Medication Pass Fundamentals Part 1:Preparation, Errors, Safety, Security and ControlledSubstancesCarrie Allen Pharm.D., CGP, BCPS, CCHP04/2014

Intended Audience* Skilled Nursing Facilities (SNF), Assisted Living Facilities/Communities(ALF/ALC), any facility or community setting that offers medication pass as partof their services Clinical and non-clinical management: Directors of Nursing, Assistant Directors ofNursing, Regional Nurse Managers, Administrators Staff that are involved in performing medication passes or who are in training toperform medication pass: Registered Nurses (RN), Licensed Vocational orProfessional Nurses (LVN, LPN), Certified Medication Aides or Technicians (CMA,CMT), etc. Staff that may require a refresher or re-training secondary to a medication error Facilities who have been permitted by their state governing body to use thetraining as part of a Plan of Correction2*Though much of this information is derived from regulations for SNF, these practices will decrease medicationerrors in any type of facility

Topics CoveredResident populationSafety and common medication errorsPrivacy, dignity and resident rightsState survey and associated F-tagsError rate calculation for med passMed pass observation: facility goals and approachPreparation for med pass (including controlledsubstance management)3

Who is your resident? Frail elderly or someone with adebilitating chronic disease state(or both) Person who recently had a traumaticevent (e.g., hip fracture) or surgery Person who likely grew up in a differentera than you, has different values andperceptions of dignity and privacy Many comorbidities (disease states)4

Who is your resident? Multiple medications High risk of fall and/or fracture Dementia, confusion, agitation Movement and mobility problems Unable to perform many tasks on theirown (e.g., transferring, toileting, eating) At high risk for:– infection– medication related problems– problems associated with their frailty orsituation5

Safety and MedicationsMedication Error1 - A medication error is any preventable event that may causeor lead to inappropriate medication use or patient harm while the medication is inthe control of the health care professional, patient, or consumer.Such events may be related to professional practice, health care products,procedures and systems, including:6 prescribingorder communicationproduct labeling, packaging, and nomenclaturecompoundingdispensingdistribution administrationeducationmonitoringuse

Safety and Medications - Common Drug ReferencesDo not administer any medication that isunfamiliar to you7

Safety and Medications - Common Drug References8

Safety and Medications – Medication Administration Guidefor Medication Technicians (ALF and SNF)9

Safety and Medications - Common Drug ReferencesOmniview and epocrates Link from Omniview10

Safety and Medications – The Geriatric Pharmaceutical CareGuidelines (GPCG) on Omniview11

Safety and Medications – GPCG Clinical Tools Example12

Medication Errors: State Operations Manual (SOM)2Medication Error - The observed preparation or administration of drugs orbiologicals which is not in accordance with:1. Physician’s orders2. Manufacturer’s specifications regarding the preparation andadministration of the drug or biological3. Accepted professional standards and principles which apply toprofessionals providing servicesActual harm orsignificantpotential forharmSignificant13Lowerlikelihood ofresulting inharmNon-significant

Medication Errors: State Operations Manual (SOM)2The facility must ensure that1. It is free of medication error rates of 5 percent or greater[F332]2. Residents are free of any significant medication errors[F333]Actual harm orsignificantpotential forharmSignificant14Lowerlikelihood ofresulting inharmNon-significant

Medication Errors: Significant and Non-significant ExamplesDrug OrderIbuprofen (Motrin) 400mg by mouththree times a dayDigoxin (Lanoxin) 0.125mg bymouth dailyNatural Tears 2 Drops in both eyesthree times a dayInsulin glargine (Lantus) 20 unitssub-Q nightlyMultivitamin one tablet by mouthdailyWarfarin (Coumadin) 5 mg by mouthevery evening15ErrorSignificanceMissed morning doseNon-significantMissed doseSignificantGave 3 drops instead of 2 in each eyeduring morning doseNon-significantGave 40 units instead of 20 unitsSignificantGave to wrong resident, resident hasno ordersGave to wrong resident, resident hasno ordersNon-significantSignificantMiralax 17 g by mouth everymorning with 8 ounces of waterGave 2 hours earlyNon-significantGlipizide (Glucotrol) 10 mg bymouth a half-hour before AM mealGave 2 hours earlySignificant

Medication Timing16

Medication Error Calculation:State Operations Manual (SOM)217

Medication Errors: State Operations Manual (SOM)2“A medication error rate of 5% or greater includes both significant andnon-significant medication errors. It indicates that the facility may havesystemic problems with its drug distribution system and a deficiencyshould be written.”18

Medication Errors: ISMP / TJC / AHRQNo one makes a medication error on their own,it is the process, the organization and all theissues associated with it that ultimately causemed errors– Institute for Safe Medication Practices– The Joint Commission(formerly JCAHO)– Agency for Healthcare Research andQuality19

Facility Goal for Medication PassWork together, with staff at all levels providing input todevelop a facility culture that:Increasesresident safetyDecreasesmedication errors20

Often Cited in Relation to Med Pass221F281 Professional Standards of QualityF309 Quality of CareF329 Unnecessary DrugsF332-333 Medication ErrorsF425 Pharmacy ServicesF431 Storage, Labeling and Controlled MedicationsF151 Resident Rights

Often Cited in Relation to Med Pass3F441 Infection ControlThe CDC has a website specific to long term care and infectionsThey state that, “Data about infections in Long Term Care Facilities arelimited, but it has been estimated in the medical literature that:1 to 3 million serious infections occur every year in these facilities.” 222


Facility ApproachThe day to day business of caring for residents in SNF, orALF, is heavily reliant on medications as the primary modeof treatment. This is why it is important to:Train the Trainer24

Facility ApproachFacilities should adopt a consistent process to perform amed pass and continually monitor it on their own toachieve the safest environment and the lowest medicationerror rate possible25

Other Facility Approaches to Decrease Medication ErrorsLead by WalkingAround4Peer Review andShadowingReport, Discussand CorrectMedication ErrorsAll departments must communicate and remember toinvolve pharmacy in the discussion26

Begin with the Basics – Resident RightsMedication administration involves preserving dignity andresident’s rights which include, but are not limited to, the right to:Be treated with respectRefuse medications or treatmentsBe given privacy during medication passBe free from physical and chemical restraints27

Resident Rights, the right toBe treated with respect, including:How the resident is addressedDo not interrupt the resident while eating for theadministration of medications without an orderDo not awaken a resident to administer a medication thatcould be scheduled or administered at other timesExplain medications, and any procedure about to beperformedAnswer questions the resident may have about themedication28

Resident Rights, the right to:Refuse medications or treatmentsA resident has a right to refuseNever force a resident to take a medicationThe facility should have policies andprocedures for refusals including timelynotification of the prescriber29

Resident Rights, the right to:Be given privacy during medication passKnock on doors before entering and identify yourselfDo not administer medications when the resident is receivingpersonal care or in the bathroomMedications are ideally given in the privacy of the resident’s roomDo not administer medications that require privacy in commonareas (e.g., those given via tube, nasal, injections, vaginal andrectal administrations, dressing changes, treatments or patchapplication requiring removal /adjustment of clothing)30

Resident Rights, the right to:Be given privacy during medication pass, thisincludes HIPAA related practicesCover MAR or go to privacy screen oncomputerBe aware of the methods and tools that willallow you to give residents privacy andrespect during a medication pass(e.g., screens, curtains, doors)31

Resident Rights, the right to:Privacy, this includes HIPAA and technology32

Resident Rights, the right to:Be free from physical and chemical restraintsMedications, especially psychopharmacologic,are not to be administered for staff conveniencePhysical restraints should not be used to hold aresident in order to administer medications33

Getting the Cart PreparedProfessionalism, supplies, infection controland organization34

Med Pass: Slow Down, Get Prepared35

Begin with the BasicsProfessionalism: Name tag on, professional appearance, med cartclean, stocked and organized36

Begin with the BasicsInfection Control:Clean pill counters, pill crushers, med cart,glucometers (special cleaning agents may apply)Hands washed and hand sanitizer availableTissues, paper towels, gloves, masks, gownsavailableRecall and always practice proper administrationtechniques to prevent infection37

Begin with the BasicsMedication Security and Safety:Meds are not expiredMeds are stored correctlyControlled substances are double locked in apermanently affixed containerCart locked and keys secured38

Have the proper supplies available on the cartto avoid the following issues:Interrupting the medication pass andincreasing the risk of making amedication administration errorLeaving the cart unattended to retrievesuppliesIncreasing the time it takes to completethe medication pass39

Medication Pass Setup: Supplies Medication administration record (MAR) Controlled substance count book Keys to cart and medication storage area(s) Pen (black or blue) Medications, dietary supplements Crackers/food items (e.g., applesauce) Thickening agents Drinking water and/or juice Alcohol-based hand sanitizer Sanitizer to clean glucometers Glucometer, lancets, other insulinadministration supplies Alcohol swabs Gloves Blood pressure cuff Stethoscope Beverage cups (8 oz.) and medication cups(rims down) Tissues Straws (covered) Drug reference, “Should Not Crush” andstorage parameters lists Spoons and mixing spatulas/tonguedepressors (handles up) Oral syringes for measuring liquid doses (e.g.,irregular or small doses, narrow therapeuticindex medications)40 Pill crusher and soufflé cups or plasticpouches Paper towels Notebook/paper Trash bag and receptacle Sharps container

Medication Pass Setup: SuppliesHandling Food and Beverages Only food and beverages used for the medication pass shouldbe on the cart, no personal food or drink All food and beverages should be labeled with the date andtime opened, none should be expired Protect against contamination:– All food, beverages and straws should be covered– spoons and mixers handles up, med and water cups rimsdown and not touching contaminated surfaces41

Medication Pass Setup: SuppliesHandling Food and Beverages Ensure you have a process to access and properly maintainrefrigerated items Do not allow refrigerated items to remain on the cart betweenmedication passes42

Medication Pass Setup: Supplies Separate internals from externals in all medication storage areas and separatemedications from sanitizers or cleaners (see Omnicare’s recommended storagedocument for reference) If possible, separate all medications by route of administration (e.g., eye, ear, nose,topical, oral) to further decrease the risk of medication errors43

Medication pass responsibilitiesControlled substances counting, shift to shiftsheet, security44

Med Pass Responsibilities: When do they start?Med pass responsibilities begin as you prepare to takecharge of the cartAs you take over the cart from the previous shift, if there arecontrolled substances, or other items the facility mandates thatyou count, you must count them Person leaving and person taking over the cart: bothindividuals should read the number from the sheet and bothshould check the actual inventory Both people: sign the shift count book if the count is correct45

INCORRECT COUNTIf incorrect counts exist: do not leave, immediatelyinvestigate, contact your supervisor and follow thefacility’s procedure for an incorrect count46

INCORRECT COUNTSurvey Implications5: If surveyors identify misuse or diversion of a controlledsubstance, they should consider and investigate these requirements: F309 - Quality of care, for evidence and/or potential outcomes, such asunrelieved pain F425 - Pharmacy Services, for policies for safeguarding and access,monitoring, administration, documentation, reconciliation and destruction ofcontrolled substances F431 - Pharmacy service consultation, for drug records and reconciliationof controlled drugs F514 - Clinical Records, accuracy of medical record and for thedocumentation of the administration of the medication and outcomes F520 - Quality assessment and assurance, for how the QAA committeemonitors the administration, reconciliation and disposition of controlledsubstances in the facility47

INCORRECT COUNT In addition, if the investigation identifies diversion of a resident’smedication, the surveyor must review for F224- Misappropriation ofResident’s Property. 5 If it is determined that a resident’s medications were diverted for staffuse, the State Agency must make referrals to appropriate agencies,such as:– Local