36C26219R0026-021.docx

VA Loma Linda Healthcare System Healthcare System (HCS) Policy 119-07 Loma Linda, CA DATE: 8 May 2019 HCS Policy 119-07

MEDICATION MANAGEMENT

I. POLICY: It is the policy of this organization to pursue a medication management system which supports patient safety and improves the quality of patient care.

II. RESPONSIBILITIES:

A. Licensed Independent Practitioners (LIPs) are responsible for:

1. Prescribing medications consistent with their licensure, clinical privileges, and these guidelines seeking and obtaining the required consults for indicated medications.

2. Safeguarding prescription forms issued for use and reporting any loss to the service chief, to the Chief of Police Service, and the Chief of Pharmacy Service or his/her designees.

3. Ordering all medications utilizing the Physician Order Entry (POE) in the Computerized Patient Record System (CPRS) or VA Form 10-1158 (Doctor’s Orders), except outpatient Schedule II Controlled Substances, which must be ordered on VA Form 10-2577F (Security Prescription Form).

4. Seeking and obtaining the required consults for indicated medications or obtaining appropriate Radiology consult for ordering contrast and radiologic agents.

B. Pharmacy Service is responsible for:

1. Controlling inventory and records for the issuance of VA Form 10-2577F.

2. Tracking Adverse Drug Events and providing reports to the Pharmacy and Therapeutics (P&T) Committee.

3. Ordering prescription forms and maintaining records showing the forms received, forms issued, dates of action, serial numbers received and issued, persons issuing these forms, and the receiving party.

C. Pharmacists are responsible for:

1. Reviewing the provider's order including, but not limited to the appropriateness of drug, dose, route, schedule, and compatibility with other drugs and the timely dispensing of the medication. Verifying the label content of a medication processed by a pharmacy technician and ensuring that accurate records are maintained for all medications dispensed.

2. Controlling, labeling, and dispensing all drugs, except for contrast media, handling drugs recalled or discontinued by the manufacturer, and managing all drugs returned to the pharmacy.

D. Imaging Service is responsible for:

1. Medication orders involving contrast media.

E. Staff who administers medications are responsible for:

1. Administering medications in accordance with the regulations and licensure included in their scope of practice, and following the Bylaws, Rules, and Regulations of the Medical Staff.

2. Assuring that the medication order has been verified to be correct.

3. Being informed about dosage, actions, side effects, and precautions concerning the medications and to resolve any clinical questions prior to administration.

4. Observing the patient for significant risks, allergic reactions, or other adverse effects, especially when therapeutic efficacy needs to be determined. Observations will be completed as outlined in these guidelines regardless of the route the medication is administered.

F. All staff members are responsible for documenting untoward events such as medication errors and adverse drug events.

III. PROCEDURES:

A. Patient Specific Information – See Attachment A

B. Selection and Procurement Procedures – See Attachment B

C. Medication Storage Procedures – See Attachment C

D. Medication Ordering and Transcribing Procedures – See Attachment D

E. Medication Preparation and Dispensing Procedures – See Attachment E

F. Medication Administration Procedures – See Attachment F

G. Self-Administered Medication Program (SMP) - Acute Care – See Attachment G

H. Self-Administered Medication Program (SMP) – Community Living Center (CLC) – See Attachment H

I. Medication Monitoring Procedures – See Attachment I

J. High-Risk/High-Alert Medications Management Procedures – See Attachment J

K. Medication Reconciliation – See Attachment K

L. Use of Multi-Dose Medication Injectors (Pens) – See Attachment L

M. Timeliness of Medication Administration – See Attachment M

N. Monitoring of Psychotropic Medications – See Attachment N

IV. SUPPLEMENTAL INFORMATION:

A. Definitions:

Emergent Situation: A situation where a delay in therapy will result in a negative outcome to the patient.

B. References:

1) VA Loma Linda Health Care System Bylaws, Rules, and Regulations of the Medical Staff

2) Joint Commission Medication Management Standards; VA Manual M-2, Part VII, Chapter 3, Part I, Chapter 3, Paragraph 3.06 (b), Part VII, Chapter 3, Part VII, Chapter 5

3) Food & Drug Administration MedWatch Program: www.fda.gov/medwatch/report

4) VHA National Patient Safety Improvement Handbook 1050.1

5) VHA Directive 2008-059 Adverse Event Reporting and Monitoring

6) VHA Directive 2008-075 National PBM Drug Safety Alert Distribution

7) HCS Policy 00-07, Patient Safety Plan

8) VA Handbook 1108.01 Controlled Substance (Pharmacy Stock)

9) VA Handbook 1108.02 Inspection Controlled Substances

10) VHA Handbook 1108.03 Self-Medication Program (SMP)

11) VHA Handbook 1108.04 Investigational Drugs and Supplies

12) VHA Handbook 1108.05 Outpatient Pharmacy Services

13) VA Handbook 1108.06 Inpatient Pharmacy Services

14) VA Handbook 1108.07 Pharmacy General Requirements

15) VA Handbook 1108.08 – VHA Formulary Process

16) VHA Directive 2008-075 National PBM Drug Safety Alert Distribution

17) HCS Policy 11-18 Guidelines for Non-Anesthesiologists

18) HCS Policy 11-59 Medication Administration

19) HCS Policy 113-02 Blood Transfusion Policy for Physicians and Nurses

20) SLP 118-D-10 Administration of Intravenous Fluids and Medications by Registered Nurses

21) HCS Policy119-06 Disposition of Medication that Are Discontinued, Unusable or Brought to the Medical Center Acute Care Hospital or the Community Living Center (CLC)

22) SLP 119-4 Investigational Medication

23) HCS Policy 119-14 Drug Recall Policy

24) Resource and Conservation Recovery Act, 42 United States Code (U.S.C.) 6901 et. Seq.

25) Federal Facility Compliance Act, 42 U.S.C. 6961

26) NIOSH Alert – Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health Care Settings, CDC September 2004

27) IL 10-2004-019, Under Secretary for Health’s Information Letter Exposure to Hazardous Drugs

28) VHA Directive 7705, Management of Hazardous Chemicals

30) USP General Chapter <800> Hazardous Drugs—Handling in Healthcare Settings

31) VHA Directive 2009-065, Waste Minimization and Compliance Report (RCN 10-99-904)

32) HCS Policy 00-15 GEMS Policy

33) California Medical Waste Management Act -California Health and Safety Code Sections 117600 – 118360

C. Attachments:

Attachment A: Patient Specific Information

Attachment B: Selection and Procurement Procedures

Attachment C: Medication Storage Procedures

Attachment D: Medication Ordering and Transcribing Procedures

Attachment E: Medication Preparation and Dispensing Procedures

Attachment F: Medication Administration Procedures

Attachment G: Self-Administered Medication Program - Acute Care

Attachment H: Self-Administered Medication Program (SMP) – Community Living Center (CLC)

Attachment I: Medication Monitoring Procedures

Attachment J: High-Risk/High-Alert Medications Management Procedures

Attachment K: Medication Reconciliation

Attachment L: Use of Multi-Dose Medication Injectors (Pens)

Attachment M: Timeliness of Medical Administration

Attachment N: Monitoring of Psychotropic Medications

V. COLLABORATED WITH: Chief of Staff; Associate Director for Patient Care and Nursing Services; Quality Manager; GEMS Coordinator; Nursing Service Executives

VI. RESCISSION: HCS 119-07 Medication Management, dated April 28, 2014

VII. REVIEW AND REISSUE DATE: 8 May 2022

VIII. POLICY COORDINATOR: Chief of Pharmacy Service

KARANDEEP S. SRAON

MEDICAL CENTER DIRECTOR

Attachment A.

Patient Specific Information

I. At a minimum, those involved in medication management will have access to the following patient information:

A. Age.

B. Gender.

C. Current medications (including non – VA meds if available).

D. Diagnoses, co-morbidities, and current conditions.

E. Relevant laboratory values.

F. Allergies and adverse drug reactions.

G. Sensitivities.

H. As appropriate to the patient, information regarding the following is also included:

1. Weight and height.

2. Pregnancy and lactation status when appropriate.

3. Drug and alcohol use and abuse.

4. Any other information required by the hospital for safe medication management.

II. This information is accessible in CPRS (except in emergency situations when time does not permit) to Licensed Independent Practitioners, appropriate health care professionals, and staff.

Attachment B

Selection and Procurement Procedures

Medications available for dispensing or administration are selected, listed and procured based on criteria.

1. The VA National Pharmacy Benefits Management (PBM) Strategic Healthcare Group develops a formulary of medications available for dispensing and administration throughout and at the VA Loma Linda based on criteria which can be found on the National PBM website (https://vaww.cmopnational.va.gov/cmop/PBM/default.aspx). Criteria include indication for use, effectiveness, risks (including propensity for drug interactions, adverse drug events, medication errors, abuse potential and sentinel events), population(s) served, and cost.

a. Potential for shortage/outage is monitored by the Pharmacy Service.

b. In the event of a shortage/outage, appropriate staff will be notified using the Notification Cascade (See HCS Policy 119-13 Pharmaceutical Shortages Policy).

c. The Chief, Pharmacy Service or designee will convene a task force to develop a substitution protocol

Attachment C

Medication Storage Procedures

Medications and biologics are properly and safely stored throughout the VA Loma Linda Healthcare System (VALLHCS).

I. General storage:

A. VALLHCS only stores approved medications selected by the facility.

B. Medications are stored according to the manufacturers’ recommendation or a pharmacist’s instructions if no recommendation is provided by the manufacturer.

C. Medications in patient care areas are maintained in the most ready-to-administer form available or in unit-doses.

D. Monthly ward and clinic inspections by pharmacy personnel are conducted to monitor proper storage, i.e., appropriate conditions to ensure stability.

E. Automated Dispensing Cabinets (ADCs) medication storage machines or Pyxis® are used throughout

F. Access to medications and areas used to store medication will be limited to a licensed healthcare providers, Healthcare students being trained by a licensed healthcare provider, Sterile Processing Service (SPS) personnel delivering solutions or supplies or pharmacy technicians who are carrying out their duties.

G. In the event of a disruption of commercial power failure, power will be provided by the facility generator. If necessary, medications stored in the ADC may be accessed manually.

H. Refer to HCS 119-06 Medication Disposition for wasted medications.

II. Controlled substances are stored to prevent diversion in according to VA regulations and federal laws and

III. Expired, damaged and/or contaminated medications – Unusable medications are segregated, stored and secured separately from medications available for administration until they are removed from the facility.

IV. Easy-to-confuse medications – Sound-alike/look-alike drugs (LASA, SALAD) are packaged differently and utilize TALLman lettering where appropriate. TALLman lettering refers to the practice of writing part of a drug’s name in uppercase letters to help distinguish sound-alike, look-alike drugs from one another to avoid medication errors.

A. Reagents and chemicals that may be mistaken for medications are stored separately to minimize the potential for an adverse event.

B. Pharmacy and Therapeutics Committee develops a list of look-alike/sound-alike medications it stores, dispenses, or administers.

C. Pharmacy and Therapeutics Committee takes action to prevent errors involving the interchange of the medications on its list of look-alike/sound-alike medications.

D. Pharmacy and Therapeutics Committee annually reviews and, as necessary, revises its list of look-alike/sound-alike medications.

V. Medications and chemicals used to prepare medications are accurately labeled with contents, expiration dates and appropriate warnings.

VI. Concentrated drugs:

A. Drug concentrations available in the Healthcare System are standardized and limited in number.

B. Concentrated electrolytes are only stored in the Pharmacy unless approved by the P&T Committee

VII. Emergency drugs and/or supplies are consistently available, controlled and secured in patient care areas.

(Healthcare System Policy 11-12: Cardiopulmonary Resuscitation or Code Blue Procedure).

A. The Medical Executive Council (MEC), in conjunction with the Critical Care Committee and the Code Blue Subcommittee decide which emergency medications and supplies will be readily available in patient care areas. Emergency medications and supplies are consistently available, controlled, unit-dosed, age-specific and secured in patient care areas in sealed emergency medication carts. Whenever possible, emergency medications are available in the most ready-to-administer forms.

B. Replacement:

1. Opened carts will be sealed with a red lock.

2. Carts with a red lock will be returned to Pharmacy where medications will be removed before being sent to SPS for cleaning and replenishment of supplies as soon as possible.

3. SPS will then return the carts to the Inpatient Pharmacy where Pharmacy personnel will

C. Inspection:

1. Pharmacy personnel will inspect each cart routinely to verify the contents and replace any outdated drugs.

2. A staff member in each area where a cart is located will inspect the seal’s integrity once a day.

VIII. Medications brought into the HCS by patients or family or licensed independent practitioners:

A. Medications brought into the HCS by patients, family members, licensed independent practitioners or other staff members will not be used by the facility as the medication’s integrity cannot be guaranteed. Under no circumstances will patient’s controlled substance medications be stored in the pharmacy for temporary custody after being dispensed to the patient (per VHA Handbook 1108.01). These medications will be

1. Sent home with a responsible individual appointed by the patient upon admission if possible.

2. Pharmacy staff members can provide pre-paid envelopes:

a. To patients for off-site destruction of medications if requested.

b. To patients to mail to address of choice.

3. VALLHS staff members cannot mail out the package on behalf of the patient to prevent diversion.

B. Medications brought in by the patients to the medical center will not be stored in the clothing room,

C. For investigational drugs for medications dispensed by VALLHCS Research Pharmacy, refer to HCS Policy 119-04.

IX. Investigational Medications and Supplies: Investigational medications and supplies will be stored as described in HCS Policy 119-04 Investigational Drugs.

X. Sample Medications: Sample medications will not be received or stored by VA Loma Linda personnel unless

XI. Refrigerated or Frozen Medications:

A. Medication requiring refrigeration or frozen storage conditions as recommended by the manufacturer will be stored in the appropriate refrigerator or freezer.

B. Refrigerators and freezers temperatures will be monitored:

1. All areas of the main hospital will be checked by a pharmacy or designated clinic staff member twice a day.

2. Ambulatory Care Center (ACC) clinic refrigerators will be checked by the nursing staff member as assigned by the clinic twice a day.

3. When an area is not open all days of the week, the temperature monitoring device will be checked for excursions during off-tour hours upon return on the first business day and recorded on the temperature monitoring sheet as in-range (IR) or not-in-range (NIR).

C. If a medication refrigerator or freezer malfunctions at any time, the discovering staff member will contact the Pharmacy Service to assess the medication’s condition and contact FMS to get a replacement refrigerator or freezer. The staff member will document the actions taken and resolution date on the back side of the refrigerator/freezer record sheet.

D. In the event of a disruption of commercial power, power for the refrigerators and freezers will be supplied from the facility generator. Medications will be relocated to an area with power if necessary.

XII. Medications Stored in Warmers (including Hot Water Baths, Incubators, etc.):

A. Medications placed in a warmer before administration will be stored at temperatures and length of time recommended by the manufacturer.

B. If the manufacturer has no recommendation, the service wanting to use and store medications in

C. The temperature of the warmer should be monitored:

1. A minimum of once a day when the areas are open.

2. When an area is not open 7 days a week, a temperature wheel or other monitoring device will

XIII. Ward Stock (including ADC): Items being requested for addition to the ward stock will be done with the approval of the P&T Committee. The ward stock items will be reviewed annually by the P&T Committee.

XIV. Medication Taken Out of the VA Loma Linda Health Care System (VALLHCS): If a medication is

XV. Status of Medication Prior to Administration:

A. When a provider (RN, LVN, physician, etc.) authorized by the VA Loma Linda to possess and

1. Administer the medication immediately.

2. Place the medication in a secure area which is suitable for medication storage if they are unable to administer the medication immediately.

3. Securely maintain possession of the medication until they can administer the medication

B. Medications must either be administered or returned per VA Loma Linda Health Care System Medication Management HCS Policy 119-07 by the end of the provider’s tour of duty.

XVI. Access to Medication Room: Persons who are authorized to handle medication by the VA Loma Linda

XVII. NIOSH Medications: Hazardous drugs (HD) on the facility’s NIOSH list will be stored separately from non-hazardous drugs in the pharmacy. Staff members will comply with all hand hygiene, garbing and personal protective equipment (PPE) requirements while handing HD in accordance with HCS COS 11-29 Handling of Hazardous Drugs and Agents.

Attachment D Medication Ordering and Transcribing Procedures

I. Only medications needed to treat the patient's condition are ordered.

II. Each medication ordered will have a documented diagnosis, condition, or indication for use in CPRS.

III. The following providers may write orders:

A. Physicians.

B. Dentists.

C. Nurse Practitioners.

D. Clinical Pharmacists with clinical privileges or scope of practice.

E. Podiatrists with clinical privileges or scope of practice.

F. Physician Assistants with countersignature of an attending physician and indication of their status.

G. Medical Students with countersignature of an attending physician and indication of their status.

H. Clinical Nurse Specialists with clinical privileges or a scope of practice.

IV. All medications ordered should be on the approved VA National Formulary (Attachment B, Selection and Procurement).

V. Non–formulary, restricted or prior authorization (PA) drugs require approval by the P&T Committee, VISN 22 PBM or their designee for a provider to prescribe the drug.

VI. Medication orders must be clear and transcribed accurately.

A. When questions arise concerning the appropriateness of a medication order or orders that are

1. Supervision Attending Physician.

2. Section Chief Physician.

3. Service Chief Physician.

4. Chief of Staff.

B. A complete medication order consists of:

1. Date and time ordered.

2. Full name of the drug or the Healthcare System’s (HCS) approved abbreviation.

Generic names are preferred.

3. Dosage, strength, route of administration, frequency, and site, if necessary.

4. Start Date/Time as appropriate.

5. Indication for use documented in CPRS for designated areas outlined below:

a) All orders for the community living center (CLC) will include an indication for use.

b) All as needed (PRN) orders in the inpatient settings will include an indication for use.

6. Rate of administration for large volume IV infusions, irrigations, and hyperalimentation

(TPN).

7. Signature of ordering provider.

C. Medications orders may be given in various ways:

1. Electronic – Medications should be primarily ordered through CPRS in the patient’s chart.

2. Written – When electronic order entry is unavailable, medications may be written by a

3. Verbal – Medication orders may be verbally communicated to pharmacists in emergent

4. Telephone – Medication orders may also be communicated to pharmacists via telephone in

VII. Ordering look-alike/sound-alike (LASA) drugs

VIII. Required elements for specific types of orders:

A. As needed (PRN) orders in the CLC and inpatient setting will include criteria for use including, but not limited to indication, dose, and frequency.

B. Standing orders are in the form of an order set and require approval by the medical staff to be used in defined situations.

C. Signed and held orders must be released by the ordering provider before administration. Medications

D. Automatic stop dates: Medications will be administered until automatic stop dates take effect, the orders are discontinued, or the orders are renewed.

1. Acute Care:

a) Schedule II through V Controlled Substance medications:

(1) Will be ordered per VHA Handbook 1108.01.

(2) All meperidine orders expire within 48 hours. A non-formulary request

b) Orders for clozapine must be renewed every 7-14 days after reviewing laboratory work.

c) Orders for ketorolac will expire after five (5) days of therapy. A Non-Formulary Request Form will be required to continue therapy beyond five (5) days.

2. Community Living Center (CLC):

a) Medication Orders: Medication orders expire at 2400 hours on the last day of the 28 day prescribing period for the CLC (except I.V. solutions and antibiotics).

b) Schedule II through Schedule V medications will be ordered (VHA Handbook 1108.1)

c) Oral Antibiotics: Orders for oral antibiotics written for CLC expire after ten (10)

d) Orders for ketorolac will expire after five (5) days of therapy. A Non-Formulary Request Form will be required to continue therapy beyond five (5) days.

E. Titrating orders (doses that are either progressively increased or decreased in response to patient status) will include parameters for titration that include:

1. Medication name

2. Medication route

3. Initial or starting rate of infusion (dose/min)

4. Incremental units the rate can be increased or decreased

5. The frequency for incremental doses (how often dose/rate can be increased or decreased)

6. Objective clinical endpoint (RASS score, CAM score, etc.)

7. Conditions necessary to contact the provider

Attachment D

F. Taper orders (dose is decreased by specific amounts with each dosing interval) will include tapering parameters.

G. Range orders will not be accepted without specific parameters. Pharmacy Service will contact the ordering clinician upon receipt. Range orders must include:

1. Medication name

2. Medication route

3. Minimum and maximum total dose that can be given within the dosing interval

4. Minimum dosing interval. This may be given as a range.

5. Objective clinical assessment parameters (Pain Scale) H. Orders for compounded drugs or drug mixtures not commercially available are prepared only in the Pharmacy or by an approved contracted service.

I. Investigational medications will be ordered as described in HCS Policy 119-04 Investigational Drugs.

J. Herbal products will not be ordered by VA staff. Herbal products used by patients are documented in the "Non-VA Medications" section on the CPRS cover sheet.

K. Discharge medication orders include documentation of instruction from a clinical staff member.

L. Verbal or telephone orders are limited to emergent situations when a provider is unable to enter orders because he/she is providing direct patient care, e.g. a code in progress or an emergent Operating Room (OR)/Procedure Room order. Verbal and telephone orders require write-down/read-back of physician order.

M. Pre-printed order sheets are not acceptable.

N. Blanket reinstatement of previous medication orders are not acceptable. New orders are required when a patient changes from one service to another.

O. Orders for IV antibiotics will be administered based on Standard Medication Administration Times, except as defined in the IV Antibiotic Algorithm.

P. Orders for medications to be administered on a non-conventional schedule (i.e., every 48 hours, “Every Monday”) will have administration times set appropriately.

Q. Orders for medication-related devices (i.e., inhalers, spacers) or supplies can be ordered by all providers.

IX. Transfers:

A. Medication Transfer- Acute Care and CLC:

1. All current orders will automatically be canceled in CPRS for the following patient movements:

a. Change in acuity level.

b. One treating specialty to another or service change.

c. Operating Room: Patients receiving general anesthesia.

d. Discharge, i.e., from acute care/ICU to CLC.

e. Exception:

i. ICU to SDU transfers does not require the cancellation of orders.

ii. Cancellation of orders is not necessary when transferring from one bed to another or same level of care. For example, if the patient is moved from 4SW to 4NW in order to place a patient in a private room, or due to staffing needs, the orders do not need to be canceled as the patient is remaining with the same service.

Attachment D

B. ALL HANGING INFUSIONS will be discontinued and removed when changing from one specialty/service to another.

1. Exception:

a. Total Parental Nutrition.

b. Pain Medications administered via a PCA.

c. Enteral feedings.

d. Currently infusing antibiotics.

e. Chemotherapy or Oncology Pharmacy prepared infusions.

C. Currently infusing medications that need to continue for patient safety and continuity of care,

Attachment E

Medication Preparation and Dispensing Procedures

All prescriptions or medication orders are reviewed by a pharmacist for appropriateness.

I. Preparing:

A. Pharmacist Verification:

1. All routine medication orders will be verified by a pharmacist as correct before the medication is administered to the patient except:

a) When a Licensed Independent Practitioner (LIP) controls the ordering, preparation, and administration of the medications.

b) In urgent or emergent situations when the resulting delays would harm the patient, including situations in which the patient experiences a sudden change in clinical status.

2. For orders in “Delayed” status, nurses will contact the appropriate personnel to have the orders

3. Verification includes, but not limited to the review of:

a) Appropriateness of the drug, dose, frequency and route of administration.

b) Therapeutic duplication.

c) Real or potential sensitivities or Adverse Drug Reactions (ADR).

d) Real or potential interactions between the prescription and other medications, food, and laboratory values.

e) Variation from organizational Criteria for Use (CFU).

f) Other contraindications.

4. All concerns, issues or questions are clarified with the individual prescriber before dispensing the medications.

B. Safety: Medications are prepared safely.

1. Compounding/Admixtures: Sterile drug compounding and admixture activity is restricted to the

2. Hazardous Medications: Refer to HCS COS 11-29

3. Wherever medications are prepared, staff will use techniques to assure accuracy. Staff will visually inspect medication for particulates, discoloration, or other loss of integrity.

4. Avoidance of Contamination: Wherever medications are prepared, staff will use appropriate.

techniques to avoid contamination, which include but are not limited to:

a) Clean or sterile technique as appropriate.

b) Clean, uncluttered and functionally separate areas for product preparation to minimize the possibility of contamination.

c) Laminar airflow hood or other ISO Class 5 environment while preparing:

i. IV admixtures.

ii. Sterile product that will not be used within 24 hours.

d) Wash hands.

C. Labeling: Medications are labeled.

1. Responsibility: Containers are labeled whenever medications are prepared but not immediately

2. NIOSH drugs: HDs identified as requiring special HD handling precautions will be clearly labeled with the appropriate warning/auxiliary label, “Hazardous Drug” in accordance with HCS COS 11-29 Handling of Hazardous Drugs and Agents.

Attachment E

3. Label Contents: Information on medication labels is displayed in a standardized format, in

a) Inpatient:

i. Drug name, strength and amount/concentration.

ii. Bar code label.

iii. Expiration Date (expiration when medication is no longer to be used occurs in less than 24-hours) and Lot Number.

iv. Any applicable cautionary or auxiliary labels, e.g. “Requires refrigeration,” Protect from light,” etc.

v. The location where the medication is to be delivered.

b) IV/Irrigation/TPN solutions, in addition to the above:

i. Type, concentration and amount of additive(s).

ii. Type and volume of solution.

iii. Diluent for all compounded IV admixtures and parenteral nutrition solutions.

iv. Date prepared.

v. Any applicable cautionary or auxiliary statements, e.g. “Requires refrigeration,” “Protect from light.”

c) Outpatient:

i. Name, address, and telephone number of Pharmacy.

ii. Date.

iii. Prescription number.

iv. Name of patient.

v. Drug name, strength and amount dispensed.

vi. Directions for use.

d) Individual medications prepared for multiple patients or when someone other than

III. Transport: HDs that need to be transported must be labeled, store, and handled in accordance with HCS 11-29: Handling Hazardous Drugs. Pneumatic tubes will not be used to transport any HDs.

IV. Dispensing: Medications are dispensed safely.

C. Quantities of medications are dispensed which minimize diversion yet are consistent with patient needs.

1. Outpatient:

a) Non-controlled substances will be dispensed in quantities not to exceed a 90-day supply, refillable for up to a maximum of 12 months of therapy based on clinical judgment.

b) Controlled Substances:

i. Schedule III, IV, & V Controlled Substances are dispensed in 30-day quantities unless

ii. Schedule II Controlled Substances are dispensed in 30-day quantities unless approved for

2. Inpatient:

a) The ADC is the primary medication distribution system for Inpatient medication areas.

b) The unit dose distribution system is the secondary medication distribution system for inpatient areas.

c) The unit dose distribution system is the primary medication distribution system for the CLC.

Quantities more than a 24-hour supply will be issued.

d) When a patient is to receive less than the full tablet (dosage unavailable), Pharmacy will:

i. Split a full tablet in half.

ii. When less than half a tablet is required, the medication will be put into a solution.

iii. Tablet-or-pill-cutters are not to be used in the Acute Care Hospital,

D. The Pharmacy dispenses medications:

1. According to laws, regulations, licensure and professional standards of practice, including recordkeeping.

2. The hospital dispenses medications within time frames it defines to meet patient needs.

a) Stat – within 30 minutes of written order

b) Dose Now - within 60 minutes of written order

3. In the most ready-to-use forms available from the manufacturer or, if feasible, in units that have been repackaged by the Pharmacy.

4. In a consistent dose packaging system, or provides education about the use of the dose packaging system to the appropriate patients.

5. Medications dispensed by the Pharmacy will have an expiration date no greater than one year from the time they are removed from the original packaging.

C. Recalled/Discontinued Medications are retrieved as outlined in HCS Policy 119-14, Drug Recall Policy.

1. Upon receipt of a drug recall notice, the Pharmacy will verify that the affected drug has been purchased by this Healthcare System and, if so:

a) Retrieve the recalled drug and handle appropriately per laws and regulations and instructions provided in the recall/discontinuation notice.

b) Notify staff who order, dispense and/or administer the affected drug.

c) Identify and notify affected patients by telephone and/or letter requesting that the patient not consume the drug and return it to the Pharmacy Service for replacement.

D. Medications Returned to the Pharmacy are appropriately managed.

1. All unused, expired, or returned medications are managed by the Pharmacy Service.

2. Expired medications found in the wards or clinic areas as a result of Pharmacy inspections

3. All unused, expired or returned medications are disposed of by a VA approved contracted organization.

Attachment F

Medication Administration Procedures

Medications are safely and accurately administered.

I. The medication prescriber is notified in the event of an adverse drug reaction or medication error. Medications are generally administered by nursing staff in accordance with nursing procedures in response to a medication order from an authorized provider. The Bar Code Medication Administration (BCMA) software system is utilized for administration of all bar-coded medications as outlined in HCS Policy 118-05 Bar Code Medication Administration. The Medical Executive Council (MEC) determines which licensed independent practitioners and the clinical staff disciplines are authorized to administer medication, with or without supervision, in accordance with law and regulation as outlined in HCS Policy 11-59 Medication Administration.

Before administering a medication, the appropriate provider administering the medication:

A. Verifies that there is a valid order for the medication.

B. Verifies the five rights:

1. Right medication.

2. Right patient.

3. Right dose.

4. Right route.

5. Right time.

C. Verifies that the medication is stable based on visual examination for particulates or discoloration and that the medication has not expired.

D. Verifies that there is no contraindication for administering the medication.

E. Advises the patient or, if appropriate, the patient's caregiver about any potential clinically significant adverse reaction or other concerns about administering a new medication.

F. Discusses any unresolved, significant concerns about the medication with the patient’s provider and relevant staff involved with the patient's care, treatment and service.

II. Additional Information:

A. Patients who claim an allergy to a specific medication may receive the medication if the clinician

B. Intravenous (IV) medications will be administered as defined by Nursing SLP 118-D-10 Administration of Intravenous Fluids and Medications by Registered Nurses.

C. Expiration or discard date for:

1. Bulk or multi-dose containers of non-sterile medications in (e.g., topical creams and

2. Multi-dose vials (MDV) containing sterile products will have an expiration or discard date as outlined in the HCS Policy 11-31 Single Dose/Multi-Dose Vial and Multi-Use Containers.

D. Moderate Sedation Medications are administered per HCS Policy 11-18 Guidelines for Non Anesthesiologists E. Contrast Agents:

1. Licensed Radiology Technologists who are certified in venipuncture and contrast administration are authorized to administer parenteral contrast agents under the direction or general supervision of a Radiologist or licensed physician (HCS 114-04 Contrast Agents).

2. Nursing personnel are authorized to administer oral contrast for C. or Cholecystography to patients on written orders from a physician.

3. Approved registered nurses and GU health technicians in Urology/Cystoscopy Clinic instill contrast agents for cystourethrography.

4. Use of contrast material in the cardiology unit (Cardiac Cath Lab) will be under the direction/ supervision of the attending cardiologist.

Attachment F

5. Authorization to administer parenteral contrast agents is granted to the following Health Care Groups: Diagnostics, Spinal Cord Injury/Disorder, Surgical and Medical.

6. A designated Nuclear Medicine Technician may administer radioactive compounds.

7. After hours, the licensed Emergency Department physician will be physically present and

III. Self-administered medications are safely and accurately administered.

A. Procedures guide the safe and accurate self-administration of medications and address training, supervision and administration documentation.

1. Attachment G: Self-Administration Medication - Acute Care.

2. Attachment H: Self-Administration Medication (SMP) – CLC (CLC Policy 19).

B. Patients who self-administer medications receive training on how to monitor the effects of the medications on the patient.

C. Patients who self-administer medications are determined to be competent at medication administration before being allowed to administer medications.

Attachment G

Self-Administered Medication Program (SMP) Acute Care

I. POLICY:

A. Self-administration medications are not allowed in the acute care units except for extenuating circumstances whereby, the patient’s care may be jeopardized. Examples may include: Patient utilizes their self infusion pump, a model the medical center does not carry; research protocol medications. If a self-administered medication(s) is deemed necessary, this policy will be followed accordingly.

B. Should self-administered medications be necessary, this policy is to give guidance and education to the patient for the self-administration of medications while in the medical center. The self-administration of medications teaches patient to assume responsibility for adherence of medication regimen and storage. Patients will be authorized to self-administered medications by their health care provider.

C. Before implementing SMP, a provider with prescriptive privileges or other qualified staff must assess patients who may benefit from participating in a SMP. A progress note, with a provider’s order, must document that the patient has been assessed and is eligible for the SMP.

This assessment must include the patient’s degree of knowledge and understanding of the following:

1. The name and type of each medication.

2. How to administer each medication (such as appropriate frequency, routes of administration, dose, etc.).

3. Storage requirements.

4. Reason for taking medication.

5. Common side effects of the medication.

6. Integration of medications into the patient lifestyle.

7. Possible barriers to compliance.

8. Possible barriers to learning.

9. Monitoring the effects of the medication.

10. Procedures for requesting a change in medication regimen (VHA Handbook 1108.03).

D. The treating providers determine that the patient or the family member who administers the medication is competent at medication administration before allowing him or her to administer medications.

E. Before discharge from the SMP, the provider must assess the patient’s ability to demonstrate knowledge of self-medicating, as described in C, and document the outcome (VHA Handbook 1108.03).

II. RESPONSIBILITIES

A. The Medical Center Director is responsible for ensuring a written SMP policy for each ward, unit or program. Associate Directors, service chiefs, area leaders ensure compliance with the policy as written.

B. Physicians:

1. Participates as a member of interdisciplinary team to assess patient’s ability to accurately and safely self-administer and manage his/her medication regimen.

2. Orders medications for self-administration in the Computerized Patient Record System (CPRS).

3. Documents all over-the-counter (“OTC”) and herbals being used by the patient in the Non-VA medication section in CPRS.

C. Pharmacists:

1. Participates as a member of the interdisciplinary team to assess the patient’s ability to accurately and safely self-administer and manage his/her medication regimen.

2. Documents the findings of the initial assessment in the patient’s medical record.

3. Provides initial teaching about the medications, including the use and major side effects of each medication (including information sheets) and other pertinent information.

Attachment G

4. Prepares and dispenses medications ordered for use at the bedside in accordance with current regulations.

5. Pharmacy staff will deliver medications to the Nursing Station (when indicated).

6. Monitors adherence on an ongoing basis.

D. Registered Nurses:

1. Participates as a member of the interdisciplinary team to assess the patient’s ability to accurately and safely self-administer and manage his/her medication regimen.

2. Verifies the doctor’s transcribed orders in CPRS.

3. Obtains signed patient agreement (below).

Patient Self-Medication Program Agreement Dear __________________, The treatment team wants your stay to be pleasant and productive. Therefore, we are presenting you with the following Self-Medication Program contract. Prior to enrolling in the Self-Medication Program we need assurance that you agree to the following:

1. I will work with the treatment team to properly document my medications taken on the calendar provided.

2. I will allow nursing staff or pharmacy personnel to audit my medications as scheduled.

3. I will adhere to the Self-Medication program policy.

4. I understand that failure to comply with Self-Medication Program will result in removal from the program.

I have read and understand the above Self-Medication Program Agreement and I agree to cooperate as described above.

Patient Signature Date Nurse’s/Pharmacist’s Signature Date

4. Provides each patient with a copy of “Patient Guidelines for Self-Administered Medications” and discusses it with them (below).

5. Reinforces patient education regarding the prescribed medications and updates as needed in collaboration with the interdisciplinary team.

6. Prepares the patient’s “calendar” with the appropriate and essential information regarding self-administered medications (below).

7. Verifies the medications delivered from the Pharmacy.

8. Ensures a locked and secured location for storage of medications.

9. Documents adherence of the program in CPRS.

Attachment G

Patient Calendar Medication Instructions Patient Name: _____________________________ SSN: _________________

Name of Medication:

Actifed

Why Taking:

Clear nasal passages

When to Take:

1 tablet, every 8 hours

Special Instructions:Sample COMPLETED Form

Take at 0600/1400/2200 hours

Note: Place a check mark after taking each dose in appropriate block

Attachment G Patient Name: _____________________________ SSN: _________________

Patient instructions and information:

Name of Medication:

Why Taking:

When to Take:

Special Instructions:Sample BLANK Form

E. The Patient:

1. Agrees to participate in the SMP and signs an agreement (above).

2. Stores medications in the locked and secured…