UTHCPC Procedures - Medication Policy

SME: Director of Pharmacy
Last Review Date: 7/23/08

Medication is an important part of treatment. Policies have been developed to promote safety and accuracy in:

Physician's orders

For...

Policies are...

Authorization

Only medications ordered by a member of the UTHCPC medical staff or an authorized member of the house staff shall be administered

Orders for research drugs can only be written or given verbally by the physician involved in that research protocol. See Physician's Tasks

Signatures

A licensed physician prior to transcription must cosign all orders written by consulting physicians

Medical Student's orders must be cosigned by an active member of the UTHCPC Medical Staff or an authorized member of the House Staff

All signatures and medication orders must be written legibly. See Legibility

General rules for orders

Use hard-tipped pens (ball-point) and not soft-tipped pens (felt-tip, marks-a-lot, etc.) Orders written in felt-tip, marks-a-lot, cannot be processed since no copy is available.

All orders must start with the date and time the order is written

All allergies must be in red ink on the Physician's Orders form and Medication Administration Record (MAR). Allergy tape must be placed on the outside of the chart.

Any order questioned by nursing or Pharmacy shall be recalculated and checked with the prescribing physician and/or attending physician. The hospital chain of command will be activated if necessary.

See Abbreviations and Symbols for Charting for further information

General Rules for Order Entry for Sunrise

Entering Medication Orders into Sunrise

	From your patient list, click once on the patient’s name that you are going to enter scheduled medications on. Check on allergy information before placing an order.

2	Click on the “Enter Orders” icon (clipboard with the pen) along the toolbar
3	The “Requested by” box will appear
4	In the line that says “Requested by”, enter the ordering physician’s name---not the attending physician for that patient.
5	At the Source box, select if it is a telephone or written order.
6	The Order Entry Worksheet will now appear
7	On the left side you will see some headings, Lab, Nursing, Order sets, Pharmacy, Medications etc. These are order sets that already have pre-defined information included in the order for your convenience and to increase accuracy of ordering to match current guidelines. Whenever possible, order using the order set version of a med.
8	To find the medication you wish to order, click on the + sign beside the Medication heading.
9	This will open a list that says Non-Psychiatric Meds, PRN meds and Psychotropics.
10	If the order is for scheduled psych meds, click on the word Psychotropics. If the order is for a PRN med, click PRN Medication. All other meds, including Antibiotics, are included in the Non-Psychiatric Medications category. On the right side of the screen you will see a list of the classifications of all the meds included in the category
11	Double click on the appropriate classification.
12	A list of the available drugs will appear. Double click on the correct drug name
13	Fill in the dose ordered and the frequency. The unit of measure (mg) and the route (PO/IM) are already filled in.
14	When the order is completed, click OK
15	Click OK again to close the classification order selection box. Do not use the X at the top right corner.
16	Repeat steps 10 -15 for any other meds from other classifications as needed.
17	The orders will now be in a pending order state. You can review the orders for correctness in the window at the lower part of the Order Entry Worksheet.
18	If corrections are needed, click once on the order you would like to edit, and select the Edit button on the right of the screen. This will take you back to the original order and you can make any necessary changes.
19	. Click on Submit to submit the orders. This will send a print out of the medication order to Pharmacy.
	Any order questioned by nursing or Pharmacy shall be recalculated and checked with the prescribing physician and/or attending physician. The hospital chain of command will be activated if necessary.
20	Repeat this process for any other meds---if a non-psych med (i.e. antihypertensive, vitamins, antibiotics etc) is ordered, you will find those meds under Non-Psychiatric Meds.
21	NOW orders are entered through the “Emergency Medication Order (NOW Order)”
22	Single med orders may also be entered by searching for the med name – however, this is not the preferred method.
23	At time of discharge, all inpatient meds should be discontinued and any discharge meds should be entered – these are indicated by an asterisk. E.g. Haldol is a discharge version that will print to Pharmacy and on the unit.

General Rules for Orders

(Computer Down-Time Only)

	Use hard-tipped pens (ball-point) and not soft-tipped pens (felt-tip, marks-a-lot, etc.) Orders written in felt-tip, marks-a-lot, cannot be processed since no copy is available.
	All orders must start with the date and time the order is written
	All allergies must be in red ink on the Physician's Orders form and Medication Administration Record (MAR). Allergy tape must be placed on the outside of the chart.
	Any order questioned by nursing or Pharmacy shall be recalculated and checked with the prescribing physician and/or attending physician. The hospital chain of command will be activated if necessary.
	See Abbreviations and Symbols for Charting for further information

Medication orders

Orders must include the name of the drug, dose, route, frequency, and licensed physician's signature

All medication order doses written for pediatric patients shall be based on age, weight, etc.

All orders for a drug dose less than one shall have a zero preceding the decimal amount.
Example: Write 0.25mg instead of .25mg.

Do not use decimal points or trailing zeros.
Example: Write 2mg instead of 2.0mg. See Unacceptable Abbreviations

All orders for microgram amounts shall be clearly written as "microgram" to clearly distinguish from milligrams (mg). Unacceptable Abbreviations, symbols, Greek letters, and other conventions are not to be used in orders.

All orders for units shall be clearly written as "units". See Unacceptable Abbreviations

Orders calculated in either milligrams or microgram doses shall be left in the units in which the calculation was made to avoid possible decimal errors

Medication hold orders must have a specified duration (e.g. hold for one dose, hold for twenty-four hours) or the hold order will be considered a stop order

	Abbreviations for drug names will not be accepted. Acceptable drug names include: Generic name, brand name.
	Discharge prescription given to the patient, should be on a Tamper Resistant Prescription Pad

	Prescriptions written for discharge medications are to be given to the patient or family member prior to discharge and documented in the patient record
	The Physician is required to sign all discharge prescriptions before it is given to the patient.

Telephone orders

Telephone orders for medications shall be used only when necessary. Telephone orders will be read back to the prescriber to assure accuracy. Numbers will be stated as words and as the count.
RECORDING TELEPHONE ORDERS
Telephone orders shall be immediately entered on the physician's order form or other authorized document. In addition to the information required for a written order, verbal orders shall include:

	The date and time of entry.
	The prescribing practitioner's name.
	The signature and title of person accepting order.

The clinician taking the telephone shall “read back” the order to the physician as verification. The read shall also include double verification of numbers (say both fifteen, one-five, fifty, five-zero)
AUTHENTICATION (VERIFICATION) OF TELEPHONE ORDERS
Orders that are not written by a prescriber (e.g., telephone orders) shall be subsequently authenticated (verified) and countersigned by the prescribing practitioner or other responsible practitioner within the hospital’s approved timeline.
PERSONS WHO MAY TRANSMIT TELEPHONE ORDERS
Telephone orders shall be transmitted only by authorized prescribers designated in medical staff rules and regulations and only consistent with federal laws and the laws and regulations of this state.
PERSONS WHO MAY ACCEPT TELEPHONE ORDERS Telephone orders for drugs and verbal clarification of drug orders shall be accepted and written in the patient's record only by personnel so designated in the medical staff rules and regulations. Medical staff rules and regulations limit the acceptance of verbal orders to:
Registered Nurses
Registered Pharmacists

Extreme Emergency Orders(Verbal Orders)

Extreme Emergency Orders(Verbal Orders) shall be processed in accordance with medical staff rules and regulations and as described in this policy; and shall be exercised only if the condition below is met

Purpose: To ensure safety of patients and staff in cases of extreme emergencies (when medication delay would increase risk of serious harm to staff or patients).

Procedure: In cases of extreme emergencies (e.g. assault in progress or patient seriously injuring self); the physician may verbally order emergency medications. The nurse would document the order then read back the order verbally repeating the order to confirm it to the physician who verifies/confirm the content of the order before the medication is administered. The order must be documented in the medical record as soon as practically possible but no later than one hour following the emergency. The physician must sign and date the order within one hour. The nurse receiving the verbal order will be responsible for following up to ensure that the order is consigned promptly.
RECORDING EXTREME EMERGENCY ORDERS
Extreme Emergency Orders shall be immediately entered on the physician's order form or other authorized document. In addition to the information required for a written order, verbal orders shall include:

	The date and time of entry.
	The prescribing practitioner's name.
	The signature and title of person accepting order.

AUTHENTICATION (VERIFICATION) OF EXTREME EMERGENCY ORDERS
Orders that are not written by a prescriber (e.g., Extreme Emergency Orders) shall be subsequently authenticated (verified) and countersigned by the prescribing practitioner or other responsible practitioner within the hospital’s approved timeline.

PERSONS WHO MAY TRANSMIT EXTREME EMERGENCY ORDERS Extreme Emergency Orders shall be transmitted only by authorized prescribers designated in medical staff rules and regulations and only consistent with federal laws and the laws and regulations of this state.

PERSONS WHO MAY ACCEPT EXTREME EMERGENCY ORDERS

Extreme Emergency Orders for drugs and verbal clarification of drug orders shall be accepted and written in the patient's record only by personnel so designated in the medical staff rules and regulations.

Medical staff rules and regulations limit the acceptance of verbal orders to:
Registered Nurses
Registered Pharmacists

Transcription of physician's orders

The following policies should be adhered to when transcribing physician's orders:

Handling medications

If a label on a container from the Pharmacy is in error, difficult to read, or accidentally removed, the container will be returned to the Pharmacy for correction. Follow these policies when handling medications:

For...

Policies are...

Open vials

Open multi-dose vials of medications are dated when first reconstituted and are good until the manufacturers expiration date or for 28 days maximum.

Open vials without preservatives must be discarded after usage

Medication in glass ampules

Parenteral medications packaged in glass ampules shall be discarded if not completely utilized a the time of opening

Controlled medications packaged in glass ampules shall be discarded and witnessed with two signatures if not completely utilized at the time of opening

Medication cart

The medication cart is used in the preparation and passage of medications on the units

The cleanliness of the medication cart is important for infection control and safety

It is the responsibility of the nurses on each unit to clean the medication cart weekly or more frequently if needed

The unit medication cart will be locked at all times when not in the designated medication room or when not attended. See Emergency Medical Supplies Verification

Storage and accounting of medications

Controlled substances, Class II and floor stock Class III, will be stored in a designated locked area on the nursing units and accounted for according to Pharmacy controlled procedures. See Controlled Substance Audit

Unit stock medications will be accounted for according to Pharmacy policies

Patient chargeable stock medications are charged to the individual patient according to policy, every shift

Medication variances

Medication variances including errors and adverse reactions must be reported by a health professional

See Medication Error Reporting Process and Reporting Adverse Drug Reactions for procedures and appropriate reporting forms

In addition, for adverse reactions or errors with potential or actual patient impact, the health professional will report the reaction or error to the physician, nurse manager, Pharmacy, and activate departmental or nursing chain of command communication procedures

Dispensing and administering

For...

Policies are...

Dispensing

Only medications that have been dispensed by the UTHCPC Pharmacy may be administered. All medications not approved by the Pharmacy and Therapeutics Committee for administration by the nurses are so labeled by the Pharmacy (i.e., research drugs are stipulated by protocol.)
Medication Usage Evaluation
Formulary

At HCPC all medications prescribed will be dispensed the Generic or Chemical equivalent unless otherwise indicated by the words-MEDICAL NECESSITY written/typed by the physician.

If at all possible, medications brought from home should be taken home by the patient's family. If this is not possible, the medications are forwarded to the Pharmacy for temporary storage. Licensed staff will document the information about the medication.

Under rare and unusual circumstances when an item is not attainable through normal channels (specific allergy antigen, birth control pills, etc.), the drug must be brought to the Pharmacy where it will be labeled and distributed in the usual manner.

After Hours Medication verification process

Purpose: To define process for after hours medication verification process. Timely receipt of medications prescribed for medical conditions is important to prevent complications which might result from a delay if process were only available during regular pharmacy hours.

Procedure: It is the expectation that all doses of patient's personal medicine be verified by the pharmacist prior to administration.
Prescription bottles of newly admitted patients are held in night box until they are reviewed by the pharmacist. In case of emergency only, inhalers that are well labeled may be used. The pharmacist is available on call 24hr/7days a week.

Authorization to administer

Only licensed nursing personnel, graduate nurses with valid permits, and physicians may administer medications
Exception: LVN's may not administer any IV medications.

Licensed staff who have completed the educational training class for the particular protocol can only administer research protocol meds

Nursing students and Medical students under the direct supervision of their instructor or licensed person may also administer medications

RN's may administer IV piggyback medications and IV main line fluids
Exception: Licensed staff may not administer IV push medications. See Insertion and Maintenance of Peripheral Intravenous Infusion

Rules of administering meds

	All personnel administering medications shall demonstrate competency prior to administering approved medications
	Authorized and dispensed medications from the pharmacy shall only be administered to patients admitted to the UTHCPC except in an emergency situation as determined by the P&T Committee

Self-administered medications will not be utilized at UTHCPC

Insulin dosage must be verified by (2) licensed staff prior to administration. Verification should include correct dose/insulin.

The person preparing the medication should administer the medications.
Note: Medications shall not be pre-poured.

Medication administration will follow the five rights: right drug, right dose, right route, right time, and right patient

	Prior to medication administration, patients must be indentified by using two of three patient identifiers
	Armband
	Photo
	Another Staff Member
	All patients must have signed consent for each class of psychoactive medications administered (scheduled/PRN) except in emergencies. In the case of an emergency, refer to Consent to Treatment with Psychoactive Medication procedure.

Document administration of medications on the Medication Administration Record (MAR)

Emergency Department

Medications may be administered without prospective pharmacy review only when the need for a medication is urgent, and/or when a licensed independent practitioner (LIP) controls the ordering, preparation, and administration of the medication. LIP control is interpreted as the LIP being physically present with the patient while the medication is being administered.

Standard administration times

Chart below.

Patient education

Licensed staff and/or the physician must instruct the patient/family on drugs administered and on discharge prescription medications. Documentation of teaching should be noted in the appropriate part of the patient's record (i.e. progress notes, Patient/Family Education Sheet).

Standard medication schedule

Below is a chart depicting the standard medication administration times for staff use:

References

Related standards

If you have questions regarding the content of this site please contact the Policy and Procedure Committee. If you experience any technical problems please contact the MIS Department.

	In the event of a verbal or telephone medication order, the Nurse will place the order in Sunrise indicating the source of the order (i.e. verbal, telephone, etc.). The nurse is unable to place medication orders in Sunrise unless they choose the name of the Physician requesting the order.
	Medication orders are available for viewing in Sunrise by accessing the “Orders” tab
	The eMAR (also called the Work list in Sunrise) is used for tracking distribution of medications to the patient by nursing staff. The eMAR is also accessible by Physicians for reviewing patient medication compliance

	The following policies should be adhered to when transcribing physician's orders when Sunrise is unavailable

	Orders transcribed and initialed by the Support Specialist must be cosigned by a licensed nurse

How Often	Standard Administration Times
DAILY
BID	0900, 1700
TID	0900, 1300, 1700
QID	0900, 1300 1700 2100
Q2H	2400, 0200, 0400, 0600, 0800, etc.
Q3H	0300, 0600, 0900, 1200, 1500, 1800, 2100, 2400
Q4H	0100, 0500, 0900, 1300, 1700, 2100
Q6H	2400, 0600, 1200, 1800
Q8H	0600, 1400, 2200
Q12H	0900, 2100
BEDTIME (HS)	2100
AC	30 minutes before mealtime
PC	30 minutes after mealtime
BIDMEALS	Twice a day with scheduled meals
TIDMEALS	Three times a day with scheduled meals

Medication Policy

Introduction

Physician's orders

Transcription of physician's orders

Handling medications

Dispensing and administering

Standard medication schedule

References

Related standards