POLICY AND PROCEDURE: MEDICATION
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1 POLICY AND PROCEDURE: MEDICATION Cheshire does not administer medication. However, front line staff provide physical assistance with medication at the consumer/client s direction. (Exception: Cheshire recognizes that some individuals may require additional assistance such as medication reminders). This policy is intended to clarify the scope of Cheshire s services regarding medication for all staff and consumers/clients. Cheshire will make every attempt to keep these policies and procedures up to date. Cheshire will let consumers/clients and staff know when changes have been made to the policy. This policy will be reviewed annually and revised as necessary. SCOPE & DEFINITION Cheshire operates on the premise of the Independent Living philosophy. Services are provided under the direction of the consumer/client. Cheshire recognizes the consumer/client s right to dignity of risk, and their right and responsibility to direct their services and make decisions/choices as it pertains to their life. Cheshire does not administer medication to consumers/clients, the front line staff provide physical assistance to consumer/client s taking medication. Consumers/clients are encouraged to disclose their medication to be attached to their Annual Service Review for availability to Emergency Response Personnel as required. EXCEPTION The exception to providing only physical assistance occurs when a consumer/client has difficulty remembering to take his/her medication. For this individual, medication assistance may be more than physical. For example, staff may provide additional prompting or reminders regarding medication. Where consumers/clients require assistance with medication reminders/cueing/physical assistance it will be identified in their signed Annual Service Review. PROCEDURES Upon assisting the consumer/client with medication, Cheshire wants to ensure the 7 R s, the: Right Person Right (read medication bottle/blister pack/dosette and confirm with consumer/client) Right Purpose Right Dose (according to the blister pack/dosette/bottle) Right Time (as per directions from client/consumer) Right Route (liquid or tablet) (by mouth or G-tube/nasal) Right Documentation (as per policy) 1 Page
2 Cheshire MEDICATION ASSISTANCE PROCEDURES Blister Pack Compliance Cheshire recommends that consumers/clients, who require any type of assistance with their medications, receive their medication in blister packs. As per the consumer/client s direction, staff will review blister pack label with the consumer/client and then physically give the consumer/client their medication out of their blister pack. Blister Pack Advantages Blister packs are filled by a pharmacist. Ensures all medication details are clearly provided, (e.g. frequency and dosage). Blister packs are fully labeled by the pharmacist, including cautionary labels (potential side effects of certain drugs on ability to drive/cause drowsiness etc.). Blister packs are sealed, providing a moisture-proof container and minimizing the possibility of accidental mix-ups or accidental spillage. Delivery and Cost Where the consumers/clients are using prescription bottles, the employee will review the label on the medication with the consumer/client and physically give them the medication. will only be given as prescribed. The consumer/client is responsible for picking up their blister pack medication from the pharmacy or arranging for delivery. All blister packs are to be delivered or picked up in a timely fashion to allow for continuum of medication (as prescribed by the attending Doctor/Pharmacist). Reminders Consumer/client will pick up their blister pack medication from the pharmacy or arrange for delivery. Consumer/client shall pay for the cost of the blister packs. Staff will remind consumers/clients as required so that they are more likely to take their prescribed medications at the desired times. reminder to be added to the booking sheets/schedules, as identified in consumer/client service plan. 2 Page
3 Confirmation and Physical Assist Cheshire has developed the following guidelines to ensure that medication only be provided to the specific consumer/client to which the medication has been prescribed for. The consumer/client will participate as much as possible with their own medications. PRN (e.g. Aspirin and Tylenol) 1. Consumer/client directs staff to give them their medication 2. Staff to wash hands before touching medication. 3. Staff to ensure consumer/client can see what you are doing. 4. Staff to open blister packs, or bottles for consumer/client, if needed. 5. Staff to read the medication labels to the consumer/client, if needed. 6. Staff to take out medication/pour the liquid medication, if needed. 7. Staff to assist with the physical act of taking medication (e.g. putting medication into mouth, if a consumer/client is unable to do this without assistance or placing pills where consumer/client can access them, and providing water with the pill/s). 8. Staff to stay and observe the consumer/client while they take oral medication, if needed 9. Staff to maintain the medication s original composition (fully formed pill/tablets) unless authorization is provided by the consumer/client s physician and consented to by the consumer/client receiving the medication. 10. At times, the staff will be required to assist consumers who are receiving nutrition and medication through a GI or nasal feeding tube. The staff will follow the direction of the medical professional regarding preparation of medication (for example: tablets may need to be dissolved or crushed, some medication may come in a thick liquid form and may need to be diluted). Staff may be required to wear PPE when crushing/cutting meds. The staff may be required to assist or perform insulin injections. Please refer to health and safety policy # 1-81, Safe Sharps Handling & Safety Engineered Medical Sharps (SEMS). 11. STAFF WILL WASH THEIR HANDS AFTER HANDLING MEDICATION. PRN is commonly used in medicine to mean "as needed" or "as the situation arises." It is generally used as the acronym PRN to refer to dosage of prescribed medication that is not scheduled; instead administration is left to the person s choice. For example, over the counter medication like Aspirin or Tylenol are considered PRN s. PRN medication is the responsibility of each consumer. PRN medications are to be taken at the consumer s choice and are to be used when needed. : 1. Consumer/client directs staff to give them their medication. 2. Staff will confirm the last dosage taken with consumer/client. 3. Staff to ensure the consumer/client can see what you are doing. 4. Staff to wash hands before touching medication. 3 Page
4 Errors / Incident 5. Staff to open blister packs or medication package (bottle) for consumer/client, if needed. 6. Staff to read the medication labels to the consumer/client, if needed. 7. Staff to take out medication, if needed. 8. Staff to assist with the physical act of taking medication (e.g. putting medication into mouth, if a consumer/client is unable to do this without assistance and providing water with the pill/s). 9. Staff to observe the consumer/client while they take oral medication. 10. Staff to maintain the medication s original composition (fully formed pill/tablets) unless authorization is provided by the consumer/client s physician and consented to by the consumer/client receiving the medication. Cheshire recognizes that no matter how high the service standards are and how good our policies are, medication errors can still occur. This refers to errors made from medication being incorrectly given, omitted doses and medication lost or stolen. Cheshire has an open no blame policy where staff are required to report such medication errors and incidents without delay. If an error has been identified it must be reported immediately to the Supervisor and followed by a completed Hazard/Consumer Incident Report form. errors or medication incidents can include, but are not limited to: Wrong medication is requested/given. Wrong dosage (amount) of medication is requested/given. is requested/given at the wrong time (greater than one hour before or after) in exceptional situations. Failure to give medication. In the event of any medication error, the front line staff are required to: 1. Identify the error, e.g. incorrect medication has been given, or a dose has been missed. 2. Verbally confirm with the consumer/client that there has been a medication error. 3. Ask the consumer/client or the family member if appropriate, what he/she would like to do regarding the medication error. 4. Where directed to do so by the consumer/client or their family member, the staff may be required to obtain medical consultation on what to do by calling: Prescribing physician for instructions. Dispensing Pharmacist. Telehealth Ontario At the consumer/client s request if time allows and if appropriate provide the missed dose and provide documentation to reflect the change. 6. During business hours, contact the Program Manager or the Emergency Response Pager after hours to report the error. 4 Page
5 Documentation List, Adverse/Allergic Reactions, Medical Emergencies Disposal 7. Complete a Hazard/Consumer Incident Report form and submit immediately, if possible, or at least by the end of shift. Update the booking/schedule sheet and communication book to immediately report the error/incident to other staff. 8. The Program Manager will review the situation at their first opportunity. 9. These types of incidents will be tracked and trended by the Program Manager. 10. The Program Manager will debrief the situation at an upcoming staff meeting. Booking sheets and schedules to reflect necessary assistance as outlined in the Annual Service Review. Staff to complete a Hazard/Consumer Incident Report Form for medication errors. Update the Annual Service Review upon receiving medication update from the consumer or their Substitute Decision Maker. In the event of a medical emergency, the Consumer/client s Emergency Contact Information sheet is kept in the consumer communication book in the staff room. It is the consumer/client s responsibility to keep their contact information, emergency contact information and medication information up to date. The consumer will contact the Program Manager to keep the information up to date. In event of any medical emergency the staff will follow the consumer/client direction. Where the consumer/client is unable to decide, the staff will contact 911. The employee will assist the consumer and emergency personnel as required and will document the emergency on the Consumer/client Incident/Accident form. must be disposed of in a manner that is not harmful to the environment. The responsibility for safe disposal of medication rests with the consumer/client. This includes disposal of discontinued medication and/or expired medication. : Consumer/client should return medication to the pharmacy for appropriate disposal. 5 Page
6 RESPONSIBILITIES Agency Cheshire will ensure that they: review and update the policy on an annual basis and as necessary. communicate changes to the policy to consumers/clients and staff. Management Management will ensure that they: maintain accurate consumer lists. maintain consumer/client s contact information sheet. provide adequate staff training on Policy and s. gather and review all documentation required in the event of a medication error have read and understood this policy. enforce and adhere to this policy. address any consumer/client or staff questions or concerns regarding this policy in a timely manner. Staff Staff will ensure that they: have read and understood this policy as indicated by signing the Read and Sign sheet. ask management if they have any questions or concerns regarding this policy. follow this policy and procedures, recognizing that failure to follow it will result in corrective action, up to and including termination. familiarize themselves with all medication policies and procedures. complete all documentation required in the event of a medication error or incident. Identify and report to management if consumers seem to be experiencing problems in selfmedicating. contact Supervisor/designate/on-call personnel if issues/concerns require immediate attention. Consumers/Clients Consumers/clients will ensure that they: have read, understood and follow this policy. ask the Program Manager if they have any questions or concerns regarding this policy. identify what assistance is needed take responsibility for their own medication at all times. inform the Program Manager whenever there is a change in medication inform management in writing of any allergies and adverse drug reactions pick up or have their medication delivered in a timely manner. carefully read all medication information and educate themselves on any risks/side effects (patient information leaflet - which should be supplied with all medicines) with the assistance of the staff, if needed. The consumer/client should contact their physician or pharmacist if there are any questions regarding their medication. safely dispose of medication through their pharmacy. 6 Page
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