MedAdmin Manual 07.07.09 - Charlotte AHEC · 3. Treat a disease or reduce symptoms (antibiotic for infection, psychotropic for mental illness). 4. Restore normal function (insulin

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Copyright (2008) by the North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services

North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services

Medication Administration

A Course for

Unlicensed Personnel

in Community Facilities

MH | DD | SASdivision of mental health | developmental disabilities | substance abuse services

Medication Administration: A Course for Unlicensed Personnel in Community Facilities A-i

Acknowledgments At the request of the North Carolina Department of Health and Human Services, Division of MH/DD/SAS, this training program was developed as a revision of manuals previously available through the Department of Human Resources in 1981, 1987 and 1996. This manual was reviewed and approved by the Division in 2003 and adopted as the standardized training curriculum for unlicensed personnel who administer medications in community facilities. A new committee was formed in 2007 to update the manual. Significant changes to the 2003 version include:

• Online Training will be available in 2009 • The two State Approved Medication Education Classes are defined and contrasted • The Five Addendums are now an integrated component of the curriculum and listed in the

table of contents • Glossary has been moved to the end • Common central nervous system drugs has been updated • The following charts have been added:

Antidepressants in the Elderly Antipsychotics in the Elderly Hypnotics in the Elderly Mood Stabilizers in the Elderly Anti-Anxiety in the Elderly

The Division wishes to acknowledge and thank the following individuals for their work in the development and production of the 2003 manual:

• Bob Allen, RPh • Lana Balltzglier, RN, Nursing Supervisor, Murdoch Center, Butner, NC • Jan Brickley, RPh, Adult Care Licensure Section, Division of Health Service Regulation,

Raleigh, NC • Bajei Garrett, RN, C/CHN, Community Services Department, Caswell Center, Kinston, NC • Brenda Gwyn, RN, Gwyn's Consulting Service, Reidsville, NC • Brenda Jordan-Choate, BSN, RN, Division of Health Service Regulation, Raleigh, NC • Todd King, PharmD,RPh, Director, Clinical Services, Neil Medical Group, Lillington, NC

Medication Administration: A Course for Unlicensed Personnel in Community Facilities A-ii

The Division wishes to acknowledge and thank the following individuals for their work in updating the manual in 2007.

Name Credentials Title Section Division City, State

Renee Ames RN, BSN Team Leader Mental Health Licensure & Certification Section

Division of Health Service Regulation Raleigh, NC

Frankie Ballard

PhD, MSN, RN-BC

Clinical Nurse Specialist, Nursing Education Instructor

Dorothea Dix Hospital DMH/DD/SAS Raleigh, NC

Jan Brickley RPH Adult Care Licensure Section


Kimberly Corder

PharmD Candidate UNC School of

Pharmacy Chapel Hill, NC

Susan Cornett RPH John Umstead Hospital DMH/DD/SAS Butner, NC

Barbara J. Davis

MEd, LPC, NCC Director Mental Health

Education AREA L AHEC Rocky Mount, NC

Michelle Edelen Communications and

Training Team Leader Operations Support Section DMH/DD/SAS Raleigh, NC

Michiele Elliott RN, BSN Eastern Branch Manager

Mental Health Licensure & Certification Section


Leigh Foushee PharmD

Associate Director of Pharmaco-Therapy Services

Eastern Branch Manager Division of Health Service Regulation

Wake AHEC Raleigh, NC

Steven Hairston Operations Support

Section Chief Operations Support Section DMH/DD/SAS Raleigh, NC

Kristopher Joyce Staff Development

Coordinator Operations Support Section DMH/DD/SAS Raleigh, NC

Susan Kelley Administrative Support Operations Support Section DMH/DD/SAS Raleigh, NC

Bethel Knapp Project Coordinator Mental Health, Pharmacy, & Quality Education

Charlotte AHEC Charlotte, NC

Margaret Valderrey

MSN, RN, CNS Director

Mental Health, Pharmacy, & Quality Education

Charlotte AHEC Charlotte, NC

Medication Administration: A Course for Unlicensed Personnel in Community Facilities A-iii

Reference Materials • “Revised Interpretive Guidelines: Intermediate Care Facilities For the Mentally Retarded,”

June 2005 • “Nursing 2010 Drug Handbook,” Springhouse Corporation • “Medication Training-895.06,” The North Dakota Statewide Developmental Disabilities

Staff Training Program, February 1999 • “Rules for Licensing of Adult Care Homes,” Division of Health Service Regulation. G.S.

131 D-2 April 1, 2006 • “Rules for Mental Health, Developmental Disabilities and Substances Abuse Services of

North Carolina,” Division of MH/DD/SAS, APSM 30-1, March 2009 • NC Board of Nursing “Administrative Code,” Policies and Procedures Section • “Community Alternatives Program for Persons with Mental Retardation and Other

Developmental Disabilities,” Division of MH/DD/SAS, March 2009 • “Service Records Manual for Area Programs and Contract Agencies,” Division of

MH/DD/SAS, APSM 45-2, March 2009 • Medication Study Guide for Unlicensed Personnel in Adult Care Homes, Division of Health

Service Regulation. http://www.ncdhhs.gov/dhsr/acls/pdf/medstudy.pdf • “ISMP’s List of Error Prone Abbreviations, Symbols, and Doses,” Institute for Safe

Medication Practices, Used by Permission, 06.19.09, KStevers

Medication Administration: A Course for Unlicensed Personnel in Community Facilities A-iv

Introduction

Medication Administration is a Serious Responsibility Medication administration is a serious responsibility. The dictionary defines the term “medication” as a substance or mixture (other than food) that is used to do one or more of the following:

1. Prevent disease (vaccines such as tetanus immunization). 2. Aid in diagnosis of disease (barium chloride for x-ray). 3. Treat a disease or reduce symptoms (antibiotic for infection, psychotropic for mental

illness). 4. Restore normal function (insulin to replace the hormone not produced by individuals who

have diabetes). 5. Maintain normal function (a heart medication to regulate a heartbeat).

Terminology may differ in different types of settings. For clarity in this package, the following words may be used interchangeably.

Agency = Facility Client = Consumer/Resident/Individual/Person Drug = Medication

Important reasons for this course Although most adults are familiar with physicians and pharmacists and have used a variety of medications, there are some important reasons for this course.

1. Medications may be dangerous if not administered correctly. 2. Many medications taken by clients in your agency may be unfamiliar to you. 3. Although most people do not follow formal rules and procedures when giving and taking

medication in their own home, such rules and procedures are required by law and policy in your agency to protect:

a) The clients taking medications. b) The staff carrying out medication procedures. c) The agency providing services to client.

A medication treatment program needs many people to make it work. State Approved Medication Aide Instructor Educational Programs There are two State Approved Medication Aide Instructor Educational Programs for use in North Carolina’s public programs to treat the mentally ill, people with developmental disabilities and substance abuse problems. This course may be used for medication training of unlicensed personnel in adult care facilities. For more information go to: http://mats.dhhs.state.nc.us The North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services trainer orientation course is for nurse RNs, pharmacists, physicians or physician assistants who will train unlicensed staff in the administration of medication in group homes that are licensed as mental health facilities. Attendance is required to receive a copy of the curriculum and to apply to be listed on the Division’s website as a course trainer. The course is one day, approximately 4 hours.

Medication Administration: A Course for Unlicensed Personnel in Community Facilities A-v

Contact information on the instructional course for unlicensed personnel in community facilities is: [email protected] or call 704-512-6501. North Carolina Board of Nursing Program The North Carolina Board of Nursing program is for registered nurses who will teach the NC Board of Nursing Medication Aide curriculum to CNA1 in skilled nursing facilities. It prepares two categories of instructors: Medication Aide Instructors and Master Teachers for Medication Aide Curriculum. The course length is from 2 to 3 days. Information on the North Carolina Board of Nursing program can be found at: www.ncbon.org.

Medication Administration: A Course for Unlicensed Personnel in Community Facilities A-vi

TABLE OF CONTENTS - Section “A” Medication Administration - Instructor Materials

Acknowledgments .............................................................................................................................. A-i

Reference Materials......................................................................................................................... A-iii

Introduction ..................................................................................................................................... A-iv Medication Administration is a Serious Responsibility .........................................................................A-iv Important reasons for this course ..........................................................................................................A-iv State Approved Medication Aide Instructor Educational Programs ....................................................A-iv

Section A - Table of Contents.......................................................................................................... A-vi

Section B - Table of Contents........................................................................................................ A-viii

Instructor Materials for Medication Administration - A Course for Unlicensed Personnel in Community Facilities .................................................................................................................. A-1

How to receive the training course materials ....................................................................................... A-1 Online Training....................................................................................................................................... A-1 Clinical skills performance evaluation checklist .................................................................................. A-1 Documentation of training completion ................................................................................................. A-1 Monitoring of medication storage areas ............................................................................................... A-2 Update training in medication administration..................................................................................... A-2 Testing...................................................................................................................................................... A-2 Medical Administration Clinical Skills Performance Checklist......................................................... A-3 Sample Certificate of Completion ......................................................................................................... A-6 Sample Certificate of Update Completion............................................................................................ A-7 Monthly Medication Room/Closet Audit.............................................................................................. A-8 Daily Medication Refrigerator Temperature Log ............................................................................... A-9 Periodic Medication Administration Clinical Skills Checklist ......................................................... A-10 Seizure Record - Descriptive Daily...................................................................................................... A-11 Seizure Record - Cumulative Monthly & Yearly............................................................................... A-12 Control Drug Count Sheet ................................................................................................................... A-13 Stool Record .......................................................................................................................................... A-14 Menses Record ...................................................................................................................................... A-15 Height and Weight Record................................................................................................................... A-16 Immunization Record........................................................................................................................... A-17 Sample Table of Contents for a Medication/Pharmacy Policy and Procedure Manual................. A-19 Medication Administration Policies and Procedures ........................................................................ A-20 Medication Error Report (Sample #1)................................................................................................ A-24 Medication Error Report (Sample #2)................................................................................................ A-25 Medication Error Report (Sample #3)................................................................................................ A-26 Medication Administration Report (MAR) - Front........................................................................... A-27 Nurse’s Medication Notes - Back of MAR.......................................................................................... A-28 Medication Release Form..................................................................................................................... A-29 Medication Test 1.................................................................................................................................. A-30 Medication Test 2.................................................................................................................................. A-33 Medication Test 3.................................................................................................................................. A-36

Medication Administration: A Course for Unlicensed Personnel in Community Facilities A-vii

General Medication Test Questions .................................................................................................... A-39 Answer Key - Medication Test Number 1 .......................................................................................... A-45 Answer Key - Medication Test Number 2 .......................................................................................... A-46 Answer Key - Medication Test Number 3 .......................................................................................... A-47 General Medication Test Questions - Answer Key ............................................................................ A-48 Medication Administration Test 1 - Worksheet................................................................................. A-49 Medication Administration Test 2 - Worksheet................................................................................. A-50 Medication Administration Test 3 - Worksheet................................................................................. A-51 General Medication Test - Worksheet ................................................................................................ A-52

Appendix for Trainers Section ..................................................................................................... A-53 Appendix 1............................................................................................................................................. A-53

The Path and Effects of Medication................................................................................................. A-53 The Important Role of the Liver and Kidneys................................................................................ A-53 Individual Differences in Medication Outcome.............................................................................. A-53 Factors that Influence Medication Response .................................................................................. A-53 Three Broad Effects of Medication.................................................................................................. A-54 Medication Interactions .................................................................................................................... A-55 Two Important Points to Remember Concerning Medication Interactions ................................ A-55 Observe and Report all Suspected Effects of Medication.............................................................. A-56 Medication Names ............................................................................................................................. A-56 Summary ............................................................................................................................................ A-56

Appendix 2............................................................................................................................................. A-58 PRN Medications and Behavior ....................................................................................................... A-58 Consideration One: Is Medication a First Choice? ........................................................................ A-58 Consideration Two: Is Medication a Permanent Solution?........................................................... A-58 Consideration Three: Is Medication a Complete Solution?........................................................... A-58

Appendix 3............................................................................................................................................. A-60 Medication Requirements................................................................................................................. A-60

Appendix 4............................................................................................................................................. A-63 Seizure Management ......................................................................................................................... A-63

Available Trainers of Medication Administration: A Course for Unlicensed Personnel in Community Facilities Form ............................................................................................................... A-64

Medication Administration: A Course for Unlicensed Personnel in Community Facilities A-viii

TABLE OF CONTENTS - SECTION "B" Medication Administration - Trainee Materials

Trainee Materials for Medication Administration - A Course for Unlicensed Personnel in Community Facilities ................................................................................................................ B-1

Purpose and Introduction ................................................................................................................B-1 Agency and Instructor Responsibilities ..........................................................................................B-1 Client Role .........................................................................................................................................B-1 Instructor Qualifications..................................................................................................................B-1 Trainee Qualifications ......................................................................................................................B-1 Course Length...................................................................................................................................B-2 Written Examination........................................................................................................................B-2 Continuing Education.......................................................................................................................B-2 Maintaining Quality Control ...........................................................................................................B-2

Unit 1 - Medication Administration is a Serious Responsibility ........................................... B-2 Important Reasons for this Course .................................................................................................B-2 Direct Service Staff do Not Make Medication Judgments ............................................................B-2 The Medication Process Provides Opportunities for Teaching and Learning............................B-2 Encourage the Client to Take an Active Role in All Stages in the Medication Process..............B-4 Teaching Independence and Being Person-Centered ....................................................................B-4 Age Appropriate Manner.................................................................................................................B-4 Independence.....................................................................................................................................B-5 Person-Centered................................................................................................................................B-5 Decisions are Made by a Team ........................................................................................................B-5 Know and Observe Effects of Medication Administration ...........................................................B-5 Your Responsibility is to Observe and Report Change, Not to Diagnose....................................B-5 Develop a Keen Observational Sense ..............................................................................................B-6 Be Alert to Changes in Health Patterns..........................................................................................B-7 Summary ...........................................................................................................................................B-7

Unit 2 - Staff Responsibility...................................................................................................... B-8 The Medication Cycle has Five Areas.............................................................................................B-8 Staff Member Responsibility in the Cycle ......................................................................................B-8 Staff has Four Broad Responsibilities Regarding the Medication Process .................................B-9 Knowing and Adhering to Laws and Agency Policies ...................................................................B-9 Completion of this Medication Course is Only Part of Your Training........................................B-9 Prescription and Non-Prescription Medication .............................................................................B-9 No Medication is Harmless ..............................................................................................................B-9 Federal and State Law......................................................................................................................B-9 Food and Drug Act .........................................................................................................................B-10 Controlled Substances ....................................................................................................................B-10 General Guidelines .........................................................................................................................B-10

Unit 3 - Six Rights of Medication Administration.................................................................B-11 Most Medication Errors are Made Because One of the Six Rights was Not Observed............B-11

1. Right Client ..............................................................................................................................B-11

Medication Administration: A Course for Unlicensed Personnel in Community Facilities A-ix

2. Right Dose ................................................................................................................................B-11 3. Right Time................................................................................................................................B-12 4. Right Route ..............................................................................................................................B-13 5. Right Medication .....................................................................................................................B-14 6. Right Documentation ..............................................................................................................B-14

Medical Administration Record is a Legal Document.........................................................B-14 Summary .........................................................................................................................................B-14

Unit 4 - Administration Procedures........................................................................................B-15 Oral, Sublingual, and Buccal Medication Administration..........................................................B-15 Table 1. Procedure for Oral Medication Administration ...........................................................B-15 Table 2. Procedure for Liquid Medication Administration........................................................B-18 Procedure for Sublingual Medication Administration................................................................B-19 Procedure for Buccal Medication Administration.......................................................................B-19 Legal Issues......................................................................................................................................B-19 Best Practice Guidelines .................................................................................................................B-19 Medication Administration Record...............................................................................................B-19 Medication Administration Record - Front Sample....................................................................B-21 Nurse’s Medication Notes - Back of MAR Sample ......................................................................B-22

Unit 5 - Special Medication Procedures .................................................................................B-23 Procedure for New Medication/Changes in Medication .............................................................B-23 Discuss Medication Change with Client .......................................................................................B-23 Physician's Order Information......................................................................................................B-23 Procedure for When the Client is Away From Agency ...............................................................B-24 Procedure for Verbal Orders.........................................................................................................B-24 Procedure for PRN Medication .....................................................................................................B-25 Over The Counter Medication.......................................................................................................B-25 Other Procedures for Medication Administration ......................................................................B-25 Provide Privacy for Client .............................................................................................................B-26 Proper Techniques for Administrating Medications...................................................................B-27

Two Methods for Crushing Medication ....................................................................................B-27 Technique for the Proper Administration of Ear Drops to Adults .........................................B-28 Technique for Proper Administration of Eye Drops to Adults ...............................................B-29 Technique for Proper Administration of Eye Ointment to Adults .........................................B-30 Technique for the Proper Administration of Fleets Enemas...................................................B-31 Technique for the Proper Administration of Metered Dose Inhalers.....................................B-32 Technique for the Administration of Medication Using a Metered Dose Nasal Pump .........B-33 Technique for the Proper Administration of Nebulizer Treatments ......................................B-34 Technique for the Proper Administration of Nose Drops or Nose Sprays to Adults ............B-35 Technique for the Proper Administration of Rectal Suppositories ........................................B-36 Technique for the Proper Administration of Topical Medications.........................................B-37 Technique for the Proper administration of Transdermal Patch ...........................................B-38 Technique for the Proper Administration of Vaginal Medication..........................................B-40

Unit 6 - Special Issues in Medication Administration...........................................................B-41 Assisting the Client Who has Difficulty Swallowing....................................................................B-41 Adhering to Time Span ..................................................................................................................B-41

Medication Administration: A Course for Unlicensed Personnel in Community Facilities A-x

Assisting Clients Who Refuse Medication ....................................................................................B-41 Clients Who Continue to Refuse....................................................................................................B-42 Errors in Medication Administration ...........................................................................................B-42 A Medication Error has Occurred If: ...........................................................................................B-42 When an Error Occurs...................................................................................................................B-43 Learning from Mistakes .................................................................................................................B-43

Unit 7 Medication Observation ...............................................................................................B-44 Four broad responsibilities in monitoring medications...............................................................B-44 Table 3. Common medication categories & side effects ..............................................................B-45 Commonly used scheduled drugs ..................................................................................................B-46 Common central nervous system drugs (psychotropic drugs) by therapeutic class .................B-46

Antidepressants in the Elderly.........................................................................................................B-48 Antipsychotics in the Elderly ....................................................................................................B-49 Hypnotics in the Elderly............................................................................................................B-50 Mood Stabilizers in the Elderly ................................................................................................B-51 Anti-Anxiety in the Elderly .......................................................................................................B-52 Appendix..........................................................................................................................................B-53 Abbreviations ..................................................................................................................................B-53 *ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations .......................B-54 Measuring Tips ...............................................................................................................................B-56 Glossary ...........................................................................................................................................B-57

*Copyright © Institute for Safe Medication Practices (ISMP) .Used with permission, 06.19.09, KStever

Medication Administration: A Course for Unlicensed Personnel in Community Facilities A-1

Instructor Materials for Medication Administration - A Course for Unlicensed Personnel in Community Facilities Training course materials introduction for Unlicensed Personnel in Community Facilities consists of the following: • Instructor materials • Trainee materials

How to receive the training course materials

The Division of Mental Health, Developmental Disabilities and Substance Abuse Services partners with the North Carolina’s Area Health Education Centers to provide instructor training for pharmacists, Registered Nurses, physician assistants and physicians in the presentation of materials. Successful completion of the instructor training class provides access to the manual and training materials and the opportunity to be listed on the Divisions website database of instructors available for hire to provide the instruction.

More information on the instructor training course and database can be found on the Division webpage: http://www.ncdhhs.gov/mhddsas/training/medadmin.htm

Online Training

In 2008, the Division in partnership with the AHEC system plans to introduce an online training course covering the same materials. Pharmacists, nurse Registered Nurses, physician assistants and physicians will be able to receive the training at the place and time of their choice, download the training materials directly from the web and be listed on the instructor database upon successful completion of the course.

Clinical skills performance evaluation checklist

Once a person has successfully completed the class requirements, the agency should ensure that a clinical skills evaluation occurs. Refer to agency specific policies regarding clinical skills evaluation. A sample Medication Administration Clinical Skills Performance Checklist is shown on the following pages. It can be used as determined by the instructor/agency. Remember that it does not replace the skills checklist required by the Division of Health Service Regulation for facilities licensed under General Statute 131D. Copies of it may be obtained through the Adult Care Licensure Section of the Division of Health Service Regulation.

Documentation of training completion

It is recommended that staff successfully completing the medication administration class be given a certificate of completion. A copy of the certificate should be placed in the client’s personnel file as determined by the agency policy. A sample certificate is included for possible use.

Monitoring of medication storage areas

It is recommended that periodic monitoring of medication storage areas be implemented. This is to ensure safety of medications and clients receiving these medications. It is suggested that the Registered Nurse, pharmacist or qualified supervisor conduct this monitoring on a monthly basis. A sample Monthly Medication Room/Closet Audit form is included for reference.


Periodic monitoring of staff administering medications It is recommended that periodic monitoring of staff administering medications be conducted. This is to ensure that proper procedures are being followed in the medication administration process. This monitoring should be done by the registered nurse or registered pharmacist. Each staff member in the agency should be monitored at least annually. Attached is a sample checklist which can be used to monitor staff performance.

Update training in medication administration

Certain regulations and agency policies may require annual updates for staff that administer medications. Refer to your agency licensure/regulation/policy. In the event that update training is required, it is suggested that each agency nurse or pharmacist review the medication errors that have occurred over the prior year and develop training around those areas. Once staff has completed an update in Medication Administration training it is suggested that they be given a certificate of completion. A copy of this certificate should be maintained in the employee’s personnel file. A sample certificate for update training is included for reference.

Testing

In order to successfully complete the requirements for the class an individual must make at least 80 percent on a written test. Tests are generally administered in written form. Security of tests must be maintained at all times. Included with this packet are three versions of an approved test, along with a general medication knowledge test. These tests may be used for both the initial medication administration class and for update classes. The general test may be used as a test question bank from which new tests may be formed.

Sample Forms and Policy Table of Contents

Additional sample forms, as well as a table of contents from an agency policy and procedure manual are included and may be used by your agency. They are as follows:

Control Drug Count Sheet Seizure Record Stool Record Menses Record Height and Weight Record Immunization Record


Medication Administration Clinical Skills Performance Checklist

Name:___________________________________Agency:___________________________________ Behavioral Objective: The unlicensed staff member must (without prompting or error) demonstrate the following skills with 100% accuracy to the supervising monitor.

Unlicensed Staff Member Date Completed Monitor Signature

1. TRANSCRIBED MEDICATIONS ORDERS: (Stat, PRN, Routine)

a. Verified order and physician’s signature b. Used proper abbreviations c. Calculated stop dates correctly d. Copied orders completely and legibly and/or checked computer labels against orders and applied to MAR sheet e. Signed off orders properly

2. REQUISITIONED AND RECEIVED MEDICATIONS FROM THE PHARMACY

3. PREPARED AND ORGANIZED MEDICATIONS:

a. Checked MAR sheet with physician’s orders b. Looked up information about drugs to be administered (e.g., desired effects, side effects, harmful effects) utilizing appropriate resources c. Gathered appropriate equipment

4. POURED AND ADMINISTERED ORAL MEDICATIONS:

a. Poured oral medications 1. Utilized antiseptic technique by washing hands and keeping equipment clean 2. Read the label three times 3. Poured liquid medications away from label 4. Poured medications into appropriate container without touching the medication 5. Poured the accurate amount 6. Did not mix liquids (unless directed to do so by the pharmacist)

b. Administered oral medications 1. Identified the client (verbally, photo, etc.) 2. Assessed the client (e.g., visually, took vital signs where indicated, listened to client’s comments)


3. Utilized the six rights 4. Used the appropriate beverage or food 5. Assured that the medication was swallowed.

5. PREPARED AND ADMINISTERED MEDICATIONS BY OTHER ROUTES:

a. Topical b. Suppositories

1. Rectal 2. Vaginal

c. Instillation 1. Eye 2. Ear 3. Nose

d. Inhalants e. Other

6. UTILIZED OPPORTUNITIES FOR CLIENT TEACHING.

7. UTILIZED SPECIAL ADMINISTRATION OR MONITORING TECHNIQUES AS INDICATED (vital signs, mix with food, crush meds, check stool record).

8. ASSESSED CLIENT’S CONDITION AND REACTIONS TO THE MEDICATIONS.

9. REPORTED CLIENT’S CONDITON TO THE Registered Nurse, MANAGER, AND/OR PHYSICIAN AS INDICATED:

a. Reported information that required immediate interventions b. Reported routing information

10. DOCUMENTED MEDICATION ADMINISTRATION:

a. Documented on the medication record after administering b. Recorded information on other agency forms as indicated c. Wrote a progress note (when indicated)

11. COMPLETED MEDICATION PROCESS CORRECTLY:

a. Stored medication properly b. Kept medication storage area clean and arranged systematically c. Disposed of refused or contaminated medications d. Disposed of, washed, and/or disinfected equipment


e. Rechecked MAR sheet to make sure all meds had been given and charted

12. MAINTAINED DRUG SECURITY: a. Locked drug room/cart/cabinet when not in use b. Accounted for controlled substances

1. Store controlled substances appropriately, in accordance with facility policy 2. Counted and signed out controlled substances per facility policy

c. Maintained security of med keys at all times

13. DETECTED MEDICATION ERROR: a. Took appropriate action b. Notified the Registered Nurse/Supervisor/and/or Physician c. Documented the error (error report, progress note) per facility policy d. Observed client for changes in behavior or health status e. Assessed reason error was made f. Took corrective action to prevent future error

Date:______________Signature of Unlicensed Staff Member:________________________________ Date:______________Signature of Monitor/Manager: ______________________________________


Sample Certificate of Completion

SAMPLECertificate of Completion

is hereby granted to:

[name here]To certify their satisfactory completion of the

Medication Administration for Unlicensed Personnel in Community Facilities

{name, title}

Date:__________________

Location:___________________________

Contact Hours:_______________________

Agency:____________________________

Address:____________________________

_____________________________

_____________________________


Sample Certificate of Update Completion

SAMPLECertificate of Completion

is hereby granted to:

[name here]To certify their satisfactory completion of the

Medication Administration Update

{name, title}

Date:__________________

Location:_____________________

Contact Hours:_________________

Agency:______________________

Address:______________________

_______________________

_______________________


Monthly Medication Room/Closet Audit Item Yes No N/A

1. There is adequate security of drugs. All drugs are locked in a cabinet, cart, or closet.

2. The person responsible for medication administration has keys in his/her possession.

3. Any drugs stored in the refrigerator are in a locked container. 4. Medications that require refrigeration are refrigerated and stored at appropriate temperatures. Daily refrigerator log maintained with the date, time, temperature verification and signature. (Approximately 36-46 degrees F)

5. All medications taken internally are stored separately from drugs taken externally.

6. Stock (bulk) medications are stored separately from regularly administered meds.

7. Toxic chemicals are locked and stored separately from nourishments and medications.

8. If needles are used they are not recapped after use and are discarded in a puncture proof, leak proof container.

9. Check medication labels. Pharmacy labels are easily read and clean. 10. Check expiration dates. All meds in date as noted on pharmacy label. 11. All discontinued meds are disposed of or returned to pharmacy according to policy.

12. There is general cleanliness and orderliness of medication area. All bottles, utensils, pill cutters, etc. are cleaned after each use and stored clean.

13. All medications are in labeled containers. There are no unauthorized drug samples present.

14. Floor stock is stored separately, labeled, organized (internal separate from external) and reasonable quantities on hand.

15. Medication closet contains only items related to med administration. 16. Items necessary for drug administration are available (pen, paper, gloves, straws, medical supplies, etc.)

17. Medical equipment is stored clean and organized (gauze, gloves, glucose monitors, specimen collection supplies, etc.).

18. Nourishments used with meds are clean and in date. 19. Hand washing facilities with soap/towels are available or an antiseptic cleaner is in the immediate area.

20. There is a current written order for every medication on hand; including PRNs. Orders are signed by the physician.

21. Instructions on the MAR match the Physicians order. 22. There is a current MAR for every client. All meds are charted to date and time. Initials are identified. All allergies are noted.

23. There is a control drug count sheet for all controlled drugs. The count is correct and validated by policy.

24. There is a medication disposal sheet available. Comments:______________________________________________________________ Signature ________________________________ Date: ________________________ of Reviewer:


Daily Medication Refrigerator Temperature Log

Month_______________ Year ________________

Appropriate Refrigerator Range = 36° F to 46° F

Temperatures outside this range must be reported to the nurse or supervisor immediately. Immediate action must be taken to insure the medications are stored between 36 and 46 degrees F.

Day Time Temperature Check Expiration Dates Action taken Signature

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

In the event that the refrigerator temperature (including min/max temperature values for refrigerator) are not within the accepted range, staff shall IMMEDIATELY NOTIFY the nurse or supervisor who will seek consultation to determine if medications and antigens remain viable.


Periodic Medication Administration Clinical Skills Checklist

ADMINISTRATION OF MEDICATIONS A Identified client: _______________________________________________________________________ B. Gathered appropriate equipment and keeps equipment clean: ____________________________________ C. MAR used when medications are administered and when medications are poured: ___________________ D. Read label 3 times; label checked against order on MAR:_______________________________________ E. Used sanitary technique when pouring and preparing medications: _______________________________ F. Offered appropriate fluids with medications:_________________________________________________ G. Observed client taking medications and assured medication swallowed: ___________________________ H. Had client come to medication closet whenever possible: _______________________________________ I. Encouraged independence when possible: ___________________________________________________ J. Utilized special administration/monitoring techniques as indicated (i.e., vital signs, crushed meds, thickened fluids): __________________________________________________________ K. Administered medications at appropriate time: _______________________________________________

DOCUMENTATION OF MEDICATION ADMINISTRATION

A. Initialed MAR appropriately (equivalent signature for initials is documented): ______________________ B. Documented medications that are refused, held, or not administered appropriately:___________________ C. Administered and documented PRN medications appropriately:__________________________________ D. Recorded information on other facility forms as needed: _______________________________________ E. Wrote a note in the client’s chart when indicated: _____________________________________________

COMPLETION OF MEDICATION PASS

A. Stored medications properly: _____________________________________________________________ B. Disposed of contaminated or refused medications: ____________________________________________ C. Rechecked MARs to make sure all medications had been given or documented: ____________________

MEDICATION STORAGE

A. Maintained security of medications during medication administration: ____________________________ B. Stored controlled substances appropriately and counted and signed controlled substance sheets per facility policy: ________________________________________________________________ C. Rechecked MARs to make sure all medications had been given and documented:____________________

ADMINISTERED MEDICATIONS USING APPROPRIATE TECHNIQUE FOR EACH FORM/ ROUTE AND IN ACCURATE AMOUNT

A. Oral tablets and capsules: ________________________________________________________________ B. Oral liquids: __________________________________________________________________________ C. Other: _______________________________________________________________________________

OTHER TASKS AND SKILLS

A. Located and used facility’s policy manual for medication administration: __________________________ B. Located and used drug reference book: _____________________________________________________ C. Located contact information: _____________________________________________________________ Comments: ______________________________________________________________________________ _______________________________________________________________________________________

Employee Name: ______________________________________________ Date:__________________________ Name of Facility/Program: _____________________________________________________________________ The employee noted above has demonstrated competency validation in the areas as indicated on this checklist. Instructor's Signature: __________________________________________ Date:__________________________


Seizure Record - Descriptive Daily

Client’s Name: __________________________________Record #:____________________________ Date Time Seizure Description Duration Comments Signature


Seizure Record - Cumulative Monthly & Yearly Client’s Name: __________________________________Record #:____________________________ Enter number of seizures per day in appropriate blank. YEAR:______________________________

Day JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Total


Control Drug Count Sheet

Client’s Name: __________________________Record #:____________________________________ Medication: ________________________________________________________________________ Date Received:__________________________ Quantity:____________________________________

Date Beginning amount Time Dose

given Dose

given by: Ending amount

Count verified by:


Stool Record

Client’s Name: _________________________ Record #:______________ Year:_________________

S = small stool N = normal stool Lax = laxative M = moderate stool C = constipated Supp = suppository L = large stool D = diarrhea E = enema

Day 3rd Shift Init 1st

Shift Init 2nd Shift Init Comments

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31


Menses Record

Client’s Name: __________________________________Record #:____________________________ Year JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

Started Stopped Started Stopped Started Stopped Started Stopped Started Stopped Started Stopped Started Stopped Started Stopped Started Stopped Started Stopped Started Stopped Started Stopped Started Stopped Started Stopped Started Stopped Started Stopped Started Stopped Started Stopped Started Stopped Started Stopped


Height and Weight Record

Client’s Name: __________________________________Record #:____________________________

Year JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Height Weight Height Weight Height Weight Height Weight Height Weight Height Weight Height Weight Height Weight Height Weight Height Weight Height Weight Height Weight Height Weight Height Weight Height Weight Height Weight Height Weight Height Weight Height Weight

Information Source:

Recorder: (Name/Title/Date)

DMH 4-90-94 MRM 4-40-94 IMMUNIZATION RECORD

North Carolina Division ofMental Health, Developmental Disabilitiesand Substance Abuse Services

IMMUNIZATIONSIMMUNIZATIONS GIVEN PRIOR TO ADMISSION IMMUNIZATION DATES (SEE SOURCE FOR TYPE,

DTP (Diphtheria, Tetanus, Pertussis)Td (Tetanus, Diphtheria)TetanusPolioTuberculin Skin TestRubeola (Red Measles)MumpsRubella (German Measles)Other:Other

ALLERGIES SCREENINGSYES NO DATE NURSE SIGNATURE/TITLE TYPE DATE NURSE’S SIGNATURE/TITLE RESULTS

EGGS

FEATHERS

HORSE SERUM

TUBERCULOSIS SKIN TEST AND CONTROLS

DATE TIMETYPE

DOSAGE ROUTE SITE MANUFACTURER LOT # NURSE SIGN/TITLEGIVEN

READING IN MM OF INDURATION





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HEPATITIS B VACCINEDATE TYPE ADMINISTERED DOSAGE ROUTE SITE MANUFACTURER LOT # NURSE SIGN/TITLE

MISCELLANEOUS IMMUNIZATIONSDATE TYPE ADMINISTERED DOSAGE ROUTE SITE MANUFACTURER LOT # NURSE SIGN/TITLE

NAME:

NUMBER:

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Sample Table of Contents for a Medication/Pharmacy Policy and Procedure Manual

Administration of medications/treatments Admissions Control of medication keys Controlled drugs Conjunctivitis Cleaning/maintenance of hygiene supplies Drugs for off campus trips Drugs for school/work Drug storage Hand washing Medication administration records/treatment administration records Medication delivery Medication ordering Medication errors Medication refusal Notification of guardian Obtaining medical services Refrigerator storage Routine stock Self-Administration Training for staff in medication administration Unused drugs/drug recall


Guidelines for the Development of Medication Administration Policies and Procedures

It is recommended that the following items be considered in developing a facility’s policies and procedures for medication management. 1. Policies and Procedures

a. Frequency of review/revision of policies and procedures b. Consultation with pharmacist, registered nurse or prescribing practitioner c. Orientation of staff

2. Pharmacy Services (Dispensing Services)

a. Name of Pharmacy, address and phone numbers b. Contract (for homes licensed with 13 or more beds) c. Hours of Operations d. Delivery Schedule e. Emergency Services e.g. use of back-up pharmacy or “after hours” of pharmacy f. Medication Delivery System (Quantities to be dispensed and description of delivery system, i.e., 7 day unit dose, 30 day punch card, 30 day loose pak, 30 day unit dose, etc.) g. Non-contract Pharmacy provider (e.g., resident using outside pharmacy)

3. Consultant Services for Medication Review

a. Frequency of reviews and inspections b. Qualified health professional responsible for review c. Description of what review will involve, e.g., review of records, observation of medication

passes, inspection of medication storage areas, training/in-services for staff d. Documentation of medication review for each resident and other responsibilities e. Method of reporting discrepancies and recommendations from medication review f. Methods of documenting action taken, follow-up to reports by facility, physician, etc. g. Sample of forms used

4. Medication Staff (Identify who can administer medications and qualifications required)

a. Qualifications of unlicensed staff 1. Validation of Medication Administration Checklist 2. Training Requirements 3. Other requirements, i.e., CNA or HS diploma, facility training

b. Training/Inservices 1. Insulin 2. Psychotropics

c. Documentation and verification of qualifications – Where is it maintained 5. Methods used in receiving, recording, transcribing, maintaining and implementing of

physician’s written, verbal and telephone orders, including at least: a. Elements of complete order b. Clarification of orders, e.g. Documentation of clarification obtained c. Psychotropic orders d. Verbal/telephone orders


1. Procedures for taking verbal orders 2. Time lapse for obtaining prescribing practitioner’s signature 3. Maintaining copy

e. Admission/transfer orders 1. Verification of orders on FL2, i.e., when and who is responsible and documentation of

verification 2. Admission Orders 3. Readmission orders

f. Physician Order Sheets, (if used) 1. Frequency 2. Review by facility 3. Signature of prescribing practitioner

g. Written medication orders 1. Prescriptions 2. Fax Orders

h. Changes in medication orders, e.g., new orders and discontinuing orders i. Orders for and from outside agencies, e.g., home health

6. Ordering medications from pharmacy and documentation of same:

a. New orders b. Admission orders c. Refills d. Emergency or “after hours” of pharmacy

7. Time lapse for starting administration of new orders:

a. Emergency or stat orders b. Antibiotics c. Routine Medications

8. Medications for leave of absence

a. Methods of providing medications, e.g., for one administration time and multiple administration times

b. Forms 1. Documentation 2. Retention or filing of forms

9. Receipt of medications

a. Security – Who is authorized to receive deliveries? b. Verification of receipt from pharmacy, e.g., invoice, manifest, delivery sheet, etc. c. Medications brought in at admission or by families and used, e.g., documentation, forms, etc. d. Retention of records, e.g., by whom and for how long e. Reporting discrepancies

10. Medication labeling and packaging guidelines and requirements:

a. Prescription medications b. Non-prescription medications c. House Stock medications d. Samples supplied by prescribing practitioner


e. Medication label errors f. Medication label changes

11. Medication Administration: a. Medication Administration Record (MAR)

1. Methods of recording: a. Routine doses (not PRN) b. Omitted dose, refused doses, etc. c. PRN doses (i.e., justification and response) d. Signature equivalents of initials

2. Scheduled hours of administration (e.g., frequency and administration times-if order states tid – administration times 8 am, 12 noon and 4 pm.; insulin and oral hypoglycemic medications; medications prescribed in accordance with meals, ac and pc)

3. Procedures for identifying of residents, i.e., photos b. Step by step procedures for the administration of, including infection control:

1. Oral solid medications, e.g., tablets and capsules 2. Oral liquids 3. Sublingual medications 4. Oral Inhalers 5. Eye drops and ointments 6. Ear drops 7. Nose drops and Nasal sprays/inhalers 8. Topical or External medications, e.g., creams and ointments 9. Transdermal medications/patches 10. Nebulizers 11. Suppositories, i.e., vaginal and rectal 12. Enemas 13. Injections, i.e., infection control policies for syringes, site rotation and documentation

a. Insulin 1. Parameters for when to hold insulin and notification of supervisor or appropriate

health professional 2. Interventions for abnormal blood glucose readings

b. Other subcutaneous medications 16. Gastrostomy Tube

c. Crushing of solid dosage forms 1. Physician’s Order 2. Proper technique 3. Identification of medications that can not be crushed, e.g., Do Not Crush List

d. Self-Administration 1. Physician’s Order 2. Storage of medications 3. Monitoring of resident’s ability to self-administer and documentation of monitoring, e.g.,

form and who is responsible for monitoring e. Medications brought in by residents/families

1. How they are handled, e.g., obtaining medications (new orders or refills), change in medications

2. Labeling f. Medication Administration Errors

1. Definition of medication error


2. Methods of reporting and taking corrective action 3. Methods of analyzing

g. Steps to be taken, e.g., notification of supervisor or appropriate health professional, when routinely prescribed medications are frequently omitted, e.g. refused or unavailable and “prn”

or “as needed” medications are frequently administered 12. Disposition of medications

a. Release of medications to discharged residents, e.g., forms and documentation b. Storage of medications for destruction or return to pharmacy c. Methods of destruction

1. Omissions/Refusals or contaminated doses 2. Medications discontinued, expired or belonging to deceased resident

d. Staff or Health Professionals authorized to dispose of medications e. Records of disposition and retention of records f. Disposition of controlled substances

1. Omissions/Refusals or contaminated doses 2. Medications discontinued, expired or belonging to deceased resident

13. Medication storage

a. Security b. Internal and External Separation c. Who has access to medication storage areas, i.e., authorization of keys d. Refrigeration storage

1. Temperature 2. Separation of medications and food (when stored together)

e. Controlled Substances f. Medications in residents’ rooms

14. Controlled Substances

a. Method of accountability, i.e., declining count b. Reporting discrepancies c. Retention of records d. Storage and security

15. Quality Assurance (Methods of monitoring including frequency and staff and/or health professionals responsible for monitoring)

a. Monitoring MARs b. Monitoring /observing actual act of medication administration c. Monitoring controlled substance accountability d. Monitoring medication storage e. Monitoring qualification of medication staff f. Monitoring medication reviews and follow-up g. Tracking or review of identified problem areas and corrective action

16. Accepted abbreviations 17. Tables of weights and measures conversion 18. References for staff


Medication Error Report (Sample #1) Client’s Name: _____________________________Record #:__________________________________ Date/Time Error Occurred:____________________Date Report Completed: ______________________ Type of Error: __________ Wrong Client

__________ Wrong Medicine __________ Wrong Dose __________ Wrong Time

__________ Wrong Route __________ Wrong Recording __________ Wrong Medicine __________ Control Drug __________ Count Incorrect

State what happened: __________________________________________________________________ ____________________________________________________________________________________ Reasons for making errors: ______________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ What was the physician order? ___________________________________________________________ Supervisor/Nurse Notified: Date: _______________________ Time ____________________________ Comments: __________________________________________________________________________ Physician notified: Date:_________Time: ________ Who notified the physician? _________________ Comment____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Action Taken & Precautions to prevent a similar error: _______________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ __________________________________________ _______________________________________ Staff Submitting Report Date __________________________________________ _______________________________________ Staff Making Error Date __________________________________________ _______________________________________ Supervisor Date __________________________________________ _______________________________________ Physician Signature (if required) Date


Medication Error Report (Sample #2) Date of Report: ____________________ Client: ____________________________________Physician: _________________________________ (Last Name First) Room No. ________ Date of Error: ________________Time of Error: _________ A.M.________ P.M. Medication Given: ____________________ Dosage Given: _____ Route of Admin: _______________ What was Physician’s order? ____________________________________________________________ What was your source of information regarding the medication given? MAR Chart Verbal Order

Reason for making error: _______________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ What is the actual effect of the error made on the client? ______________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ How was the error discovered? __________________________________________________________ By whom? _______________________________________When? ______________________________ Who notified the physician? ________________________When? ______________________________ Has Physician seen the client since the error was made? Yes _______ No_________ What precautions can you take to prevent a similar error?______________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Signature of staff making error _________________________________ Date____________________ Signature of supervisor ________________________________________ Date____________________ Physician Signature___________________________________________ Date____________________ (if required)


Medication Error Report (Sample #3) Date of Report: _____________________________ Client: ____________________________________Physician: _________________________________ (Last Name First) Date of Error: ______________________________Time of Error: ___________ A.M.__________P.M. Medication Given: __________________________Dosage Given: _____________________________ Route of Administration: _______________________________________________________________ What was Physician’s order? ____________________________________________________________ What was your source of information regarding the medication given? MAR Chart Verbal Order

Reason for making error: _______________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ What is the actual effect of the error made on the client? ______________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ How was the error discovered?___________________________________________________________ By whom? ________________________________ When? ___________________________________ Who notified the physician? ___________________ When? ___________________________________ Has Physician seen the client since the error was made? Yes _______ No_________ What precautions can you take to prevent a similar error?______________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Signature of staff making error _________________________________ Date____________________ Signature of supervisor ________________________________________ Date____________________ Physician Signature___________________________________________ Date____________________


MEDICATION ADMINISTRATION RECORD (MAR)

Medications Hour

Charting for the month of: through Physician Telephone # Medical Record #:

Alt. Physician: Alt. Physician Telephone #:

Allergies: Rehabilitation Potential:

Diagnosis: Admission Date:

Resident’s Name: Room and bed #:

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31


Instructions: Result Codes: Injection/Patch Site Codes: A. Put initials in appropriate box when medication given 1 Effective 1 -Right dorsal gluteus 7 -Right deltoid B. Circle initials when medication refused 2 Ineffective 2 -Left dorsal gluteus 8 -Left deltoid C. State reason for refusal on Nurse’s Notes 3 Slightly Effective 3 -Right upper chest 9 -Right upper arm D. PRN medication: Reason given should 4 No Effect Observed 4 -Left upper chest 10 -Left upper arm be noted on Nurse’s Notes 5 -Right lateral thigh 11 -Upper back left E. Indicate injection site (code) 6 -Left lateral thigh 12 -Upper back right

NURSE’S MEDICATION NOTES (Back of MAR)

Temperature Respiration Pulse Blood Pressure

Initials Nurse’s Signature Initials Nurse’s Signature Charting Codes: A. chart error B. drug unavailable C. resident refused D. drug held E. dose contaminated F. out of facility G. see notes H. drug holiday

Date/Hour Medication/Dosage Route Reason Initials Results/Response Initials

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31


Medication Release Form (This form is used for leave of absences and discharges)

Facility Name: _______________________________________________________________________

Client: ____________________________________Room/Unit: _______________________________

Proposed Date of Departure: __________________Proposed Date of Return: _____________________

____________Day(s) Supply of the Following Medication(s) Provided:

Medication Strength Directions Quantity On

Leaving Quantity Returned

1. 2. 3. 4. 5. 6. 7. 8.

.................................................................................................................................... Staff: Instruct responsible party (may be the person who self-administers the medication) to:

1. Read all directions carefully. 2. Store all medication out of the reach of children. 3. Give and take each dose exactly as ordered by physician. 4. Check medication to assure amount will last until client returns. 5. Return any unused medication. 6. Other:

Staff Signature: _____________________________________ Date: ___________________________ ....................................................................................................................................

I have been instructed in the proper usage, dosage, frequency and reason for the medication dispensed. I accept responsibility for the medication and will assure that it is properly stored and that it is properly administered. I understand that in the event that the drugs are accepted in non-child proof containers I hereby release the facility named above and the pharmacy from responsibility. Responsible party’s signature (may be the person who self-administers the medication) Date: _____________ Relationship ______________________________________________________ ....................................................................................................................................

Drugs returned: _______________________________________________________________________ Date and Time: _____________________________Staff Signature: _____________________________


Appendix for Trainers Section Appendix 1 The Path and Effects of Medication

The pathway medication takes from the time it enters the body until it produces its effect is complex. Oral medication is taken into the body and travels the same route as food. It starts in the mouth and travels to the stomach by way of the esophagus. Although some medications begin absorption into the blood stream while they are still in the stomach, most medications are absorbed from the upper part of the small intestine. Some medications are covered with special enteric coatings to prevent their digestion in the stomach and keep them from causing irritation. After medications are absorbed through the stomach lining or intestinal walls it enters the blood stream.

The blood stream is the transporting system for the whole body. For this reason, physicians will often order blood tests to find out how well organs are functioning and the effect the medication is having. However, the presence of medication in the bloodstream does not necessarily mean that it produces immediate effects. Once the medication has been absorbed into the bloodstream, it must still make its way into the fluids that bathe the tissues. The medication must reach a certain concentration before it can exert its effects on the cells.

The Important Role of the Liver and Kidneys

Eventually the medication is transported to the liver, the single most important site of medication detoxification (converts medication to a harmless substance). Although medications can be excreted (eliminated) by many routes including kidneys, lungs, sweat glands, saliva and mammary glands—the kidneys are the most important organs for removal of medication from the body. The kidneys filter the medication and, in time, all the medication is eliminated from the body in the urine. As you can see, the pathway for medication is complex. Any breakdown can significantly alter medication response. For instance, if the kidneys were damaged and could not excrete this medication, there would be a buildup of the medication and possibly a toxic effect. This is one reason to observe the client for any changes while taking any medication.

Individual Differences in Medication Outcome

Medications, even when properly prescribed and administered, can have several possible outcomes. Clients react differently to medication. In some clients, the medication effect may be unexpectedly potent (strong) while others will show little, if any, response to the same dose. In fact, the same client may react in quite different ways when she/he receives the identical dose at different times.

Factors that Influence Medication Response

1. Body weight: Generally speaking, the more a client weighs the more diluted the medication becomes in the body and the smaller the amount of medication that accumulates in the targeted tissues. The less a client weighs the greater the amount of medication that concentrates in the tissues and the more powerful is the effect of the medication. The dosage is often calculated and administered on the basis of the ratio of milligrams (mg) of the medication to the kilograms (kg) of the client’s body weight.


2. Age: The age of a client will affect his/her response to medication. Different age groups vary in their ability to eliminate medication. Very young infants may not have the liver enzyme system for breaking down certain medications. Because the elderly usually experience a decrease in the function of some organs, smaller doses of medications may be required. It is not uncommon to see bizarre, unpredictable reactions to medications given to older people (especially with sedatives).

3. Sex: The sex of a client sometimes affects the response to medication. This is due to two factors: the

difference in the distribution of fat and water and the difference in size. Women usually have more fatty pads than men, and men have more body fluid than women. Some medications may be more soluble in fat and others are more soluble in water.

4. Pregnancy and lactation (breast feeding): The most important consideration when medication is

ordered for a woman of childbearing age is that she may be pregnant and the medication may affect the fetus. Medication taken by the mother may enter the milk and be swallowed by a breastfeeding baby.

5. Genetic factors: Clients may react differently as a result of inherited factors. For example, a client

may be abnormally sensitive to a medication or have a different medication metabolism. This is why it is important to obtain family histories of medication sensitivities and/or allergies.

6. Psychological factors: The way a client feels about a medication and what one believes it can do are

major factors in the effect of a medication. If a client has no confidence in the medication, chances are the medication will not work as well.

7. Illness/disease: Illness and disease can affect the action of medications upon a Client. For example, a

client who has severe pain may require more pain medication than someone who has less pain. A person with kidney disease may not excrete medications like a healthy person and the medication may build up in the body causing an overdose.

Three Broad Effects of Medication

1. Desired effects When the prescribed medication is working correctly, the medication is producing the desired effect.

The desired effect is what we want the medication to accomplish. Reducing seizure activity with Dilantin, eliminating a headache with aspirin and preventing polio with oral vaccine are all examples of desired effects.

2. Side effects

Whether or not the desired effect occurs, there is always the possibility that side effects will also occur. Side effects are effects produced by the medication other than the one for which it was prescribed. Side effects may be expected and predictable (such as drowsiness when taking seizure medication) or completely unexpected and unpredictable. Side effects can be relatively harmless (such as urine discoloration from Dilantin) or potentially fatal (such as severe allergic reaction to penicillin). Side effects may show up as physical or behavioral changes. These changes may be readily observable, such as a rash, diarrhea, vomiting or fainting, or harder to discern, such as lightheadedness, blurred vision or dryness of the mouth. As a staff member involved in medication administration, it is your responsibility to observe and report all effects to the nurse or supervisor.


When a client is first exposed to a foreign substance, the body may develop a reaction called an “allergic reaction”. Allergic reactions can also occur after later exposure to the medication even if it is several months to years after the first prescription. For example, a client takes penicillin for an infection and no reaction occurs. Several years later penicillin is again prescribed and the client develops a rash. This is also an allergic reaction. Allergic reactions can be mild or severe. A mild reaction might show up as a skin rash, diarrhea, itching, watery discharge from the nose, tearing or nausea. Reactions can occur anytime from a few hours to two weeks after the administration of a medication.

A severe allergic reaction known as anaphylactic shock usually occurs immediately after the administration of the medication. This response can be fatal if symptoms are not reported immediately and assistance is obtained. The earliest symptoms are irritability, extreme weakness, nausea, and vomiting, which are followed quickly by wheezing, tongue swelling, acute shortness of breath, low blood pressure and death.

3. No apparent desired effects

Different medications require various amounts of time before their full benefit is expected. However, sometimes there is no apparent effect from taking the medication. The term no effect is self-descriptive. After allowing the typical amount of time for a medication to begin showing an effect, the client still shows no effect from taking the medication. For example, aspirin may be prescribed every four hours for a fever. After 24 hours, the fever remains unchanged. It is important for the physician to know if there is no effect. The physician may then prescribe an alternate medication with the same desired effect, change the dosage of the present medication, etc.

Medication Interactions

Whenever a client is taking more than one medication, interactions may occur. “Medication interactions” are effects resulting from the combination of two or more substances (such as medications, alcohol, food, etc.) that produce changes different from the effect of each substance alone. The resulting interaction may be:

Example: Sue has been on Coumadin to prevent blood clots. Today she has a headache and is given two aspirin. Four hours later she still complains of a headache, staff gives her another two aspirin. That evening as she is brushing her teeth, she notices that her gums are bleeding and it takes longer for the bleeding to stop.

Example: David recently saw the doctor for a sinus infection. He has been taking the medication Tetracycline regularly for one week now; but his infection doesn’t seem to go away. When asked about what he takes the medication with, he replies “a big glass of milk”. 1. Potentiation – an increase in the effect of one or more of the medications. (When a person is on any

anticoagulant such as Coumadin, caution is needed when giving any dose of aspirin, since it will cause the person to bleed more easily and be harder to stop the bleeding. Aspirin is not recommended for persons on anticoagulants. However, occasional use may be possible, but only under the direction of a physician.)

2. Antagonism – a decrease in the effects of one or more of the medications. (When taking Tetracycline

and milk together, the milk will bind with the Tetracycline and result in the medication not being absorbed.)


3. Unique effect – Some combinations of medications produce new and unique effects. Sometimes the

effect will be a different action than what either of the medications usually has. Think about what happens when you mix blue and yellow food coloring in water. You get green water. In the same way, two or more different medications given together may have an effect different than either one of them alone.

Two Important Points to Remember Concerning Medication Interactions

1. The greater the number of medications taken at one time, the greater the possibility that a medication interaction will occur.

2. By being notified of what medication a client is now taking, the physician can prescribe a new medication that has the best chance of being compatible with the current medication.

While the examples emphasize unwanted medication interactions, staff should be aware that medication might be prescribed together in order to produce a desired interaction. An example of this is the medication Diamox. It is usually given for glaucoma, but when given with certain seizure medications it will potentiate (increase) the effect of the anticonvulsant so that a much smaller dose can be given.

Observe and Report all Suspected Effects of Medication

The important thing to remember is that any change (physical or behavioral), especially during the first few days of a new medication, may have been caused by that medication. As a direct service staff member, you are the person best able to observe for any behavioral or physical changes. In fact, it is up to you to observe and report any and all suspected effects of medication.

Medication Names

One medication can have many different names. The chemical name is the one by which a chemist can precisely identify the components of the medication.

Because several companies may sell one medication, it can have several trade or brand names. The generic name is the common name given before trade names are adopted. The family or category describes the general purpose of the medication. Medications sold under the generic name are usually less expensive than those sold under a trade name. The medication is chemically the same and most of the time the effect is the same. Pharmacists are required to dispense the generic medication to clients who receive Medicaid funds from the Social Security Act, unless the prescribing physician indicates otherwise.

Example:

Trade or brand name Tylenol, Tempra Generic name (classification) acetaminophen Chemical name 4#-hydroxacetanilide Family or category analgesic (Pain Relief)

Summary

Medications can affect every organ of the body. Prescribing medications is a very complex task and can only be done by a physician, dentist or those advanced practice professionals with prescriptive


privileges. Even then, the effect of the medication may be different for each person depending on his or her age, sex, weight, health, heredity and feelings.

As a staff member you are responsible for:

1. Applying the six rights - client, dose, time, route, medication and documentation. 2. Observing what effect occurs - desired, side or no apparent effect. 3. Reporting the information to the health professional/supervisor.


Appendix 2 PRN Medications and Behavior

Most of the time medication does not serve as a long-term, complete solution to behavior problems. At the same time, medication can be used appropriately and effectively as a part of a comprehensive plan. Look at the example and decide if some type of medication would be appropriate in this situation.

Example: Betty Mixon has just started work at a factory. The machine she operates was adapted to fit

both Betty and her wheelchair, and for the first couple of weeks she had a good work record. Recently, she has seemed to become much more irritable. She gets upset if she is criticized in any way, and if she makes a mistake, she yells and throws things. The staff has no idea why she has shown such a dramatic change in behavior. They’ve decided to meet and discuss what to do.

Based on our limited information, we obviously can’t decide, but there are a few considerations we can address.

Consideration One: Is Medication a First Choice?

Almost never. It would be much more appropriate for staff to look at Betty’s work environment for possible cause(s) of behavior seen as challenging. Have they given her the appropriate supports to do her job? Have they inadvertently paid too much attention to her (reinforced her) when she acts agitated? An environmental change, which can be designed to change a specific behavior, would almost always be preferable to the use of a medication.

Medications:

• May also affect behaviors other than the one intended • Require a more complicated procedure involving physicians, nurses, the people who care about and

understand her and others • Have the potential of reinforcing an image of the client as sick or diseased

Conclusion: Medication intervention is not usually a “first choice” solution. Consideration Two: Is Medication a Permanent Solution?

Not usually. Medication is effective in controlling or influencing challenging behavior only as long as it is taken. Unlike medications such as antibiotics, which may actually eliminate the cause of the problem (kill the germs or eliminate the infection), behavior- controlling medication only temporarily controls behavior. Even if a tranquilizer might decrease Betty Mixon’s aggressive behavior, we should not be surprised to see the aggressive behavior increase after the medication is removed.

Conclusion: Medication intervention is not a permanent solution. Consideration Three: Is Medication a Complete Solution?

Again, not usually. Even if medication is effective, it would not serve as a complete solution to the problem. Betty must also learn socially appropriate and effective ways of dealing with criticism and failure. The most we can expect of the medication is that it might decrease challenging behavior; however, we cannot expect appropriate, adaptive behaviors to “automatically” appear.


Conclusion: A “complete” solution to challenging behaviors involves effort on the part of staff as well as the person herself. Is the person being treated respectfully? Does the care plan reflect the person's life goals? Is the environment comfortable and supportive? Is the person included when making plans to help decrease challenging behavior? Is a systematic teaching program in place? Is the person participating in the teaching program? It is important to consider these and other issues and to ask, “Why are we recommending the prescription of a medication?” Is it for staff benefit, or the client’s? What are the alternatives?

As you consider the examples in this chapter, remember that not all medications used to modify behavior are psychotropic medications. The key to determining if medication is a behavior modifying medication is the intended or desired effect of the medication. These three considerations apply to any medication prescribed with the intent to change behavior.


Appendix 3 10A NCAC 27G .0209 MEDICATION REQUIREMENTS (a) Medication dispensing: (1) Medications shall be dispensed only on the written order of a physician or other practitioner licensed to prescribe. (2) Dispensing shall be restricted to registered pharmacists, physicians, or other health care practitioners authorized by law and registered with the North Carolina Board of Pharmacy. If a permit to operate a pharmacy is not required, a nurse or other designated person may assist a physician or other health care practitioner with dispensing so long as the final label, container, and its contents are physically checked and approved by the authorized person prior to dispensing. (3) Methadone for take-home purposes may be supplied to a client of a methadone treatment service in a properly labeled container by a registered nurse employed by the service, pursuant to the requirements of 10A NCAC 26E .0306 SUPPLYING OF METHADONE IN TREATMENT PROGRAMS BY REGISTERED NURSE. Supplying of methadone is not considered dispensing. (4) Other than for emergency use, facilities shall not possess a stock of prescription legend drugs for the purpose of dispensing without hiring a pharmacist and obtaining a permit from the NC Board of Pharmacy. Physicians may keep a small locked supply of prescription drug samples. Samples shall be dispensed, packaged, and labeled in accordance with state law and this Rule. (b) Medication packaging and labeling: (1) Non-prescription drug containers not dispensed by a pharmacist shall retain the manufacturer's label with expiration dates clearly visible; (2) Prescription medications, whether purchased or obtained as samples, shall be dispensed in tamper-resistant packaging that will minimize the risk of accidental ingestion by children. Such packaging includes plastic or glass bottles/vials with tamper-resistant caps, or in the case of unit-of-use packaged drugs, a zip-lock plastic bag may be adequate; (3) The packaging label of each prescription drug dispensed must include the following: (A) the client's name; (B) the prescriber's name; (C) the current dispensing date; (D) clear directions for self-administration; (E) the name, strength, quantity, and expiration date of the prescribed drug; (F) the name, address, and phone number of the pharmacy or dispensing location (e.g., mh/dd/sa center), and the name of the dispensing practitioner. (c) Medication administration: (1) Prescription or non-prescription drugs shall only be administered to a client on the written order of a person authorized by law to prescribe drugs. (2) Medications shall be self-administered by clients only when authorized in writing by the client's physician. (3) Medications, including injections, shall be administered only by licensed persons, or by unlicensed persons trained by a registered nurse, pharmacist or other legally qualified person and privileged to prepare and administer medications. (4) A Medication Administration Record (MAR) of all drugs administered to each client must be kept current.


Medications administered shall be recorded immediately after administration. The MAR is to include the following: (A) client's name (B) name, strength, and quantity of the drug (C) instructions for administering the drug (D) date and time the drug is administered; and (E) name or initials of person administering the drug (5) Client requests for medication changes or checks shall be recorded and kept with the MAR file followed up by appointment or consultation with a physician. (d) Medication disposal: (1) All prescription and non-prescription medication shall be disposed of in a manner that guards against diversion or accidental ingestion. (2) Non-controlled substances shall be disposed of by incineration, flushing into septic or sewer system, or by transfer to a local pharmacy for destruction. A record of the medication disposal shall be maintained by the program. Documentation shall specify the client's name, medication name, strength, quantity, disposal date and method, the signature of the person disposing of medication, and the person witnessing destruction. (3) Controlled substances shall be disposed of in accordance with the North Carolina Controlled Substances Act, G.S. 90, Article 5, including any subsequent amendments. (4) Upon discharge of a client or resident, the remainder of his or her drug supply shall be disposed of promptly unless it is reasonably expected that the client or resident shall return to the facility and in such case, the remaining drug supply shall not be held for more than 30 calendar days after the date of discharge. (e) Medication Storage: (1) All medication shall be stored: (A) in a securely locked cabinet in a clean, well-lighted, ventilated room between 59º and 86º F.; (B) in a refrigerator, if required, between 36º and 46º F. If the refrigerator is used for food items, medications shall be kept in a separate, locked compartment or container; (C) separately for each client; (D) separately for external and internal use; (E) in a secure manner if approved by a physician for a client to self-medicate. (2) Each facility that maintains stocks of controlled substances shall be currently registered under the North Carolina Controlled Substances Act and shall be in compliance with the North Carolina Controlled Substances Act, G.S. 90, Article 5, including any subsequent amendments. (f) Medication review: (1) If the client receives psychotropic drugs, the governing body or operator shall be responsible for obtaining a review of each client's drug regimen at least every six months. The review shall be to be performed by a pharmacist or physician. The on-site manager shall assure that the client's physician is informed of the results of the review when medical intervention is indicated. (2) The findings of the drug regimen review shall be recorded in the client record along with corrective action, if applicable. (g) Medication education: (1) Each client started or maintained on a medication by an area program physician shall receive either oral or written education regarding the prescribed medication by the


physician or their designee. In instances where the ability of the client to understand the education is questionable, a responsible person shall be provided either oral or written instructions on behalf of the client. (2) The medication education provided shall be sufficient to enable the client or other responsible person to make an informed consent, to safely administer the medication and to encourage compliance with the prescribed regimen. (3) The area program physician or designee shall document in the client record that education for the prescribed psychotropic medication was offered and either provided or declined. If provided, it shall be documented in what manner it was provided (either orally or written or both) and to whom (client or responsible person). (h) Medication errors. Drug administration errors and significant adverse drug reactions shall be reported immediately to a physician or pharmacist. An entry of the drug administered and the drug reaction shall be properly recorded in the drug record. A client's refusal of a drug shall be charted. History Note: Authority G.S. 90-21.5; 90-171.20(7),(8); 90-171.44; 122C-26; 143B-147; Eff. May 1, 1996; Recodified from 10 NCAC 14V .0207 to 10 NCAC 14V .0209 Eff. January 3, 2001.


Appendix 4 Seizure Management Seizure management is taught in both AHA First Aid and in ARC First Aid and there is a seizure record on pages A-11 and A-12 of the instructor's manual. The instructor will teach insertion of rectal medications such as suppositories, enemas, and the syringe method, especially if a client has been ordered Diazepam rectal gel (Diazepam rectal gel is commonly used in seizure emergency treatment plans. It is safe and effective in terminating seizures and reduces the time to treatment and the need for emergency department visits when used and can be administered by professional medical personnel or trainees who have completed this course.) If the instructor is not familiar with seizure management they can obtain a copy of an AHA book or take the ARC course on seizure management. They need to review the protocol/procedure of the agency that they are contracting with. Three free videos for teaching, especially the first site, which provides step by step instructions and then reviews each step again at the end of the film. 1. http://www.youtube.com/watch?v=ZWvttgYRqD8 2. http://www.youtube.com/watch?v=_HnAhYtDsgI&feature=channel 3. http://www.monkeysee.com/play/7021-how-to-treat-a-victim-having-a-seizure


Available Trainers of Medication Administration: A Course for Unlicensed Personnel in Community Facilities

As a service to agencies and trainers like you, NC Division of Mental Health is willing to keep an informal list of those who are have successfully completed this course who are available to train unlicensed staff using this curriculum. You must be licensed in the state of North Carolina as a Registered Nurse, Pharmacist, Physician or a Physician Assistant to provide this training. Being on the list is not an endorsement by the state or AHEC, and does not indicate that you are willing to accept all requests to provide training but it would indicate your interest in providing this training. Please complete this form if you are qualified to present the curriculum and would like to be on the list.

Please Print Clearly all your information on this form. Contact Information: Salutation: Dr. Mr. Mrs. Ms. _______________________ ___________ ________________________________

First Name Middle Initial Last Name _________________________________________ _________________ ____________ ___________

Preferred Address City State Zip Code __________________ (_____ ) _________________ (______ ) _________________

Home County Phone Number Fax Number

Email: ____________________________________________________________________________________

Degree or Education (BSN, MSN, MD, PharmD, PA):_______________________________________________

Clinical Specialty ____________________________________________________________________________

Age of typical clients/patients: Infant/Neonatal Adolescent Toddler Adult Child/Youth Geriatric

Licensure details: What is your license to practice? ________________________________ License number: ________________ (Registered Nurse, Pharmacist, Physician, Physician Assistant)

Availability: How far from home could you travel to provide training on the curriculum? ________________________ miles

Would you need to charge a fee to provide the training? Yes No Under these conditions____________________________________________________

Please return this information to DMH/DD/SAS Communication & Training Team FAX: 919-733-1221, or Email: [email protected]

Medication Administration: A Course for Unlicensed Personnel in Community Facilities B-i

TABLE OF CONTENTS - SECTION "B" Medication Administration - Trainee Materials

Trainee Materials for Medication Administration - A Course for Unlicensed Personnel in Community Facilities ................................................................................................................ B-1

Purpose and Introduction ................................................................................................................B-1 Agency and Instructor Responsibilities ..........................................................................................B-1 Client Role .........................................................................................................................................B-1 Instructor Qualifications..................................................................................................................B-1 Trainee Qualifications ......................................................................................................................B-1 Course Length...................................................................................................................................B-2 Written Examination........................................................................................................................B-2 Continuing Education.......................................................................................................................B-2 Maintaining Quality Control ...........................................................................................................B-2

Unit 1 - Medication Administration is a Serious Responsibility ........................................... B-2 Important Reasons for this Course .................................................................................................B-2 Direct Service Staff do Not Make Medication Judgments ............................................................B-2 The Medication Process Provides Opportunities for Teaching and Learning............................B-2 Encourage the Client to Take an Active Role in All Stages in the Medication Process..............B-4 Teaching Independence and Being Person-Centered ....................................................................B-4 Age Appropriate Manner.................................................................................................................B-4 Independence.....................................................................................................................................B-5 Person-Centered................................................................................................................................B-5 Decisions are Made by a Team ........................................................................................................B-5 Know and Observe Effects of Medication Administration ...........................................................B-5 Your Responsibility is to Observe and Report Change, Not to Diagnose....................................B-5 Develop a Keen Observational Sense ..............................................................................................B-6 Be Alert to Changes in Health Patterns..........................................................................................B-7 Summary ...........................................................................................................................................B-7

Unit 2 - Staff Responsibility...................................................................................................... B-8 The Medication Cycle has Five Areas.............................................................................................B-8 Staff Member Responsibility in the Cycle ......................................................................................B-8 Staff has Four Broad Responsibilities Regarding the Medication Process .................................B-9 Knowing and Adhering to Laws and Agency Policies ...................................................................B-9 Completion of this Medication Course is Only Part of Your Training........................................B-9 Prescription and Non-Prescription Medication .............................................................................B-9 No Medication is Harmless ..............................................................................................................B-9 Federal and State Law......................................................................................................................B-9 Food and Drug Act .........................................................................................................................B-10 Controlled Substances ....................................................................................................................B-10 General Guidelines .........................................................................................................................B-10

Unit 3 - Six Rights of Medication Administration.................................................................B-11 Most Medication Errors are Made Because One of the Six Rights was Not Observed............B-11

1. Right Client ..............................................................................................................................B-11

Medication Administration: A Course for Unlicensed Personnel in Community Facilities B-ii

2. Right Dose ................................................................................................................................B-11 3. Right Time................................................................................................................................B-12 4. Right Route ..............................................................................................................................B-13 5. Right Medication .....................................................................................................................B-14 6. Right Documentation ..............................................................................................................B-14

Medical Administration Record is a Legal Document.........................................................B-14 Summary .........................................................................................................................................B-14

Unit 4 - Administration Procedures........................................................................................B-15 Oral, Sublingual, and Buccal Medication Administration..........................................................B-15 Table 1. Procedure for Oral Medication Administration ...........................................................B-15 Table 2. Procedure for Liquid Medication Administration........................................................B-18 Procedure for Sublingual Medication Administration................................................................B-19 Procedure for Buccal Medication Administration.......................................................................B-19 Legal Issues......................................................................................................................................B-19 Best Practice Guidelines .................................................................................................................B-19 Medication Administration Record...............................................................................................B-19 Medication Administration Record - Front Sample....................................................................B-21 Nurse’s Medication Notes - Back of MAR Sample ......................................................................B-22

Unit 5 - Special Medication Procedures .................................................................................B-23 Procedure for New Medication/Changes in Medication .............................................................B-23 Discuss Medication Change with Client .......................................................................................B-23 Physician's Order Information......................................................................................................B-23 Procedure for When the Client is Away From Agency ...............................................................B-24 Procedure for Verbal Orders.........................................................................................................B-24 Procedure for PRN Medication .....................................................................................................B-25 Over The Counter Medication.......................................................................................................B-25 Other Procedures for Medication Administration ......................................................................B-25 Provide Privacy for Client .............................................................................................................B-26 Proper Techniques for Administrating Medications...................................................................B-27

Two Methods for Crushing Medication ....................................................................................B-27 Technique for the Proper Administration of Ear Drops to Adults .........................................B-28 Technique for Proper Administration of Eye Drops to Adults ...............................................B-29 Technique for Proper Administration of Eye Ointment to Adults .........................................B-30 Technique for the Proper Administration of Fleets Enemas...................................................B-31 Technique for the Proper Administration of Metered Dose Inhalers.....................................B-32 Technique for the Administration of Medication Using a Metered Dose Nasal Pump .........B-33 Technique for the Proper Administration of Nebulizer Treatments ......................................B-34 Technique for the Proper Administration of Nose Drops or Nose Sprays to Adults ............B-35 Technique for the Proper Administration of Rectal Suppositories ........................................B-36 Technique for the Proper Administration of Topical Medications.........................................B-37 Technique for the Proper administration of Transdermal Patch ...........................................B-38 Technique for the Proper Administration of Vaginal Medication..........................................B-40

Unit 6 - Special Issues in Medication Administration...........................................................B-41 Assisting the Client Who has Difficulty Swallowing....................................................................B-41 Adhering to Time Span ..................................................................................................................B-41

Medication Administration: A Course for Unlicensed Personnel in Community Facilities B-iii

Assisting Clients Who Refuse Medication ....................................................................................B-41 Clients Who Continue to Refuse....................................................................................................B-42 Errors in Medication Administration ...........................................................................................B-42 A Medication Error has Occurred If: ...........................................................................................B-42 When an Error Occurs...................................................................................................................B-43 Learning from Mistakes .................................................................................................................B-43

Unit 7 Medication Observation ...............................................................................................B-44 Four broad responsibilities in monitoring medications...............................................................B-44 Table 3. Common medication categories & side effects ..............................................................B-45 Commonly used scheduled drugs ..................................................................................................B-46 Common central nervous system drugs (psychotropic drugs) by therapeutic class .................B-46

Antidepressants in the Elderly.........................................................................................................B-48 Antipsychotics in the Elderly ....................................................................................................B-49 Hypnotics in the Elderly............................................................................................................B-50 Mood Stabilizers in the Elderly ................................................................................................B-51 Anti-Anxiety in the Elderly .......................................................................................................B-52 Appendix..........................................................................................................................................B-53 Abbreviations ..................................................................................................................................B-53 *ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations .......................B-54 Measuring Tips ...............................................................................................................................B-56 Glossary ...........................................................................................................................................B-57


Medication Administration: A Course for Unlicensed Personnel in Community Facilities B-1

Trainee Materials for Medication Administration - A Course for Unlicensed Personnel in Community Facilities

Purpose and Introduction

This course is designed to provide basic information on medication training for unlicensed personnel. It is a generic training course based on a best practices approach. This instruction is designed to insure the competency of those staff members who administer medications to clients in community facilities and adult care homes. Successful completion of this course minimally prepares unlicensed personnel to administer medications by oral, topical, rectal, sublingual, inhalation and instillation methods. The course does not include any clinical observations.

Agency and Instructor Responsibilities

Each agency is responsible for providing clinical training and observations on an ongoing basis to evaluate the competency of the staff giving medications. The instructor should inform the employing agency of participants’ successful completion of the course. This training does not license, register or certify the trainee. Each agency, as noted above, is responsible for evaluation of skills and competencies and the delegation of duties related to medication administration within its own agency. These credentials are not transferable outside the employing agency. This manual is designed to meet the training requirements for medication administration for Intermediate Care Facility for Persons with Mental Retardation (ICF-MR) and supervised living for adults with developmental disabilities (DDA group homes) and adults with mental illness. This manual may also be used for medication administration training in adult care homes. Please refer to licensing regulations specific to your facility for additional information on medication administration, procedures and reporting policy.

Client Role

Independence and increased participation by the client in the medication process should be a primary goal for all consumers. A comprehensive functional assessment for each client should include his or her ability to participate in the medication cycle.

Instructor Qualifications

The instructor should be licensed and competent to prepare and administer medications to consumers. A registered nurse knowledgeable in the North Carolina Nurse Practice Act and other licensing regulations which impacts the process of medication administration is highly recommended. Other instructor options include a pharmacist or physician. The instructor should have knowledge of regulations applicable to the work setting.

Trainee Qualifications

The trainee is an unlicensed person working in a program who is required to administer medications to consumers. The trainee must: • Be 18 years of age or older • Have a High School Diploma or passed the GED • Read and write fluently in English • No criminal record


Course Length This course will vary in length depending on the type, number, and needs of the clients in each agency facility. Instruction of the initial course is projected to take a minimum of six to eight hours to complete.

Written Examination

The written examination completed by each trainee requires a score of 80 or better. The clinical performance checklist provided in Section II of this curriculum may be used by the agency to evaluate clinical performance skills.

Continuing Education

The employing agency will be responsible for providing on-going training to all staff administering medication (group homes, workshops, etc.) regarding new medications, treatments, policies and procedures, which are facility specific. All training provided shall be documented for future reference. The performance of the person administering medications should be evaluated on an on-going basis and training provided as needed. Each agency will be responsible to insure that annual updates and continuing education requirements, as required for the agency, are met.

Maintaining Quality Control

It is recommended that course contents be reviewed at least every five years by qualified professional staff from designated facilities. Community representatives should be included in this evaluation process.


Unit 1 - Medication Administration is a Serious Responsibility

Important Reasons for this Course A medication treatment program needs many people to make it work: 1. The physician who prescribes a medication. 2. The provider or vendor pharmacist who fills the prescription. 3. The consultant pharmacist who helps monitor the beneficial effect of the medication versus

any side effects. 4. The licensed nurse who monitors the physical/emotional well being of the client and

reports changes to the physician. 5. The staff member who observes for changes in the client and reports to the nurse or

supervisor (or the appropriate health professional according to the agency policy).

Example: David lives in a group home. He has seizures three to four times a month. He currently takes Dilantin. A staff member of the group home noticed David was unsteady when he came out for breakfast this morning. The staff reported it to the nurse. The nurse recognized the unsteadiness as a possible side effect of Dilantin. Although David was not due to see the physician for another month, the nurse called to inform the physician of the observation. The physician requested a laboratory test to see if David’s blood level of Dilantin was too high. The test revealed that it was high so the physician prescribed a lower dose of Dilantin. The pharmacist sent out the new prescription and David’s unsteadiness decreased and gradually disappeared. Everyone involved in a medication treatment program must do his or her part consistently and carefully. Any questions on a medication treatment program must be forwarded to the appropriate health professional (nurse, pharmacist, etc.)

Direct Service Staff Do Not Make Medication Judgments

As a direct service staff member you are NOT to make judgments about medications, only to observe and report. Remember: 1. A pharmacist, physician or advanced practice professional, such as a family nurse

practitioner or physician’s assistant, are the only persons qualified to dispense drugs to a client or facility. He/she is also the only one who may label medications or change a label.

2. Those advanced practice professionals with prescriptive privileges are the only people qualified to prescribe medication.

3. The staff cannot administer medications to a client without a physician order. However, the staff must know enough about how medication works to understand what the physician is trying to accomplish with the medication. Observations, when accurately reported, are invaluable to the physician in the treatment of a client.

4. Direct service staff are responsible for monitoring clients who self administer their medications. On-going assessment of the client’s understanding of their medication needs and capabilities is critical to fostering independence and ensuring compliance with medications. Clients residing in licensed facilities must have an order to self administer their medications.

The Medication Process Provides Opportunities for Teaching and Learning

Many people assume a client with disabilities is totally dependent and has little to offer in the medication process. Counteract this attitude by working with the client to become as independent as possible and by providing an appropriate role model for health care professionals. Although clients


will vary in their abilities to participate, they should be involved to the best of their ability. When people assume responsibility for their own medication, it increases their sense of independence and self worth.

Example: Mary, an adult with a history of developmental disabilities, lives in an adult residential

setting. During the past month, staff reminded Mary only once to take her prescription medication. Mary selects the correct container from the tray, states the name and purpose of the medication, and takes the correct dose without assistance while staff observe. Staff assists Mary to order a refill over the telephone when she is down to a three or four day supply. Mary compares the name and dose to what she has been taking when the refill is delivered.

Encourage the Client to Take an Active Role in All Stages in the Medication Process

Whenever opportunities are created for clients to be responsible for their own daily needs, support for having a sense of some control over the environment is increased. A client becomes an active rather than a passive participant.

In addition to teaching clients to take their own medications, other learning experiences linked to medications should be provided. The team will help the client to determine how he/she should be involved in activities, such as calling for appointments, arranging for transportation, visiting with health professionals, getting the prescription filled and monitoring for medication effects.

Teaching Independence and Being Person-Centered

State laws and agency policies do not allow agencies to follow medication practices used in a typical home. Medications in settings served by your agency must be kept in a locked area; forms must be filled out; administration procedures must be documented.

However, every effort should be made to use procedures that are as normal as possible within the rules and regulations. Practices to avoid include: • Having people line up to receive medication. • Shouting out the names of clients to come for medication. • Using identification tags or bracelets.

Such practices draw unnecessary attention to the fact that clients are on medication and decreases “normalization”.

Age Appropriate Manner

Another factor to consider when applying the principle of “normalization” is the age of the client. If he/she is an adult, you can apply the principle of normalization by considering what is typical for someone of that same age in the community. For example, do most 35-year-old men have someone else open the container for them or do they do it themselves? Do most 35-year-old men take the medication without comment or does someone say, “Here comes the airplane, open your mouth wide and I’ll pop it in!!”? Obviously, you would not do this!

The principle of normalization requires that the client do as much as possible independently, and that staff assist in an age appropriate manner, if assistance is necessary.


Independence The principle of the least restrictive alternative stresses a client’s independence. Even if a client cannot do what is typical of others, the client has the right to do as much as possible with staff assisting and teaching the remainder. Staff should not do things for clients just because it is easier or faster. For example, you would not take a medication out of a cabinet or container for a client who could reach it alone. Using an adaptive device such as a cookie sheet on the counter is an example of a simple accommodation for a client who has difficulty opening containers and removing the correct amount without spilling. However, do not let the client attempt tasks that might cause severe harm if done incorrectly. For example, you would not have a client with visual impairment pour a liquid medication without adaptive equipment. Sometimes there is a fine line between risk-taking and negligence.

Person-Centered

The principle of being person-centered stresses that the client receiving services and support is in control of his/her life. In developing a person-centered plan, staff and those close to the client, along with the client, must first determine what is most important to the client, what is necessary to keep him/her healthy and safe, and then develop the supports to assure that these thing occur. For example, if a client must take medication and they will only take it if they have coffee, accommodations should be made to provide the coffee. Perhaps the client should not have caffeine for some reason—then decaffeinated coffee should be provided. Person-centeredness changes the concept of control from that of staff being in charge to that of the person having control of his/her life. Often it takes skillful negotiation to ensure the client has control and at the same time meet regulations around the administration of medication. Remember that the goal is for the client to successfully take the needed medication to be safe and healthy with as much control on their part as possible, while at the same time meeting all the requirements of policy, licensure and laws.

Decisions are Made by a Team

As a staff member you must remember that decisions regarding a client’s program plan are made by a team. The team is made up of the client and other people active in the person's care and wellbeing, including direct service staff, physician/nurse/specialists. You do not make the decision regarding who can keep and take medication independently. If you have questions regarding medication administration for a specific client, contact your agency nurse, supervisor or health care professional.

Know and Observe Effects of Medication Administration

Prior to administering any medication or medicated treatment, you should know about each medication, the expected effects for the client and what to do if the expected does not occur or the unexpected does occur. You should have access to current drug manuals, as well as pharmacy inserts and client education forms, along with information provided by the health professionals working with your agency. Report to the nurse or supervisor any changes in the client, but leave the diagnosis to the medical professional.

Your Responsibility is to Observe and Report Change, Not to Diagnose

A change can be either a sign or a symptom. A change that can be clearly seen (such as, cough, loss of weight, vomiting or rash) is called a sign. A change that is only perceptible to the client (such as pain, nausea or dizziness) is called a symptom. Although signs are easily observed, you may need to


ask the client specific questions and observe his/her behavior to detect symptoms. In addition, body language such as facial expressions and body positions may give clues to symptoms.

In order to observe effectively for abnormal symptoms and behavior, you need to know: 1. How does the client look and act most of the time? 2. What medication is being taken and what is the desired effect? 3. What potential side effects occur with this medication? 4. What can you do to increase the effectiveness of the medication and decrease side effects?

Develop a Keen Observational Sense In your capacity of working with clients with disabilities you will come to know them very well. In some cases, you will know more about them than anyone else. Your observation on a day-to-day basis will be important in determining if something is physically wrong. Developing a keen observational sense will be a very important aspect of recognizing when something goes wrong. The first thing you will need to know is what the person is generally like. For instance, what do they look like and how do they smell, sound, feel and react in a normal or healthy state? Your ability to observe clearly and pass on information in an objective and detailed manner is your best tool when assessing for signs and symptoms of an illness or injury. You’ll use all your senses (sight, hearing, smell, touch and taste) to describe what is occurring. Observation of the following sixteen characteristics will help you establish a basic description of how the client normally appears.

1. General appearance: How is he/she dressed? Well-groomed? Body odor? Is hair combed? 2. Body posture: Is usual posture “good” or “slumped”? 3. General state of health: Strong or frail? Symptoms of illness? 4. Physical activity level: What is the usual pace - fast or slow? Need assistance? Tremors or paralysis? 5. Physical condition of skin: Note color and texture. Rashes? Bruises? 6. Physical condition of hair and scalp: Note texture and quantity. 7. Physical condition of senses: Glasses? Hearing Aids? Numbness? 8. Speech: Verbal or Nonverbal? Slow or fast? Slurred? 9. Mouth, gums and teeth: Color of gums? Teeth or dentures? Breath odor? 10. Facial expressions: Happy, sad, flat, anxious, strained? 11. Vital signs: Usual temperature, blood pressure, pulse, respirations? 12. Weight: Usual weight? Normal weight for height and body build? 13. Bowel and bladder: Regular bowel habits? Appearance of stool/urine? 14. Appetite and eating habits: Fussy eater? Hearty eater? All meals? 15. General emotional state: Happy, passive, uncooperative, depressed? 16. State of awareness: Alert, inattentive, drowsy?

The staff member may become, in a sense, the eyes, ears and nose for the supervisor, nurse and physician. Through the staff member, health concerns regarding the person may first be recognized. Later, observations and documentation will assist the nurse and physician in gathering significant information to make an accurate diagnosis and develop an appropriate plan of care.


Be Alert to Changes in Health Patterns Staff members, for the most part, will be working with clients who are healthy. However, some signals may alert staff members that there is something abnormal about how the client looks or acts. These changes may occur suddenly or over the course of time. It is your role as staff member to monitor clients and to inform the health care professionals or the supervisor in the event you identify any health concerns. These observations will assist the client’s health care professionals in their assessment of the client’s condition. If staff members have an idea of what to look for when someone shows signs of a change in his or her health pattern, they will be further ahead in planning for recovery.

Summary

Bearing in mind the necessity of supporting clients to develop their abilities and to promote their integration in normal life, the following concepts are to be applied.

1. A client is to be encouraged to be as independent as possible in medication administration. 2. Staff involved in medication administration must observe for physical and/or behavioral changes. Such changes should be reported to the agency nurse or supervisor. 3. Only medications that a physician has prescribed or approved for the client can be given. 4. A client/guardian (or parents if under age 18) has a right to know why the medication is prescribed, its actions, side effects and any changes in medication orders.

5. Medications should not be given for staff convenience, but for benefit of the client. 6. A positive approach should be taken when giving medication. If a client refuses or other circumstances interfere with medication administration, notify the agency nurse, supervisor or health professional.


Unit 2 - Staff Responsibility

The Medication Cycle has Five Areas Medication administration is more than simply handing out medication. It should be looked at as a cycle that includes five areas: 1) observation, 2) prescription, 3) dispensing, 4) administration and 5) documentation. Each area is important and each leads into another area. Observing a change in a client leads to documentation. Documentation influences the physician’s prescription. The prescription determines administration. Administration requires documentation and subsequent observation of the changes that should occur in the client. Each area has a cause and effect relationship with the others.

Staff Member Responsibility in the Cycle

As a staff member you are responsible for portions of the medication administration cycle. It is important to understand that safe medication administration involves all of these job functions, and that it is much more than simply handing out medication.

A client may not receive needed medical attention unless you conscientiously observe him/her and report changes.

Medication may be prescribed that a client is allergic to unless you communicate important information to the nurse, physician or pharmacist.

Medication is dispensed by a pharmacist from whom information can be obtained about the medication. Check all medication labels on new medication to be sure it matches the written physician’s order. A client may receive the wrong amount of a medication unless you monitor administration of medication correctly.

A client may not receive a prescribed medication unless you check medication administration records (MAR) carefully and consistently. A client may suffer an undesirable or even fatal medication effect unless you OBSERVE and REPORT significant physical or behavioral changes to the right person at the right time by the right means. It is important to know where your responsibility ends and that of the health professional begins.


Staff has Four Broad Responsibilities Regarding the Medication Process 1. Knowing and adhering to laws and agency policies. 2. Applying normalization principles and teaching independence. 3. Knowing and observing the effects of each medication on the client. 4. Ensuring that safety and sanitation procedures are followed. Each of the four broad responsibilities includes numerous duties. Although your agency will provide specific policies and procedures for you to follow, this module will provide information on the responsibilities that apply to staff in all agencies following the best practices model.

Knowing and Adhering to Laws and Agency Policies

Every staff member must learn the boundaries of authority and responsibility of the position. When entering a new job or a familiar position with a new employer, staff may feel insecure and tentative. As time passes and confidence grows, staff may be tempted to assume responsibilities outside the scope of the position and training. In the area of medication administration, this can have dangerous consequences for both staff and client.

Staff is trained to work in some areas independently, and in other areas, under the guidance of a nurse or other health care professional. In the area of medication administration, the nurse, physician or pharmacist should provide guidance. While the training of staff should be of sufficient depth for the procedures that they perform routinely, they must never attempt to perform tasks for which they are not trained.

Completion of this Medication Course is Only Part of Your Training

The other part of your training will be a clinical check off in the actual work setting. Your agency will delegate medication administration based on your demonstrated knowledge and capabilities.

Prescription and Non-Prescription Medication

Medication can be prescription or non-prescription. Prescription medications are those medications that must be ordered by a physician and dispensed (obtained from) by a pharmacist. Non-prescription medications are those that can be obtained by the general public with simple purchase in a store. Non-prescription medications are frequently called “over the counter” medications because anyone can obtain them without a prescription. These medications have been proven safe for most people if taken according to package instructions. Examples of over the counter medications are aspirin, stomach antacids such as Maalox, and many cold medications.

No Medication is Harmless

Any medication carries with it some degree of danger; no medication is harmless. A written physician’s order must be obtained for both prescription and nonprescription medications.

Federal and State Law

Laws, regulations, statutes, ordinances, agency policies and procedure -- what purposes do they serve? Laws, agency policies and procedures seek to protect each of us in our dealings with others. Medication legislation is designed to protect the public from fraud, false advertising and untested medications and to regulate the manufacturing and dispensing of medications.


Food and Drug Act The Food and Drug Administration (FDA) requires medication manufacturers to prove the value and safety of new medications before they are released for sale. This act determines:

1. Which medications may be sold with or without prescriptions 2. Prescription medication labeling: a clear description of contents, directions for use, the quantity

of medication dispensed and the date of expiration 3. Non-prescription medication labeling: the name of the medication, the strength, quantity and

average directions for use 4. Warning statements on certain medication labels

How does this act affect you in your work?

1. Every medication must have a label 2. Look for additional colored labels that indicate a warning statement 3. Example: “This medication may cause drowsiness” 4. If a client takes the same medication at more than one location, both containers must have a

label containing the medication name, dosage of the medication and directions for use. If you do not understand a label as written, contact your agency nurse, supervisor or pharmacist

Controlled Substances

Some medications have a higher potential for abuse and therefore are classified as controlled substances. These drugs require stricter federal and state regulations for ordering, dispensing, delivery, administration, storage and disposal.

General Guidelines

• Agency policy should always be followed. • Pharmacies require signing for these drugs when received. • Any discrepancies in number received should be reported to the pharmacy immediately. • These drugs should be transported in a locked container. • These drugs should be kept in limited supply (do not overstock). • Controlled drugs that are no longer needed should be noted on inventory and returned to the

pharmacy according to agency policy. • Wasted, contaminated or other discarded doses must be documented on appropriate forms and

witnessed according to agency policy. • Any drugs unaccounted for must be recorded on the appropriate form according to agency policy. • Some regular, recurring system to monitor (count) and document these drugs should occur

according to agency policy. • Controlled drugs should be stored according to facility policy. • Best practice guidelines would encourage routine counting/documenting of all controlled

substances (not only Schedule II substances). • Each agency should develop a process or procedure to clearly notify staff when controlled

substances are received into the facility. For example, a staff member must sign for receipt of controlled substances when delivered from the pharmacy. This will insure records are in place for both delivery and receipt of controlled substances. Unsecured controlled substances should never be left unattended by staff.


Unit 3 - Six Rights of Medication Administration

In order to give medications correctly, staff need to observe the six rights (6 R’s) of medication administration:

1. Right client 2. Right dose 3. Right time 4. Right route 5. Right medication 6. Right documentation

Most Medication Errors are made because one of the Six Rights was not observed.

In this section, the six rights will be discussed. All are of equal importance. Carelessness in any one could result in serious error.

1. Right Client It is essential to confirm the identity of the client prior to medication administration. Never give

medications to someone unfamiliar to you. Staff should also avoid giving medications to more than one person at a time. Giving the medication to the wrong client involves danger for two people. The client not receiving the medication is deprived of the desired effect and the client receiving the medication may experience serious negative consequences.

A current photograph of the client placed on the medication administration record (MAR) is the

most common method of correctly identifying a client. Never rely only on a staff member or the client to provide correct identification. Insure that the client’s name is placed on the photograph should it become separated from the MAR.

2. Right Dose

Physicians prescribe an amount within the dosage range depending on how strong an effect is needed and on the age, size and physical condition of the client. For this reason most medications come in different strengths. For example, Tylenol tablets come in strengths of 325 mg and 500 mg. When giving medication, you need to record the strength (dosage) given. ALWAYS check to see that you are giving the strength that the physician has ordered. If you gave a 500 mg tablet instead of a 325 mg tablet, you would be giving almost twice the dosage prescribed.

There are different packaging systems by which pharmacies supply medications.

• Unit dose – Each tablet or unit is individually wrapped or bottled. Each package or unit is

labeled with the medication name, strength and expiration date. • Single-dose – Each single-dose package contains the proper dose of a medication for one

administration. The package may contain more than one tablet or unit. It is also labeled with the medication name, strength and expiration date and sometimes the client’s name.

• Multi-pak or Medpak – Each single dose package contains all the medications for one administration. In this type of packaging, two or more different medications are packaged in the same package. It is also labeled with the medication names, strengths and an expiration date and the client’s name.

• Multiple-dose – This is when multiple doses of a medication are dispensed in a bottle, vial or package. The amount of medication to be administered must be poured or counted out.


The most frequently used system for measuring medication is metric. Most liquid medications are administered in milliliters and most solid forms of medication are measured in milligrams, grams and kilograms. Always use the proper measuring device to insure proper dosage is administered. Never use a household spoon to measure medications! (Refer to “Measuring Tips” Pg B-56)

3. Right Time Medications are scheduled at regular times to maintain consistent levels of effectiveness.

Medications that are quickly used by the body need to be taken more often to maintain an adequate amount in the blood so that the desired effect will occur. Other medications can be given less often because the body does not use the medication as rapidly. For this reason, follow the medication routine as scheduled by the pharmacist or your agency.

Medications may be given in a grace period of one hour before scheduled dosing time until one

hour past dosing time. This allows some flexibility in schedules and activities, which may occur around scheduled dosing times in your agency. Check with your agency to see the grace period policy.

Your agency grace period policy should include the procedure to follow if medications cannot be

given within the grace period allowed. This may constitute a concern of dosing times being too close together for the same medication or other medications that should not be taken near the scheduled medication. Omitting the medication because the administration is not within the grace period may also constitute concern and cause harm to the client. A suggested policy could include contacting the nurse, pharmacist, supervisor or physician for directions.

Example: Mike is scheduled to receive Neurontin for seizure control at 8 pm each evening. Tonight,

Mike has gone with a group of peers to a ball game and is not scheduled to return until around 8:45 pm. The staff member administering medications is aware that Mike may legally receive his medications upon return home since the agency policy allows for the grace period of one hour before to one hour after scheduled dosing times (i.e., Mike could receive his 8 pm medications from 7 pm until 9 pm and still remain within the grace period.)

You would contact the supervisor, pharmacist or nurse if Mike returned after the hour grace

period to determine what to do. Other medications are scheduled before or after meals because:

1. Some medications are irritating to the stomach and food in the stomach reduces this irritation.

2. Some medications are taken on an empty stomach because they enter the system quicker if there is not food on the stomach.

3. Some medications are used to coat the stomach and protect it during meals. When a physician prescribes medication he will indicate when to give it by the

abbreviations listed below:


Errors can be eliminated by writing out each of these abbreviations, e.g. “use every” or “at bedtime,” etc.

q = every tid = 3 times a day a.c. = before meals qh = every hour qod = every other day p.c. = after meals bid = 2 times a day q6h = every 6 hours prn = as needed

Check your agency policies to learn the standard times for each of the above. (For more abbreviations, refer to “Abbreviations.” Pgs. B-53 and B-54)

4. Right Route The route is the part of the body to which the medication is administered. Most medications

are given by the oral route, i.e., they are taken by mouth and swallowed. They are called internal medications. Other medications are applied to the outside of the body such as skin creams, eye drops, and eardrops. They are called external medications.

You must insure that clients are taking medications by the correct route. The route or method

to administer the medication is determined by: 1. The medication’s chemical and physical properties (some medications are poisonous if swallowed but are not harmful if put on the skin). 2. The site of the desired action (some medication is only needed on a small portion of the body, a “local” effect; whereas some medication is needed by the entire body, a “systemic” effect). 3. How quickly the desired effect is needed (speed of absorption) is quickest in the following order:

a. Intravenous (directly into the bloodstream) b. Intramuscular (injected into the muscle) c. Subcutaneous (injected just under the skin) d. Oral (swallowed and absorbed from stomach or intestine like food)

These abbreviations pertain to routes of administration: po = by mouth IM = intramuscular injection supp = suppository opth = pertaining to the eye otic = pertaining to the ear SL = sublingual sub-Q, SQ = subcutaneous injection buc = inside the cheek OS = left eye OD = right eye OU = both eyes pr = per rectum (For more abbreviations, refer to the Appendix “Abbreviations”) Staff may administer medications only by the routes for which they have been trained and have demonstrated competence to a nurse or agency selected person. State regulations may also limit the type of injections that may be administered by unlicensed staff. No injections may be administered unless staff are specifically trained. Refer to your agency policies.


5. Right Medication The right medication must be given to have the desired effect. Matching the label of the container with the Medication Administration Record (MAR) and physician’s order is one way to insure the right medication is given. If at any time you think you have the wrong medication, do not administer it until you have verified accuracy. Medications are given for many purposes. The physician may prescribe a medication for one client to control seizures, while the same medication may be prescribed for another client to control manic-depressive symptoms. It is your responsibility to know the specific purposes of each medication you administer. Once a medication or medicated treatment is administered to a client, the staff member should immediately document (sign his/her initials) in the correct area of the Medication Administration Record (MAR). A staff member may never sign off on the MAR prior to administering the prescribed order. Also, a staff member should not delay signing off on the MAR for any period of time after the medications or treatments have been completed. An initialed dosing space signifies to others that a medication has been given at the scheduled time.

6. Right Documentation Medical Administration Record is a Legal Document

Use the Medical Administration Record (MAR) throughout the administration of medications and medicated treatments. After the medication or treatment has been administered to the right client, immediately record this on the MAR, including the right dose, right date and time, right route, right medication, and finally right documentation with the Med Tech’s (your own) right initials according to agency policy and procedures. Refer to your agency policy for correct procedure for reporting and following up when you find a blank entry on the MAR for a medication that should have previously been administered. Do not assume that the medication has not been administered and automatically administer the medication. This could lead to a client receiving a double dose of the prescribed medication. Do not sign the initials of another staff member in the vacant space, even if you discover that they did administer the medication. The MAR is a legal document and placing someone else’s initials on the record would be considered fraudulent documentation.

Summary

Your careful observation of the six medication rights (6 R’s) is extremely important to the safety of the clients that you serve. Insuring you properly perform the six rights each time you administer medications and medicated treatments will go far in eliminating medication errors.

1. Right client 2. Right dose 3. Right time 4. Right route 5. Right medication 6. Right documentation


Unit 4 - Administration Procedures Oral, Sublingual and Buccal Medication Administration When staff administers oral (tablet or liquid) medication, they need to follow established procedures in their agency. The following pages list common steps and rationale frequently used in community based programs.

Table 1. Procedure for Oral Medication Administration Steps Rationale

1 Time Schedule – Organize a schedule of things to accomplish at the beginning of your shift. Check each client’s MAR to determine times for medication.

1. Right time – Medication is given at the right time. Medication may be taken one hour before or one hour past the designated time. Example: Medication ordered for 12 noon may be taken from 11a.m. to 1p.m.

2. Wash hands. Both staff and the client should wash their hands prior to medications administration procedures and each time hands are contaminated during the procedures.

2. Prevents spread of infection to the client and to staff.

3. Unlock medication storage area. Key must be stored according to agency policy. In many situations this means staff must carry it during the entire work time.

3. Protects others from improper use of medications. (Double locking is required for some controlled substances.) The pharmacist will indicate which medications are controlled and require a double lock.

4. Check the label – Check the information on the MAR with the label on the medication container (and with the physician’s orders in some agencies). When checking they must agree on the first Five Rights. Read the label three times: 1) when taken from the storage area (whether by the client or staff) 2) when removed from the container and 3) after pouring and before administering

4. Prevents medication errors. Give medication only upon written/verbal orders from the physician. (Agency policy may prevent staff from accepting verbal orders from the physician.) Checking the label three times insures accuracy. Never give a medication unless the label is on and clearly readable. (Best Practices recommends use of a faxed physician order vs. a verbal order.)

5. Teaching based on the client’s Person Centered Plan. Question the client or describe the name and purpose of the medication.

5. The client has a right to know what medication he/she is taking and why.

6. Remove the right dose from the container.

6. When using solid forms of medication (tablet, capsule), place the correct number of tablets in the lid or cap of the bottle. Handle in such a way that the fingers do not come into contact with the medication to prevent contamination. Because not all medications will come in the exact dose prescribed, two or more tablets may


need to be taken to make the correct dose. Example: Depakote comes in 250 mg and 500 mg strength tablets. To take a prescribed dose of 750 mg, the client would need to remove two different tablets.

7. Teaching based on the client’s Person Centered Plan. Ask the client “How much are you supposed to take?” or explain how many he/she should take.

7. The client has a right to know how much medication he/she should take.

8. Report changes in appearance of the medication to the nurse, supervisor, or pharmacist.

8. Insure the right dose and medication is being taken. The pharmacist will determine if it is a generic substitute, change in brand of the medication or the wrong medication. Example: Damage due to sunlight, moisture, breakage may change the odor or appearance of the medication and perhaps make it inactive (ineffective) or poisonous. The wrong medication or dose may have been placed in the container.

9. Observe the swallowing of the medication.

9. Observe one client at a time so your attention can be directed to the actual swallowing. The client may keep pills in the cheek, choke, hide the medication, etc. Do not leave medication in the room or send with client to carry to a water fountain, etc. Some may store the medication in a suicide attempt, may take at a wrong time, drop the medication or give to another person. Avoid distractions. Do not talk with others while working with medication. If a medication is dropped, do not have the client take it. Dispose of it according to your agency's policies.

10. Replace medication in locked storage area.

10. Internal (oral) medications must be stored separately from external (skin, ear, rectal) medications. Each client must have a separate container (drawer, bin, etc.) for personal prescribed medications. Stock medications (Tylenol, aspirin, etc.) must be stored separately from clients’ prescribed medications. Therefore, the medication area may have these storage areas: a) Internal (Oral) prescribed medications b) External prescribed medications c) Internal stock medications d) External stock medications


11. Chart the medication (the sixth right). 11. Your signature (initials) verifies that you witnessed the medication being swallowed by the client.

12. Observe for desired and side effects of the medication.

12. The staff administering (or assisting the client) with medications has the responsibility to know the purpose for which it is being given, any side effects, warnings or special directions and the usual dose. Staff must also be familiar with the condition of the client (i.e., allergies, etc). Information on each medication is written on medication information sheets, medical referral forms, or in medication reference books. If you have a question about a medication, contact the healthcare professionals, pharmacists or supervisor working with your clients. Refer to agency policy for contact procedures.


Table 2. Procedure for Liquid Medication Administration Steps Rationale 1. Time Schedule – refer to oral procedure. 1. Right time. 2. Wash hands. 2. Prevent spread of infection.

3. Unlock storage area. 3. Safe storage of medication. 4. Check label:

as bottle is taken from shelf before pouring after pouring and before administering

4. Never give liquid unless label is present and clearly readable to insure that the right medication is being taken.

5. Shake before pouring (shaking is not required for liquid medication which does not separate).

5. Medication settles to bottom in a suspension; should be evenly distributed to insure correct dose.

6. Pour away from label side. 6. Prevents messy, unreadable label. 7. Pour at eye level. 7. Looking down gives wrong reading.

8. Pour just before giving. 8. Liquid may deteriorate, or evaporate while standing.

9. Do not mix liquid medications.

9. One may interact with the other causing precipitation (medication falls to bottom) or give an unpleasant look, or unpredictable reaction.

10. Individual teaching per agency regulation.

10. Assist individual to shake, and pour liquids correctly.

11. Report change in appearance of medication to nurse, pharmacist or supervisor. Do not use if changes in appearance of medication are noted.

11. Medication may change color or clarity as it ages or if contaminated.

12. Observe swallowing of liquid. 12. Right time, right route.

13. Replace in locked storage area. 13. Safety. Note that some liquid medications require refrigeration so you need a locked box for the refrigerator.

14. Chart medication taken. 14. Legal record.

15. Observe for action and side effects. 15. Report desired and side effects to health professional and supervisor.

For administering liquid dosages less than 5cc, the use of a syringe is recommended for measuring the medication.


Procedure for Sublingual Medication Administration Sublingual medications are in the form of tablets. Follow the basic procedures for administering oral medications. However, instead of swallowing the tablets, the medication is placed under the tongue where it is quickly absorbed through the mucus membrane. The client should not drink or eat until all of the medication is dissolved.

Procedure for Buccal Medication Administration

Buccal administration is similar to sublingual administration except that the tablet is placed in the mouth next to the cheek. The medication should not be swallowed, and the client should have no food or drink until the medication is dissolved.

Legal Issues

One function of the law is to protect clients from mistreatment. The client should be able to reasonably expect that his life and other human rights will be protected from inadequate care.

Today, many judges are being confronted with the complex problem of deciding whether a client received adequate care from competent staff. Under law, the client expects and is entitled to quality care. The law supports these expectations and makes the staff responsible for a “duty of care,” which becomes a legal duty.

Example: John takes medication for seizure control. In the rush of getting everyone on the van for work, John’s morning medication was taken by Jesse. Jesse became very drowsy late that morning. He fell and broke his wrist. If the court proved the fall and resulting fracture were a result of taking the wrong medication, the staff working with John and Jesse that morning could be liable for negligence and sued in court.

Example: Dave and Bob are both on antibiotics for respiratory infections. Dave is allergic to penicillin so he takes a different medication than Bob. The phone rang while both were taking the bedtime dose, so the staff member did not notice that Dave accidentally took Bob’s medication. Soon after, Bob began scratching his arms. Staff noticed a rash and notified the nurse. Dave’s reaction was a result of inattention of staff. The staff could be liable for negligence.

Best Practice Guidelines

If staff does not meet this legal duty of “reasonable care” and if consequently some harm does come to the client, the staff may be held liable and negligent. Negligence is not only failure to give any care (omission), but also the giving of poor care (commission). Remember, you are still responsible for anything you do, or do not do. However, following policies and procedures increases your protection. Best practice guidelines are intended to assist you in providing safe and legal care to the clients to whom you are assigned. Follow both the agency policy and the individual client guidelines to properly administer medications and treatments. Medication policies and procedures are established to protect the client, staff, and agency.

Medication Administration Record

The following is an example of a medication administration record (MAR). Although this MAR may be different from the form used in your agency, it contains much of the same information. The hour column of the MAR simply tells at what times the medications are to be taken. Unless such times are specified by the physician, each facility sets up its own schedule of times. The numbers across the top indicate the


days of the month and initials indicate who observed the administration. All initials on the MAR must be identified by signature. In some cases, other information may appear below the initials.

Example: Some heart medication should not be given if the pulse falls below 60. Staff should always take the pulse prior to administering the medication and the rate would be recorded below their initials.

Great care must be taken to insure the accuracy of the records. Some suggestions are as follows:

1. Before administering medication, check that the current month is entered on the MAR. At the same time, check to see if there is more than one MAR for this client.

2. Use black ink unless your agency specifies otherwise. 3. If an error in charting occurs, draw one line through, date and initial. Never use “white out”, pencil

or scribbling. White Out has the appearance of a cover-up. Pencil can be erased and changed; therefore is not admissible as a legal record. Scribbling is open to misinterpretation. If someone else needs to read your scribbling, it may be misunderstood. Do not use a felt tip pen since it runs if wet.


MEDICATION ADMINISTRATION RECORD - Sample

Medications Hour

Charting for the month of: through Physician Telephone # Medical Record #:

Alt. Physician: Alt. Physician Telephone #:

Allergies: Rehabilitation Potential:

Diagnosis: Admission Date:

Resident’s Name: Room and bed #:

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31


Instructions: Result Codes: Injection/Patch Site Codes: A. Put initials in appropriate box when medication given 1 Effective 1 -Right dorsal gluteus 7 -Right deltoid B. Circle initials when medication refused 2 Ineffective 2 -Left dorsal gluteus 8 -Left deltoid C. State reason for refusal on Nurse’s Notes 3 Slightly Effective 3 -Right upper chest 9 -Right upper arm D. PRN medication: Reason given should 4 No Effect Observed 4 -Left upper chest 10 -Left upper arm be noted on Nurse’s Notes 5 -Right lateral thigh 11 -Upper back left E. Indicate injection site (code) 6 -Left lateral thigh 12 -Upper back right

NURSE’S MEDICATION NOTES - Sample (Back of MAR)

Temperature Respiration Pulse Blood Pressure

Initials Nurse’s Signature Initials Nurse’s Signature Charting Codes: A. chart error B. drug unavailable C. resident refused D. drug held E. dose contaminated F. out of facility G. see notes H. drug holiday

Date/Hour Medication/Dosage Route Reason Initials Results/Response Initials

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31


Unit 5 - Special Medication Procedures

A prescription blank is used by the physician to write medication orders. The written prescription is kept by the pharmacy. Therefore, to insure that a medication is given as ordered by the physician, staff must obtain either a copy of the prescription or a separate written physician’s order.

Procedure for New Medication/Changes in Medication

Whenever staff administers medication, they are responsible for knowing where to find the following information: 1. What is the purpose and desired effect of the medication? 2. What is the response time? (How long until the effect will be noted in the client – some

medications take one or two weeks to build a sufficient level within the blood in order for the desired effect to occur).

3. What are the side effects? 4. Are there any possible interactions of this medication with other medications? 5. Are there any special storage or administration procedures? For example, does it need to be

refrigerated? 6. Is it a controlled substance? (Special storage and recording procedures may be required for

controlled substances). When a new medication is ordered or there is a change in a medication order, staff should follow agency policies for obtaining this information. In addition, whenever a new medication or a change in dosage is ordered by the physician, verify that the medication label and physician’s order are the same. Do this by: 1. Comparing the label directly with the physician’s order. 2. Calling the agency nurse or pharmacist to verify the order if it does not accompany the

medication. It is preferable for the doctor’s order to be in the home prior to administration.

Discuss Medication Change with Client Remember to discuss the change in a medication order with the client. When changes are made in a medication order, the agency should have a policy/procedure for identifying direction changes until the medication container is correctly labeled.

Physician's Order Information

No person other than a pharmacist or advanced practitioner with prescriptive privileges should write on or alter a label. The use of stickers placed on the label to identify that the directions on the label are incorrect could be one suggestion.


The information from the physician’s order includes: • Medication name. • Dose - both the amount of drug in each tablet or strength of the medication and the number of

tablets to be taken. Example: Tegretol 200 mg. Take 2 tablets (400 mg) po four times daily. • When the medication is to be taken. • How the medication is to be taken.

The information from the physician’s order must be transcribed (put on) to the MAR. If you are asked to transcribe new orders or a change in order, be sure it is compared to the physician’s order to verify the accuracy. Anything not transcribed correctly could have serious consequences. Any time you have a question about the way an order is transcribed onto the MAR, you should call the agency nurse, pharmacist or your supervisor for clarification. If an error is made in transcribing, discontinue that section of the MAR and rewrite it into a new section. If a medication dose is changed during the month, mark the section as “discontinued” and rewrite the change in a new section. If a second staff member is available, it is recommended that that person double-check the transcription for accuracy. Because the client may take medications at two sites, your agency will have a procedure for receiving medications in two locations. The containers are still to be labeled with the client’s name, name of the medication, dose and directions for use.

Procedure for When the Client is Away From Agency

To avoid missing a scheduled dose of medication when a client will be away from the agency, follow your agency policy regarding: 1. Sending an individual dose with the client if gone during one scheduled medication time. 2. Sending the medication as packaged by the pharmacy if the client will be gone for more than one

scheduled medication time. 3. Ensuring the proper medication release is accurately completed and signed. Ensure proper packaging and labeling is carried out according to your agency policies and regulations governing your program. Instruct family/friends when the medication is to be taken; be sure they have labeled containers with clear instructions; and explain why the client needs the medication. Always document the amount of medication sent home and the amount returned. (Refer to the Appendix for “Packaging Medications for Administration Outside the Facility” “Medication Release Form”).

Procedure for Verbal Orders

Med Techs do not take verbal orders.


Procedure for PRN Medication PRN means “only as needed.” It is a term applied to prescription or over the counter medications that are taken only if the client has a symptom that can be relieved by the medication.

Example: Tylenol for headaches is generally not taken every day, but rather only as needed for a headache.

Over The Counter Medication

OTC is an abbreviation for “over the counter” medication. These are medications that are considered safe for most people if taken according to package directions. Although OTC medications do not need a prescription for purchase, any OTC administered requires a written physician’s order for administration within your agency. An agency may use a “standing order” form prescribed by their physician for the use of common OTC’s.

The procedure for giving an over the counter medication on standing orders or from current PRN physician orders is:

1. Check the standing orders or current physician orders to see if a client can take a medication for

the symptom mentioned. Some agencies require the prior approval from the agency nurse or supervisor before administering a PRN medication.

2. Follow the outlined steps for oral/external medications. 3. Record the following information on the MAR (per agency policy):

a) Medication b) Dose (how much in each tablet as well as total tablets taken) c) Time taken d) Route (oral or external) e) Reason it was required f) Effect the medication had

Example: 3:15 pm Tylenol 325 mg; 2 tablets (650 mg) po for headache. (Documented in records: 4:30 pm, no further complaints about headache after receiving Tylenol.) Evaluate the client within ½ hour (or an appropriate amount of time) after the medication is given to see if the desired effect has been achieved.

Other Procedures for Medication Administration

The following pages provide instructions for administration of medication by the following routes/methods: • ear medications • eye medications • metered dose nasal pump • metered hand held inhalants • nasal drops/spray • rectal medications and enemas • techniques for crushing medications • topical medications


• transdermal patch • vaginal medications

Note: Staff must NEVER administer medications by a route for which they have not been trained.

Provide Privacy for Client Remember to always provide privacy for treatments administered to each client. A general guideline: if clothes are removed, the client should go into the bedroom or bathroom for provision of the treatment. Use of a screen is acceptable when appropriate.


Proper Techniques for Administrating Medications Two Methods for Crushing Medication Crushing a tablet that is NOT individually packaged 1. To crush a tablet, be certain that the mortar and the pestle are clean and no remnants from previously crushed tablets are present. 2. Then place the tablet in the mortar and crush it completely into a fine powder with the pestle. 3. Place the crushed tablet into a medicine cup or directly into the food or liquid in which it will be mixed. 4. Then remove all particles from the mortar. Wash both the mortar and the pestle completely and put away in storage area. 5. The use of crushing with 2 cups in a tablet crusher may be a substitute for the mortar and

pestle. Crushing tablet that IS in an individual packet

This method can be a timesaver, and there is less to clean up afterward. 1. Place the unopened medication packet in the mortar. 2. Crush the unopened medication packet with the pestle, until finely crumbled. 3. Remove the unopened medication package from the mortar. 4. Open the packet carefully and pour the crushed medication into the proper container, medication cup, liquid or food. 5. Wash both the mortar and the pestle carefully and store in the proper place per agency guidelines.


Technique for the Proper Administration of Ear Drops to Adults 1. Check medication administration record (MAR) for order. 2. Read label three times before administering. 3. Explain procedure to client. 4. Wash hands and put on examination gloves. 5. Instruct client to lie down and to turn head so affected ear is facing up. 6. Straighten the ear canal by gently pulling ear lobe up and backward. 7. Instill the prescribed dose into ear canal. Do not touch the tip of the dropper to any surface, including the ear. 8. Replace the lid promptly. Do not rinse the dropper after use. Keep the container tightly closed. 9. Instruct the client to remain in position approximately 5 minutes with affected ear upward. Use sterile cotton to prevent excessive leakage of medication, if necessary, following agency policy. Discard cotton appropriately. 10. Wash hands. 11. Document on the medication administration record (MAR).


Technique for Proper Administration of Eye Drops to Adults 1. Check medication administration record (MAR) for order. 2. Read label three times before administering. 3. Explain procedure to client. 4. Wash hands and put on examination gloves. 5. Position client with head back. 6. Remove cap from bottle and place it on a clean, dry surface. 7. If bottle has a separate dropper, draw required amount of solution into dropper, holding dropper upright. If self-contained unit, invert bottle. 8. Use gauze to pull down lower eyelid to form a “pouch,” instructing client to look up. 9. Place hand against client’s forehead to steady. Instill the required number of drops inside the lower eyelid close to the outer corner of eye. Do not let dropper touch any part of eye. 10. Instruct client to close eyes slowly to allow for even distribution over surface of eye. The client should refrain from blinking. Keep eye closed for 1-2 minutes. Eyelid should not be squeezed shut, since this will force medication out of the eye. 11. Wipe off excess solution with gauze. 12. Recap bottle. 13. Wash hands. 14. Document on the medication administration record (MAR).

Note: When two or more different eye drops must be administered at the same time, allow a 5-minute period between each.


Technique for Proper Administration of Eye Ointment to Adults 1. Check the medication administration record (MAR) for order.

2. Read label three times before administering. 3. Explain procedure to client. 4. Wash hands and put on examination gloves. 5. Position client with head back. 6. Remove cap from tube and place it on a clean, dry surface. 7. Use gauze to pull down lower eyelid to form a “pouch,” instructing the client to look up. 8. Apply a thin line of ointment into the pouch from midway of eye toward the outer corner of the eye. Do not touch eye with medication container. 9. Instruct client to close eyes and rotate eyeball to allow for even distribution over surface of the eye. The client should also refrain from blinking. Keep eye closed for 1-2 minutes. Eyelid should not be squeezed shut, since this will force medication out of the eye. 10. Wipe off excess ointment with gauze. 11. Replace cap on tube. 12. Wash your hands. 13. Document procedure on the medication administration record (MAR).

Note: When two or more different eye ointments must be administered at the same time, allow a 5-minute period between each.


Technique for the Proper Administration of Fleets Enemas 1. Check medication administration record (MAR) for order. 2. Read label three times before administering. 3. Explain procedure to client. 4. Wash hands and put on examination gloves. 5. Have client lie down on left side with the upper knee bent. 6. Remove the cover from tip of bottle. 7. Hold Fleets bottle upright and insert with steady pressure into rectum with tip pointing to navel. 8. Discontinue use if resistance is felt. If continued, this could result in an injury. 9. Have client try to hold contents of Fleets as long as possible, so they can have better results. 10. Assist client to toilet or bedpan. 11. Remove gloves and wash hands. 12. Document procedure on the MAR or treatment administration record (TAR). 13. Record results on stool record or progress notes.


Technique for the Proper Administration of Metered Dose Inhalers 1. Check medication administration record (MAR) for order. 2. Read label three times before administering. 3. Explain procedure to client. 4. Wash hands and put on examination gloves. 5. Remove the cap and hold inhaler upright. 6. Shake the inhaler. 7. Ask the client to tilt the head back slightly and breathe out. 8. Position the inhaler in one of the following ways: • Open mouth with inhaler one to two inches away. • Use spacer with inhaler; place spacer in mouth. (Spacers are particularly beneficial for older adults & young children). • Position inhaler in mouth, close lips around inhaler. 9. Press down on inhaler to release medication as the client starts to breathe in slowly. 10. Encourage the client to breathe in slowly (over 3 to 5 seconds). 11. Ask the client to hold breath for 10 seconds to allow medication to reach deeply into the lungs. 12. Repeat puffs as directed. Wait one minute between “puffs” for multiple inhalations of the same drug. Waiting one minute between puffs may permit additional puffs to penetrate the lungs better. Wait five minutes between the administration of different inhalers. Spacing and proper sequence when different inhalers are prescribed is important for maximal drug effectiveness. 13. Document on the medication administration record (MAR).


Technique for the Administration of Medication Using a Metered Dose Nasal Pump 1. Check medication administration record (MAR) for order. 2. Read label three times before administering. 3. Wash hands and put on examination gloves. 4. Explain procedure to client. 5. Instruct client to gently blow nose to clear nasal passages of secretions prior to use, unless contraindicated, e.g. risk of intracranial pressure or nose bleeds. 6. Ensure client can sniff air through each nostril before spraying. 7. Remove the cap. 8. Follow manufacturer’s directions for “priming” the bottle prior to initial use. The bottle is squirted a few times until a fine mist comes out. 9. Instruct client to keep head upright and to breathe slowly. 10. Using your finger, close the nostril not receiving the medication. 11. Instruct client to breathe in slowly through the nose. 12. Tilt the nozzle of the bottle until it is in a straight line with the nasal passage. 13. Activate the pump as the client begins to breathe in slowly. 14. Instruct client to breathe out through the mouth. 15. Repeat these steps for multiple sprays or for the other nostril if needed. 16. Instruct client to try not to sneeze or blow nose just after administering the spray. 17. Wipe the tip with a clean tissue after use. 18. Wash hands. 19. Document procedure on the medication administration record (MAR).


Technique for the Proper Administration of Nebulizer Treatments 1. Check medication administration record for order. 2. Real label three times before administering. 3. Explain procedure to client. 4. Wash hands and put on examination gloves. 5. Assemble needed supplies: nebulizer, nebulizer mask or mouthpiece and medication. Set up the nebulizer machine and nebulizer cap. 6. Have client sit upright. 7. Place the medication into the nebulizer cup and replace the cover on the cup. Attach the nebulizer cup to the nebulizer tubing and mouthpiece or mask. The cover must be screwed on correctly to ensure client receives all of the medication. 8. Ask client to place the mouthpiece in his/her mouth with lips closed tight around the mouthpiece. Or, place the mask over the client’s face. 9. Turn on the machine. A steam-like vapor should be noted. 10. When the machine makes a different sound, it is close to being done. Tap the cup a few times to tap down solution clinging to the sides of the cup. The treatment will take approximately 10 minutes to complete. 11. Once the cup is empty, turn the machine off and remove the mask/mouthpiece. 12. Wash the nebulizer cup, the tube to the mouthpiece and the mouthpiece or mask in hot soapy water. Do not wash the other tubing connected to the machine. 13. Wash hands. 14. Document the procedure on the MAR.


Technique for the Proper Administration of Nose Drops or Nose Sprays to Adults 1. Check medication administration record (MAR) for order. 2. Read label three times before administering. 3. Explain procedure to client. 4. Wash hands and put on examination gloves. 5. Position client properly:

• If in a bed, place pillow under shoulders to allow head to drop back so forehead will be lower than chin (This is the preferred method.) • If sitting up in a chair, instruct client to hold head well back. Nurse stands behind client’s head

6. Instill prescribed number of drops into nostril(s), directing flow toward floor of nasal cavity. Insert dropper tip not more than ¼ inch. 7. Instruct client to maintain position for about 2 minutes to allow sufficient contact of medication with nasal tissue and flow of medication to sinuses. 8. Wipe any excess or drainage immediately. 9. Rinse the outside of dropper/container with hot water and dry with a clean tissue, keeping dropper/container pointed down to prevent water from getting into dropper/container. 10. Replace bottle cap. 11. Wash hands. For nose spray:

Instruct client to hold head in an upright position; spray quickly and forcefully the prescribed amount of medication while the client “sniffs” quickly and forcefully. It may be necessary to have client tilt head back to aid penetration of the medication into the nasal cavity.


Technique for the Proper Administration of Rectal Suppositories 1. Check medication administration record (MAR) for order. 2. Real label three times before administering. 3. Explain procedure to client. 4. Wash hands and put on examination gloves. 5. Remove wrapper from suppository. 6. Lubricate tip of suppository with a water soluble lubricant such as K-Y Jelly. Do not use petroleum jelly (Vaseline). If lubricant not available, moisten the rectal area with tap water. 7. Have client lie on his/her side with lower leg straightened out and upper leg bent forward toward the stomach. 8. Lift upper buttocks to expose rectal area. 9. Insert suppository with finger until it passes the muscular sphincter of the rectum, about ½-1 inch in infants and 1 inch in adults. If not inserted past this sphincter, the suppository may pop back out. 10. Hold buttocks together for a few seconds. 11. Have client remain lying down for about 15 minutes to avoid having the suppository come back out. 12. Remove gloves and wash hands. 13. Document on the MAR.


Technique for the Proper Administration of Topical Medications 1. Check medication administration record (MAR) for order. 2. Read label three times before administering. 3. Explain procedure to client. 4. Wash hands and put on examination gloves. 5. Remove top from container and place upside down to avoid contaminating the medication. 6. Observe the affected area for unusual conditions, which should be reported to the nurse/physician. 7. Cleanse the area if indicated. 8. Apply the medication using the correct procedure for the medication form. • Creams: Rub in gently. • Lotions: Pat or dab on skin. • Liniments: Rub in vigorously. • Ointments: Apply with appropriate applicator or gloved finger. • Aerosol sprays: Hold the can upright and spray the area from a distance of 3-6 inches, then spray a second and third time as indicated. • Foam medication: Hold the can inverted next to the skin and spray. 9. Remove gloves before replacing container lid. 10. Wash hands. 11. Document on the MAR or treatment administration record (TAR). 12. Document in client's progress note records per agency policy.


Technique for the Proper administration of Transdermal Patch

Follow any specific instructions received from the physician or pharmacist regarding application of transdermal patches. It must be applied correctly to achieve safe and accurate drug administration.

1. Check medication administration record (MAR) for order. 2. Real label three times before administering. 3. Date and initial the patch. 4. Wash hands and put on examination gloves. 5. Explain procedure to client. 6. Remove old patches before applying a new one. When removing a patch, fold it in half with the sticky surface on the inside. 7. Rotate application sites to help prevent skin irritation. 8. Choose a site that is clean and dry with little or no hair. The location may be specified by the manufacturer. It is usually on the upper arm, chest, and back. Avoid any irritated skin areas. 9. Clean the skin with soap and water, not alcohol. Rinse and wipe dry. 10. Apply the patch to the cleaned skin when dry. Firmly press the patch in place with the palm of the hand for 10 – 20 seconds. Avoid touching the sticky side of patch that contains the drug. 11. Remove gloves (gloves are optional), and wash hands thoroughly. 12. Check the client daily for the presence of the patch. 13. Follow your facility’s policies and procedures for verifying the date on the patch with the date of administration on the MAR. Document site of patch placement on the MAR. 14. Change the patch per physician’s orders.

Precautions and special notes • If patch is packaged in a sealed pouch, do not remove until you are ready to use it. • Follow your facility’s policy and procedure for disposal of transdermal patches. • Special Note: Use only water (no soap) when applying fentanyl (Duragesic) patches without gloves. Soap, alcohol, and other solvents may increase the drug’s ability to go through the skin.


• Special Note: Nitroglycerin patches are often ordered by the physician to be removed after 12 – 18 hours to allow a nitrate-free period. This prevents tolerance to nitroglycerin. • Special Note: Catapress Patch: There will be two patches in the box. One patch is the actual drug and the second patch is medication free and is used as an overlay. Read label carefully and follow directions.


Technique for the Proper Administration of Vaginal Medication 1. Check medication administration record (MAR) for order. 2. Read label three times before administering. 3. Explain procedure to client. 4. Wash hands and put on examination gloves. 5. Ask the client to go to the bathroom and empty the bladder, if possible. 6. Assist client to lie on her back, with her knees bent and legs spread apart. If unable to lie in this manner, have client lie on her side with her upper leg bent. 7. Insert the medication:

• By applicator: Gently insert the applicator about 2-3 inches into the vagina. Push the plunger to release the suppository and withdraw it.

• If ointment, cream, or jelly, slowly withdraw the applicator as you push the plunger. 8. Assist client to wipe vaginal opening if necessary. 9. Clean or discard the applicator. 10. Remove gloves and wash hands. 11. Document on the MAR or treatment administration record (TAR) and client's progress notes,

as well.


Unit 6 - Special Issues in Medication Administration

Assisting the Client Who has Difficulty Swallowing Many clients have difficulty swallowing medications, especially tablets and capsules of large size. The following techniques may be helpful in gaining cooperation as well as enabling successful administration:

1. Have the client bring the head to a neutral position if possible (such as sitting up or elevating the head of bed). Avoid overextending the neck. 2. Have the client take a small sip of water before medication to moisten throat passage. 3. If several tablets must be taken, have the client take them one at a time. 4. Have the client take sips of water after each tablet. 5. Have the client rest a minute or two after each tablet. This quiets the cough reflex and enables the person to take all the medication. 6. A tablet may be swallowed fairly easily if given in a teaspoon of foods such as pudding, jelly or applesauce if these foods are permitted. 7. If continued difficulty, consult agency nurse/pharmacist as some medicines come in liquid as well as solid (tablet) form. 8. Have the client take liquid medication slowly – follow with sips of water except in the case of cough syrup. Cough syrups often act by coating the throat lining – taking sips of water would wash away this effect. If liquids continue to be a problem, consult with the nurse or physician on the possibility of using thickened fluids or some other alternative. Adhering to Time Span

If a prescription medication has been ordered, it is important that the medication be given within the time span designated by agency policy. As mentioned previously, this is one hour before the time through one hour after the designated time. This time may be shortened according to agency policy.

Assisting Clients Who Refuse Medication

You may work with a client who refuses to take the medication. While the client does have the right to refuse medication, if staff uses the following approaches, many times the client will agree to take the medication.

1. Accept the refusal initially and wait approximately 10 minutes to see if the client will independently decide to come for the medication. 2. Offer choices. 3. According to the client’s tolerance, repeat the offer of choices within the time span allotted for that medication.


Example: Joe, do you plan to take your medication before you eat supper or after? (if not specified by order).

4. Use the “sandwich technique” to suggest medication compliance. The sandwich technique is giving a compliment, followed by an action needing to be done, followed by a beneficial effect if the action is completed.

Example: “Joe, it is good that you took your medication yesterday. If you continue to take your medication regularly you may have fewer seizures!”

5. Use the Premack Principle by stating what “liked” activity will follow after medication was taken. The Premack Principle consists of offering a client the choice of participating in a highly preferred activity after the completion of a less preferred activity.

Example: “Let's have coffee after you take your medication.”

Clients Who Continue to Refuse 1. Once refusals continue past the time limit, notify the nurse, supervisor, or physician per agency policy. 2. Chart that the medication was refused. In most agencies this will be noted on the MAR and/or by a medication error report. 3. Options to consider: • Why is the client refusing? For control? As a means to assert independence? Don’t let medications become a power struggle between you and the client — offer a choice. • Explain the importance of this medication for the client and the purpose for which it was prescribed. • Allow the client time to think about taking the medication between repeated approaches with a choice. 4. For repeated refusals, call a team meeting to address these refusals per the program plan. The team should include the client, family, the nurse, pharmacist or physician, and other staff as indicated. Errors in Medication Administration

A medication error may be any violation of the six rights (right client, right time, right medication, right dose, right route, right documentation) or incorrect medication procedure. An error must be reported immediately to the agency nurse/supervisor per agency policy.

A Medication Error has Occurred If: • The wrong client was given a medication.

Consequence: Potentially dangerous effect, perhaps involving two clients


Example: In the rush to get everyone in the van in the morning, John’s medication was taken by Jesse.

• The wrong medication was given to a client.

Consequence: a potentially dangerous effect for at least one client.

Example: Since Jesse took John’s medication and was drowsy all morning in the workshop, he cut his hand on the handsaw.

• The wrong dose was given to a client.

Consequence: a potentially dangerous effect for the client.

Example: Staff gave Joe two tablets for high blood pressure instead of one. Joe felt faint all morning and passed out getting up from his chair.

• The medication was administered at the wrong time to a client.

Consequence: a potentially dangerous effect for the client.

Example: Margaret did not take her morning medication until noon. Her blood sugar at midmorning was 285 (normal 80-120).

• The medication was administered by the wrong route.

Consequence: potentially dangerous effect.

Example: Karen’s eardrops were administered into her right eye. By mid-morning her eye was red, burning and swollen shut.

• The wrong documentation was noted on the medication record.

Consequence: Potential for medication over or under dose.

Example: A staff member fails to sign off a med. given at 4:00 PM. Staff gives medication again assuming it was not given.

When an Error Occurs

Notify the agency nurse, supervisor, pharmacist, or physician according to agency policy. Fill out a medication error report. Legally, you are in a better position if you can show that you promptly recognized the error and that you took action to remedy it. This is not a punishment.

Learning from Mistakes

Be humble. Remember, everyone makes mistakes: people who are wise learn from them. Admit any errors made; document, but do not dwell on past mistakes. Relax. Tension and anxiety cause mistakes.

The sample Medication Error Forms are found in the Forms Section. Refer to your agency policy and procedure for your exact form and procedure.


Unit 7 Medication Observation Four broad responsibilities in monitoring medications

The previous units emphasized the four broad responsibilities you have as a staff member monitoring medications. These were:

1. Knowing and adhering to laws and agency policies about medication administration. 2. Teaching independence when working with the medication process. 3. Knowing and observing the effects of each medication on the client. 4. Ensuring that safety and sanitation procedures are followed throughout the medication administration.

Laws, principles and procedures are similar for all clients (1, 2, 4, above). Once you learn the general responsibility, you can apply it to all work situations. The third responsibility (knowing and observing medication effects) is very specific; consequently more difficult to apply.

Example: Knowing that older people may require smaller doses of medication and that overweight clients need larger doses, doesn’t tell you what to watch for when a 68 year old, 192 pound client is taking Navane 15 mg daily.

It would be impossible to provide, within this course, all the information necessary to observe the effects of each individual medication. Physicians, pharmacists, and nurses continually study and update medication knowledge. Staff must also assume the responsibility of studying about each medication which you monitor. Information to do this may be provided by your agency consultant pharmacist and nurse. A drug reference manual should be located in each work area.

Remember to be aware of potential medication side effects

The following table lists categories of medication commonly taken by clients, the usual purpose and the most common or most serious side effects. This is only a very broad listing.

Remember to report any change observed in the client.


Table 3. Common medication categories and side effects

CATEGORY PURPOSE SIDE EFFECTS (*SERIOUS)

1. Anticonvulsant -Dilantin -Neurontin -Lamictal

Control seizures

Drowsiness, Upset stomach, constipation, lack of appetite *Easy bruising, *Sore throat/infections *Dizziness/ unsteadiness, *Slurred speech

2. Antibiotics -Ampicillin -Amoxicillin

Treat infections; given for 4 to 10 days, but important to take all the medications.

*Rash or hives Itching Nausea/vomiting

3. Analgesics -Acetaminophen -Aspirin -Tylenol with codeine

Relieve pain Drowsiness, constipation, headache, nausea, vomiting *Slow respiration

4. Psychotropics -Navane (Thiothixene) -Lithium -Chlorpormazine -Zyprexa -Risperdal -Seroquel

Reduce symptoms of emotional disorders

Drowsiness, constipation; nausea/upset stomach, dry mouth, rigid body posturing *Extrapyramidal symptoms (usually irreversible) -Tremors of hands/feet -Shuffle walk -Restless

5. Hormones a. Thyroid Synthroid Stimulate metabolism Weight loss

Overactive

b. Birth control Estrogen/progesterone -Ortho Novum -Lovral

Prevent pregnancy

Nausea, weight gain, breasts tender *A-abdominal pain C-chest pain H-headache E-eye problems S-severe leg pain

c. Insulin/oral hypoglycemic -NPH -Lente -Glyburide

Treat diabetes and enable body to use nutrients

*Insulin shock (pale, headache, dizzy, confused) *Diabetic coma (warm, flushed, deep and rapid breathing, nausea, abdominal pain)

d. Steroids -Kenalog -Prednisone

Reduce inflammation *Mask signs of infection, *Easy bruising Mood change, muscle weakness, acne, hair growth, stomach distress

6. Antacids -Maalox -Mylanta

Relieve upset stomach Constipation

7. Laxative -Metamucil -Colace

Relieve constipation Abdominal cramps Nausea

8. Antihypertensives -Dyazide -Lopressor

Lower high blood pressure Lack of appetite, dizzy, dry mouth, fatigue *Weakness

9. Cardiovascular -Inderal

Slow and strengthen heartbeat (pulse)

Confusion, nausea/vomiting, headache If pulse below 60, contact nurse first


Commonly used scheduled drugs ** This is not a complete list of all controlled substances. Only the most commonly used controlled substances are included in these tables.

TIPS- To help identify controlled substances: The pharmacist can stamp the medication labels with a red “C”. The controlled medications may be dispensed in different packaging.

Common central nervous system drugs (psychotropic drugs) by therapeutic class

BRAND GENERIC

Antianxiety Agent: Adapin/Sinequan Doxepin Atarax/Vistaril Hydroxyzine Ativan Lorazepam Buspar Buspirone Equanil Meprobamate Librium Chlordiazepoxide Tranxene Clorazepate Valium Diazepam Xanax Alprazolam Anticonvulsant: Depakene/Depakote Valproic Acid Dilantin Phenytoin Klonopin Clonazapam Lamictal Lamotrigine Mysoline Primidone Neurontin Gabapentin Solfoton Phenobarbital Tegretol Carbamazepine Valium Diazepam Zarontin Ethosuximide Antidepressant: Anafranil Clomipramine Celexa Citalopram Desyrel Trazodone Effexor Venlafaxine Elavil Amitryptyline Lexapro Escitalopram Norpramin Desipramine Pamelor/Aventyl Nortriptyline Paxil Paroxetine Prozac Fluoxetine Sinequan Doxepin Tofranil Imipramine Wellbutrin Bupropion Zoloft Sertraline


Antimanic Agent: Eskalith/Lithane Lithium Antiparkinson Agent: Artane Trihexyphenidyl Benadryl Diphenhydramine Cogentin Benzotropine Eldepryl/Emsam Selegiline Laropopa/Dopar Levodopa Sinemet Levodopa/Carbidopa Symmetrel Amantadine Antipsychotic Agent: Abilify Aripriprazole Clorazil Clozapine Geodon Ziprasidone Haldol Haloperidol Loxitane Loxapine Mellaril Thioridazine Moban Molindone Navane Thiothixene Prolixin Fluphenazine Risperdal Risperidone Serentil Mesoridazine Seroquel Quetiapine Thorazine Chlorpromazine Zyprexa Olanzapine CNS Stimulant: Cylert Pemoline Dexedrine/Adderall Dextroamphetamine Ritalin/Concerta/Daytrana Methylphenidate Sedative/Hypnotic: Ambien Zolpidem Butisol Sodium Butabarbital Dalmane Flurazepam Halcion Triazolam Lunesta Eszopiclone Nembutal Pentobarbital Noctec Chloral Hydrate Phenobarbital Phenobarbital Placidyl Ethchlorvynol Restoril Temazepam Rozerem Ramelteon


Antidepressants in the Elderly

Drug Renal Impairment Hepatic Impairment Celexa (citalopram)1 Avoid if CrCl < 20 mL/min Decrease dose Lexapro (escitalopram) Avoid if CrCl < 20 mL/min 10 mg/day Prozac (fluoxetine) Accumulation may occur in

severe renal impairment Lower dose or less frequent dosing

Fluvoxamine2 N/A Reduce dose Paxil (paroxetine) CrCl<30, conc 4x higher, CrCl

30-60, conc 2x higher Plasma conc 2x higher

Zoloft (sertraline) N/A Lower dose or less frequent dosing

Remeron (mirtazapine)3 CrCl 11-39 – 30% decreased Cl CrCl <10 – 50% decreased Cl

Clearance decreased by 30%

Trazodone N/A N/A Wellbutrin (bupropion) ESRD decrease frequency or

dose Mild to moderate – use with caution reduce dose/frequency Severe – Extreme caution Max doses Wellbutrin 75 mg/day Wellbutrin SR 100 mg/day or 150 mg QOD Wellbutrin XL 150 mg QOD

Cymbalta (duloxetine) Not recommended in CrCl<30 Not recommended Effexor (venlafaxine) CrCl 10-70 – decrease dose by

25%. Decrease dose by 50% in dialysis clients

Decrease total daily dosage by 50%

Amoxapine4 Do not use in elderly Do not use in elderly Desipramine5 N/A N/A Nortriptyline5 N/A Lower doses and slower titration Vivactil (protriptyline) N/A N/A Elavil (amitriptyline) *Avoid in elderly

N/A Use with caution

Clomipramine6 Doxepin Use lower dose and adjust

gradually Use lower dose and adjust gradually

Imipramine7 Not drug of choice in elderly Not drug of choice in elderly Surmontil (trimipramine) No Adequate studies in elderly No adequate studies in elderly

1. Escitalopram bioavailability and half-life are increased by 50% in elderly 2. Fluvoxamine – Do not use in elderly due to drug interactions and limited information available, select a different agent for depression in the elderly 3. Mirtazapine – decreased clearance seen in elderly (40% males and 10% females) No specific dosage adjustment recommended by manufacturer


4. Amoxapine is not a drug of choice in the elderly due to significant anticholinergic and orthostatic effects that can occur. There is also a risk for tardive dyskinesia and neuroleptic malignant syndrome. 5. Nortriptyline and Desipramine are the best TCA’s to use in the elderly due to milder side effect profiles 6. Clomipramine – Elderly clients were found to have higher dose-normalized plasma concentrations as a result of decreased demethylation (decreased 50%) and hydroxylation (25%) 7. Imipramine – Can cause orthostatic hypotension, precipitate arrhythmias in predisposed clients or aggravate seizures. Not a drug of choice for elderly

Anti-psychotics in the Elderly

Drug Renal Impairment Hepatic Impairment Abilify (aripiprazole)8 No adjustment necessary No adjustment necessary Clozapine Do not use in elderly Do not use in elderly Zyprexa (olanzapine)9 No adjustment necessary Dose adjustment may be needed.

Monitor closely Symbyax (olanzapine/fluoxetine)

No adjustment necessary Metabolism may be decreased. Start at 6/25 mg and use caution adjusting dose.

Invega (paliperidone) CrCl 50-80 – max dose 6 mg/day CrCl 10-49 – max dose 3 mg/day

No adjustment necessary for mild-to-moderate Not studied in severe

Seroquel (quetiapine)10 No adjustment required 30% lower clearance, start at 25mg/day and increase by 25-50 mg/day to effective dose

Risperdal (risperidone)11 Start at 0.5 mg BID, Cl is decreased by 60% with moderate to severe renal disease

Free fraction in plasma increased by 35% , start at 0.5 mg BID

Ziprasidone (Geodon)12 No adjustment required No adjustment required Fluanxol (flupenthixol)13 N/A N/A Haldol (haloperidol)14 N/A N/A Loxitane (loxapine) N/A N/A Moban (molindone) N/A N/A Orap (pimozide)15 No adjustment required Reduction in dose Thiothixene N/A N/A Zuclopenthixol N/A N/A Chlorpromazine No adjustment required Avoid use in severe dysfunction Prolixin (fluphenazine)16 No adjustment required N/A Perphenazine17 No adjustment required Reduce Dose Compro (prochlorperazine) N/A N/A Thioridazine18 N/A N/A Stelazine (trifluoperazine)19 No adjustment required N/A 8. Abilify – Increased incidence of serious cerebrovascular events in the elderly, some fatal. An extensive risk:benefit analysis should be performed prior to use. Not approved for dementia- related psychosis.


9. Zyprexa – Half life in elderly is 1.5 times that in younger adults, therefore, lower initial doses are recommended. Zyprexa has a higher incidence of falls in elderly. An extensive risk: benefit analysis should be performed prior to use. Therefore, use with caution and at lower recommended doses. Consider starting at a dose of 2.5-5 mg/day. 10. Seroquel – 40% lower mean oral clearance in elderly, higher plasma levels expected and therefore dosage adjustment may be needed. Elderly clients usually require a slower titration schedule. 11. Risperdal – Additional monitoring of renal function and orthostatic blood pressure may be warranted. If once-a-day dosing in the elderly is considered, a twice daily regimen should be used to titrate to the target dose, and this dose should be maintained for 2-3 days prior to attempts to switch to a once-daily regimen. 12. Geodon – Since diabetes is prevalent in the elderly, monitor closely when using this agent in this population 13. Fluanxol – 5 mg test dose is recommended in elderly and in clients whose individual or family history suggests a predisposition to extrapyramidal reactions. In the subsequent 5-10 days, the therapeutic response and the appearance of extrapyramidal symptoms should be carefully monitored. 14. Haldol – Prevalence of tardice dyskinesia appears to be highest among the elderly, especially elderly women. Kinetics in geriatric clients generally warrants use of lower doses 15. Orap – Use with extreme caution in the elderly due to cardiovascular effects. 16. Prolixin – Max dose in elderly is 20 mg. Dose should be started at 1 mg/day and slowly increased to prevent side effects or decrease their severity. Dosing intervals can be increased as necessary to control response or side effects. 17. Prochlorperazine – Max dose - 75 mg. 18. Thioridazine – Max daily dose - 400 mg 19. Stelazine – Max daily dose - 40 mg

Hypnotics in the Elderly Lunesta20 No adjustment required Mild-to-moderate – use with caution.

Dosage adjustment unnecessary. Severe – Max dose 2 mg

Ambien21 No adjustment required Max dose – Ambien 5 mg, Ambien CR 6.25 mg

Temazepam22 N/A N/A Sonata23 No adjustment required in

mild-to-moderate renal impairment. Use in severe impairment not studied.

Mild-to-moderate 5 mg max dose. Do not use with severe impairment.

Flurazepam24 N/A N/A Triazolam25 N/A Reduce dose or avoid use in cirrhosis 20. Lunesta – In elderly, if the client is having difficulty falling asleep, initiate 1 mg before bedtime with a max dose of 2 mg. If the client is having difficulty staying asleep, initiate 2 mg before bedtime. In clients >65 years of age, the AUC was increased by 41%, however the adverse reactions in elderly subjects was not different from that seen in younger adults. 21. Ambien – In doses >5mg, there was subjective evidence of impaired sleep on the first post- treatment night. There have been few reports of increased hypotension and/or falls in the elderly with this drug. It can be considered a drug of choice in the elderly when a hypnotic is indicated.


With Ambien CR, the adverse event profile of 6.25 mg in elderly clients was similar to the 12.5 mg dose in younger adults. Until there is more experience with this dosage form, use with caution in the elderly. 22. Temazepam – because of its lack of active metabolites, temazepam is recommended in the elderly when a benzodiazepine hypnotic is indicated. Hypnotic use should be limited to 10-14 days. Max dose in elderly is 15 mg. 23. Sonata – In clinical trials, elderly responded to the 5 mg dose with decreased sleep latency. Max dose in elderly is 5 mg. 24. Flurazepam – Due to its long-acting metabolite, flurazepam is not considered a drug of choice in the elderly. Long acting benzodiazepines have been associated with falls in the elderly. Max dose if used is 15mg. 25. Triazolam – In the elderly for short-term use in insomnia, use 0.0625-0.125 mg at bedtime. Max dose is 0.25 mg/day. Due to the higher incidence of CNS adverse reactions and its short half-life, this benzodiazepine is not a drug of first choice in the elderly.

Mood Stabilizers in the Elderly Lithium26 CrCl 10-50 – Give 50-75%

of normal dose CrCl<10 – Give 25-50% of normal dose

No adjustment required

Tegretol (carbamazepine)27 N/A N/A Lamictal (lamotrigine) Decreased doses needed

with significant renal impairment. Use caution.

Moderate-to-severe w/o ascites – decrease initial, escalation, and maintenance doses by 25%. Moderate-to-severe with ascites – decrease initial, escalation and maintenance doses by 50%.

Depakote (valproic acid)28 No adjustment required if on dialysis

Reduce dose (free conc may be elevated while total conc appear normal)

Topamax (topiramate) CrCl<70 – 50% of dose and titrate more slowly

Clearance may be reduced

Neurontin (gabapentin) CrCl Dose >60 300-1200 mg TID 30-59 200-700 mg BID 15-29 200-700 mg daily <15 100-300 mg daily

No adjustment required

26. Lithium – Initial doses adjusted for renal function. Then adjust doses based upon serum

concentrations and response. 27. Tegretol – Elderly may have increased risk of SIADH-like syndrome. Elderly are more

susceptible to carbamazepine-induced confusion and agitation, AV block, and bradycardia. 28. Depakote – Elimination is decreased in the elderly. Studies of older adults with dementia show a

high incidence of somnolence and in some clients, weight loss. Starting doses should be lower and increased slowly with careful monitoring of nutritional intake and dehydration.


Anti-Anxiety in the Elderly Valium (diazepam)29 No adjustment needed Reduce dose by 50% in cirrhosis and

avoid in severe/acute liver disease Xanax (alprazolam)30 Use caution Reduce dose by 50-60% or avoid in

cirrhosis Librium (chlordiazepoxide)31

CrCl <10 – Give 50% of dose

Avoid use

Klonopin (clonazepam) Metabolites may accumulate

Accumulation of active drug

Ativan (lorazepam)32 Reduce dose Use cautiously Oxazepam32 N/A N/A Traxene (clorazepate)31 N/A N/A Vistaril (hydroxyzine)33 N/A Change dosing interval to every 24 hours

in clients with primary biliary cirrhosis

29. Valium – Watch for hypotension and excessive sedation 30. Xanax – Elderly clients may be more sensitive to the effects of alprazolam including ataxia and

over sedation. 31. Librium and Tranxene– Due to their long-acting metabolites, these drugs are not considered drugs

of choice in the elderly. 32. Ativan and oxazepam – Because these drugs are relatively short-acting with an inactive

metabolite, they are preferred agents to use in elderly clients when a benzodiazepine is indicated. 33. Vistaril – Anticholinergic effects are not well tolerated in the elderly and frequently result in

bowel, bladder, and mental status changes. Hydroxyzine may be useful as a short-term antipruritic, but it is not recommended for use as a sedative or anxiolytic in the elderly.


Appendix

Abbreviations

DOSES ROUTES OF ADMINISTRATION gm = gram PO = by mouth mg = milligram PR = per rectum mcg = microgram SL = sublingual ml = milliliter IM = intramuscular injection tsp = teaspoonful Tbsp = tablespoonful gtt = drop oz = ounce mEq = milliquivalent

TIMES OTHER

q = every MAR = medication administration record QD = every day OTC = over the counter BID = twice a day SIG = label TID = three times a day QID = four times a day q h = every hour hs = at bedtime qhs = every bedtime ac = before meals pc = after meals PRN = as needed QOD = every other day ac = before meals pc = after meals stat = immediately

These are the abbreviations you can use but read the ISMP Error-Prone list carefully. You will find this list on pages B-54 and B-55.

Institute for Safe Medication Practices

ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations

Abbreviations Intended Meaning Misinterpretation Correctionµg Microgram Mistaken as “mg” Use “mcg”

AD, AS, AU Right ear, left ear, each ear Mistaken as OD, OS, OU (right eye, left eye, each eye) Use “right ear,” “left ear,” or “each ear”OD, OS, OU Right eye, left eye, each eye Mistaken as AD, AS, AU (right ear, left ear, each ear) Use “right eye,” “left eye,” or “each eye”

BT Bedtime Mistaken as “BID” (twice daily) Use “bedtime”cc Cubic centimeters Mistaken as “u” (units) Use “mL”D/C Discharge or discontinue Premature discontinuation of medications if D/C (intended to mean

“discharge”) has been misinterpreted as “discontinued” when followedby a list of discharge medications

Use “discharge” and “discontinue”

IJ Injection Mistaken as “IV” or “intrajugular” Use “injection”IN Intranasal Mistaken as “IM” or “IV” Use “intranasal” or “NAS”HS

hs

Half-strength

At bedtime, hours of sleep

Mistaken as bedtime

Mistaken as half-strength

Use “half-strength” or “bedtime”

IU** International unit Mistaken as IV (intravenous) or 10 (ten) Use “units”o.d. or OD Once daily Mistaken as “right eye” (OD-oculus dexter), leading to oral liquid

medications administered in the eyeUse “daily”

OJ Orange juice Mistaken as OD or OS (right or left eye); drugs meant to be diluted inorange juice may be given in the eye

Use "orange juice"

Per os By mouth, orally The “os” can be mistaken as “left eye” (OS-oculus sinister) Use “PO,” “by mouth,” or “orally”q.d. or QD** Every day Mistaken as q.i.d., especially if the period after the “q” or the tail of

the “q” is misunderstood as an “i”Use “daily”

qhs Nightly at bedtime Mistaken as “qhr” or every hour Use “nightly” qn Nightly or at bedtime Mistaken as “qh” (every hour) Use “nightly” or “at bedtime”

q.o.d. or QOD** Every other day Mistaken as “q.d.” (daily) or “q.i.d. (four times daily) if the “o” ispoorly written

Use “every other day”

q1d Daily Mistaken as q.i.d. (four times daily) Use “daily”q6PM, etc. Every evening at 6 PM Mistaken as every 6 hours Use “6 PM nightly” or “6 PM daily”

SC, SQ, sub q Subcutaneous SC mistaken as SL (sublingual); SQ mistaken as “5 every;” the “q” in“sub q” has been mistaken as “every” (e.g., a heparin dose ordered“sub q 2 hours before surgery” misunderstood as every 2 hours beforesurgery)

Use “subcut” or “subcutaneously”

ss Sliding scale (insulin) or ½(apothecary)

Mistaken as “55” Spell out “sliding scale;” use “one-half” or“½”

SSRI

SSI

Sliding scale regular insulin

Sliding scale insulin

Mistaken as selective-serotonin reuptake inhibitor

Mistaken as Strong Solution of Iodine (Lugol's)

Spell out “sliding scale (insulin)”

i/d One daily Mistaken as “tid” Use “1 daily”TIW or tiw 3 times a week Mistaken as “3 times a day” or “twice in a week” Use “3 times weekly”

U or u** Unit Mistaken as the number 0 or 4, causing a 10-fold overdose or greater(e.g., 4U seen as “40” or 4u seen as “44”); mistaken as “cc” so dosegiven in volume instead of units (e.g., 4u seen as 4cc)

Use “unit”

Dose Designations and Other Information

Intended Meaning Misinterpretation Correction

Trailing zero afterdecimal point (e.g., 1.0 mg)**

1 mg Mistaken as 10 mg if the decimal point is not seen Do not use trailing zeros for dosesexpressed in whole numbers“

“Naked” decimal point (e.g., .5 mg)**

0.5 mg Mistaken as 5 mg if the decimal point is not seen Use zero before a decimal point when thedose is less than a whole unit

he abbreviations, symbols, and dose designations found in this tablehave been reported to ISMP through the USP-ISMP Medication

Error Reporting Program as being frequently misinterpreted andinvolved in harmful medication errors. They should NEVER be usedwhen communicating medical information. This includes internalcommunications, telephone/verbal prescriptions, computer-generatedlabels, labels for drug storage bins, medication administration records,as well as pharmacy and prescriber computer order entry screens.

The Joint Commission (TJC) has established a National PatientSafety Goal that specifies that certain abbreviations must appear onan accredited organization's do-not-use list; we have highlighted theseitems with a double asterisk (**). However, we hope that you will consider others beyond the minimum TJC requirements. By usingand promoting safe practices and by educating one another abouthazards, we can better protect our patients.

© IS

MP

2007

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Institute for Safe Medication Practices

Dose Designations and Other Information

Intended Meaning Misinterpretation Correction

Drug name and dose runtogether (especiallyproblematic for drugnames that end in “l”such as Inderal40 mg;

Tegretol300 mg)

Inderal 40 mg

Tegretol 300 mg

Mistaken as Inderal 140 mg

Mistaken as Tegretol 1300 mg

Place adequate space between the drugname, dose, and unit of measure

Numerical dose and unitof measure run together

(e.g., 10mg, 100mL)

10 mg

100 mL

The “m” is sometimes mistaken as a zero or two zeros, risking a10- to 100-fold overdose

Place adequate space between the dose andunit of measure

Abbreviations such as mg.or mL. with a period

following the abbreviation

mg

mL

The period is unnecessary and could be mistaken as the number1 if written poorly Use mg, mL, etc. without a terminal period

Large doses withoutproperly placed commas

(e.g., 100000 units;1000000 units)

100,000 units

1,000,000 units

100000 has been mistaken as 10,000 or 1,000,000; 1000000 hasbeen mistaken as 100,000 Use commas for dosing units at or above

1,000, or use words such as 100 "thousand"or 1 "million" to improve readability

Drug Name Abbreviations Intended Meaning Misinterpretation CorrectionARA A vidarabine Mistaken as cytarabine (ARA C) Use complete drug nameAZT zidovudine (Retrovir) Mistaken as azathioprine or aztreonam Use complete drug nameCPZ Compazine (prochlorperazine) Mistaken as chlorpromazine Use complete drug nameDPT Demerol-Phenergan-Thorazine Mistaken as diphtheria-pertussis-tetanus (vaccine) Use complete drug nameDTO Diluted tincture of opium, or

deodorized tincture of opium(Paregoric)

Mistaken as tincture of opium Use complete drug name

HCl hydrochloric acid orhydrochloride

Mistaken as potassium chloride (The “H” is misinterpreted as “K”)

Use complete drug name unless expressedas a salt of a drug

HCT hydrocortisone Mistaken as hydrochlorothiazide Use complete drug nameHCTZ hydrochlorothiazide Mistaken as hydrocortisone (seen as HCT250 mg) Use complete drug name

MgSO4** magnesium sulfate Mistaken as morphine sulfate Use complete drug nameMS, MSO4** morphine sulfate Mistaken as magnesium sulfate Use complete drug name

MTX methotrexate Mistaken as mitoxantrone Use complete drug namePCA procainamide Mistaken as patient controlled analgesia Use complete drug namePTU propylthiouracil Mistaken as mercaptopurine Use complete drug nameT3 Tylenol with codeine No. 3 Mistaken as liothyronine Use complete drug nameTAC triamcinolone Mistaken as tetracaine, Adrenalin, cocaine Use complete drug nameTNK TNKase Mistaken as “TPA” Use complete drug name

ZnSO4 zinc sulfate Mistaken as morphine sulfate Use complete drug nameStemmed Drug Names Intended Meaning Misinterpretation Correction

“Nitro” drip nitroglycerin infusion Mistaken as sodium nitroprusside infusion Use complete drug name“Norflox” norfloxacin Mistaken as Norflex Use complete drug name“IV Vanc” intravenous vancomycin Mistaken as Invanz Use complete drug nameSymbols Intended Meaning Misinterpretation Correction

Dram

Minim

Symbol for dram mistaken as “3”

Symbol for minim mistaken as “mL”

Use the metric system

x3d For three days Mistaken as “3 doses” Use “for three days”> and < Greater than and less than Mistaken as opposite of intended; mistakenly use incorrect

symbol; “< 10” mistaken as “40”Use “greater than” or “less than”

/ (slash mark) Separates two doses orindicates “per”

Mistaken as the number 1 (e.g., “25 units/10 units” misread as“25 units and 110” units)

Use “per” rather than a slash mark toseparate doses

@ At Mistaken as “2” Use “at”& And Mistaken as “2” Use “and”+ Plus or and Mistaken as “4” Use “and”° Hour Mistaken as a zero (e.g., q2° seen as q 20) Use “hr,” “h,” or “hour”

**These abbreviations are included on TJC's “minimum list” of dangerous abbreviations, acronyms and symbols that must be included on an organization's“Do Not Use” list, effective January 1, 2004. Visit www.jointcommission.org for more information about this TJC requirement.

Permission is granted to reproduce material for internal newsletters or communications with proper attribution. Other reproduction is prohibited withoutwritten permission. Unless noted, reports were received through the USP-ISMP Medication Errors Reporting Program (MERP). Report actual and potentialmedication errors to the MERP via the web at www.ismp.org or by calling 1-800-FAIL-SAF(E). ISMP guarantees confidentiality of information received andrespects reporters’ wishes as to the level of detail included in publications.

© IS

MP

2007

ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations (continued)

Institute for Safe Medication Practices www.ismp.org

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MEASURING TIPS

10 ml

mg does not equal ml

A mg is NOT the same as a ml!!!! Write it out - Write it out

TIP: Always read the label carefully to be sure you are measuring the right thing.

This 20 ml cup contains 20 mg of medication in it.

This 20 ml cup contains 40 mg of medication in it.

20 ml

YOU CAN'T TELL THE DIFFERENCE BY LOOKING

TIP: Don't use household teaspoons. They are not accurate!

TIP: To be accurate, use the correct measuring tool. Ask your pharmacist. Some liquid medicines have special measuring tools.

=

1 Tbsp = 3 tsp

=3 tsp = 15 ml

TIP: Use an oral syringe for amounts less than 5 ml

1 tsp = 5 ml

15 10 5

TIP: When measuring liquids, hold the cup at eye level.


Glossary Advanced practice registered nurse – a person who holds a current license to practice in this state as an advanced practice registered nurse and has a graduate degree with a nursing focus or has completed the educational requirements in effect when the person was initially licensed. Anaphylactic shock – severe allergic reaction resulting from contact with a substance (medication) to which an client has become sensitized. Death may occur if emergency treatment isn’t given. Antagonism – the joint action of two or more substances (i.e., medication(s), alcohol, food, etc.) in which the total effect of the medication(s) is less than the effect of the medication independently. Client – equals Individual/Resident/Person/Consumer; someone who is receiving services/supports Controlled substances – medications (drugs) considered to have a high potential for abuse. Special documentation and storage procedures may be required. Dispense – a primary responsibility of pharmacists whereby prescription medication is issued or released to a person for which the physician ordered (prescribed). Enteric coating – tablets or capsules that are coated with a special substance that will not dissolve until it reaches the small intestine. External medication – a category of medications that are not swallowed, such as eye drops, eardrops, rectal suppositories. Individual – equals Client/Resident/Person/Consumer; someone who is receiving services/supports. Interaction – a response occurring whenever two or more medications are taken by an client, which may result in an antagonism, potentiation or unique effect. Internal medication – a category of medications that includes only those taken orally. Least restrictive alternative – making sure that care restricts the person's freedom as little as possible. Medication administration record (MAR) – a legal document signed by staff trained in medication administration that verifies administration of a medication. Non-prescription medication – medications proven safe for most people if taken according to package instructions. Such forms of medication do not require a physician’s prescription to be purchased. (Note: These medications still require a physician’s order for administration.) Nurse – within a community facility, a staff member or consultant who has professional nursing training/license and whose primary responsibility is to identify the health needs of clients being served. Order – a written direction from a physician required to administer medication.


Over-the-counter (OTC) medication – medication that can be purchased without a physician’s prescription. Also referred to as non-prescription. Physician – a medical doctor or dentist who has extensive, professional medication training and who is licensed to practice medicine. Physicians may legally prescribe medication. Potentiation – the joint action of two or more substances (i.e. medication(s), alcohol, food, etc.) in which the total effect of the medication(s) is greater than the effect of each medication acting independently. Prescription – a written direction or order from a physician for the dispensing and administering of medication. Prescriptive privileges – assessing the need for drugs, immunizing agents, or devices and writing a prescription to be filled by a licensed pharmacist. PRN – medication taken only as needed to relieve a particular symptom. Side effect – effects produced by medication other than the one for which it was prescribed. Side effects may also be referred to as unwanted or undesired effect. Sign -- a change that can be clearly seen by some one other than the client involved such as a cough, loss of weight, vomiting or rash. Staff – in this course, refers to persons who are adequately trained and qualified to administer medications. Symptom – a change that is only perceptible to the client such as pain, feeling nauseated or dizzy. Therapeutic range – the upper and lower limits (range) in which a medication is usually effective with minimal side effects. Such ranges provide a margin of safety for a person, i.e., medication above the range may be toxic; medication levels below the range could prove ineffective. Topical medications - substances that are applied to the skin, scalp or nails. The body absorbs topical drugs through the epidermis and the dermis. Topical medications include creams, pastes, ointments, lotions, powders, sprays and patches.

Documents

MedAdmin Manual 07.07.09 - Charlotte AHEC · 3. Treat a disease or reduce symptoms (antibiotic for infection, psychotropic for mental illness). 4. Restore normal function (insulin