ADVENTIST MIDWEST HEALTH REGIONAL POLICY PROFILE
Category
Patient Care
Index Number
(RG)PTC.804
Title
Medication Administration
Effective Date
Review Date/s
01/05/12
Applicable Regional Entities: Chicago-area Hospitals
Revision Date/s
Page 1 of 5
Cross Reference
RG PTC. 818 RG PTC.628 RG PTC.827 RG PTC.825
I.
Purpose
To provide standardized guidelines for medication administration
II.
Policy
Medications will be administered only by appropriate personnel (RG) PTC.818 and in
accordance with hospital policy using the Medication Positive Patient Identification (mPPID)
system, unless in circumstances noted in this policy.
III.
Procedure
A. Medications are administered only upon a physician/licensed independent practitioner
(LIP) order and must be verified prior to administration by comparing to Electronic
Medication Administration Record (eMAR) and Medication Administration Wizard
(MAW) . Exceptions are noted in (E) below.
B. Before administering medications, the practitioner will verify
1.
patient’s identity using two (2) patient identifiers is required. (RG) PTC.628
2. Correct medication
3. Correct dose
4. Correct route
5. Appropriate time
C. The healthcare practitioner administering the medications is expected to
1. know the primary action of each medication administered
2. verify there are no allergies or contraindications to administering the medication
ADVENTIST MIDWEST HEALTH REGIONAL POLICY PROFILE
Category
Patient Care
Index Number
(RG)PTC.804
Title
Medication Administration
Effective Date
Review Date/s
01/05/12
Applicable Regional Entities: Chicago-area Hospitals
Revision Date/s
Page 2 of 5
Cross Reference
RG PTC. 818 RG PTC.628 RG PTC.827 RG PTC.825
3. verify the medication product or compound is not deteriorated, adulterated or
expired
4. address any unresolved significant concerns regarding the medication with the
ordering provider
5. observe the patient for signs of therapeutic results or adverse effects; including
the patient’s response to first doses of new medications. The physician /LIP is to
be informed of any allergic reactions or adverse effects the patient manifests.
D. Before administering any new medication, the healthcare practitioner will advise the
patient or family about the purpose of the medication, expected results, possible side
effects and potential clinically significant adverse reactions.
E. Medications must be administered by the healthcare practitioner and documented on the
eMAR using the mPPID process except in those areas that document on a paper MAR or
the situation is a noted exception as outlined below.
1. Practitioner will verify medication orders from Physician/LIP and compare to
eMAR.
2. Immediately prior to obtaining medications, the eMar will be reviewed to identify
the medications to be removed from pyxis for each patient.
3. All meds will be scanned with the following exceptions:
a. Code Blue
b. Rapid Response
c. Meds that are over-ridden in Pyxis as STAT medications prior to order
verification by pharmacy
ADVENTIST MIDWEST HEALTH REGIONAL POLICY PROFILE
Category
Patient Care
Index Number
(RG)PTC.804
Title
Medication Administration
Effective Date
Review Date/s
01/05/12
Applicable Regional Entities: Chicago-area Hospitals
Revision Date/s
Page 3 of 5
Cross Reference
RG PTC. 818 RG PTC.628 RG PTC.827 RG PTC.825
d. Medications from patient’s own supply that are non-formulary and have
been approved by pharmacy
e. Cerner Downtime
f. Self Administered medications
These medications will be documented on appropriate paper documentation or
in the eMAR.
4. Meds will be taken to the patient, scanned and opened in front of the patient.
Practitioner will confirm verification using two patient identifiers, scan the
patient’s wristband and scan the medication and document in the MAW.
F. If administering a controlled substance in which an amount of the medication must be
wasted, a second nurse witnesses the disposal of waste and documents in the PYXIS.
Practitioner must keep the medication container with barcode intact and proceed with
(III. E. ) above.
G. 2nd Nurse verification and documentation for High Alert medications (RG PTC.825) is
required at the point of drawing up and administration after appropriate patient
identification. Primary nurse will scan the wristband and the medication and follow the
mPPID process. 2nd nurse will verify dose and witness in MAW window.
H. When a medication must be crushed or split, practitioner will take the medication into the
room intact in its unit dose package with the appropriate resources to crush or split the
medication. mPPID process will be followed prior to opening unit dose package.
I. For multi dose medication, barcoded “flags” will be attached to the vial/containers, after
appropriate dose removed from multidose container, barcoded “flag” will be applied to
syringe and brought to patient. Practitioner will confirm patient identification using two
identifiers, and follow the mPPID process.
J. When medications are to be administered to patients with isolation precautions, the
following steps should be followed.
ADVENTIST MIDWEST HEALTH REGIONAL POLICY PROFILE
Category
Patient Care
Index Number
(RG)PTC.804
Title
Medication Administration
Effective Date
Review Date/s
01/05/12
Applicable Regional Entities: Chicago-area Hospitals
Revision Date/s
Page 4 of 5
Cross Reference
RG PTC. 818 RG PTC.628 RG PTC.827 RG PTC.825
1. Wash hands prior to entry into isolation room
2. Don appropriate PPE before entry into isolation room.
3. Wipe down the WOW workspace with appropriate cleansing wipes
4. After scanning medications and patient’s arm band, change gloves prior to
medication administration.
5. Prior to leaving the room, close to the doorway, wipe down mPPID Scanner, cord
and WOW with appropriate wipes, before removal of PPE.
K. Medications are not to be left unattended and are to be stored in an approved, secure
manner. RG PTC.827
L. If practitioners are found not to be following appropriate mPPID procedures, disciplinary
action will occur as defined in the Discipline policy (RG) HMR 277.
Poon, Eric G. et al (2010). Effect of Bar-Code Technology on the Safety of Medication Administration.
The New England Journal of Medicine, 362 (18), 1698-1707
DISTRIBUTION:
Email distribution to Adventist Midwest Health Leadership
Posting on the Adventist Midwest Health Intranet
APPROVAL:
Regional Executive Council (Date): 01/05/12
Other Required Committee/s:
Regional Chief Nursing Officers
AHH/ALMH P & T Committee:
10/19/11
11/2/11
ADVENTIST MIDWEST HEALTH REGIONAL POLICY PROFILE
Category
Patient Care
Index Number
(RG)PTC.804
Title
Medication Administration
Effective Date
Review Date/s
01/05/12
Applicable Regional Entities: Chicago-area Hospitals
Revision Date/s
Page 5 of 5
Cross Reference
RG PTC. 818 RG PTC.628 RG PTC.827 RG PTC.825
ABH P & T Committee:
AGH P & T Committee:
12/14/11
11/15/11