eg rash, nausea and vomiting, dizziness, falls, confusion). It is the responsibility of the Director of Resident Care to see that a report form has been filled out, and a copy forwarded to pharmacy. A copy of the report should be filed in the resident's clinical record behind the MARs (see sample). Where appropriate, pharmacy will file a report form (using residents initials only) with the "Adverse Reaction Program" in Ottawa. REPORT OF ADVERSE DRUG REACTION OR DRUG ALLERGY
*Patient Name: Age: *Weight: *Height: _ *Brief Description of Adverse Reaction (eg rash): *Date of Onset of reaction: Outcome: Recovered : _ Recovered with residual effects: _ Patient did not recover: _ Unknown: _ *Suspected Products: _ *Indication for use: Concomitant drugs: _ *Pharmacy Notified: _ *Physician Notified: _ A copy of this report may be sent by pharmacy (without patient's name) in confidence to: BC Regional ADR Centre c/0 BC Drug and Poison Information Centre 1081 Burrard St. Vancouver, B.C. V6Z 1Y6 Tel: (604) 631-5625 1 copy resident's file 1 copy to pharmacy Facility staff: Please complete the sections marked with a * and forward a copy of this report to pharmacy. XXIII NEW ADMISSIONS
When a resident is admitted, please notify pharmacy by phone or fax, even if the resident may not be taking any medication on admission. Before contacting pharmacy, please check with the resident regarding any medications that they may be bringing into the facility with them (this should include any other the counter medication they may have purchased and may be using (possibly without their physicians knowledge)). Please include the following information: * resident full name, birth date, weight, date admitted, physician's name, personal health number and room number (where appropriate). * diagnosis and known sensitivities and allergies to medication, food or blood products * a list of all medications (prescription and non prescription) Pharmacy will verify current medication required with the physician and notify staff. XXIV COMMONLY USED ABBREVIATIONS
drug identification before meals or food right ear (arivis deptra) as desired, at pleasure doctor/physician activities of daily living Deep vein thrombosis atrial fibrillation acquired immune deficiency medication administration morning /before noon EPS extra-pyramidal symptoms Amp or amp ampule Doctor of Medicine physician medication review acetylsalicylic acid as soon as possible physician release for self- arteriosclerotic heart disease automatic stop policy myocardial infarction millilitre ( 1ml=1cc) milk of magnesia basal metabolic rate multiple sclerosis gastrointestinal motor vehicle accident benign prostatic hypertrophy blood urea nitrogen NIIDM non-insulin dependent coronary artery disease diabetes mellitus initiated orders cubic centimeter (1cc=1ml) no known allergies congestive heart failure nothing by mouth insulin dependent diabetes mellitus non-steroidal anti- central nervous system ischemic heart disease inflammatory drug chronic obstructive nausea & vomiting pulmonary disease CPR cardiopulmonary CPS Compendium of Pharmaceuticals and urinary tract infection Parkinson's disease personal health number prn when necesssary peptic ulcer disease four times a day approximately equal to increase or elevated decrease or lowered rheumatoid arthritis red blood cells or count mark/write down on label sublingual (under the tongue) tablespoon (15cc) transient ischemic attack three times a day thyroid stimulating hormone teaspoonful (5cc) STRAIGHT NARCOTICS WHICH REQUIRE A WRITTEN ORDER FROM THE PHYSICIAN
Morphine (all forms) Cephylac/Cephalic Expct Novahistex DH, DH Expct Demerol (meperidine) Perocet/Percocet Demi Percodan/Percodan Dei Dilaudid Seconal Dimetane DC Expct Talwin (pentazocine) Triaminic DH Expct Tussaminic DH Expct Leritine(anileridine) Lomotil (diphenoxylate) Tylenol with Codeine Elixir
Note: A triplicate prescription form is not required for written orders for residents in
Long Term Care.
Please be sure that all Narcotic orders contain: * resident name, * directions for use (indicating minimal interval or maximum daily doses), * quantity to be dispensed, and
* signature of prescribing physician. PHARMACY HOURS AND EMERGENCY SERVICES
Monday thru Friday 09:30 am to 6:00 pm 10:00 am to 2:00 pm Sunday and Holidays DELIVERY SCHEDULE
For same day delivery, orders must be phoned or faxed to pharmacy before 2:00 pm New orders, changes of order or refill requests received after 2:00 pm weekdays will be available for pick-up or delivery on the next working day. EMERGENCY AFTER HOURS PHARMACY SERVICES – Call the Spectrum Cell to access
these after Hours numbers.
An after hours professional services fee will be charged for call out of a pharmacist and delivery of medication orders after hours.
Reason for EMERGENCY calls to a pharmacist:
1. Medication errors:
Possibility of danger to the resident eg: wrong medication given, double dose or
2. New prescription:
Resident seen by doctor or an emergency ward after pharmacy hours
and has a prescription that needs immediate fill
eg: pain killer or antibiotic
3. Adverse Reaction to new medication:
The pharmacist or doctor may instruct staff to watch for possible adverse reaction
staff to phone for instruction if these reactions are noticed
Feb 17, 2012
To Facility Staff Serviced by Paragon Crestview Pharmacy
Re: Hours of Operation and On Call Pharmacist Services
Please be advised effective March 1, 2012, Paragon Crestview Pharmacy will be closed
on Saturdays. Our new hours of operation will be Monday to Friday from 9:30am to
6pm. We will be closed Saturdays, Sundays, and statutory holidays.
An on call pharmacist will be made available 24 hours a day, 7 days a week for clinical
inquiries and/or urgent orders. The after-hours on call phone number is (604) 353-7150
effective March 1, 2012.
Please be sure to update the last page of your medication policy and procedures manual
to reflect these changes and notify all staff involved in medication administration.
We thank you for your cooperation and understanding. Should you have any questions or
concerns, please feel free to contact me directly at (604) 879-8808.
Paragon Crestview Pharmacy
3138 Main Street
Vancouver, BC V5T 3G7
Policy Brief • April 2016 GPE's Work in Conflict-affected and Fragile Countries Accelerated Support in Emergency and Early Recovery Situa-tions, GPE has successfully promoted coordinated deci-sions about the best way to utilize resources in crisis settings, such as shifting them to non- governmental 28 GPE's developing country partners are classified providers for direct service provision during acute