Information for the Nursing Staff
The nursing and pharmacy staffs frequently interact in the routine and emergency situations involving patient care. This Section will attempt to provide information and established procedures that have been developed to improve services and/or how services are requested or provided.
- Routine, NOW and STAT Orders
- Patient Credits
- Medication Brought To The Hospital By The Patient
- Use Of Drugs Brought To The Hospital By The Patient
- Self Administration Of Medications
- Leave Of Absence Medication
- Discharge Medications
- Medication Stop Orders
- Patient Transfer-Pharmacy Notification
- Monthly Inspection Of Drugs And Pharmaceuticals On Nursing Units.
- Crash Carts Within The University Hospital
- Security Of Controlled Drugs On Nursing Units And Clinics
- Infusion Pumps — Guidelines For Use
- Expiration Dating For Multiple Dose Vials Of Injectables
- Disposal Of Live Attenuated Vaccines
- Total Parenteral Nutrition (TPN) Orders
- I.V. Push Policy
- Medication Administration Times
“ROUTINE ORDERS” FROM THE PHARMACY
a. Routine orders constitute the majority of drug and pharmaceutical orders handled by the pharmacy. The approximate turn around time is 30 minutes. This takes into account the entering of the information onto the patient’s medication profile, identifying patient-drug or drug-drug interactions and the filling-checking process.
b. Some orders will take longer. This occurs when extra preparation time is involved in preparing the medications (i.e….reconstitutions, compounding, etc.). It also occurs when additional information is required to assure that the patient receives the right drug, strength, and so forth. The pharmacy will not dispense an ambiguous order or one by which the patient may be harmed or receive a questionable dose.
“NOW” ORDERS FOR DRUGS AND PHARMACEUTICALS
- A “NOW” order is NOT a STAT order. An order which is written “NOW” and q.i.d. means that the first dose should be given as soon as possible, then the remaining doses follow the scheduled dosage times.
- Orders of this type should be infrequent. Such orders should be annotated in a conspicuous manner and an orange “NOW” ticket attached.
“STAT” ORDERS FOR DRUGS AND PHARMACEUTICALS
- Few drugs are life-saving and require immediate use. Items of this nature are usually found in the CRASH CART. The “STAT” designation should be restricted for drugs of this type.
- “STAT” orders require personal communication from the nursing unit when sent to the pharmacy. The orders will be filled and sent immediately when the notification and written order are received.
Drugs and pharmaceutical Items sent to the nursing stations for a specific patient are charged to that patient at the time that the order is filled and sent. In the event that this material is not used it is to be returned to the pharmacy along with a credit slip with complete patient identification. Credit material returned in excess of 72 hours after discontinuation of medication cannot be credited.
Parenteral admixtures prepared by the pharmacy have a 24 to 48 hours expiration dating. If an order for such parenteral medication is discontinued the material must be returned immediately. A credit to the patient’s account will be made only if the medication can be dispensed to another patient.
A “RED” MISCELLANEOUS CREDIT ticket must accompany the medications for each patient. The Credit Ticket must be imprinted with the patient’s card.
A Patient may have prescription and non-prescription drugs in their possession at the time they are admitted to the hospital. During the admitting process the patient should be encouraged to give these drugs to a family member or trusted friend to take home with them. The only exception would be if the drugs are brought to the hospital at the request of the attending physician. The nursing staff are to reinforce this procedure at the time the patient is admitted to the nursing unit. Every effort should be made to have the drugs removed from the hospital by reliable means.
In the event that it is not possible to send the medications home, the nursing staff is to bag the medications and put the patient’s name and home address on the bag. Nursing Units not supported by the Pharmacy Satellites are to send these medications to the inpatient pharmacy. For the other units, the bagged medications should be placed in a pre-designated area in order that the Pharmacy Satellite staff can pick up the medication during one of the visits to the unit.
The pharmacy completes a “Pharmacy Drug Receipt Form.” The original (white copy) is attached to the bag. The yellow and pink copies are forwarded to the Nursing Unit. The yellow copy is to be placed in the patient’s medical record and the pink copy given to the patient.
Any medications remaining in the inpatient pharmacy for more than one week will be mailed to the patient’s home. In the event that the patient is discharged before the week time frame is attained, the medications can be obtained from the pharmacy and returned to the patient.
Should the attending physician prescribe a non-formulary drug which is available from the patient’s drug supply the following procedure is to be followed. Forward the physician’s order and the drug to the Inpatient pharmacy. The pharmacist shall examine the contents of the patient’s bagged medication and attempt to make a visual identification for the drug requested. In the event the positive identification is made, the drug will be relabeled and dispensed to the nursing station. If a positive identification is not possible or if the drug is not in a useable condition, the nursing station will then be informed. The physicians order will then be handled under the policies and procedures for “non-formulary” drugs.
Patients at the University Hospital shall receive their medications from the pharmacy of the hospital. Medication filled for the patient outside the University Hospital shall not be used for in-patient treatment. Professional discretion by the pharmacy may be exercised to allow the patient’s home supply to be used in the following circumstances.
- The drug is non-formulary, has been identified by the hospital pharmacy, and is needed for an immediate dose.
- If the hospital stay is very short and a supply is not obtainable and (a) is true.
- The drug or prescription is a limited dose drug such as an oral contraceptic or oral antibiotic and is continued in-hospital.
If it is necessary for a patient to self-administer medication, the following conditions must be met.
- The physician must write an order for self-administration in the patient’s medical record specifically naming the drug(s), dosage strength and frequency of dosing.
- Nursing personnel must observe all doses and chart them in the appropriate place in the medical record.
- Medication will be dispensed by the pharmacy and stored in the nursing medication room.
For renal transplant patients drugs will be dispensed in containers labeled to simulate an out-patient prescription with appropriate instructions for use. Patients will receive multiple doses not to exceed a 7 days supply which will be limited to non-controlled oral medications.
A supply of pancreatic enzymes may be dispensed for storage at the patient bedside for self-administration as needed with snacks and meals if ordered by the physician for a patient accustomed to managing these drugs.
Patients on a nursing unit may need a supply of medications to cover a period of time that they are visiting with their families away from the hospital. When this occurs the physician shall write an order in the chart authorizing a “LEAVE OF ABSENCE” from the hospital. The order shall specify the time authorized for the LEAVE and any drugs which are to be sent with the patient. This order will be sent to the pharmacy and filled and labeled like an outpatient prescription. Orders should be received by the pharmacy at least two hours before the LEAVE is to begin.
Prescriptions written for the patient at the time of discharge should be given to the patient. If the patient requests it, the prescriptions may be faxed or taken to the out-patient pharmacy by the patient /family. Medications must be paid for appropriately. Discharge prescriptions will not be charged to the patient’s hospital bill. Services for discharge prescriptions are not available on weekends or holidays.
Medication Stop Orders are established and implemented for patient safety and to assure adequate follow up of care while on an inpatient status. The following Stop Orders will be observed for Inpatients of the University Hospital.
- All orders for Schedule II drugs will expire in 72 hours.
- All orders for Schedule III, IV and V Controlled Substances expire in 7 days.
- All orders for steroids will be rewritten every 7 days.
- Antibiotic orders must be renewed every 10 days.
- All routine drug orders not specifically covered by another stop order will expire in 30 days.
- All orders for oxytocics will be reordered every 12 hours in ante-partum patients and every 24 hours in post-partum patients.
- All medication orders will automatically be discontinued when the patient goes to surgery, changes level of care (eg. from a Nursing Unit to an Intensive Care Unit…) or changes professional services.
- All orders for Controlled Substances will automatically be discontinued upon the transfer of a patient to another Nursing Unit. Other drugs may be continued for the duration of the order or as stated herein.
- All orders for anticoagulants will need to be reordered every 48 hours until the patient achieves a stable therapeutic level of anticoagulation, as determined by the attending physician, thereafter the order needs to be renewed every 7 days.
When a drug order expires for the above reasons, continuation of the medications will be contingent upon a new written order.
When a patient is transferred from one Nursing Unit to another, any drugs supplied specifically for that patient should be transferred to the gaining unit.
In accordance with the criteria of the Joint Commission for the Accreditation of Healthcare Organizations (J.C.A.H.O.) the Pharmacy is tasked with the monthly inspections of drug and pharmaceutical supplies. The main intent is to assure that all available items are safe and suitable for use in patient care. At the same time we are fulfilling a hospital cost containment requirement by returning to stock all pharmacy items that are in excess of patient needs. Pharmacists will routinely check all patient care areas for drug safety and security. All other areas of the hospital will be inspected as needed for potential medication safety issues.
Standard Crash Carts within the University Hospital are handled and processed by the Central Sterile Supply and the Hospital Pharmacy. The following policies and procedures are important to assure that a Crash Cart is ready for use in case of an emergency.
- CRASH CARTS WILL REMAIN SEALED WHILE ON THE NURSING UNIT. The resuscitation equipment is to remain sealed in the plastic box which is located on the top of the Cart.
- Immediately following the use of a crash cart, the used cart should be cleaned on the Unit and then brought to the Central Sterile Supply and exchanged for a completed cart.
- When the label on the cart indicates that an item(s) has reached or is approaching the expiration dating, Central Supply personnel will exchange the cart with an updated cart as part of the scheduled maintenance checks on the cart.
- a. Controlled substances will be secured in the automated dispensing system or double locked in a designated cabinet. Only doses being readied for administration to the patient will be removed from locked storage. Safeguarding of such dose quantities will be the responsibility of the nursing staff.
- b. When a controlled substance is accessed, an inventory of the amount remaining is made and recorded by the nurse obtaining the drug.
- c. Differences of theoretical inventory and actual inventory will be resolved by Nursing staff when they occur. The Inpatient Pharmacy may be asked to advise on record keeping procedures only.
- d. Areas not using automated dispensing systems will perform a shift to shift inventory. Areas with automated dispensing systems will count all controlled substances every Monday and Thursday morning. Discrepancies in count must be resolved at the time discovered. Discrepancies which cannot be resolved must be reported to the charge nurse, the pharmacy and the nursing supervisor, and documentation made of the communication.
- e. If the narcotic keys are missing from the hospital, pharmacy is notified and a back-up set is obtained. If the keys are not back on the nursing division within an hour, the lock on the narcotic box must be changed. Nursing must initiate this lock change.
- f. Narcotic charges on areas not using automated dispensing systems will be recorded on a pre-printed narcotic charge ticket and identified with a patient label. This charge is in addition to recording the dose(s) on the appropriate controlled drug administration record.
- g. Controlled Substances may not be sent off the unit with or without a patient nor may a physician obtain a dose on his signature to be removed from the unit.
Alaris infusion pumps and the Patient Controlled Analgesia (PCA) pumps and Gemstar Pain Management Pumps (PMP) for epidural use are used at the UAMS Medical Center. Alaris pumps are to be used for infusion of the following types of solution.
- Central and peripheral line infusions and drug administrations.
- Total Parenteral Nutrition solutions and other I.V.s administered via subclavian or other central line catheters.
- Administration of small volumes of solutions or drugs in adults (i.e. less than 250 ml. per 24 hours when accuracy is required).
- Potent and dangerous drugs, such as heparin, aminophylline, chemotherapy drugs, etc.
Other approved uses for pumps are:
- Epidural infusions
- Magnesium therapy on obstetric patients
- Renal transplant fluid replacement
- Potassium replacement greater than 40 mEq./liter
- Multiple antibiotics
- Positional I.V.s
- Fluid restricted patients
- Patients on absolute accurate Intake and Out-Put
- Cerebral Edema patients
Injectables packaged in multiple dose vials normally contain a bacteriostatic agent. This agent retards the growth of minute bacterial contamination that may be introduced when withdrawing a dose. To assure that the product is safe for patient use the following procedures will be followed.
- Swab the top of the vial with alcohol
- Entries for withdrawal should be made at different sites on the vial stopper.
- It is not necessary to date the vial when it is opened. The vial may be used until the manufacturer’s expiration date unless
- The integrity of the stopper has been compromised and no longer provides a safe barrier against contamination.
- The contents of the vial appear to have changed appearance, bacterial contamination is suspected, and/or deterioration is evident upon visual inspection.
- All opened multiple dose vials except Insulin and TB skin tests will be discarded monthly when the unit inspection is performed by pharmacy personnel.
INSULIN PREPARATION ARE AN EXCEPTION TO THIS POLICY. INSULIN CAN BE USED UNTIL THE MANUFACTURER’S EXPIRATION DATING ON THE VIAL HAS BEEN REACHED, OR IF THE INSULIN SUSPENSION DOES NOT EVENLY DISTRIBUTE WHEN PROPERLY SHAKEN.
Live vaccines contain viable microorganisms which must be killed before the material can safely be disposed of. Materials of this type are to be returned to the pharmacy when it becomes unusable because of deterioration, the expiration dating has been exceeded, etc. The Pharmacy will autoclave such vaccines before discarding. Examples of Live Attenuated Vaccines are measles, mumps, polio, and rubella. When there is any doubt whether an item is a live vaccine, return it to the Pharmacy. Do not discard or destroy it on the Nursing Unit or in the Clinic.
- A TPN order must be written for each 24 hours of patient feeding.
- Orders must be received in the pharmacy no later than 4:00 P.M. daily. Late orders will be placed in a lower priority than other medication orders. If the next TPN bottle is not available when needed on the Nursing Unit, a Dextrose 10% Solution will need to be hung until the order is available.
- The Pharmacy will provide each TPN fluid in a sequential number series with the number appearing on the label of the container. Before hanging a TPN the nurse is to compare the label data to the most recent physician’s order. Discrepancies or questions are to be directed to the Pharmacy before the TPN is hung.
- All TPN solutions will be sent to the nursing unit at 7:00 P.M. and are to be hung at 8:00 P.M. This includes the initial fluid order.
- No additional ingredients are to be added without first contacting the Pharmacy.
- Normal expiration dating for a TPN fluid is 36 hours from the time of preparation.
- TPN orders are not considered to qualify for a “STAT,” “NOW,” or “EMERGENCY” designation. A Dextrose 5% Solution is to be hung when a new subclavian line is put into place until a chest X-ray verifies the placement of the catheter in the vena cava. When positioning has been verified, hang a Dextrose 10% Solution until 8:00 P.M. when the first unit of TPN fluid is delivered.
- No TPN order will be prepared if the order is incomplete or questionable until all information is clarified by a physician.
- The Pharmacy is to communicate to the nurse any changes in orders that the physician may make directly with the Pharmacist. The nurse should make an annotation to the original TPN order and the physician is to initial the changes as soon as possible.
- Registered nurses may administer I.V. bolus doses of any emergency drug of other standard I.V. drug while in the presence and under the supervision of a physician.
- Registered nurses may administer I.V. bolus doses of certain standard I.V. drugs on written orders when the physician is not present.
- Any drug administered must be on the approved hospital list.
- Certification of the competency of the nurse to administer I.V. bolus medication is subject to the Department of Nursing.
- A general listing of drugs approved for consideration for inclusion on a nursing unit list can be found in the appendix of this formulary. Any additions of drugs to the over-all list will be submitted and approved by the Pharmacy Committee.
- Certain drugs will only be administered by IV bolus unless a specific therapeutic reason exists to administer the drug by piggyback or continuous infusion. These drugs are listed in the appendix of this formulary.
A joint nursing-pharmacy committee has developed and the Pharmacy and Therapeutics Committee has approved Standard Medication Administration times for the Hospital. Every effort shall be made to conform to these administration times for all patients. A schedule for converting patients to the times no matter what time the first dose is administered has been developed and is posted on each nursing division with the medication administration times. A chart of the medication administration times is listed in the Appendix of this book.