Phase 2 as Related to the DOH Survey Process Pharmacy Services - - PowerPoint PPT Presentation
Phase 2 as Related to the DOH Survey Process Pharmacy Services Richard A. Zelkowitz, RPh, MS, FASCP President, Pharmacon Co. Pharmaceutical Consultants to Health Care Institutions (914) 961-3372 www.PharmaconConsulting.com Phase 2 / DOH
Pharmaceutical Consultants to Health Care Institutions (914) 961-3372 www.PharmaconConsulting.com
Phase 1: November 28, 2016 Phase 2: November 28, 2017 Phase 3: November 28, 2019
Drug Regimen Review (DRR)
Reported to attending physician,
Specifies attending physician’s
If disagree, why?
Phase 1, cont.
Policies/Procedures need to address
Time frames for each step of the DRR process Pharmacist actions when need for urgent action
to protect resident
Definition expanded to include
Anti-psychotic Anti-depressant Anti-anxiety Hypnotic
ALL REQUIRE GRADUAL DOSE REDUCTION
Psychotropic PRN Orders limited to 14 days
Unless Physician documents rationale and
indicates duration of the PRN order.
This includes meds other than antipsychotics
Anti-anxiety (Ativan, Xanax) HYPNOTICS ( Ambien, Restoril)
Alternative : MELATONIN
ANTIPSYCHOTIC PRN Orders limited to 14
Cannot be renewed unless the physician evaluates
for the appropriateness of that medication.
Survey Risk Areas
Nursing Station Inspections Medication Pass Documentation
Nursing Station Inspection
Refrigerator
Temperature 36-46 degrees F
Keep Temperature Log
Open Multi-dose Vials & Pens
Must be dated when opened Discard after expiration date (varies) Refrigerator should be checked on a daily basis
Food Storage
Only in Pantry area None in medication room or REFRIGERATOR
Discharged, Discontinued & Patient Property
Must be segregated
Suppositories
Store as per manufacturer’s guidelines Room Temperature – In container in medication
cabinet
Cool or Cold – In refrigerator
Medication Cart
Dating of open containers
Xalatan – 6 weeks from opening Advair – 30 days from opening Protein Supplements – 30 days Glucose Control Solutions – 30 days
Expired medications
Old blister cards – PRN meds over 90 days Stock medications Nebulizer Solutions – Albuterol & Ipratropium
Controlled Medications
Control Cabinet
Metal, Double-locked (2 doors), TWO
DIFFERENT KEYS, Mounted on the wall
Same regulations apply to refrigerator. Controlled medications must be removed from
medication cart after medication pass
Only controlled medication stored in cabinet –
No syringes, No jewelry, No wallets, No hearing aides or batteries. AVIOD CONSTANT OPENING
Shift Audit
NO BLANK SIGNATURE BOXES All shifts must reconcile controlled
Reconciliation of controlled medications
Separate sheet for each Rx
Date Received Resident Name and Room # Drug Name & Strength Rx # Quantity Physician RN Signature Signature
Receiving Nurse Anticipated Date of Return Quantity Returned Date Returned
CONTROLLED DRUG RECEIPT LOG
Release of Control Medication Upon
Physician must write order stating
medication, strength and amount
Must sign waiver for non-childproof
container
Release only to responsible party - not
ambulance driver
Emergency Kit
Must be sealed
Preferably with serial number on lock Expiration date must be clearly discernable Content list must agree with contents
Controlled Medication Emergency Kit
Stored separately from routine controlled medications Must be counted each shift by nursing personnel Par levels MUST be maintained by informing vendor
pharmacy each time medication is used
Medication Pass
Gastrostomy Tube: Infection Control Dilantin Suspension via G-Tube
Must be separated from feeding – hold feed,
wait 60 minutes, flush tube, administer, flush tube, wait 60 minutes, restart feed
Viscous Medication Via G-Tube
Dilute Watch for residue in cup
Common Errors
Wrong Number of Tablets Administered
Highlight label and MAR
Check ID Wait 3 minutes between 2 drops of same
Wait 1 minute between each “puff” of
Measurement of Liquids
On flat surface At eye level Use proper size water cup (5 oz. vs. 8 oz.)
Charting Omissions & Transcription Errors
Considered medication errors Check at end of shift
Unavailable Medication / Delay of Delivery
Do not borrow Do not chart “unavailable” Contact your pharmacy for availability (via supervisor) Contact physician for further orders “Hold until available”
Crush vs. Liquid
If medication is available in liquid form, even if
it is crushable, Physician should order the medication in liquid form
Crush only with MD order EACH MEDICATION CRUSHED SEPARATELY
Infection Control
HANDWASHING Gloves should be worn for all Injectable
Administration
Medication Strength & Type
Make sure that actual strength and type of
stock medication is the same as the medication
Examples:
Calcium with Vitamin D Fish Oil/Omega 3 Nephrocaps Vitamin D2 vs. Vitamin D3 Regular vs. Enteric Coated Aspirin
Medication orders
Strength and quantity of liquids
Route of Administration
Must be consistent – PO or G/T
Medication Indication for Use
Antipsychotic – Must have Psychotic Indication (NOT DEMENTIA OR AGITATION)
Schizophrenia, Bipolar
NON-PHARMACOLOGIC INTERVENTIONS MUST BE TRIED FIRST (EVEN AFTER FAILED GDR)
PRN Use – Reason and Follow-Up
Anti-anxiety Medication Must document failure of behavioral interventions Caution with use, MAY BE CONSIDERED CHEMICAL
RESTRAINTS.
14 day limit Analgesics Acetaminophen < 3 gm/day
Interactions
Synthroid & Calcium Levaquin & Iron WARFARIN
Medication Refusal
Proper documentation by nursing and physician Proper destruction of refused dose
Crush and destroy in water
Prevnar 13 vs. Pneumovax 23
Check CMS site if previously administered Prevnar first One year (and one day) in between
TREATMENT OF PAIN
Frequent use of PRN Medications
Order as routine
Use of 2 or more analgesics
Document need and efficacy Use pain scale
Pre-treatment analgesia
Must be timed properly
MONITORING
Warfarin
INR: ordered, picked up, obtained, MD notified Increased monitoring with antibiotics Administer at 9 PM (allow time to adjust re: lab work)
Anti-Diabetic
Fingerstick – NO GAPS, Follow sliding scale Is Sliding Scale needed??
Anti-Hypertensive
BP Parameters – NO GAPS MINIMIZE USE OF HOLD PARAMETERS
Laboratory Tests
Results should be filed in a timely manner Results should be signed and noted by
physician
Psychiatric Consults
Should be done at least every 3 to 6 months Attempt at dose reduction or reason why not
“I have personally assessed this resident to
determine the need for a GDR and because he/she has a diagnosed enduring condition of _______, a GDR is clinically contra-indicated at this time.”
Benefit vs. Risk
New Concerns
Interim MRR for new admission, significant
Must have system in place May be done off-site
rzelkowitz@pharmaconconsulting.com