TL7b, Medication Mgmt. Medication Administration Times.pdf
PATIENT CARE POLICY: MEDICATION ADMINISTRATION TIMES Effective Date: November, 2011 Page 1 of 3 I.
DEFINITIONS A. Scheduled medications include all maintenance doses administered according to a standard, repeated cycle of frequency (e.g. q 4 h, QID, TID, BID, Daily, weekly, monthly). Scheduled medications may be time-critical or non-time critical. •
Scheduled medications DO NOT include: STAT and Now doses, First doses and loading doses, One–time doses, Specifically timed doses (e.g., antibiotic for surgical patient to be given before incision), On-call doses, and PRN medications.
B. Time-critical scheduled medications are those where early or delayed administration of maintenance doses of greater than 30 minutes before or after the scheduled dose may cause harm or result in substantial sub-optimal therapy. C. Non-Time-Critical scheduled medications are those where early or delayed administration within a specified range of either 1 or 2 hours should not cause harm or result in substantial sub-optimal therapy or pharmacological effect. II.
POLICY A. Time-critical scheduled medications shall be administered within thirty minutes before or after the scheduled time. 1.
Time-Critical Scheduled Medications include all of the following: a. Medications with a dosing schedule more frequent than every 4 hours b. Scheduled (non-PRN) opioids used for chronic pain or palliative care c. Immunosuppressive agents used for the prevention of solid-organ transplant rejection or to treat myasthenia gravis.
2.
Some Time Critical Medications require nursing judgment regarding the actual scheduled time of administration which may fluctuate based on meal delivery time, actual consumption of the meal, the patient’s condition, etc. These timecritical medications shall be administered at the time specified on the medication label or medication administration record: a. Rapid-acting insulin which must be timed in relationship to meals
1
TL7b, Medication Mgmt. Medication Administration Times.pdf
Page 2 of 3
b. Medications that must be administered apart from other medications; such as antacids and fluoroquinolones, c. Gentamycin and Vancomycin which must be administered at specific times to ensure accurate peak/through/serum drug levels) 3. Prescribers may declare any medication to be time-critical (i.e., must be given within 30 minutes before or after the scheduled time) by including this designation with the medication order and/or medication administration record (MAR) entry. B. Non-Time-Critical scheduled medications 1. Medications prescribed more frequently than daily, but no more frequently than every four hours shall be given within one hour before or after the scheduled time. 2. Medications prescribed daily, weekly, or monthly shall be given within two hours before or after the scheduled time. C. Administrations outside of the time frames specified in this policy are allowed for valid clinical reasons, such as to accommodate procedures or meals. III.
LITERATURE A. “CMS 30-minute rule for drug administration needs revision,” ISMP Medication Safety Alert, Volume 15, Issue 18, September 9, 2010, pages 1-2, http://www.ismp.org/Newsletters/acutecare/articles/20100909.pdf B. ISMP Guidelines: http://www.ismp.org/tools/guidelines/acutecare/tasm.pdf
Original Adoption & Prior Revision Dates: None Policy Owner: Cheryl Simkins Approvals: Nursing Standards Pharmacy and Therapeutics Policy & Communications Committee Medical Executive Committee Governing Body
September 12, 2011 October 11, 2011 November 16, 2011 November 21, 2011 November 28, 2011
2
TL7b, Medication Mgmt. Medication Administration Times.pdf
Page 3 of 3
Attachment “A”
Timeliness of Scheduled Medications Time Critical Scheduled Medications Every 1 hr
Within 30 minutes
Every 2 hrs
Before or after the scheduled time
Every 4 hrs
Non Time Critical Scheduled Medications BID or Every 12 hr
Within 1 hour
TID or Every 8 hr
Before or after the scheduled time
QID or Every 6 hr
Daily, Weekly, Monthly medications
Within 2 hours Before or after the scheduled time
3
TL7b, Medication Mgmt. Medication Administration Times.pdf
REGULATORY ANALYSIS:
Hospital requirements do not specify when medications must be administered. Neither state licensing regulations (Title 22) nor applicable accreditation standards (The Joint Commission) address the issue directly. Medicare regulations (“Conditions of Participation”) likewise do not address the timeliness of medication administration, merely stating that “drugs and biologicals must be administered ... in accordance with ... [hospital] ... policies and procedures.” The Institute for Safe Medical Practices (ISMP), which is an advisory rather than a regulatory or accrediting body, documented a number of safety hazards observed when hospitals try to hold nurses to a 30 minute window from the MAR schedule for all medications. (http://www.ismp.org/Newsletters/acutecare/articles/20110113.asp.) In January 2011 ISMP established guidelines thought to be safe in administering medications. It suggests that hospital develop a list of “time sensitive” medications, which would be subject to a 30 minute administration window (± 30 minutes of time on the MAR). Other medications would be administered following a more flexible administration window. This hospital’s Medication Administration Times policy follow’s ISMP guidelines. This approach fully complies with all applicable regulations and standards.
REGULATORY EXTRACT Medicare Conditions of Participation: Hospitals Tag A-0405 (Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08) §482.23(c)(1) - All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. Survey Procedures §482.23(c)(1) Verify that there is an effective method for the administration of drugs. Use the following indicators for assessing drug administration: .... Observe the preparation of drugs and their administration to patients in order to verify that procedures are being followed. Are patients addressed by name and/or identity checked? Does the nurse remain with the patient until medication is taken? Are drugs administered within 30 minutes of the scheduled time for administration?
4
TL7b, Medication Mgmt. Medication Administration Times.pdf
The Joint Commission MM.06.01.01 EP.1 The hospital defines, in writing, licensed independent practitioners and the clinical staff disciplines that are authorized to administer medication, with or without supervision, in accordance with law and regulation. (See also MM.06.01.03, EP 1) EP.2 Only authorized licensed independent practitioners and clinical staff administer medications. Note: This does not prohibit self-administration of medications by patients, when indicated. (See also MM.06.01.03, EP 1) EP.7 Before administration, the individual administering the medication does the following: Verifies that the medication is being administered at the proper time, in the prescribed dose, and by the correct route. California Title22 Sec. 70263 (g) No drugs shall be administered except by licensed personnel authorized to administer drugs and upon the order of a person lawfully authorized to prescribe or furnish. This shall not preclude the administration of aerosol drugs by respiratory therapists. The order shall include the name of the drug, the dosage and the frequency of administration, the route of administration, if other than oral, and the date, time and signature of the prescriber or furnisher.
5
