CL 6050 Medication Administration UPDATED With Changes

8/12/2019 CL 6050 Medication Administration UPDATED With Changes

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POLICY/PROCEDURE

TITLE: WRITING, TRANSCRIBING MEDICAL ORDERS,AUTHRIZATION AND ADMINISTRATION OFMEDICATIONS AND RECORDING

ORIGINAL DATE:AUGUST 2004

IDENTIFICATIONNUMBER:

CL 6050 LAST REVISION DATE:MAY 2012

NEXT REVIEW DATE:MAY 2015

HOSPITAL(S) ALL HMC HOSPITALS / ENTITIES

Sheet No. 1 of 10

Medication Management and Use (MMU) Quality Management DepartmentRegulatory & Accreditation

1.0 POLICY STATEMENT/PURPOSE:

1.1 This policy is formulated for all Hamad Medical Corporation (HMC) healthcareproviders about ordering, writing and transcribing medical orders, authorization formedication administration, recording medication in the medical record and on thesafe and accurate administration of medications.

2.0 DEFINTIONS:

2.1 A MEDICAL ORDER An authoritative direction or instruction, issued by aphysician, in writing, or by dictation, verbally or by phone, or otherwise, a rule or acourse of action to be implemented by other health care providers, patient, family,legal guardians, or significant others, in the treatment, plan of care or service, for thepatient. This may include prescription of medications, diagnostic tests, etc.

2.2 TRANSCRIBING MEDICAL ORDERS -- To copy, write over again, transfer ortranslate Information from the physicians medical order or instructions on to thepatients medical records for further medical or nursing action e.g. issuing of themedication by pharmacy department and administration of the medication to thepatient.

2.3 AUTHORIZATION FOR MEDICATION ADMINISTRATION--The process of givingcertain health care providers legal and professional permission to provide a patient

with a substance prescribed and intended for the diagnosis, treatment, or preventionof a medical illness or condition.

2.4 MEDICATION ADMINISTRATION -- The practice of administering medications,which involves providing the patient with a substance prescribed and intended forthe diagnosis, treatment, or prevention of a medical illness or condition.

2.5 TIME CRITICAL SCHEDULED MEDICATION Are those where early or delayedadministration of maintenance doses of greater than 30 minutes before or afterscheduled dose may cause harm or result in substantial sub-optimal therapy orpharmacological effect.


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3.0 PROCEDURE/PROCESS:

3.1 All medical orders shall be written on a physician order sheet. These include but arenot limited to diagnostic, therapeutic, treatment and palliative care as well asreferrals to other disciplines and healthcare facilities, and orders for medications.

3.2 Medication orders shall be written on the Physicians Prescription Sheet or throughComputer Physician Order Entry (CPOE).

3.3 Orders shall be accurately transcribed by qualified health care providers.

3.4 Medications administered by HMC qualified health care providers shall be written onthe designated forms, including the date, time, signatures and stamp.

3.5 Writing Medical Orders

3.5.1 Only qualified physicians should write medical orders at HMC.

3.5.2 Only orders written on designated order sheets should be considered validto be carried out by health care providers.

3.6 Physicians Prescription Sheetshould be used for medications order only and

should be completed only by a privileged physician.

3.6.1 The bottom duplicate copy should serve as the medication prescription thatshould be filled by the Pharmacy (See Prescribing of Medications, PolicyNo. CL 6048).

3.7 Physician Order Sheetshould be used for all orders other than medication orders,and should be completed only by privileged Physicians.

3.8 Transcription of Medication Orders

3.8.1 The staff nurse who transcribes the medication order should complete thefollowing:


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3.8.1.1 Order date.

3.8.1.2

Medication.3.8.1.3 Dosage and Frequency.3.8.1.4 Route.3.8.1.5 Time.3.8.1.6 Commencement date, if applicable.3.8.1.7 Discontinuation date, if applicable.

3.8.2 Any change in the medication dose, route or frequency should be written asa new prescription. These changes should then be transcribed as a neworder. Order date should indicate the date when the new prescription iswritten.

3.8.3 Transcriptions of all medication orders should require a verification of theaccuracy of the transcribed order by a second nurse and it should bedocumented on the Medication Administration Record (MAR).

3.9 Recording Medication Administration

3.9.1 The Medication Administration Record should be utilized in all inpatientunits, Emergency Department (Short Stay Unit), Day Care Unit andRadiology Department for documenting medications administered by all

routes.

3.9.2 The Intensive Care and Intermediate Care Units should utilize the IntensiveCare or Intermediate Care Flow Sheet for documenting the full details ofmedications administered by intravenous infusions.

3.9.3 Procedural areas and the peri-operative areas should document medicationadministration on their respective Medication Administration Records orFlow Sheets.

3.9.4 All health care providers authorized to administer medications should

document the medication administration on the designated administrationrecording form immediately after administration with date and time.


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3.10 Authorizat ion for Medicat ion Administration

3.10.1 At Hamad Medical Corporation, medications shall be administered to apatient by the following staff:

3.10.1.1 Staff Nurses with a validated competency.

3.10.1.2 Anesthesiologist, Dentists and other Physicians who arelicensed and have clinical privileges at Hamad MedicalCorporation.

3.10.1.3 Respiratory Therapist (Respiratory Treatments only), PhysicalTherapist, Radiology Technologist and Electro-Encephalogram(EEG) Technicians shall administer medication within the scopeof their practice, Anesthesia Technicians and/or Technologistsadminister medications under the supervision of theanesthesiologist.

3.10.2 Nursing students should administer oral, intramuscular, subcutaneous andtopical use medications only under the direct supervision of the Preceptor orClinical Instructor.

3.10.3

The Clinical Instructor or Preceptor should be a staff nurse who assumesresponsibility for the nursing practice of the student.

3.10.4 The Medication Administration Record (MAR) should be countersigned bythe Preceptor.

3.11 Medication Administration

3.11.1 All medication administration by any route shall be safely and correctlyperformed by authorized HMC staff consistent with the seven rights ofmedication administration:

3.11.1.1 Right patient.


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3.11.1.2 Right medications.3.11.1.3 Right dose.

3.11.1.4 Right route.3.11.1.5 Right time.3.11.1.6 Patients right to refuse.3.11.1.7 Right to patient and family education.

3.11.2 All HMC staff administering medications, including Physicians, shall followproper procedures as described in this Policy.

3.11.3 Only medications prescribed for the patient based on clinical necessity shallbe administered.

3.11.4

All medications administered to patients shall be recorded in theirMedication Administration Record (MAR) or appropriate flow sheet.

3.11.5 The nurse shall have the right and responsibility to question and to refuse tocarry out the order, until clarified, in the following circumstances:

3.11.5.1 Contraindicated due to drug incompatibility.3.11.5.2 Inappropriate to the patients condition.3.11.5.3 Known allergy to the medication.3.11.5.4 Inappropriate for age and weight.

3.11.5.5

Illegible or any part of the Physicians order is unclear or aconcern; e.g., dosage, route.

3.11.6 A medication order transcription shall clearly indicate the following:

3.11.6.1 The date and time the order was written.3.11.6.2 The name of the drug in generic or as prescribed.3.11.6.3 The dose of the drug.3.11.6.4 The route.3.11.6.5 The frequency of the doses.3.11.6.6 The medication discontinuation date.

3.11.6.7

The initials of the transcribing nurse.3.11.6.8 The initials of the witnessing nurse.


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3.11.7 Nurses shall never administer medications via the following routes or

methods:

3.11.7.1 Intra-cardiac.3.11.7.2 Intra-pericardial.3.11.7.3 Intraosseous.3.11.7.4 Intrathecal.3.11.7.5 Intraarticular.

3.11.8 A history of medication response, allergies, sensitivities and any substanceabuse should be correctly assessed and recorded by the Physician or nursedoing the initial assessment process or history and physical examination.

3.11.9 Patients/family or caregivers and next of kin should be educated aboutmedications they are receiving (Refer to Patient and Family Education,Policy No. CL 6090).

3.11.10Patients should be identified prior to drug administration using two identifiers(Refer to Patient Identification, Policy No. CL 7026).

3.11.11All medications should be properly labeled (Refer to Dispensing ofMedication, Policy No. CL 6049).

3.11.11.1 Nurses should not re-label any medication.

3.11.12A valid medication order should be written in English and should be clear(Refer to Prescribing of Medication, Policy No. CL 6048).

3.11.13The health care providers administering medications should observe thepatient taking and/or swallowing the drug.

3.11.14Administered medications must be recorded by the person who administersthe medication and signed by the witness if applicable (Refer to Narcotics

and Controlled Drugs Administration, Storage Maintenance andAccountability, Policy No. CL 6053).


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3.11.15The Standard Medication Timing as recommended by the Pharmacy

Department should be followed unless specified by the Physician.

3.11.15.1 If the order is written between the standard medication timing,the prescriber should clearly specify the initial dose timing andthe subsequent dose.

MEDICATION ADMINISTRATION SCHEDULE

Once Daily 0800 Hours or as prescribed by thePhysician

Twice Daily 0800 Hours and 2000 Hours

Three Times Daily 0800 Hours 1300 Hours 2000 Hours

Every 8 Hours 0600 Hours 1400 Hours 2200 Hours

Four Times Daily 0800 Hours 1200 Hours 1800 Hours 2200 Hours

Every 6 Hours 0600 Hours 1200 Hours

1800 Hours 2400 Hours

Every 4 Hours 6 times a day0800 Hours 1200 Hours 1600 Hours 2000 Hours 2400 Hours 0400 Hours

Every 12 Hours 0600 Hours 1800 Hours

At bedtime 2000 Hours or 2100 Hours


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3.11.16 Scheduled Medication Administration Time Frame: Scheduled

Medications might be given within one hour (1 hour) before or after thescheduled time, with the following exceptions:

3.11.16.1 Stat orders.3.11.16.2 First doses and loading doses.3.11.16.3 One -time doses.3.11.16.4 Preoperative drugs.3.11.16.5 On call doses (e.g., pre-procedure sedation).3.11.16.6 Time-sequenced or concomitant medications (e.g.

chemotherapy and rescue agents, n-acetaylcysteine andiodinated contrast media).

3.11.16.7

Drugs administered at specific times to ensure accuratepeak/trough/serum drug levels.

3.11.16.8 Ante and post cibum medication (before and after meals).3.11.16.9 Surgical Prophylactic Antibiotics should be given one hour of

induction of anesthesia.3.11.16.10 Febrile Neutropenia patients order is considered as stat order

even if not specified.3.11.16.11 PRN medications.3.11.16.12 Time Critical Scheduled Medications (Refer to individual

hospitals list).

3.11.16.13

If administration time specified by the prescriber.

3.11.17Medications prepared in clinical areas should not be stored in a syringe tobe administered at a later time or date. This excludes procedures undermoderate sedation when a top-up dose may be required (Refer to ModerateSedation, Policy No. CL 6029).

3.11.18The appropriate time to administer oral medications after an NPO (Nil PerOrum) order should be specified by the Physician.

3.11.19Intravenous medications administered intermittently via capped vascular

access ports should be flushed with 3 to 6 ml of compatible IV fluid orheparin lock before and after medication administration.


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3.11.20Continuous intravenous (IV) medication administration requires special

assessment, monitoring and interpretations.

3.11.21Intravenous medications should be administered by infusion.

3.11.22Medications such as IV push through cannula should be performed only bya physician, competent nurse or a competent paramedical staff.

3.11.23Midnight audit of the Medication Administration Record should be conductedby the assigned nurse on the night shift for all patients against the originaltop copy of the prescription form for the previous 24 hours. This auditshould be noted and signed by the nurse on the top copy of the prescriptionform.

3.11.24Moderate sedation should be administered by a nurse certified in ImmediateLife Support (ILS), as per Moderate Sedation Policy No. CL 6029.

3.11.25Nurses or other health care providers should not administer anyexperimental or investigational medication unless approved by ResearchCommittee.

3.11.26If a patient refuses to take a prescribed medication or if the health care

provider omits to administer a medication, the following actions should betaken:

3.11.26.1 The incident should be documented.3.11.26.2 The Physician should be notified.3.11.26.3 The nurse should complete an Occurrence, Variance and

Accident (OVA) report if the outcome of 3.11.26 above, is likelyto have serious potential or actual consequence to the patient.


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3.11.27 Medication Administration to a Discharged Patient

3.11.27.1 If a patient is discharged but remains in the patient care area,medications should be given as ordered until the patientphysically leaves the unit, or the Physician writes an orderindicating otherwise.

4.0 DOCUMENTATION:

4.1 Documentation as per Hamad Medical Corporation Guidelines.

5.0 REFERENCES:

5.1 Joint Commission International Accreditation Standards for Hospitals, 4th Edition.Medication Management and Use Chapter, Standards MMU 6, MMU 6.1, MMU 6.2

5.2 Medication Administration. (2003). American Academy of Pediatrics, RetrievedDecember 12, 2008, from http://nrc.uchsc.edu/SPINOFF/MED/Medication.pdf.

5.3 ISMP Guidelines for timely medication administration :response to the CMS (30minutes rule) www.ismp.org./newsletters/acutecare/articles/20110113.asp

6.0

ATTACHMENTS: Not Applicable.

Documents

CL 6050 Medication Administration UPDATED With Changes