Introduction - Welcome | Network North · Web viewMinistry of Health website. References...
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Medication Management
Transcript of Introduction - Welcome | Network North · Web viewMinistry of Health website. References...
Medication Management
Table of Contents1. Introduction.........................................................................................................................................3
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2. Responsibilities For Medication Management Processes....................................................................4
2.1 Medicines reconciliation and prescribing..........................................................................................4
2.2 Dispensing and administering............................................................................................................5
3. Administering/Supervising/Taking Medication...................................................................................6
Administering medication cont...........................................................................................................7
3.1 PRN – As required medication...........................................................................................................8
3.2 Self management of medication..................................................................................................9
3.3 Medication arrangements at other than the usual locations..........................................................10
4. Adverse Reactions To Medication.....................................................................................................11
5. Controlled Drugs................................................................................................................................12
6. Receiving, Transporting, Storing and Returning Medication.............................................................13
7. Medication Delivery – Med-Run........................................................................................................14
8. Respite Services.................................................................................................................................15
9. Emergency, Over-The Counter, Complimentary and Alternative Medication...................................16
9.1 Emergency Medication....................................................................................................................16
9.2 Over-The Counter, Complimentary and Alternative Medication.....................................................17
10. Medication Management Competency...............................................................................................18
11. Medication Charts, Prescriptions, Medication Records.......................................................................19
12. Medication Errors – Incident Reporting...............................................................................................20
Medication Errors – Incident Reporting cont.....................................................................................21
13. Quality Assurance and Improvement Activities...................................................................................22
1. IntroductionThe purpose of this document is to ensure that:
Version: V1 Issue Date 070214 Created by: GSHarnischReview Date 070217 Authorised by: NRA Working Group
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Purpose Support service user’s informed choices to take medication Persons being responsible for medication processes complete their tasks in a
manner that is consistent with legislation, relevant standards and guidelines.Scope The processes described in this document apply to persons involved in name of service
medication processes.Policy name of service will maintain systems that ensure safe medicines management
processes for service users that are engaged with name of service.name of service will support the service users’ informed choices to take medication medication in line with contractual responsibilities and duty of care. The service provider will aim to maintain maximum service user independence in managing their medication and other remedies.At all times, the person who is taking the medicine is the focus of the medicines management system.
Quality Indicators
To measure the effectiveness of the medication management system, the following quality indicators are put in place:
Documentation, analysis and resulting improvements of medication related incidents/adverse events.
Number of service users that have achieved a defined level of independence in taking their medication.
Adherence to the medication processes competency systems. External audits results will comply with all standards/criteria for medication
management processes.
Rongoā Māori Standards New Zealand is developing a standard on safe Rongoā practices. The final version of this standard was not available at the time this document was developed.To follow up on Rongoā practices please refer to the Ministry of Health website.
References
Legislation Medicines Act 1981Medicines Regulations 2002Misuse of Drugs Act 1975Misuse of Drugs Regulations 1977Health Practitioner Assurance and Competency Act 2003Misuse of Drugs amendment Regulations 2005
Guidelines Medicines Management Guide for Community Residential and Facility-based Respite Services – Disability, Mental Health and Addiction.2013. Ministry of Health NZ.Standing Order guidelines, NZ MOH 2012Guidelines for Nurses on medicines administration (NZ Nurses Organisation 2012)Advance Care Planning, NZ MOH, 2011HealthNavigator resources
Standards Medication Charting Standards. 2011. Health Quality and Safety Commission.NZS 8134:2008 Health and Disability Services StandardNZS 8158:2012 Home and community support sector StandardSafe And Quality Use of Medicines Group
Professional Registration bodies
www.mcnz.org.nzwww.nursingcouncil.org.nzwww.pgnz.org.nz
name of servicePolicies and Procedures
Adverse Events/Incident ManagementOpen DisclosureInformed ConsentHome and Community Visits
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2. Responsibilities For Medication Management Processes
2.1 Medicines reconciliation and prescribing
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Prescribing
Medical Practitioner/Prescriber
Staff/Service Provider/Clinical Team
Informs the service user of the reason, effects and side effects of the medication prescribed.
Prescribes the medication as required.
Ensures that the prescription is given to the identified person(s).Example: pharmacist, service user, service provider.
Reviews the medication regime at least 6 monthly.
Service User/Family
Attends doctors’ visits to ensure ongoing supply of medication.
Processes the prescription as required.
Asks any questions if the prescription is not clear.
Accesses information about the medication prescribed.
Initiates a medication review as necessary.
Facilitates the processing of the prescription as required.
Do not transcribe Medication
Refer to page 31 of the NZNO 2012 guideline. Ensures that medication
reviews occur as required.
Medicines Reconciliation
A written message from a Doctor that officially tells someone to use a medicine, therapy, etc.
Staff/Service Provider
Obtains the required information from the service user and others.
Documents the medication information obtained.
Provides the prescriber with information: On the current and past
medication taken. On adverse responses to
medication/allergies.
Facilitates that the required information is given to the prescriber and/or clinical team member.
(Nurses can do medicines reconciliation)
A process of obtaining the most accurate list of medicines and other remedies, allergies and adverse drug reactions and comparing this with the current prescribed medications, documented allergies and adverse drug reactions.
Service User/Family
Medical Practitioner/Prescriber
GP, Psychiatrist, Specialist Physician
Tangata WhaioraConsumer
Client Whanau
KaimahiSupport Worker
Clinical Team Member
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2.2 Dispensing and administering – responsibilities cont.
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Dispensing
The preparation, packaging, labelling, record keeping, and transfer of a prescription drug to a patient or an intermediary, who is responsible for administration of the drug (Mosby’s medical dictionary 9 th ed., 2013).
Administering/Supervising/Taking Medicines
Medical PractitionerPharmacist Service User Staff/Service Provider/Clinical
Team
Do not tamper with the original package of the dispensed medication.
Ensures they leave the medication in its original package/container.
Only medical practitioners and pharmacists can dispense medication.
For details refer to Medicines Regulations.
Nurses are legally not authorised to dispense medication unless they are ‘delegated prescribers’ by the Minister of Health or nurse practitioners. Refer to page 17 of the NZNO guideline and the Medicines Regulations .
To give or take medication to a person in the correct way.
Prescriber Service UserStaff/Service
Provider/Clinical Team
Facilitates medicine administration in a manner that supports maximum independence for the service user.
Takes part in taking medication to their capability
Fully self-administers their medication.
Agrees to the service users self administration plan or delegates this decision to another clinician.
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3. Administering/Supervising/Taking Medication
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Staff/Service User
Before Administering Prepare environment: Have the paperwork ready –
script, signing sheet. Info on Medico packs
No disruptions: Activate answerphone. Administer:
o in a quiet spaceo one person at the time
Right RouteExamples
Ensure the service user provided informed consent to the medication.
Hand HygieneWash and dry hands
Check the name on the medication container/pack.Check that the identity of the service user matches the name on the pack.
Check the medication against the medication chart/record. Check expiry date. Check the noted allergies.
Ensure the dose in the medico-pack/container is the one charted on the medication chart/record.
Read the medication related instructions to confirm the time for administering the medication.Check the time when the last dose of the medicine was administered.Check if there is a period of time to take the medication in relation to foods or liquids (for example antibiotics ).
Read and follow the direction on the medication chart/record.
If the service user chooses not to take medication prescribed make a note on the signing sheet (use appropriate abbreviation) and inform the prescriber/clinical team.
Provide written information Access videos Discuss the medication information with the service user/family
Right Person
Right MedicineMedico packs
Right Dose
Right Time
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Administering medication cont.
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Administer the
medication
Oral Medication - swallowingTake always with water – never with grapefruit juice or
milk
Oral Medication- sublingualOral Medication – buccal
Asthma InhalersVentolin HFA
Topical:Applied to a specific area of the skin (for example creams).
Staff/Service User
After Administering
Observe the effect of the medication if it is new for the service user, and follow any instruction given by the prescriber/clinical responsible service.
Eye DropsHand-out for service user
Sign the medication administration sheet.
If not administered Using accurate abbreviations, note this on the signing sheet.Respond according to the processes outlined on page 10.
Dropped or spilled
medication
Never administer dropped or spilt medication, nor put it back in the container: return dropped medication to the pharmacy for disposal wipe up any spilt liquid with a disposable cloth, and dispose of the cloth in
an outside bin. administer the correct dose from the remaining medication if possible arrange for the dropped or spilt medication to be replaced complete an incident/adverse event report
Hand Hygiene
If you have not observed the service user having ingested/swallowed their medication you cannot sign the administration record. You have to specify exactly how the medication has been processed.
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3.1 PRN – As required medication
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Each time PRN (pro-re-nata) is administered/given
Person administering/taking the PRN medication
Some PRN can only be administered/taken if the clinical responsible team or the services on-call person approves – check for instructions.
Only administer/take PRN medication for the purpose noted on the prescription/medication chart/medication record.
Observe the effect of the PRN medication on the service user.
Follow the medication administering processes.
Document the observations in the service users’ records.
Discuss ongoing PRN use with the prescriber/clinical service.
Over the Counter PRN remedies
Discuss with the service user: possible allergies to the remedy possible interaction with the prescribed
medication consult with the GP/prescriber
If alternatives to PRN are available try those before administering/taking PRN medication. Examples:
breathing exercise sensory modulation diversion therapy/activities talking therapies document a pre-PRN plan refer to the relapse prevention plan
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3.2 Self management of medication
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When the prescription is issuedWhen goals are discussed
Service user/familyService providers
Prescriber
Decision Making Principles
Other participants as identified:InterpreterAdvocatePeer supportCultural supportsKey workerPharmacistSupport as identified by the service user.
If required service users will be: supported to manage their
medication supported to gain the skills to
manage their medication provided with resources and
training to manage their medication
linked to self management support
Programme to gain medication self management skills.
Medication plan.
The clinical responsible service will approve the
self-administration medication management
plan.
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3.3 Medication arrangements at other than the usual locations
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Services need to ensure ongoing use of the service users’ medication when they are away from their usual place of residence. This applies, for example, to service users that visit friends or family overnight, go away on a holiday or attend conferences or training.
Before going on leave
Staff/service user/family
Consult with and obtain permission from the prescriber/clinical responsible service about the amount of medication given to the service user or person responsible to ensure medication is taken.
Ensure enough medication is taken away. Provide extra medication in case the
service users’ return is delayed.
Identify and record the person responsible for storing, administering and bringing back any leftover medication.
It is preferable to have the medication in a medico-pack.
Provide the service user/person responsible for the medication with: information about the medication contact details of service to call if there are
any issues
Complete the template and provide a copy to the service user/person responsible for the medication.
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4. Adverse Reactions To Medication
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Definition = any unexpected, unintended, undesired or excessive response to medication.
Common antipsychotic drug adverse reactions:
As soon as the medication response is identified
Person identifying/reporting the response
Contact the prescriber or the clinical on-call service immediately if you observe the following symptoms:
Involuntary spastic muscle contractions: Dystonia
Extremerestlessness:
Akathisia
Abnormal involuntary muscle movements of the face, tongue, trunk and extremities: Tardive dyskinesia
Difficultywithmovement:Akinesia
Mild allergic reactions
A side effect is a predictable effect of the medicine, and it may be desirable or undesirableAn adverse medicine reaction is always undesirable and may not be predictable.
A true medicine allergy results in a physical allergic reaction (see below).
Life-threatening anaphylaxis
Immediately Immediately
Person/service user observing the symptoms: Person/service user observing the symptoms:
Warm sensation Mild shortness of breath/coughFullness in mouth/throat Nasal congestion/sneezing/tears Eye swelling Pruritus (severe itchiness) Anxiety
Severe – Abrupt onset Severe difficulty breathing/wheezing/noisy breathing Throat swelling Cyanosis (blue skin, especially around mouth)Difficulty swallowing Seizure Coma Cardiac arrest
• Remain with the person. • Maintain airway, breathing, circulation. • If able to, lay the person flat and elevate
their feet.• Contact your manager/team leader for
support and guidance.
CALL 111
• Remain with the person.
• Follow instructions given by the prescriber or clinical service.
CALL:• Prescriber• Clinical responsible
service• Manager/team
leader
• Go to the closest accident and emergency clinic if a clinician is not available.
effect of
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5. Controlled Drugs
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All staff that manage controlled drugsOverall responsibility: regulated health
professional or manager
Controlled Drugs
At all times
Storing Documentation
Controlled drugs registerControlled drugs to be kept in a locked controlled drug cabinet – separate from other medication.
One designated staff member will be in possession of the controlled cabinet key each shift.
Controlled drugs received/delivered will never be left anywhere else than in the designated controlled drug cabinet.
All controlled drug transactions are documented in a controlled drug register.
The Police will be contacted if controlled drugs are missing because of possible theft.
This register is kept in the controlled drug cabinet.
A separate page is used for each medication and for each strength of the medication and includes:
Time and date of administering.
Quantity and dose of the medicineadministered.
How much medication is left: running balance.
Amount of medication received/delivered in mg or ml (milligram or millilitre).
Service user’s name (the drug is prescribed for)
Name of prescriber
Check balance weekly for accuracy
If possible: two staff sign the completed controlled transactions and the weekly balance.
Consider having the service user pick the controlled drug up daily from the local pharmacy.
The relevant professional body will be informed if a regulated health professional has been involved in the theft or misappropriation of medication including controlled drugs.
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6. Receiving, Transporting, Storing and Returning Medication.
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Do they have to adhere to cold chain accreditation requirements?
At all times- every time
Staff involved the medication processesService users/families involved in managing medication
Receiving
Confirm in writing the medication received:o dateo amounto countersignedo check the received
medication is correct
Transporting
Never re-label medication Never give a service user medication from another service user’s packed medication.
Ensue the medication is transported safely: in the locked boot of a car in a locked brief case in a reasonable temperature
Storing
Store immediately according to the instructions in the original package in a cupboard that is accessible
to authorised persons only separate prescribed and over the
counter medication provide service users that
manage their medication with safe storage
If medication needs to be stored in the fridge, fridge temperature needs to be monitored.
Returning
always return no longer used and expired medication to the pharmacy
maintain a record of returned medication
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7. Medication Delivery – Med-Run
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Have clear documented and signed instructions of the medication process
tasks expected by the prescriber or clinical responsible team.
Documentation
Ensure you are provided with:
a script/medication chart any risk issues to be aware of
including medicine related allergies/sensitivities
contact details for emergency situation
medico-packs (blister packs) for each individual service user
service users consent for the service
Some service providers have contracts to deliver and/or administer medication to service users in their homes.All processes described in this manual apply to medication delivery services as relevant.It is suggested that services consider additionally the following:
Record clearly how you have provided the medication to the service user, for example: handed over a week’s blister-pack
(medico-pack) handed over the morning
medication dose in a blister administered the medication
Ensure an environmental and personal health and safety scan has been completed
Implement the organisations home-visiting procedure.
Staff involved in medication delivery
Before delivering the medicationEnsure: you take a mobile phone with you someone knows where you are going that the organisation has a back-up
system following up if the staff requires support
note the time and date of the interaction contact the clinical responsible service/
prescriber if you have concerns about the service user and note this in the service user’s records
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8. Respite Services
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There are planned and crisis respite services contracts that are sometimes required to manage the medication of service users. . Additionally to the documented processes in this manual the Ministry of Health guidelines require an additional focus on the following processes:
Responsible staff: manager/team leader
Documentation
Before the service user enters the respite service.
Confirmation by the referrer what role the respite service (authorisation required) the service user the clinical service/prescriber have in the medication management processes.
Ensure that you receive: the service user’s current prescription - or medication chartrecorded by the prescriber – not a nurse.Confirmation of all the medication the service user is currently prescribed and taking (incl. GP prescribed).
Ensure written instructions for: PRN are provided any other medication required (example:
inhaler, insulin) verbal instructions need to be followed up
by a confirming fax, scanned document or other written confirmation within 8 hours
Provide the clinical responsible service with information on changes by multiple prescribers or a change in the allergy/medicine related sensitivity (medicine reconciliation) at discharge (medicines reconciliation).
Medication Containers
Medication need to be labelled according to legislation (refer to example).
Do not accept brown envelopes with medication that are not legally dispensed and
labelled!
Medication need to be dispensed according to legislation.
Request that all medication is in medico-packs at the time the service user enters the respite service.
Ensure you have the contact details of the prescriber and the pharmacist.
That the situation is resolved immediately. That the referrer/service user provides the
necessary documentation and/or the medication in the required manner without delay.
That the service user is not able to use respite unless the required documentation and processes are provided.
The Ministry of Health guideline suggests the following if the required documentation and/or medication processes are not followed by the
referrer/service user:
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9. Emergency, Over-The Counter, Complimentary and Alternative Medication
9.1 Emergency Medication
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Staff responsible for service delivery
At all times and in every situation
Service users service delivery plans include:
Additional responsibility: service user family/whanau medical staff/GP other identified services
There is always a person on shift that has a First Aid
Certificate.
Staff/service users’ will have training in using the emergency
medication.
medical condition medical needs medical emergency plan acute management plan
For conditions such as: asthma diabetes (low glucose, high glucose) anaphylaxis poorly controlled epilepsy
When the emergency is identified
Staff on duty/service user
Follow the medical emergency/acute management plan. Check the emergency medications expiry date. Call for assistance if needed – on-call staff.
After the emergency
Delegated staff/service user/family
Ensure the emergency medication is replaced. Manage the situation through the incident/adverse
event process.
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9.2 Over-The Counter, Complimentary and Alternative Medication
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Service users may choose to use over-the counter medication and remedies and/or are engaged with practitioners of complimentary or alternative practitioners that provide remedies. It is essential that the psychiatrist, GP and pharmacist know that the service user is using such remedies as they can interact with the medication they prescribe.
When the service user reveals using over the counter, complimentary or alternative medication
orexpresses the wish to do so.
Provide the service user/family with access to the complementary/alternative practitioners
Registration information
Service provider
At service entry
Include Information on the use of over-the counter, complementary and alternative medication in the orientation/service information
Example: Ministry of Health Medical CouncilRongo ā
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10. Medication Management Competency
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Ensures safe medication management practices are implemented.
Staff/Service User/Family
Are familiar with the policies and procedures that apply to medication management responsibilities and processes.
Yearly Medication Management Competency
Activity Options:
Utilise the outcomes from medication incidents to develop a competency plan.
Complete a medication management test within given timeframes.
Invite speakers that provide information on specific medication and its management.
Have medication administration observed against a standardised observation template.
Use on-line medication training and other information.
Utilise mental health support work educational material through, for example, careerforce.
Ensure cultural views are considered during the medication management processes. Cross-Cultural ResourceMāori and MedicationsCultural Factors in Medicine TakingInterpreters are made available.
Manager or Delegate
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11. Medication Charts, Prescriptions, Medication Records
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Staff/Service User/Family
Before accepting responsibility to be involved in medication management processes
The guidelines require that all prescriptions will be checked for the following information:(check: how to read a prescription)
Date when the prescription is issued.
Name of medication.
Dosage of the medication.
Frequency when the medication is to be taken.
Times when the medication is to be taken.
Route of administration.
Duration of prescription (short-term medication should have an end date).
Duration of treatment (if displayed on packaging).
Date on which the medication is to be reviewed or discontinued (if displayed on the packaging)
Expiry date (if displayed on the packaging).
Special instructions for administration of medication (if displayed on the packaging).
Ensure that you have a record of the detailed prescription. Options:
Prescription – written script. Medication chart. Medication record from the dispensing
pharmacist (this option might not be accepted by all auditors)
Medicine related allergies/sensitivities to be noted on the prescription information.
Recommendation: best practice requires that the prescriber’s registration number is noted on the prescription.
Contact the prescriber or pharmacy/pharmacist if any information is missing.
Put duplicate name warnings on medication documents and medication containers for service users with the same or similar names.
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12. Medication Errors – Incident Reporting
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Wrong dispensing
The service user received/took: the wrong medication – for whatever
reason medication that is contraindicated
(for example allergy or non-compatibility with other medications)
wrong form of drug (for example long acting versus short acting or pill versus capsule)
A service user received/took another person’s medication that is different from the one prescribed.
Blister packs or medication containers are not dispensed correctly by the pharmacist.
Wrong person
Wrong medication
Staff/Service User
Same day
Contact the pharmacy and arrange the correct medication to be dispensed.
As soon as the error is discovered
Staff/Service User
Contact the prescriber/clinical responsible person. Follow their instructions. If the service user shows adverse symptoms get an ambulance or get the service user to the closest accident and emergency clinic.
As soon as the error is discovered
Staff/Service User
Typeof
ErrorResponse
All medication errors are processed through the organisations/services Adverse Event/ Incident management system.
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Medication Errors – Incident Reporting cont.
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Contact the prescriber/clinical responsible person. Follow their instructions. If the service user shows adverse symptoms get an ambulance or get the service user to the closest accident and emergency clinic.
Wrong doseA service user took too much or not enough medication.
Staff/Service User
As soon as the error is discovered
Typeof
Error
Response
Wrong timeA service user took the medication over 30 minutes before or after it is noted on the prescription/or required.
Wrong route
A service user took the medication incorrectly, for example instead sublingual (under the tongue, the service user swallowed the medication.
Contact the prescriber/clinical responsible person. Follow their instructions. Do not re-commence medication without the prescribers’ approval as some medication needs to be slowly re-introduced.
OmissionA service user is not getting the prescribed medication at all – for any reasons (example: forgetting to take it)
Contact the prescriber/clinical responsible person. Follow their instructions.Check/ observe whether the service user shows any unusual symptoms.
Service user chooses not to
take medication
A service user chooses not to take medication Explore the reasons for their
decision with the service user.
Medication is missing
Contact the manager.If the medication is a controlled drug the Police will be contacted.
As soon as the error is discovered
Staff/Service User
As soon as the error is discovered
Staff/Service User
As soon as the error is discovered
Staff/Service User
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13. Quality Assurance and Improvement Activities
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Regular activities to ensure safe medication management practices will be implemented.
Internal Audits: prescriptions, medication charts or
medication records medication signing sheets storage controlled drug documentation disposal
Governing Body &
Delegated Roles
Examples of Quality Activities
Adverse Events/Incident Reporting: analyse medication error trends ensure service improvement s are
implemented Review effectiveness of systems
Service User & Workforce Development: competence assessments performance development workshops/training provision of medication information
Interagency Liaison/Communication between: service user service user’s family/ whānau family decision maker name of service staff pharmacist prescriber general health provider clinical key-worker/coordinator mental health support staff cultural advisors /support peer support any other identified service provider
Evaluation: Include satisfaction with medication
processes in the service user and family whānau satisfaction surveys.
Collect data and analyse service user’s self-medication management processes.
Legal context ensures that all persons involved in medication management do so: according to their scope of practice in line with relevant legislation and
guidelinesRefer to relevant legislation on page 3 of this Policy.
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Consultation
ConsultationGroup/Role Date
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