PATIENT CARE POLICY: MEDICATION ADMINISTRATION TIMES

Transcription

1 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 -critical or non- critical. Scheduled medications DO NOT include: STAT and Now doses, First doses and loading doses, One doses, Specifically d 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. 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 of administration which may fluctuate based on meal delivery, actual consumption of the meal, the patient s condition, etc. These critical medications shall be administered at the specified on the medication label or medication administration record: a. Rapid-acting insulin which must be d in relationship to meals 1

2 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 s to ensure accurate peak/through/serum drug levels) 3. Prescribers may declare any medication to be -critical (i.e., must be given within 30 minutes before or after the scheduled ) 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. 2. Medications prescribed daily, weekly, or monthly shall be given within two hours before or after the scheduled. C. Administrations outside of the 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, B. ISMP Guidelines: Original Adoption & Prior Revision Dates: None Policy Owner: Cheryl Simkins Approvals: Nursing Standards September 12, 2011 Pharmacy and Therapeutics October 11, 2011 Policy & Communications Committee November 16, 2011 Medical Executive Committee November 21, 2011 Governing Body November 28,

3 Page 3 of 3 Attachment A Timeliness of Scheduled Medications Time Critical Scheduled Medications Every 1 hr Every 2 hrs Every 4 hrs Within 30 minutes Non Time Critical Scheduled Medications BID or Every 12 hr TID or Every 8 hr QID or Every 6 hr Within 1 hour Daily, Weekly, Monthly medications Within 2 hours 3

4 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 liness 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. ( In January 2011 ISMP established guidelines thought to be safe in administering medications. It suggests that hospital develop a list of sensitive medications, which would be subject to a 30 minute administration window (± 30 minutes of 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: ; Effective/Implementation Date: ) (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 (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 for administration? 4

5 The Joint Commission MM 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 , 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 , EP 1) EP.7 Before administration, the individual administering the medication does the following: Verifies that the medication is being administered at the proper, in the prescribed dose, and by the correct route. California Title22 Sec (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, and signature of the prescriber or furnisher. 5