The Pressure of “Timely” Medication Passes
Those automated medication administration systems are great, right? Well, except for when all the nurses are standing in line for access to it while trying to beat the 30 minute window clock for timely medication administration. I have not met one nurse lately who didn’t acknowledge that she or he was untimely in passing medications at the required times, especially with the morning medication pass and sliding insulin scale coverage. I recently spoke to one nurse who had a medication pass every half hour except one during her shift. This is a recipe for disaster and pretty consistent with the outcomes of the research conducted in 2010 by the Institute for Safe Medication Practice (ISMP).
Everyone understands that in its Interpretive Guidelines, CMS has directed its surveyors to determine if drugs are administered within 30 minutes of the scheduled time for administration. [§482.23 (c) (1)] They have been especially diligent in reviewing this area while onsite. However, you control the scheduled times for medication administration since the providers generally order a frequency. Many times old policies hold the staff hostage to the times that are currently noted on the MAR even though practice has changed since they were last reviewed. A successful medication pass depends on a well thought out process for making it happen as expected.
You should be regularly monitoring your Medication Administration Records (MAR). Considering your daily staffing challenges in both nursing and pharmacy, look at what you can do to help yourselves to meet the requirements. For example, there is no actual standard that says you must immediately deliver a medication after it’s extracted from your automated medication system. Your medication administration process, though, must ensure that the relevant components of the medication management standards are met. So, it is okay to pour medications and place them into a secondary dispenser such as a medication cart as long as the meds are properly labeled and secured between pouring and administration. This avoids the bottleneck at the dispensing machine but only addresses one issue related to medication administration. Take a good look at your practice considering the published guidelines from professional associations such as ISMP and the American Society of Health-System Pharmacists.
In September 2010 ISMP has issued its Guidelines for Timely Medication Administration. Simply put, it suggests that hospitals identify a list of medications that are “time-critical” to be administered such as immune-suppressing agents and short acting insulins where a delay would cause the patient harm. These medications must be given within the 30 minute window. In these instances, the MAR would state the scheduled time. Conversely, “non- time-critical” medications should have guidelines established such as the administration of them within 25 percent of the scheduled time. These can include daily, twice a day and more frequently than 4 hours apart medications which would have an allowable one and two hour window from the scheduled administration time. Target timeframes also need to be established for “loading” or first- dose medications.
A pharmacy and nursing team dedicated to evaluating and resolving these types of issues can be beneficial in keeping the medication administration timely. Get your medical staff on board with the issue and make sure that there are procedures for staff to follow to promote safe and timely administration of medications. ISMP is still collecting feedback on its guidelines before issuing a final position on this issue but it makes a lot of sense. You can comment via firstname.lastname@example.org. ISMP also states that it is working with CMS to discuss the concerns of this rule on patient safety.