HOSPITAL PROCEDURE Title of Responsible Party: Vice President Patient Care and Nursing Services Origination Date: Effective Date: Review/Revision Date(s):
5/94, 9/96, 7/97, 9/99, 1/00, 3/00, 1/02, 11/02, 11/03, 9/04, 11/04,
9/05, 6/06, 6/07, 3/09, 4/09, 8/09, 9/10, 10/10, 6/11, 9/11, 3/12
Licensed Nursing Personnel, Pharmacist, Clinical Dietitian, Respiratory Care Practitioner, Physical Therapist.
Key Words: @Medications, @Administration, @Pharmacist, @Dietitian, @Respiratory Care Purpose:
To define policies and procedures to assure the safe administration of medication and to delineate the persons and circumstances under which they are administered within the hospital.
Drug Administration means the act in which a single dose of a prescribed drug or biological is given to a patient by an authorized individual in accordance with all laws and regulations governing such acts. The complete act of administration entails removing an individual dose from a previously dispensed properly labeled container, verifying the dose with the prescriber' s orders, identifying the patient prior to administering, giving the individual dose to the proper patient and promptly recording the time and dose given.
Drug Dispensing means the act entailing the interpretation of an order for a drug or biological and the proper selection, measuring, packaging, labeling and issuance of the drug or biological for a patient or for a service unit of the hospital.
All medication must be administered according to the “Eight Rights”: 2.1
Right to have medication administration documented
Licensed personnel may administer medication as follows: 3.1
RN' s - oral, rectal, vaginal, topical, inhalant, epidural, intramuscular, subcutaneous, intradermal and intravenous.
LVN' s - oral, rectal, vaginal, topical, intramuscular, subcutaneous and intradermal routes. Additional statements may modify conditions under which medications may be administered.
Pharmacists - oral, topical, and intravenous.
Respiratory care practitioners (RCP), licensed by the state of California may administer inhalants within the scope of their practice.
Physical Therapists may apply or administer topical medications within the scope of their practice.
While patients are visiting CHOC Children’ s at Mission Hospital:
While any Mission Hospital patient is visiting CHOC Childrens Hospital at Mission, medications may not be administered by Mission Hospital staff. In the event of a code, the emergency response system would be activated.
When parent/child or baby are cohorted or being treated in the same room
In the event that parent and baby/child are both inpatients, or are being treated in the same room (i.e., Emergency Department, Radiology) parent and baby/child are to be physically separated or put in separate rooms for any medication administration
Medications are administered only upon the order of a member of the medical staff, or other individual who has been granted clinical privileges to write such orders. (Refer to Pharmacy policy, “ Authorized Prescribers.” )
Orders may be written as a chart order or entered directly into the computer by the physician using CPOE (Computerized Provider Order Entry). Telephone and verbal orders may be received and transcribed to a chart order by authorized licensed personnel. (See Section 6.5)
All chemotherapy orders must be written or faxed. No verbal or telephone orders will be accepted. 6.3.1 Exception: if the pharmacist clarifies a dosage or recommends an
adjustment based on current labs or change in BSA, a chart “ telephone
order” may be made, with an opening statement including “ clarification,” and a closing statement “ read back chemotherapy order and confirmed by physician.”
Verbal physician orders in general are discouraged.
Verbal or telephone orders for drugs may only be received by a registered nurse, licensed pharmacist, respiratory therapist, or clinical dietician from a person lawfully authorized to prescribe and shall be promptly recorded in the patient' s medical record. Drug or pharmacy product orders taken by respiratory therapists or clinical dieticians are restricted to their scope of practice (i.e., nutritional product orders taken by clinical dieticians; see NCS policy, " Medical Nutrition Therapy Order Writing Privileges for Registered Dietitians." ). Verbal/telephone orders are to be written down when received and repeated back to the physician for confirmation. Verbal/telephone orders will be recorded in the patient' s medical record noting the date and time the order is received name of the prescriber giving the order and the signature of person receiving the order. The prescriber must countersign within 48 hours.
Prescribed dosage and administration frequency ranges that do not correspond to clinical parameters defined by the physician, standards of care, or protocols, will be interpreted as follows: 6.6.1 The maximum dosage within the prescribed range will be administered for
the highest severity level of the clinical parameter being treated. The midpoint dose within the range will be given for moderate parameter severity levels. The lowest dose within the range will be given for the lowest parameter severity level. For example, an order for morphine 5 - 15mg every 4 hours prn pain would receive 5mg for mild pain, 10mg for moderate pain, and 15mg for severe pain.
220.127.116.11 A separate Meditech entry is required for each level of pain.
6.6.2 An administration frequency range for a prn order will be interpreted as the
shortest frequency as the defining parameter. For example: “every 4 to 6 hours prn” will be interpreted as “every 4 hours prn” and will be entered on the Medication Administration Record (MAR) as such (“q 4hr prn” as opposed to “q 4 – 6 hr prn”).
6.6.3 Orders which allow for multiple routes will preferentially be
given as follows: 18.104.22.168Oral or rectal, oral or IV, and oral or IM, will be given orally unless
the patient is unable to tolerate the oral route.
22.214.171.124 IM or IV, and SQ or IV will be given IV unless IV access is
unavailable. Exception: orders for IV or SQ Epoetin alfa (EpogenR, ProcritR) will be given SQ for all except dialysis patients.
Drug name (either trade or generic name), dosage or strength, route of administration, dosage frequency and additional information as applicable (i.e., start and/or stop date, specialized instructions).
On-call medication orders should be qualified as to purpose.
PRN medication orders must be written to include the symptom or indication for
use (i.e., prn nausea, prn headache). 7.3.1 If there is one primary use for the medication (e.g., Bisacodyl is only for
constipation) and the reason is not specified in the order, the pharmacist will clarify the order in Meditech and on the MAR. The default Meditech reason/indication will not override the physician’ s written indication.
7.3.2 The following medications have one primary indication and their PRN
indication will be defaulted into Meditech and the MAR: 126.96.36.199
PRN Abdominal Pain/Discomfort: DonnatalR, GI cocktail,
Hyoscyamine (LevsinR), Chlordiazepoxide/Clindinium
PRN Agitation/Anxiety: Alprazolam (XanaxR), Oral
Chlordiazepoxide (LibriumR), Clorazepate (TranxeneR),
Oral Lorazepam (AtivanR), Oxazepam (SeraxR).
PRN Agitation/Sedation: Lorazepam IV (AtivanR),
PRN Constipation: Bisacodyl, Castor Oil, Docusate,
Fleets Enema, Glycerin, Mineral Oil, MiralaxR, MOM,
PRN Cough/Congestion: Dextromethorphan or
Guaifenesin containing products, HycodanR,
PRN Diarrhea: Bismuth Subsalicylate (Pepto-BismolR),
PRN Dry Eyes: Artificial TearsR, LacrilubeR.
PRN Dysuria/Urgency: Phenazopyridine (PyridiumR),
PRN Gastric Acid Suppression: Calcium Carbonate
PRN Headache: FiorinalR, FiorinalR #3, FioricetR,
FioricetR #3, MidrinR, Sumatriptan (ImitrexR).
PRN Insomina: Flurazepam (DalmaneR), Temazepam
(RestorilR), Triazolam (HalcionR), Zolpidem (AmbienR).
PRN Itching/Rash: CalamineR and CaladrylR Lotion,
Chlorzoxazone (Parafon ForteR), Cyclobenzaprine
PRN Nasal Congestion: Oxymetolazone (AfrinR),
Phenylephrine, Pseudoephedrine (SudafedR), Saline Nasal
PRN Nausea & /or Vomiting: Dronabinol (MarinolR),
Droperidol, Metoclopramide (ReglanR), Ondansetron
(ZofranR), Prochlorperazine (CompazineR), Promethazine
(PhenerganR), Trimethobenzamide (TiganR).
PRN Shortness of Breath: Albuterol, Ipratropium
(AtroventR), Ipratropium/Albuterol (CombiventR),
Levalbuterol (XopenexR), Metaproterenol (AlupentR),
Pirbuterol (MaxairR), Racemic Epinephrine.
7.3.3 All PRN medication orders except those listed above require a written
clarification as to the reason or parameter for use (i.e., temp over 101; SBP greater than.).
7.3.4 If the temperature is not specified for a “ PRN fever or temperature”
order, the default temperature will be > 101o F (38.3o C).
Procedure for duplicate PRN medications ordered for the same indication. 7.4.1 Only one medication in the following drug class may be ordered for a
particular indication unless specifically ordered otherwise by the physician (e.g., give both drug A and B).
7.4.2 When a second medication is ordered for the same indication, the prior
medication order will be discontinued (e.g., a new order for Percocet 5/325 one tab PRN moderate pain will D/C a prior order for Norco 5/325 one tab PRN moderate pain; a new order for Ambien will D/C a prior order for Halcion).
7.4.3 Multiple anti-nausea medications may be ordered, however, guidance for
medication selection is required (e.g., if ineffective, then give…). 188.8.131.52
If guidance is not provided, the following prioritization will be the default (depending upon which anti-nausea medications are ordered):
Ondansetron (Zofran), if ineffective then Promethazine (Phenergan), if ineffective then Droperidol, if ineffective then Prochlorperazine (Compazine), if ineffective then Metoclopramide (Reglan), if ineffective then Trimethobenzamide (Tigan).
Certain regularly scheduled medications have a primary purpose, for these medications, the purpose will be defaulted into Meditech and on the MAR. 7.5.1 Proton Pump Inhibitors (Pantoprazole (ProtonixR), Lansoprazole
7.5.2 Histamine H -Receptor Antagonists (Famotidine (PepcidR): Gastric Acid
7.5.5 Nasal Sprays Azelastine (AstelinR), Beclomethasone (BeconaseR),
Budesonide (RhinocortR), Flunisolide (NasalideR), Fluticazone (FlonaseR), Ipratropium (AtroventR), Mometasone (NasonexR), Triamcinolone (Nasacort AQR): Nasal Congestion.
7.5.6 If one of these medications is used for a less common purpose
(Famotidine to treat an allergic reaction), the pharmacist will delete the default purpose and enter the alternative purpose.
The use of abbreviations is discouraged.
The use of a leading decimal point or a zero following a decimal point (e.g., .1mg or 1.0mg) are known causes of tenfold medication errors and therefore should not be used.
Medication orders that contain dangerous or unapproved abbreviations, leading decimal points (.1mg) or trailing zeros (1.0mg) require written clarification. The pharmacist or an R.N may write the clarification order. If the order is unclear, the physician will be contacted by either the nurse or the pharmacist for clarification.
The date and time and the prescriber' s signature should appear on all written orders.
Stat medication orders will be considered to be a high priority. These orders will be done before other, less emergent, medication orders.
The nursing staff may carry the medication order to the pharmacy and the pharmacist will fill the order on a priority basis.
Medications that are not considered appropriate for emergency, or urgent administration, such as warfarin, bowel care medications, and oral medications, will receive a less urgent priority.
A number of medication are written with hold parameters (e.g., Metoprolol 50 mg po BID. Hold if SBP < 120 or HR< 60.
If an order for a medication with hold parameters is changed (e.g., Decrease Metoprolol to 25mg po BID), the hold parameters must be renewed or rewritten to continue. Hold parameters do not automatically roll over to the new order.
If hold parameter orders are unclear, the physician should be contacted to clarify the order.
Hold Orders 10.1 Orders written to hold medication which do not specify when to resume (time
and date) shall be discontinued from the nursing Medication Administration Record and the pharmacy medication profile in Meditech. For example: 10.1.1 “ Hold digoxin” shall be interpreted to mean discontinue digoxin. 10.1.2 “ Hold digoxin x 2 days, then resume” is specific. 10.1.3 “ Hold AM dose of insulin tomorrow” is specific.
Medication Turn-Around Time 10.1 The normal turn-around time for medication and IV orders received in the
pharmacy, entered into the Meditech System, filled, and delivered to the nursing area is anticipated to be two (2) hours or less.
10.2 Orders for TPN solutions received by the pharmacy prior to 1400 can be
expected to be delivered to the nursing unit prior to the scheduled 2000 hang time. 10.2.1 Since start times for TPN solutions are usually not urgent, TPN orders
received after 1400 may not be started until the following day (after discussion with the physician). Refer to Pharmacy policy, “ Parenteral Nutrition, Adult.”
Patient’ s Own Meds and Bedside Medications: (Refer to CPC policy, " Medication, Administration of Patient’ s Own.” ) 11.1 Patient self-administration of medications is discouraged, however there are
exceptions (e.g., lactating mother applying lanolin to breasts; RN teaching patient to self-administer Enoxaparin [Lovenox], Fondaparinux [Arixtra] or Insulin prior to discharge; Respiratory Therapist teaching a patient how to use an MDI).
11.2 If allowed, supervision as appropriate is required and administration
Automatic Stop Orders: (Refer to CPC policy, “ Medication: Automatic Stop Orders.” )
Order Verification Prior to Administration. 13.1 All medication orders will be verified by the pharmacist and patients will be
identified using two identifiers (patient name and medical record number) prior to medication administration. All medications will be given in a safe manner consistent with good nursing practice which includes, but is not limited to verifying that there is no contraindication for administering the drug, checking for significant drug interactions, and advising the patient about any potential clinically significant adverse reactions, or other concerns about administering a new medication if appropriate. 13.1.1 The pharmacist reviews all orders prior to medication administration
unless the physician controls the ordering, preparation and administration of the medication; or in an urgent or emergency situation when delay would harm the patient (i.e., new acute onset of nausea or chest pain). See CPC policy, " Pyxis Medstation" for override function guidelines).
13.2 Prior to the first-time administration of any medication, it must be acknowledged
13.3 Unverified medications will only be given in an emergency situation per hospital
policy and availability in Pyxis. (See CPC Manual, “ Pyxis Medstation” )
13.4 Patient care areas that do not utilize Pyxis override may give medications
unverified if the physician is present to oversee the ordering, dispensing, and administration of the medication following hospital policy. (See CPC Manual, “ Pyxis Medstation” )
14.1.1 All patients will be identified by an identification arm band before each
administration of medication and compared to a source document (i.e.
14.1.2 Prior to medication administration the patient arm band will be scanned
to verify the correct patient. The arm band is barcoded with the patient AV number.
14.1.3 Verify the absence of any allergies to the medication being administered
against patient’ s allergy band – compared to source document (MAR) or allergy management routine in Meditech.
14.1.4 Medications are to be administered for one patient at a time.
14.2.1 Drugs dispensed by pharmacy will include the name, strength, route, and
14.2.2 Scan the medication prior to administration. 14.2.3 Exceptions to scanning the drug include emergent/urgent or override
situations when medications are given prior to orders being entered via CPOE or by Pharmacy. These exceptions are then documented as a late entry.
14.2.4 In most cases, the bar code to be scanned will be on the original package
itself. For items that are prepared in the pharmacy (i.e., items not pre-made by the manufacturer), the barcode will be on the pharmacy label attached to the item. RX barcode examples include individualized doses, such as half-tablets, patient own medications, non-formulary medications, bulk liquids, and IVs prepared by the pharmacy including chemotherapy and TPN.
Validate the 5 rights of medication administration
Document the medication manually by clicking Administer on the eMAR
Save packaging and place in the Problem Bar Code Bin for Pharmacy to
14.3 Bedside Medication Verification (BMV) Procedure:
14.3.1 Standard (Universal) precautions must be maintained at all times. 14.3.2 Hands must be washed before medication administration. 14.3.3 Observe the 5 Rights:
Right patient, Right drug, Right dose, Right time, Right route
14.3.4 Do NOT open medications before going to the bedside 14.3.5 BMV STEPS at the patient bedside:
Scan medications • The NDC barcode is on the package for most medications
• The RX# barcode is on the pharmacy label for compounds
or items that do not come pre-made from the manufacturer
Administer the medications to the patient • Crushing/Splitting tablets:
Take meds in unopened packaging and pill crusher/cutter
to the bedside. Scan the medications and then crush/split
Take unopened items to the bedside, as well as syringes
and cups necessary for administration. Scan the
medications and then prepare the dose and administer.
14.4.1 The nurse must stay with the patient until he/she has taken the medication.
14.4.2 Chemotherapeutic agents will be administered by chemotherapy certified
nurses only. (Exception: Oral cytotoxics used for non-oncologic
14.4.3 If a patient is unable to take a prepared medication, the medication is to be
destroyed (placed in pharmaceutical waste container) Exception:
Controlled Substances. See “ Pyxis Policy.”
14.4.4 Nurses should discard all unused syringes with medications they have
prepared but not administered. Nurses are not to administer any unlabeled medications.
High Alert Medications Requiring Double-Check Co-Signatures on the MAR. Refer to
“ Medications: High Risk or High Alert,” “ Chemotherapy Administration” and “ Patient
15.1 PCA infusions (opiates and anxiolytics)
15.2 Chemotherapy, Cytotoxic agents (chemotherapy certified nurses)
IV Medication: 16.1 A Registered Nurse, pharmacist or physician may administer IV medications.
(Refer to the CPC policy, "Intravascular (IV) Devices and Central Lines: Care and Maintenance Procedures” which includes the IV Push Policy)
Medication Orders Prior to Procedures: 17.1
Orders are required in order to omit, postpone or administer a medication via an alternate route due to a procedure or surgery.
Epidural drug administration for the purpose of pain relief will be initiated by the anesthesiologist and maintained by the nurse in accordance with the CPC Manual, “Epidural/ Spinal Pain Management Therapy Protocol."
Refer to the CPC policies, “Intravascular (IV) Devices and Central Lines: Care and Maintenance Procedures” and “Nutritional Support Guidelines” and the Pharmacy policy, "Parenteral Nutrition, Adult."
Collaboratively, nursing, pharmacy and nutritional care services will review patients who are receiving medications that could cause significant food/drug interaction and interfere with the desired outcome of the drug. Refer to the CPC policy, "Food Drug Interactions.”
Medication Precautions for Pregnant or Breast Feeding Women: 21.1
Female patients (ages 11 – 49) will be assessed for pregnancy and lactation status. If the patient is found to be pregnant or lactating, this information will be documented in the medical record/Meditech.
Medications in Meditech are coded to identify the pregnancy risk for the first, second and third trimester. When a contraindicated medication (Fetal Risk Category D or X) is ordered, the medication will be withheld and the physician notified of the contraindication.
Medications in Meditech are also coded for lactation risk, either as a contraindication or a caution. When a contraindicated medication is ordered, the medication will be withheld and the physician notified of the contraindication. If coded with a caution, the physician and nursing staff will be notified. The caution indicates that the either there is no human data or the human data are limited, however, the characteristics of the drug suggest that it could represent a clinically significant risk to the nursing infant. If the physician approves, breast-feeding should occur prior to the scheduled medication administration time (when the drug concentration in the plasma and breast milk is at its lowest) to minimize infant exposure.
Medication Errors (Quality/Risk Event Form): 22.1
(Refer to the CPC policy, “Medication Errors.”).
Standard Times for Medication Administration. Refer to CPC policy, “Medication Administration, Standard Times.”
Refer to the CPC policy, “Transfer Medication Orders.” Medication orders are automatically canceled after surgery requiring general anesthesia and/or when patients are transferred into or out of designated critical care areas (ICU or CICU). 24.1.1 Post-op or post-transfer medications order must be individually rewritten or
reordered using the transfer medication reconciliation form, simply writing, "resume pre-op or prior orders" is unacceptable.
24.1.2 The discontinuation and rewriting of medication orders is not a requirement
pre- and post-procedure performed under local anesthesia and/or moderate or deep sedation (e.g., radiology, ultrasound, endoscopy, CV Lab).
Transfer from one level of care to another: Unless specified otherwise by physician order, medication will be resumed at the next regularly scheduled administration time.
Guidelines for the resumption of post-op orders. 24.3.1 In general, medication will be resumed at the next regularly scheduled
24.3.2 If there is a question as to whether or not a dose should be skipped (i.e.,
waiting until the next day to resume Digoxin or Synthroid), the physician should be contacted to clarify the post-op orders.
The following information about the patient is accessible in the Meditech EMR to licensed independent practitioners and staff who participate in the management of the patient’s medications:
Pregnancy and lactation (when applicable)
Committee Review: Pharmacy and Therapeutics Committee, Collaborative Practice Committee References: 1
California State Board of Pharmacy Rules and Regulations
Briggs, GG, Freeman, RK, Yaffe, SJ. Drugs in Pregnancy and Lactation. 9th ed. 2011.
Lippincott Williams & Wilkins. Philadelphia, PA.
Pacific In Vitro Fertilization Institute Patient Name: ____________________________ MALE HISTORY Height: ___________________________ Have you been treated for infertility before: ____No _____Yes Physician(s): ______________________ Date:____________ Physician:______________________ Date:____________ Physician: ______________________ Have you had surgery for varicocele repair? ___
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