36C25019R0093-017.pdf

VA NORTHERN INDIANA HEALTH CARE SYSTEM (VANIHCS)

September 2019 POLICY NO. 119-09-19

MEDICATION POLICY

1. PURPOSE: To establish policy and procedure for ordering, dispensing, and administering medications by qualified health care employees to both inpatients and outpatients.

2. POLICY: The policy of the Department of Veterans Affairs Northern Indiana Health Care System (VANIHCS) is that qualified health care employees ordering, dispensing, and administering medications administer medication within the scope of their delineated clinical privileges or scope of care.

3. DEFINITIONS:

a. Medication Reconciliation: Medication Reconciliation is a process to ensure maintenance of accurate, safe, effective, and above all, Veteran-centered medication information. See current version Medical Center Policy 002-03

b. Nutraceuticals: Any food component used for medicinal purposes. Examples include minerals, vitamins, amino acids, and hormones, also known as dietary supplements.

c. Expiration Date: The last day of month and hour of day of expiration date.

d. Range orders: Orders in which the dose or dosing interval varies over a prescribed range, depending on the situation or Veteran’s status.

4. RESPONSIBILITIES:

a. The Facility Director is responsible for:

(1) Ensuring local policy conforms with guidance from VHA Directives/ Handbooks and accreditation organizations as applicable; and

(2) Ensuring processes exist that provide support to Veteran, caregiver, and/or family members with being full and active partners in the Veterans’ medication use.

b. The Provider is responsible for:

(1) Entering orders via Computerized Patient Record System (CPRS) for inpatients and outpatients;

POLICY NO. 119-09-19

(2) Assessing and documenting Veteran allergies and adverse drug reactions (ADRs) See current version of Medical Center Policy 11-45, Adverse Drug Events- Food and Drug Allergies; and

(3) Performing medication reconciliation based on the current version of Medical Center Policy No. 00Q-03, Medication Reconciliation Across the Health Care System.

c. Nursing staff is responsible for:

(1) Safe handling of medications;

(2) Assessing Veteran’s allergies and ADRs as per current version of Medical Center Policy 11-45, Adverse Drug Events- Food and Drug Allergies;

(3) Reviewing and verifying medication orders for drug actions, appropriate dosages, incompatibilities, contraindications, side effects, rates, timing, and routes of administration in accordance with established procedures and policies;

(4) Complying with current version of Medical Center Policy 119-18, Guidelines for Handling Hazardous Medications;

(5) Reviewing and inspecting medication for expiration date, particulates, discoloration, and other loss of integrity; and

(6) Administration of medications.

d. Pharmacy staff is responsible for:

(1) Providing information on the preparation, compatibility, stability, dosage, and administration of intravenous (IV) solutions and medications, and any other drug information upon request;

(2) Communicating to providers when medication discrepancies are determined;

(3) Verifying that all medications and expendable supplies, such as catheters, ostomy products, gloves, incontinence supplies, etc., dispensed by the Pharmacy Service have corresponding prescriptions in the Veterans’ medication profiles. The provider listed under the dispensed product must be providing care for that Veteran; and

(4) Receiving, reviewing, transcribing, filling, checking, and providing medication orders to inpatient units, clinics, and outpatients.

5. PROCEDURES:

a. General:

(1) VANIHCS meets the Veteran needs when the pharmacy is closed. See current version of Policy 119-15: After Hours Coverage of Pharmacy Service and The Joint Commission Management .05.01: §482.25(b) Condition of Participation:

Pharmaceutical Services.

(2) VANIHCS has a process for recalled, outdated or discontinued medications.

See current version of Pharmacy Standard Operating Procedures (SOPs) 119-15:

Handling Outdated and Recalled Medications and The Joint Commission Medication Management 05.01: §482.25(b) Condition of Participation: Pharmaceutical Services.

(3) VANIHCS has a process for returned medications. See current version of Pharmacy Standard Operating Procedures (SOPs) 119-26: Returned Medication and The Joint Commission Medicine Management 05.01: §482.25(b) Condition of Participation: Pharmaceutical Services- Standard: Pharmacy Management and Administration.

(4) VANIHCS has a process for responding to potential adverse drug events, significant adverse drug reactions, and medication errors. See current version of Policy 11-45: Adverse Drug Events- Food and Drug Allergies, See current version of Policy 00Q-07: Patient Safety Program and The Joint Commission Medicine Management.07.01: §482.23(c)(5): Condition of participation: Nursing Services and §482.25(b)(6): Condition of Participation: Pharmaceutical Services.

(5) VANIHCS evaluates the effectiveness of its medication management system.

See current version of 119-01 Pharmacy and Therapeutics Charter.

(6) VANIHCS has an antimicrobial stewardship program. See current version of Policy 119-16: Antimicrobial Stewardship and The Joint Commission Medicine Management. 09.01: Antimicrobial Stewardship.

(7) Pharmacy and Therapeutics Committee (P&T) establishes a mechanism for the review of medication order sets. See current version of VHA Directive 1108.06 – Inpatient Pharmacy Services.

(8) Nutraceuticals approved as formulary by Pharmacy Benefits Management (PBM) are dispensed by the VA. Nutraceuticals that the Veteran is taking from a source outside of the VA must be entered as a Non-VA Medication for outpatients and must follow the Veteran’s own medications procedure for inpatients.

(9) Insulin infusion, also known as insulin drips, will not be used at the Marion campus and will only be allowed on the Intensive Care Unit or Emergency Room (ICU/ER) unit in Fort Wayne.

(10) Orders for medication-related devices will be provided, if appropriate.

(11) Providers or their designee will perform a complete medication reconciliation at each transition of care per facility policy. See Current Version of Policy 00Q-03-16:

Medication Reconciliation Across the Health Care System.

(12) At the initiation of a new medication, the ordering provider or designee will educate each Veteran or family member on his or her medication(s), as well as their appropriate use, potential clinically significant adverse drug reactions, or other concerns regarding administration of a new medication.

(a) Educational material about prescribed prescriptions that was provided to the Veteran(s) and/or their designated surrogate will be documented in the Veteran’s clinical record.

(b) Documentation will include the name of the person providing the education, materials provided, level of understanding demonstrated, and/or verbalized by the Veteran or their designated surrogate, and assessment of the Veteran’s learning needs.

(13) A complete medication order consists of the following. See the Joint Commission 04.01: §482.23(b)(5) and (c)(3): Condition of Participation: Nursing Services:

(a) Name of medication (generic preferred).

(b) Dosage form.

(c) Strength.

(d) Route of administration.

(e) Frequency of administration.

(f) Clarifying statements, if required. Such as, “Take with food.” or “…for constipation”.

(g) How many days are supplied, if applicable.

(h) Number of refills, if applicable.

(i) Medication administration site, if applicable.

(j) Indications for use.

1 All medication orders for inpatients require an indication for use in the order comments.

2 “As needed”, Pro Re Nata (PRN), inpatient/outpatient orders require indication for use in the order comments AND PRN orders require frequency of administration to be specified.

(14) The provider will enter orders/prescriptions via Computerized Patient Record System (CPRS) for inpatients and outpatients. At a minimum, the following information about the patient should be available to the provider for review upon initiating an order:

(a) Age and sex.

(b) Current medications, diagnosis, comorbidities, and concurrently occurring conditions.

(c) Relevant laboratory values.

(d) Allergies and sensitivities.

(e) Therapeutic duplication.

(f) If appropriate:

1 Weight and height.

2 Pregnancy and lactation status.

(15) A pharmacist reviews the appropriateness of all medication orders to be dispensed, except for when a Licensed Independent Practitioner (LIP) controls the ordering, preparation, and administration of the medication or when a delay would harm the Veteran in an urgent situation (including sudden changes in a Veteran’s clinical status).

(16) A pharmacist reviews the medication order for the following:

(a) Veteran allergies or potential sensitivities.

(b) Existing or potential interactions between the medication ordered and food and medications the Veteran is currently taking.

(c) The appropriateness of the medication, dose, frequency, and route of administration.

(d) Current or potential impact as indicated by laboratory values.

(e) Therapeutic duplication. See current version of The Joint Commission Medicine Management: 05.01: §482.25(b) and (b)(5) Condition of Participation:

Pharmaceutical Services.

(17) When medication orders are incomplete, illegible, or unclear, the provider will be contacted prior to dispensing and/or administering a medication.

(18) Order urgency will be considered routine unless the provider designates differently. See below:

(a) STAT: To be utilized when a Veteran’s condition is deemed to be life threatening by the failure to dispense and administer the ordered medication in a timely manner.

1 The prescribing provider or delegate must call pharmacy to alert them to the order to ensure a timely response for processing.

2 Appropriate orders written “STAT” will be processed by pharmacy as soon as possible, but no later than twenty (20) minutes of receipt of the order. These orders are to be administered to the Veteran as soon as possible, but no later than thirty

(30) minutes after receipt of the order.

(b) As Soon As Possible (ASAP)/NOW: To be utilized for an urgent situation in which a Veteran’s welfare may be jeopardized by the failure to dispense and administer the ordered medication in a timely manner, but not deemed critical or life threatening.

1 Appropriate orders written: “NOW”, or “ASAP” will be processed by pharmacy as soon as possible, but no later than sixty (60) minutes of receipt of the order.

2 These orders are to be administered to the Veteran as soon as possible, but no later than seventy (70) minutes after receipt of the order.

(c) Pharmacist review of orders prior to administration of medications is not required for “STAT” or “NOW” orders when it is not practical to wait for a pharmacist to review the order (i.e. emergency room (ER) orders, ambulatory orders (administered in clinic), code blue orders, operating room (OR) orders, same day surgery (SDS) orders, stress-test room(s) orders, non-scheduled contrast media orders, and a “STAT” or “NOW” intensive care unit (ICU) order when it is not practical to wait for a pharmacist to review the order).

1 In those instances, where a prior review is not possible, the clinical pharmacist must review the order as soon as possible, within twenty-four (24) hours, in accordance with The Joint Commission requirements.

(19) Titrated orders are allowed and must be entered as a complex order into

CPRS.

(20) Range orders:

(a) Inpatient orders require separate orders for each dosage requested. Each separate order must include the indication for use (i.e. pain scale).

(b) Outpatient orders may be combined within the same order, but the order must include the indication for use with specific range instructions.

(21) Delayed orders may be utilized when transferring a Veteran from one Veteran care area to another, if appropriate. .

(23) Concentrated electrolytes will not be stored in Veteran care areas. See The Joint Commission Medicine Management: 03.01: §482.23: Condition of Participation:

Nursing Services: (c)(6)(i)(D) and ©(6)(ii)(D) §482.25 Condition of Participation:

Pharmaceutical Services (a), (a)(3), (b), (b)(2)(i), (b)(2)(iii) and (b)(3), and §482.53 Condition of Participation: Nuclear Medicine Services (d)(3).

(24) Medications drawn up on and off the sterile field will be labeled with the drug name, strength, and dose. See current version of The Joint Commission Medicine Management: 05.01.

(25) Medications are dispensed in the most ready-to-administer forms commercially available and, if feasible, in unit doses that have been repackaged by the pharmacy or licensed re-packager. See current version of The Joint Commission Medicine Management: 05.01.: §482.23: Condition of Participation: Nursing Services(c) and §482.25 Condition of Participation: Pharmaceutical Services (a), (a)(3), (b).

(26) Medications prepared in the hospital are labeled appropriately with See current version of The Joint Commission Medicine Management: 05.01.:

(a) Medication name, strength, and amount (if not, apparent from the container).

(b) Expiration date when not used within twenty-four (24) hours.

(c) Expiration time when expiration occurs in less than twenty-four (24) hours.

(d) The date prepared and the diluent for all compounded intravenous admixtures and parenteral nutrition formulas.

(e) A barcode or the equivalent. See current version of VHA Directive 1108.06

– Inpatient Pharmacy Services.

(f) If Compounded Sterile Product (CSP) label will also include:

1 Storage requirements. See current version of VHA Directive 1108.06 – Inpatient Pharmacy Services.

2 Identification of pharmacy personnel that prepared and checked the CSP; one of which must be a pharmacist. See current version of VHA Directive 1108.06 -Inpatient Pharmacy Services.

(g) When preparing individualized medications for multiple Veterans, the label also includes the following:

1 Veteran’s name;

2 Identifier number; See current version of VHA Directive 1108.06- Inpatient Pharmacy Services;

3 Location where the medication is to be delivered;

4 Directions for use and applicable accessory and cautionary instructions.

(27) The pharmacy safely prepares all compounded medications per current version of SOP 119-09 – Pharmaceutical Compounding Sterile Preparations.

(28) A pharmacist, or pharmacy staff under the supervision of a pharmacist, compounds or admixes all compounded sterile preparations except in urgent situations in which a delay could harm the Veteran or when the product’s stability is short. See current version of The Joint Commission Medicine Management 05.01: §482.23:

Condition of Participation: Nursing Services and §482.25 Condition of Participation:

Pharmaceutical Services (b)(1).

(29) All unused compounded sterile products (CSPs) must be returned to the pharmacy.

(30) For compounded medications not commercially available, see current version of Pharmacy Standard Operating Procedures 119-87 – Outsourced Compounding Sterile Products (CSPs) will be used to determine if and/or how a medication will be obtained from an outsource facility.

(31) Multi-dose Medications: See current version of VHA Directive 1108.06:

Inpatient Pharmacy Services.

(a) Will not be used on more than one Veteran, except for vaccines, and purified protein derivative (PPD).

(b) Labeled with “do not use after” date, (day, month, and year), and initialed when opened.

(c) Handled carefully to prevent contamination.

(d) Examined before each use.

(e) Discarded when there are suspected or visible changes in physical appearance (i.e. cracks).

(f) Discarded when empty or at expiration date.

(g) When day is not specified, remove from use on the last hour, last day of month and year of expiration date.

(32) Expiration Dates of Medications: See current version of Attachment A.

b. Inpatient Miscellaneous:

(1) Inpatient medication hold orders will not be accepted. The provider must discontinue the medication, and then reorder if, and when necessary.

(2) All medication orders must be rewritten when the Veteran is transferred to and from a designated specialty area or service. Phrases such as “resume previous orders” or “continue medications” are not acceptable.

(3) Standing orders are allowed once approved by medical staff and the medication is ordered in CPRS.

(4) Medication orders for inpatients must be rewritten every twenty-eight (28) days.

(a) All medication orders will expire at twenty-four hundred (2400) hours on the twenty-eighth (28th) day after the initial medication orders are written. If an order is written on the twenty-seventh (27th) day, it will also expire on the twenty-eighth (28th) day along with all the other medication orders.

(b) Each medication order must be reviewed and renewed every twenty-eight

(28) days; orders such as “Renew all medications” or “Medications as before” are NOT valid orders and will not be accepted.

(c) Exceptions to the twenty-eight (28) day policy are listed as follows (please note that all medications with an automatic stop date limit will expire at twenty-four hundred (2400) hours of the designated day):

1 Schedule II and III Controlled Substances (except for hypnotics) will expire after three (3) days unless otherwise specified by the provider. Orders may be written for up to twenty-eight (28) days; however, the doctor’s orders must state the drug indication and length of therapy.

2 Hypnotics will default to and not exceed seven (7) days.

3 Topical Antibiotic and Steroid Therapy will not exceed seven (7) days unless otherwise specified in the progress notes and doctor’s orders.

4 Oral and IV/IM Antibiotic Therapy will not exceed seven days unless otherwise specified in the progress notes and doctor’s orders. (Tuberculosis drugs are exempt from this restriction.)

5 All IV Piggyback Therapy will expire in seven (7) days unless otherwise specified in the progress notes and doctor’s orders.

6 Large Volume IV Solutions will expire in seventy-two (72) hours unless the provider specifically writes alternate expiration date otherwise specified in the progress notes and doctor’s orders.

7 Total Parenteral Nutrition (TPN) orders expire one day after order entry at midnight.

8 Respiratory treatment (excluding metered dose inhalers) will not exceed twenty-eight (28) days.

(5) The Veteran’s own medications are not authorized for inpatient administration.

(a) Any exception to this rule must be ordered by a licensed independent provider, approved by a pharmacist, and must be for a medication that is not available from VANIHCS and from which abrupt cessation would be detrimental. This would also include investigational medications from other institutions.

(b) If an exception is made, all medications and over-the-counter medications brought into the facility must be visually inspected by a pharmacist and labeled appropriately.

c. Outpatient Miscellaneous:

(1) Pharmacy will allow fax prescriptions only from:

(a) Approved Community Care provider offices. See current version of Pharmacy Standard Operating Procedures 119-16: Authorized Community Care Prescription Processing Procedure.

(b) VA providers during downtime. See current version of Policy 008-35:

BCMA Policy and Contingency Plan.

(2) Pharmacy will not accept medications for disposal/re-dispensing: See current version of Policy 07B-19: Patient Medication and Disposal.

(3) Frequently prescribed non-controlled substance medications to be dispensed to Veterans upon discharge from Urgent Care (Marion Campus) are available in Automated Dispensing Machine (ADM):

(a) These medications are pre-labeled with directions, drug name, strength, and quantity.

(b) Only medications from designated ADM filled with pre-labeled medications are to be dispensed by the provider for outpatient use.

(c) Medications dispensed for the Veteran to take home by the provider from the ADM require an electronic prescription, which indicates medication was dispensed in clinic.

(d) The provider must write in the Veteran's name and complete the directions on the preprinted label.

(e) A licensed provider may dispense up to a ten (10) day supply of these medications.

(4) Prescriptions for Veterans outside the United States. See current version of VHA Directive 1108.05: Outpatient Pharmacy Services.

(a) Shipping prescriptions or supplies outside the United States or United States territories is prohibited.

(b) Early fill of a non-controlled substance prescription is allowed prior to the normal dispensing date if a Veteran will be traveling outside the United States. This may be done on a limited basis and requires consultation with the Veteran’s VA provider prior to dispensing.

(5) Facility provides transportation of medications by VA staff to off-site Veterans, using a chain of custody form (e.g. Home-Based Primary Care (HBPC), Mental Health Intensive Care Management (MHICM) home-based programs, domiciliary). See current version of VHA Directive 1108.05: Outpatient Pharmacy Services

(6) Provision of Medication in a Home Health Setting. See current version of VHA Directive 1108.07: Pharmacy General Requirements.

(a) There are authorized medical facility staff to:

1 Transport and administer medications and supplies to a Veteran’s home;

a Registered Nurses

2 Accept from pharmacy and deliver to the Veteran’s home prescription(s) and supplies specifically ordered and dispensed for that Veteran.

a Registered Nurses b Social Workers c Clinical Pharmacy Specialists

(c) There is a signed medication order or prescription, verified by a pharmacist, for all medications administered to the Veteran.

NOTE: This requirement does not apply to medications, such as influenza vaccine, that can be administered pursuant to a medical facility approved protocol which does not require a provider’s order and pharmacist verification.

(d) There are clearly defined storage and transportation requirements to include:

1 Medications are stored at the appropriate temperature while in transit (e.g., refrigeration, preventing exposure to direct heat or sunlight);

2 Security measures are reviewed and approved by the Police and Security Service;

3 Locked storage containers for transport are utilized that do not identify their contents;

4 Cooled storage containers are utilized, when required;

5 Locked medication storage containers are stored out of plain sight during transportation;

6 Unused or partially used medications taken to the home for the specific purpose of administration by VA staff are not left in the Veteran’s home, and are returned to the facility for disposal;

7 Non-Veteran specific medications are returned to the pharmacy, if the medication has not been administered by the end of the VA staff person’s shift.

(e) A procedure for the pharmacy to dispense medications is established for medications to be administered pursuant to a facility approved protocol, which does not require processing through Vista system’s pharmacy application software (e.g., Influenza vaccine to an authorized healthcare provider). This process includes a documented chain of custody that is stored in the pharmacy and is readily retrievable.

Medications are appropriately labeled prior to dispensing.

(f) There is a documented chain of custody for all prescription medications transported by VA staff from pharmacy to the Veteran. The form includes a final signature by the Veteran, or authorized surrogate, accepting control of the prescription(s). The duplicate chain-of-custody forms are reconciled and maintained by Pharmacy Services for a period of two (2) years.

(g) If medications are administered to Veterans, the staff will assure the integrity of the medication prior to administration (e.g., examination for particulate matter, discoloration, and labeling requirements).

(h) Assessment of staff competency for the appropriate safe handling and administration of medications is included during their annual competency assessment.

d. Medical Administration:

(1) Only qualified healthcare employees are permitted to administer medication to Veterans based on their scopes of care.

(a) A medication order is valid, if entered utilizing Computerized Patient Record System (CPRS) by authorized staff.

(b) Verbal or telephone medication orders are discouraged however may be accepted in an emergency; when urgency is a factor and it clearly is in the best interest of the Veteran. See current version of VHA DIRECTIVE 1108.06: Inpatient Pharmacy Services.

1 The clinical pharmacist or nurse receiving the verbal or telephone order must immediately commit it to writing and read it back to the provider to verify the accuracy. See current version of VHA directive 1108.06: Inpatient Pharmacy Services.

2 The verbal order must then be recorded electronically.

3 In case of computer downtime, the local published Clinical Computer Systems Contingency Plan will be followed.

(c) Staff administering medications are responsible for knowing, in accordance with established procedures and policies:

1 Veteran allergies and adverse drug reactions (ADR) 2 Indication for use 3 Appropriate dosage 4 IV Incompatibilities

5 Medication Interactions 6 Side effects 7 Rate and routes of administration 8 Safe handling requirements 9 Before administration, the individual administering the medication does the following:

a Verifies that the medication selected matches the medication order and product label.

b Visually inspects the medication for particulates, discoloration, or other loss of integrity.

c Verifies that the medication has not expired.

d Verifies that no contraindications exist.

e Verifies that the medication is being administered at the proper time and frequency, in the prescribed dose, and by the correct route.

f Discusses any unresolved concerns about the medication with the Veteran’s licensed independent practitioner, prescriber (if different from the licensed independent practitioner), and/or staff involved with the Veteran's care, treatment, and services.

(d) Staff administering medication will identify the Veteran by comparing the Veteran’s full name and date of birth.

1 Staff should ask the Veteran for his or her full name and date of birth and wait for his or her response before giving medication.

2 Staff will scan the Veteran’s barcoded wristband and verify the information in Bar Code Medication Administration (BCMA) or use photo identification and date of birth with the medication record when BCMA is not available.

3 If the Veteran is not able to identify himself or herself, the Veteran’s full name and date of birth on the wristband (inpatients) or photo identifications and date of birth (outpatients) must be used to identify the Veteran.

4 If there is any question about the correct identification of the Veteran, staff is not to administer the drug until identity is verified.

5 Non-controlled substance medications will be administered immediately or immediately secured in the Veteran’s drawer in the medication cart or in the medication room (if in same day surgery) after removal from an ADM or medication room.

a If not immediately administered, medications can only be stored for a twenty- four (24) hour period.

b After twenty-four (24) hours, the medication must be returned to pharmacy. The exception to this is multi-use containers (i.e. eye drops).

(e) Before administering a new medication, the Veteran or Veteran’s representative is to be informed about any potential for clinically significant adverse drug reactions or other concerns regarding administration of a new medication. See current version of VHA directive 1108.06: Inpatient Pharmacy Services.

(f) Staff administering medication should document in the medical record the strength, dose, route, date, and time of administration. See current version of The Joint Commission Record of Care, Treatment, and Services (RC) 02.01.01: §482.24, (b), (c), (c)(1): Condition of Participation: Medical Record Services and §482.53 Condition of Participation: Nuclear Medicine Services (d), (d)(2).

(2) Medications will be given at standard times (as approved by the Pharmacy and Therapeutics Committee) or as specifically ordered by the physician.

(a) All orders will be started at the next scheduled administration time, unless specified by the LIP. Medications may be ordered, dispensed, and administered as STAT, NOW, and ASAP.

(b) For STAT, NOW, and ASAP orders, pharmacy staff will hand medication to nursing staff, if possible.

(3) Automated Dispensing Machine:

(a) Controlled substances will be dispensed from Automated Medication Dispensing System, unless item is unable to be stocked in machine. See current version of Policy 119-04: Controlled Substance.

1 Controlled Substances removed from an Automated Dispensing Machine (ADM) will be administered to the Veteran within two (2) hours.

2 If the medication cannot be administered within the timeframe, controlled substance wasting procedures will be followed and documented within two (2) hours of the removal from the ADM for the removed controlled substances.

(b) On the Acute Care Unit, if an item is available via Automated Medication Dispensing System, all STAT, NOW, ASAP, first doses and PRN orders will be obtained from the machine.

(c) If medication is available in the Automated Medication Dispensing System, staff will remove dose from machine to administer.

(4) When the medication is unavailable and is determined to be missing, a missing dose request will be sent to pharmacy.

(5) Respiratory therapists will obtain medications from pharmacy for storage in a locked cabinet in the cardiopulmonary department or from an Automated Dispensing Machine. Medications will be removed from the cabinet for treatments, transported to Veterans, and returned to the cabinet if not administered to Veterans.

(6) The use of multi-dose pen injectors is prohibited on all inpatient units, such as any unit where a staff member is involved in the storage, preparation or administration of a multi-dose pen injector.

(a) Exception may be made for the following reasons:

1 Veterans being educated prior to discharge to use a Veteran – specific, multi-dose pen injector.

2 Eligible Veterans participating in the VA medical center’s Self Medication Program.

3 Veterans requiring treatment with a medication delivered in a multi-dose pen injector, and no alternative formulation is available from the manufacturer for treating the Veteran while on an inpatient unit.

4 Veterans participating in a research protocol requiring a multi-dose pen injector while on an inpatient unit.

5 Veteran is receiving U-500 Insulin.

(b) If exceptions are met, the following procedures should be followed.

1 Use a multi-dose injector pen device only by a single Veteran. It should never be shared with other Veterans, even when the needle is changed.

2 Labeled prior to dispensing with an individual Veteran name. Multi-dose pen injectors shall not be ward stocked.

e. Self – Administration of Medications

(1) Only Veterans assessed by the provider and/or other qualified staff to potentially benefit from a self-medication program, and competent to participate in a self-medication program, will be allowed to self-administer medications.

(a) While in a self-medication program, Veterans will be assessed for ability to accurately and safely manage their medications. Veterans will be monitored for clinical response to medications and adverse drug events.

(b) This information will be documented in the Veteran’s medical record.

Adverse drug events will be reported as described in local published policy and will be monitored.

(2) Veterans involved in self-administration will be educated about the following:

(a) Medication name, type, and reason for use.

(b) How to administer medication, including process, time, frequency, route, and dose.

(c) Anticipated actions and potential side effects of the medication administered.

(d) Monitoring the effects of the medication.

(3) All medications must be stored in a locked location, accessible only to staff and the Veteran for whom the medication is prescribed.

(4) Medication is not to be left at bedside for self-administration unless:

(a) Veteran is enrolled in a MH RRTP program as outlined in the current version of VHA Handbook 1162.02: Mental Health Residential Rehabilitation Treatment Program (MH RRTP).

(b) Medications that are not or cannot be determined to be safe to administer, are not allowed for use by the Veteran in a self-medication program or as Veteran’s own medications.

(c) For management of independent medications see current version of Policy 116-37: Substance Abuse Residential Rehabilitation Treatment Program (SARRTP).

6. REFERENCES:

a. Current Version of The Joint Commission Medicine Management: 03.01: §482.23:

Condition of Participation: Nursing Services: (c)(6)(i)(D) and (c)(6)(ii)(D), §482.25 Condition of Participation: Pharmaceutical Services (a), (a)(3), (b), (b)(2)(iii) and (b)(3), and §482.53 Condition of Participation: Nuclear Medicine Services (d)(3).

b. Current Version of The Joint Commission Medicine Management 04.01: §482.23 (c)(3): Condition of Participation: Nursing Services.

c. Current Version of The Joint Commission Medicine Management: 05.01:

§482.25(b) and (b)(5): Condition of Participation: Pharmaceutical Services.

d. Current Version of The Joint Commission Medicine Management 05.01: §482.23:

Condition of Participation: Nursing Services (c) and §482.25 Condition of Participation:

Pharmaceutical Services (b)(1).

e. Current Version of The Joint Commission Medicine Management: 05.01: §482.25 Condition of Participation: Pharmaceutical Services.

f. Current Version of The Joint Commission Medicine Management: 05.01:

§482.25(b) Condition of Participation: Pharmaceutical Services – Standard: Pharmacy Management and Administration.

g. Current Version of The Joint Commission Medicine Management 07.01:

§482.25(b)(6): Condition of Participation: Pharmaceutical Services.

h. The Joint Commission Medicine Management. 09.01: Antimicrobial Stewardship.

i. Current Version of VHA Directive 1108.05: Outpatient Pharmacy Services.

j. Current Version of VHA Directive 1108.06: Inpatient Pharmacy Services.

k. Current Version of VHA Directive 1108.07: Pharmacy General Requirements.

l. Current Version of VHA Handbook 1162.02: Mental Health Residential Rehabilitation Treatment Program (MH RRTP).

m. Current Version of Policy No. 00Q-03: Medication Reconciliation Across the Health Care System.

n. Current Version of Policy No. 11-45: Adverse Drug Events- Food and Drug Allergies.

o. Current Version of Policy No. 119-18: Guidelines for Handling Hazardous Medication for Appropriate Personal Protective Equipment.

p. Current Version of Policy No. 119-15: After Hours Coverage of Pharmacy Service.

q. Current Version of Policy No. 00Q-07: Patient Safety Program.

r. Current Version of Policy No. 119-16: Antimicrobial Stewardship.

s. Current Version of Policy No. 008-35: BCMA Policy and Contingency Plan.

t. Current Version of Policy No. 07B-19: Patient Medication and Disposal.

u. Current Version of Policy No. 119-04: Controlled Substance Policy.

v. Current Version of Policy No. 116-37: Substance Abuse Residential Rehabilitation Treatment Program (SARRTP).

w. Current Version of Pharmacy Standard Operating Procedures (SOP) 119-09:

Pharmaceutical Compounding Sterile Preparations.

x. Current Version of Pharmacy Standard Operating Procedures (SOP) 119-15:

Handling Outdated and Recalled Medications.

y. Current Version of Pharmacy Standard Operating Procedures (SOP) 119-16:

Authorized Non-VA Care or CHOICE Prescription Processing Procedure.

z. Current Version of Pharmacy Standard Operating Procedures (SOPs) 119-26:

Returned Medication.

aa. Current Version of Pharmacy Standard Operating Procedures (SOP) 119-87:

Outsourced Compounding Sterile Products (CSPs).

bb. Current Version of 119-01-18 Pharmacy and Therapeutics Charter.

7. RESCISSIONS: Medical Center Policy 119-09, Patient Medication Policy, dated January 7, 2016 and amended November 29, 2017 will be formally rescinded with the publication of this revised version. The processes and procedures outlined in 119-09- 15 will remain in effect until that time.

8. REVIEW DATE: September 24, 2022

9. FOLLOW – UP RESPONSIBILITY: Chief, Pharmacy Service

9/25/2019

X Dorothy A. Seeler, RPh DOROTHY A. SEELER, RPh Chief, Pharmacy Service Signed by: DOROTHY A. SEELER 176843

9/27/2019

X Laura A Johnson

AUDREY L. FRISON, DM, MHA, BSN, RN

Associate Director Patient Care Services Signed by: Laura A. Johnson 562157

X choudry

PERVAZ M. CHOUDRY, MD

Acting Chief of Staff Signed by: people

Recoverable Signature

X John P. Shealey

JOHN PHILLIP SHEALEY, DBA, MBA, HFMA, A...

Associate Director Signed by: Dr. John P. Shealey

X David M. Miller

DAVID M. MILLER

Acting Assistant Director Signed by: people

Recoverable Signature

X John P. Shealey for

MICHAEL E. HERSHMAN, MHA, FACHE

Director Signed by: Dr. John P. Shealey

Link to Attachment