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GREENVILLE HOSPITAL SYSTEM NURSING STAFF POLICY & PROCEDURE

ADMINISTRATION OF MEDICATION POLICY: Physician Orders: GHS Nursing Staff Policy and Procedure Physician Orders Document 13. Scanning Orders to the Pharmacy: 1.

All physician orders are to be scanned to the Pharmacy.

2.

When a new medication ordered “stat” or “now” is received, place the order sheet in the ‘Stat’ document carrier prior to scanning the order to the Pharmacy. (See MedProc 16 I – Administration of Medication Prior to Pharmacy Review.)

3.

When a medication order is received after the Pharmacy closes at satellite hospitals, the nurse will: A. B.

Continue to scan the physician orders to the pharmacy Following verification by the pharmacy the nurse will 1) Obtain the medication if available from the nursing unit or another unit’s automated dispensing system (ADS) 2) Contact the Pharmacist on call to obtain the medication.

Medication Administration: 1. All medications transcribed on the Medication Administration Record (MAR) or on the electronic MAR must be verified with the physician’s order before the medication is given. 2. Medication doses, routes, or administration times are not to be changed except with a physician order. 3. Nurses may only give medications prepared and labeled by the Pharmacy or prepared by the Nurse her/himself. 4. Medications removed from the automated dispensing system (ADS) or other medication storage areas must be kept in the possession of the nurse until the medication is administered. Medication must be pulled from the ADS just prior to administration of the medication(s). A. Medication containers having soiled, damaged, incomplete, illegible or makeshift labels shall be returned to the pharmacy for re-labeling or disposal. Containers having no labels are prohibited and contents shall be destroyed. B. Discontinued or outdated medications shall be returned to the pharmacy for proper disposition in accordance with pharmaceutical practice and facility policy. C. Medications that have been subjected to contamination shall not be re-dispensed.

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5. Before administering a medication, the licensed nurse or qualified individual administering the medication shall: A. Check for medication allergies. B. Verify that the medication selected for administration is the correct one based on the medication order and product label. C. Verify that the medication is stable based on visual examination for particulates or discoloration and that the medication has not expired. D. Verify that there is no contraindication for administering the medication. E. Verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route. F. When administering a new medication, advise the patient or, if appropriate, the patient’s family, what the new medication is and inform them of about any potential adverse reaction or other side effects associated with the new medication. G. With the first dose of a medication the patient must be monitored for an adverse event. H. Discuss any unresolved, significant concerns about the medication with the patient’s physician, prescriber (if different from the physician), and/or relevant staff involved with the patient’s care and treatment. 6. To identify the patient prior to medication administration, the nurse must ask the patient their name and date of birth, when possible. The nurse confirms with the patient’s armband that the information is correct. If date of birth is not available, the medical record number will be used as the second identifier. 7. The nurse will perform an ongoing assessment of the patient’s response to medications. The conclusions and findings of this assessment are communicated, when appropriate, to other healthcare professionals involved in the patient's care and are documented in the medical record. 8. Medications must be secure at all times. Medication cabinets/carts must be kept locked at all times. 9. Multiple dose vials with preservatives must be dated when opened and initialed by the nurse opening the vial. The vial can then be used for 28 days or unless there are signs of contamination present, i.e., clouding, thickening of the solution, or presence of particulate matter. (See GHS Infection Control Manual, Guidelines for Storage, Expiration, and Labeling of Opened Containers of Fluids and Multi-Dose Vials, Section 1- 22.) 10.

IV MEDICATIONS ARE NOT TO BE GIVEN THROUGH BLOOD OR BLOOD PRODUCTS, PARENTERAL NUTRITION OR CHEMOTHERAPY.

11.

Radioactive medications are not to be administered by nursing personnel except in the Nuclear Medicine section of the Radiology Department.

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Labeling of Medication: 1. All medications and solutions not prepared at the bedside must be labeled containing the name of the medication, dose, strength, route, date, and initials of the person labeling the medication or solution. After drawing up a medication into a syringe or pouring the medication in a cup, attach a label to each syringe or cup prior to leaving the prep area. 2. Labeling is to occur when any medication or solution is transferred from the original packaging to another container. 3. No more than one medication or solution is labeled at a time. 4. Any medications or solutions found unlabeled are to be immediately discarded. Labeling of Medications for Sterile Field 1. Medications and solutions both on and off the sterile field are labeled even if there is only one medication being used. 2. The label is to include the medication name, dose, strength, amount (if not apparent from the container). Medications not used for administration are to be discarded/wasted. 3. All medication labels are to be verified both verbally and visually by two qualified individuals when the person preparing the medication is not the person administering the medication. 6. No more than one medication or solution is labeled at a time. 7. Any medications or solutions found unlabeled are to be immediately discarded. 8. All original containers from medications or solutions must remain available for reference in the procedural area until the conclusion of the procedure. 9. All labeled containers on the sterile field are to be discarded at the conclusion of the procedure. 10. At change of caregiver, the oncoming and off going nurses, must review all medications and solutions and their labels both on and off the sterile field. Compounded Sterile Products (CSP): See MedProc 4 – Compounded Sterile Products (Admixtures), Preparing At Locations Other Than Pharmacy Controlled Substances: 1. All controlled substances administered within the Greenville Hospital System will be dispensed by the Greenville Hospital System Pharmacy. (Refer to GHS Department of Pharmacy Services Policy 3210: Controlled Drug Distribution.)

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2. Nurses will administer medications ordered as variable range doses based on the patient’s pain intensity rating and/or clinical condition. Specific medication dose and frequency of administration must be within the range and frequency interval. (Refer to PainMgt 7 – Variable Range Doses for Controlled Substances.) 3. All controlled substances will be kept in either the automated dispensing system (ADS) or in a separate locked drawer or cabinet. All medications accounted for on a disposition sheet must be kept under a separate single lock at all times. This includes all controlled substances and other medications as designated by the individual hospital in GHS. The keys are carried by a designated nurse or locked in the ADS. 4. Patients admitted with a Patient Controlled Analgesia (PCA) machine containing controlled substances will have the PCA discontinued as soon as orders for pain control can be obtained. The patient’s personal PCA pump with the medication is to be locked in a drawer of the medication cart. Notify the agency supplying the pump and medication for the patient. Document discontinuation of the pump, the amount of fluid remaining, and notification of the agency. Document in the patient’s medical record name of the agency staff when the pump is picked up by agency personnel. 5. All orders for Class II controlled substances will be automatically discontinued after seven days unless: A. the order indicated an exact number of doses to be administered not to exceed seven (7) days; B. an exact period of time for the medication is specified; C. the attending physician reorders the medication. 6. All orders for Class III, IV, or V controlled substances shall be automatically discontinued after 30 days unless: A. the order indicates a specific number of doses to be administered; B. an exact period of time for the medication is specified; C. the attending physician reorders the medication. 7. Expired orders will not appear on the MAR unless they are renewed. 8. When other drugs are ordered in combination with controlled substances, these drugs must be discontinued when the controlled substance expires or is discontinued. If only the non-controlled substance is discontinued, the controlled substance will be continued. 9. Controlled substances are to be checked as follows: A. On nursing units using the automated dispensing system (ADS) cabinet, the charge nurse/nurse manager must run a discrepancy report each shift to assure that all discrepancies are corrected. (Refer to MedProc 16 G – Omnicell (formerly Pyxis): Discrepancy Reports). B. On nursing units using the ADS cabinet, it is the responsibility of the Nurse Manager, Charge Nurse or designated Registered Nurse to conduct a weekly inventory of all controlled substances. (Refer to Med Proc 16E – Inventory of Controlled Substances.)

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C. On non-ADS cabinet nursing units, the nurse coming on duty and the nurse going off duty check the controlled substances each tour of duty. If any tablets or unit dose packages have been broken or torn from the original package, they must be properly disposed of and documented on the back of the disposition sheet. (Refer to MedProc 15 – Waste of Controlled Substances.) D. When controlled substances are administered via PCA, epidural/peripheral, or IV infusion, count must be completed at the end of each shift or on completion of syringe/bag. The amount must be recorded on the patient’s PCA Disposition Sheet. Two nurses must complete this count. Waste of a controlled substance must be witnessed, recorded and signed by the witness on the patient’s IV Patient Controlled Analgesia/Epidural Patient Controlled Analgesia form. (Refer to MedProc 15 – Waste of Controlled Substances.) 10. Prior to removal of a controlled substance from the automated dispensing system (ADS) cabinet, the current count is requested. If an incorrect count is entered, a recount is requested. If the recount is incorrect, a discrepancy message appears on the ADS cabinet. (Refer to MedProc 16D – ADS Control Substance Count, Verification of.) 11. The destruction of all controlled substances will be visually witnessed. Any controlled substance not administered to the patient in one single administration or at the conclusion of a single titration is considered waste. (Refer to MedProc 15 – Waste of Controlled Substances.) 12. When a partial dose of a controlled substance is to be administered, the excess must be discarded with another licensed nurse or designated person approved by Pharmacy witnessing the waste. The witness must observe the physical wasting of the medication. (Refer to MedProc 15 – Waste of Controlled Substances.) 13. When an individual dose of a controlled substance is removed from or torn from its original package, the dose will either be administered to the patient or wasted with an appropriate witness. If the controlled substance is found with a damaged blister package, dust cover of vial (vial cap) removed, or tamper evident packaging is broken, the dose must be wasted with an appropriate witness. (Refer to MedProc 15 – Waste of Controlled Substances.) 14. If a single dose of a controlled substance is prepared and then NOT administered, or is contaminated, the dose is to be disposed of with the witness of a licensed nurse or designated person approved by the Pharmacy. (Refer to MedProc 15 – Waste of Controlled Substances.) Verification of High Risk Medication: High-risk or high-alert medications are those medications involved in a high percentage of medication occurrences and/or sentinel events and medications that carry a higher risk for abuse, errors, or other adverse outcomes. (See GHS Department of Pharmacy Services Policy 3701: High-Risk Alert Medication.) Prior to the administration of the following medications, two Registered Nurses, or a Registered Nurse and a physician, or a Registered Nurse and a registered pharmacist must verify the dosage and medication. With the same individual verify the medication dose prepared and route with the Medication Administration Record and/or Physician’s Order as appropriate. Both licensed staff must initial and sign the Medication Administration Record or other form as appropriate.

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These include:

• • • • • •

intravenous (IV), subcutaneous or oral anticoagulants IV / epidural PCA subcutaneous or IV insulin parenteral nutrition IV chemotherapy medications Neuromuscular block medications

Medication Administration Record (MAR) and Chart Review: When the nurse receives a patient assignment he/she will complete a “24 hour chart check” reviewing all orders received within 24 hours of the time his/her assignment began. The physician’s orders will be checked against either the paper or electronic MAR. After completing this check the nurse will draw a line across the permanent chart copy of the Physician Order Form below the last order reviewed and document “24 hour chart check” with the date, time and signature. The 24 hour chart check will also be documented on the e-kardex for units utilizing computerized physician order entry. Unsigned verbal and telephone orders will be flagged by the nurse when completing the 24-hour chart check. (See Document 13 – Physician Orders.) Crushing of Medication for Administration: 1. If a patient cannot swallow whole tablets or capsules, check with Pharmacy to determine if a liquid suspension form of the same medication is available. Call the physician to obtain an order if the tablet, capsule or liquid suspension are not equivalent. 2. The nurse must be aware that there are many oral medications that must NOT be crushed. Refer to the message field included on the MAR for medications that must NOT be crushed. 3. When the nurse has a question concerning crushing of medications or the opening of capsules for administration, a pharmacist must be consulted. Medications for patients requiring oxygen by mask, CPAP or BiPAP: 1. If the nurse determines that the patient is unable to be off the mask or CPAP/BiPAP long enough to swallow the medication, the nurse shall check with pharmacy to see if another form of the medication is available. If another form of the medication is available call the physician for an order. 2. Prior to replacing the mask, assess the patient to determine if the patient has swallowed the medication. Reportable Medication Occurrences: See Manual of Policy Directives, S-90-2: Report of Unusual Occurrences/Accidents) 1. Definition: Reportable Medication Occurrences are defined as those listed under the Category Event section on the Medication Event Report. 2. All medications involving administration errors/occurrences must be reported to the patient’s physician, to the nurse in charge or the Nurse Manager. The Pharmacist must be called if immediate advice is deemed necessary or the occurrence was made by Pharmacy so that an immediate evaluation can be completed.

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3. All medication occurrences must be reported per GHS Manual of Policy Directives S-90-2 (Report of Unusual Occurrences/Accidents). Whoever discovers a medication occurrence will initiate an occurrence report and begin treatment if necessary. Pertinent factual information, including signs and symptoms, are to be recorded in the Patient Progress Notes. The Nurse Manager, Charge Nurse or Director of Nursing will investigate and assure that appropriate follow-up is done. 4. Near Miss – Defined as any process variation that did not affect the outcome, but for which a recurrence carries a significant risk. Near misses are to be documented on the Medication Event Report and forwarded to the Nurse Manager. Reporting of Adverse Reactions to Medication: (See GHS Department of Pharmacy Services Policy 3611: Adverse Drug Reaction Reporting.) 1. When a nurse observes signs and symptoms in a patient which may indicate an adverse/allergic drug reaction, the nurse must: A. If the medication is being administered via IV stop the medication. B. Contact the Charge Nurse and the physician. C. Call Adverse Drug Reaction Hotline (Phone # 455-9898). 2. Record pertinent information including signs and symptoms in the patient‘s chart. If the adverse reaction is determined to be an allergic reaction, the medication should be added to the patient’s allergy list on the patient’s chart and pharmacy files. Administration of FDA approved drugs for “off-label” indication: 1. Issues related to administration of FDA approved drugs for “off-label” indications shall be referred to the pharmacy. As stated by the American Society of Health-System Pharmacists standards, pharmacists can address the documentation of scientific support, adherence to accepted medical practice standards, or a description of medical necessity. In addition, the physician ordering the medication may be consulted for clarification of the order. 2. The pharmacy will determine if the indication or route of administration is appropriate by either talking with the physician or by literature review. 3. If the pharmacy determines that the route of administration is appropriate, then the medication will be dispensed to nursing with additional information, i.e. recommended rate of administration, precautions, etc. 2. If there is concern regarding continuing the administration of the medication, the Pharmacy and Therapeutics Committee must approve the “off-label” use of the medication, as described in Pharmacy policy #3310. Patient use of herbal and nutritional remedies: (See GHS Department of Pharmacy Services Policy 3321: Patient Use of Herbal and Nutritional Remedies; and GHS Nursing Policy NS-2-6: Patients’ Own Medication, Use of.)

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1. The GHS Pharmacy department will not purchase nor dispense non-FDA approved herbal or dietary supplements. These products are considered to be “dietary supplements,” not drugs, by the FDA and therefore have no government regulations. The potency and purity of these products are not controlled or regulated. 2. The Greenville Hospital System does recognize that under some circumstances it may be desirable to allow the patient to take herbal/dietary supplements during hospitalization. 3. If the prescriber wants the patient to use a particular herb/dietary supplement, a written order is required. The order shall specify the herb/dietary supplement, the dose, route, and directions for use. 4. The patient’s own supply of herbal/dietary supplements will be administered by the nurse. The Pharmacy Department will not purchase nor dispense any medication labeled as herbal medicine, dietary supplement, or alternative medicine. Home Medications: (See Nursing Policy NS-2-6: Inpatient’s Own Medications, Use of) 1. Patient medications not administered in the hospital must be sent home with the family. Write on the Medication Information List which medications are returned to the family and the name of the family member receiving the medications. 2. If a patient’s drugs cannot be returned to the family or if the family is unavailable, all drugs must be placed in a tamper evident package, labeled, sealed and placed in a secure place such as a locked area on the nursing unit. Self-Administration of Medications by Inpatients: (See GHS Department of Pharmacy Services Policy 3507: Self-Administration of Medications by Inpatients.) 1. Self-administration of medications by GHS patients is discouraged. Prior to allowing a patient to selfadminister a medication the competency of the patient must be assessed by the patient’s physician. 2. A patient who is mentally incompetent or physically incapacitated will not be allowed to self-administer medications. 3. Self-administered medications shall be recorded on the medication administration record by the appropriate licensed personnel. 4. Adult patients who are admitted as inpatient or outpatient using external continuous subcutaneous insulin infusion (CSII) pump may continue to manage his/her diabetes using their insulin pump.(see Policy xxxx) Medication administration by non-staff members such as parents, family members of patients 1. Competency will be assessed by the physician and an order must be given for administration of medications by non-staff members. 2. On going competency assessment will be performed by the nursing staff regarding the knowledge base of the non-staff member who is administering the medication. If the non-staff member requesting to

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administer medications is not deemed competent to administer medications, he or she will not be allowed to do so until further education results in approval of competency. 3. If a patient using an external continuous subcutaneous insulin infusion pump requires assistance with the operation of the pump, a person designated by the patient must stay with the patient at all times during the patient’s hospitalization. (See Policy XX) Medications Prescription at Discharge: (See GHS Department of Pharmacy Services Policy 3323: Discharge Prescriptions.) 1. No medications issued by the hospital may be taken from any inpatient nursing unit for patient use after discharge unless the drug is considered over-the-counter medication or a prescription is written and sent to the pharmacy for appropriate labeling. Medications may be sent home with a patient only if the patient is to remain on the medication. 2. Some insulin vials may require a prescription and re-labeling by the Pharmacy. While other insulin vials may be sent home without a prescription and re-labeling. Consult the Pharmacy regarding which insulins will require a prescription and re-labeling. 3. Other opened liquid medications, creams, ointments, inhalers, and special ordered non-formulary drugs may be sent home with the patient but must first be returned to the Pharmacy with a prescription for relabeling. All prescription medications must have a prescription label if the patient is to take the medication out of the hospital. 4. Opened over-the-counter products (creams, lotions, ointments, etc.) may be sent home with the patient rather than disposing of the opened medication. These products must be in the manufacturer's original package or labeled specifically. Medications are sent home with a patient only if the patient is to remain on the medication. 5. Only emergency medicine physicians working in the Emergency Department under South Carolina law may dispense up to a 72 hour supply or smallest available quantity of medication to the Emergency Room patient for home use. The physician is responsible for dispensing the medication and making sure that all labeling, packaging, and instructions meet state and federal laws. Patients requiring financial assistance with medications at discharge: Consult with Outcomes Management as soon as it is identified that the patient will need financial assistance to obtain medication at discharge. (See GHS Department of Pharmacy Services Policy 3323: Discharge Prescriptions.) Home Health Care: 1. Patients are responsible for obtaining their medication from the pharmacy of their choice. 2. Verification of medications by two nurses in the home setting is not required. 3. Documentation of medication administration by the Home Health nurse is recorded in the patient medication record.

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Transfer of inpatient to another unit: 1. When a patient is transferred from one nursing unit to another within the same hospital, the nonautomated dispensing system ADS) medications for that patient will be transferred in a bag labeled Transfer Medication sent with the patient to the receiving unit. 2. Medication Reconciliation Transfer Form will facilitate the writing of new orders when a patient is transferred to a different level of care. The receiving unit scans the orders to the Pharmacy. (Refer to MedProc 20 – Reconciliation of Patient’s Medication.) 3. Pre-operative orders for patients having surgery in the Operating Room or Delivery Room suites are to be discontinued when the patient is taken to surgery and rewritten after surgery. The Medication Reconciliation Transfer Form will facilitate the writing of new orders. Exception: See Document 13 Physician Orders. Medications for patients on Leave of Absence (LOA): 1. The physician writes on the Physician Order Sheet a request those medications (except for Schedule II Control Substances) that should be made available for patient going on a LOA. 2. A prescription for Schedule II Control Substances must be sent to the Pharmacy in order for the patient to receive this medication for an LOA. Supervision of Student Nurses: The Registered Nurse who supervises the administration of medications by a student nurse must co-sign the Medication Administration Record and any documentation related to that medication administration. The cosignature of the medication administration must be done immediately upon administration of that medication and each medication entry must be co-signed. If a Registered Nurse is not immediately available to supervise the entire administration of the medication, the student may not administer that medication. PERSONNEL: Registered Nurses and Licensed Practical Nurses (I & II) who have demonstrated competency in medication administration during orientation. Basic nursing students and refresher RN and LPN nurses, LPN-to-RN student nurses and non-employee RN degree completion student nurses can administer medications, per GHS policies and guidelines, only under the direct supervision of a Registered Nurse. This Registered Nurse may be a credentialed school of nursing faculty member, GHS RN preceptor, or other Registered Nurse involved in the care of the patient. Nursing students are not given sign-ons to Omnicell or the electronic Medication Administration Check (MAC). Medications removed from the Omnicell must be removed by the nursing faculty or an RN preceptor. The documentation of medication administration in MAC is done under the faculty members sign-on or the RN preceptor’s sign-on. When the student is using the MAC system the faculty member or RN preceptor must remain with the student during the entire process.

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DESIRED OUTCOME: The correct patient receives the correct medication by the correct route at the correct time and in the correct dose. SUPPORTIVE DATA: GHS Nursing Staff Policies and Procedures: NS-1-9 NS 2-6 MedProc 4 MedProc 7 MedProc 11 MedProc 12 MedProc 13

Supervision of Student Nurses In-Patient’s Own Medication, Use of Compounded Sterile products (Admixtures), Preparing At Locations Other Than Pharmacy Parenteral Nutrition Medication Administration Record Medication Administration, Scheduled Times for Inpatients Guideline for Administration of Intravenous Infusion and Intravenous Push Medications in Adult Patients MedProc 15 Waste of Controlled Substances MedProc 16(D) Verification of Controlled Substance Count MedProc 16(E) Inventory of Controlled Substances MedProc 16(G) Automated Dispensing System (ADS): Discrepancy Reports MedProc 20 Reconciliation of Patient’s Medications PainMgt 7 Variable Range Doses for Controlled Substances Department of Pharmacy Services, Departmental Policies: 3210 3220 3321 3323 3301 3317 3507 3611 3701

Controlled Drug Distribution Patients Own Medication The Patient Use of Herbal and Nutritional Remedies Discharge Prescriptions Prescribing/Ordering General Practices Range Orders for Medication Self-Administration of Medications by Inpatients Adverse Drug Reaction Reporting High-Risk Alert Medication

Other Sources: • • • •

“Do Not Use Abbreviations”, retrieved from GHSNet, May 2007 GHS Manual of Policy Directives S-90-2, Report of Unusual Occurrences/Accidents Infection Control Manual - Guidelines for Storage, Expiration and Labeling of Opened Containers of Fluids and Multi-dose Vials Medical Staff Policy – Patient Management, March 2007

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REFERENCES: 1. S. C. Department of Health and Environmental Control (2002). South Carolina Controlled Substances Regulations, Section 604 Pharmaceutical Services (retrieved April 18, 2007 from www.llr.state.sc.us/POL/pharmacy/PFORMS/Controlled%20Substance%20Links.pdf. 2. GHS Medical Staff Policies on Patient Care, March 2007. 3. The Joint Commission (2007). Comprehensive accreditation manual for hospitals: The official handbook. Oak Brook, IL: The Joint Commission, Medication Management, pages MM 1 – MM 18. 4. Pyxis/OMNICELL Guidelines AUTHORS: Fred Bender, PharmD, Director, GHS Pharmacy Services Richard Capps, PharmD, Pharmacy Manager Bonnie Leonard, MSN, RN, Clinical Nurse Specialist Eleanor Vaughn, MN, RN, Nursing Consultant Glenda Peninger, MN, RN, Clinical Nurse Specialist REVISION AUTHOR: Eleanor Vaughn, MN, RN, Nursing Consultant REVIEWED: Medication Procedure Task Force Nursing Clinical Practice Council REVISED: January, 1995 August, 1996 February, 2003 May, 2007 December, 2007 November, 2008

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APPROVAL SIGNATURES ON FILE IN THE OFFICE OF THE CHIEF NURSING OFFICER FOR: Fredrick H. Bender, PharmD Director, GHS Pharmacy Services / Controlled Substance Officer Suzanne K. White, MN, RN Vice President, Patient Care Services / Chief Nursing Officer Approval date: 12/29/08