CMS Clarifications11/2/2012

Medication errorsMedication administration practicesMedication review for short stays less than 30 days and/or changes in condition Faculty: Diane Atchinson, RN-BC, MSN, ANP, RAC-CTPresident, DPA Associates, IncKansas City, MO e mail: diane@dpaassociates.com

Medication errors• Administration of medications via a feeding tubeF425-facility with the consultant pharmacist must provide procedures for the accurate administration of all medications• Must reflect best practices

• Types of medications that may safely administered via a feeding tube• Appropriate dose forms• Techniques to ensure that the feeding tube is in the right location before

administering medications• Preparing drugs for administration• Administering drugs separately• Diluting drugs appropriately• Flushing the tube before, between and after drug administration and• That drugs with know incompatibilities are not given at the same time

•

Survey implications: F 322• Placement checked prior to medication administration• Amount of water to be used as flush noted via an MD order

for medication administration• Standard of Practice (American Society for Parenteral and

Enteral Nutrition) Enteral Nutrition Handbook, 2010.• Administer each medication separately followed by flushing the

tube• Exception: MD order that specifies a different flush schedule• Failure to flush will constitute 1 medication error• Surveyor will review your facility policy (F425)• Surveyor will also review F 520-QA to review for monitoring for

safe administration practice including TF medications

Enteral Nutrition Handbook (p 309-329)• Drug interactions• Compatibility • Stability

• When a drug formulation is altered, by pulverizing, adding to fluid, or combining it with other substances, drug stability may be compromised

• TF should be held when giving medications. IE medications should not be added to the TF.

• Recommendations• Do not combine liquid medications• Do not combine crushed medications • Sustained release medications should never be crushed• Do not pucture liquid filled gel capsules• Crush each medication separately and dissolve in a small amount of water

to prevent occlusion of the tube• Liquid medications can also cause problems-consult with pharmacist

Interdisciplinary team review• Develop • Guidelines• Nurse education• Pharmacist recommendations

• This reduces tube obstruction and drug errors

Drug/Nutrient Interactions• Dilantin• Hold TF for 1-2 hours before and after dose is given or• Adjust the dose based on therapeutic drug levels• Diluting is recommended to avoid tube obstruction • Consistency of procedures used should be well documented

• Carbamazepine• Hold TF for 1 hour before and after dose• Monitor serum levels closely• Dilute 1/1 with water

• Fluoroquinolones• Separate doses from food, dietary supplements, or other drugs containing

calcium, MG (antacids) or iron. • Hold TF for 1 hour before and 2 hours after dosing

• Warfarin (Coumadin)• Separate the drug from the formula• Increasing the dosage via monitoring• Hold the TF 1 hour before and after dosing• Interactions with Warfarin can be life threatening

Medication Administration Technique• Basics-verify placement ,turn off feeding if running and do not

add medications to formula• Flush the tube with at least 15cc of water• Do not mix medications together but do dilute them • Each medication administered separately• Liquid dose forms used if available and diluted• Pulverize tablets and mix with water.• Open hard capsules and dilute powder with water• Flush with at least 15cc of water between each medication

administered• Restart TF as per resident specific medication needs

Metered Dose Inhalers• If more than 1 puff is needed (same or different medication)

there should be at least 1 minute between each puff except for:• Short acting beta agonists such as albuterol-15-30 seconds is

acceptable• Ensure the device is administered correctly• Examples of education sites include:• http://nhlbi.nih.gov/health/prof/lung/asthma/nurs_gde.pdf• http://aafa-md.org/thumbdrive.htm (under pharmacy file-

handouts• You tube video: http://www.youtube.com/watch?v=Z_95ni8DJwU

Proton Pump Inhibitors (PPI)• Facility has policies related to medications and food

consumption • PPI’s given on an empty stomach at least 30-60 minutes

before a meal • Use greater than 1 year-higher risk of fractures, pneumonia

and C diff. This should be reviewed by DRR.

Borrowing medications• Not consistent with best practices• Leads to medication errors• Recommendations:• Use of an E kit • Contents decided by pharmacist and DON• P and P for medication ordering and reordering of medications

• Monitoring that medications are delivered as ordered• What to do if medication is not available for administration • MD aware• Use of Medical Director

Fentanyl patches• Polies to address: • Safe and secure storage• Limited access• Reconciliation • Safe handling, distribution and disposition

• Disposal • Same manner as wasting of any controlled substance• Must be safe and secure

• Where kept until destroyed• Control and accountability• Documentation if destruction for both full dose and partial doses

• Timely indentification and removal lf medications from current supply

Medication reviews for stays less than 30 days and changes of condition • Reviews might need to occur more frequently than monthly depending on:• Resident’s condition• Risk for adverse affects related to current medications

• Review applies to all residents including:• Respite• Residents at end of life or are using hospice• Residents with stays less than 30 days or• Residents who have experienced a change in condition• Complex residents in the transition from hospital to SNF

• This review prevents errors due to drug/drug, omissions, duplication of therapy or miscommunication between providers and care givers

• Recommendations• Facility has p and p on who needs a more frequent review (define complex resident), and risk for

consequences for residents with stays of less than 30 days• How will the need for this consult be communicated • How the review will be handled if the pharmacist is off site• How the results of the report will be communicated to the provider• Expectations for the provider’s response and follow up• How and where this information will be documented