PHARMACY                                                                                                              29-02-002

MEDICATION ADMINISTRATION

POLICY STATEMENT.

The Division of Veterans Healthcare Services (DVHS) requires each of the New Jersey Veterans Memorial Homes (VMH) to establish and enforce procedures for storing, administering, and documenting the administration of medications or other pharmaceuticals to veterans home residents.

PURPOSE.

This policy and procedure shall serve to ensure that medications and other pharmaceuticals are stored and administered to veterans home residents according to Federal and State statutes, laws, rules and regulations, and in accordance with currently accepted standards of professional practice.

DEFINITIONS.

Adverse Consequence is an unpleasant symptom or event that is due to, or associated with, a medication, such as impairment or decline in an individual’s mental or physical condition, functional or psychosocial status.  It may include various types of adverse drug reactions and interactions (e.g. medication-medication, medication-food, and medication-disease).

Adverse Drug Reaction (ADR) is a form of adverse consequence. It may be either a secondary effect of a medication that is usually undesirable and different from the therapeutic effect of the medication, or any response to a medication that is noxious and unintended and occurs in doses for prophylaxis, diagnosis, or treatment. The term “side effect” is often used interchangeably with ADR, however side effects are but one of five ADR categories, the others being hypersensitivity, idiosyncratic response, toxic reactions, and adverse medication interactions. A side effect is an expected, well-known reaction that occurs with a predictable frequency and may or may not constitute an adverse consequence.

Anticholinergic Side Effect is an effect of a medication that opposes or inhibits the activity of the parasympathetic (cholinergic) nervous system to the point of causing symptoms such as dry mouth, blurred vision, tachycardia, urinary retention, constipation, confusion, delirium, or hallucinations.

Behavioral Interventions are individualized non-pharmacological approaches (including direct care and activities) that are provided as part of a supportive physical and psychosocial environment, and are directed toward preventing, relieving, and/or accommodating a resident’s distressed behavior.

Clinically Significant refers to effects, results, or consequences that materially affect or are likely to affect an individual’s mental, physical, or psychosocial well-being either positively by preventing, stabilizing, or improving a condition or reducing a risk, or negatively by exacerbating, causing, or contributing to a symptom, illness, or decline in status.

Distressed Behavior is behavior that reflects individual discomfort or emotional strain. It may present as crying, apathetic or withdrawn behavior, or as verbal or physical actions such as pacing, cursing, hitting, kicking, pushing, scratching, tearing things, or grabbing others.

Dose is the total amount/strength/concentration of a medication given at one time or over a period of time. The individual dose is the amount/strength/concentration received at each administration. The amount received over a 24-hour period may be referred to as the daily dose. 

Excessive Dose means the total amount of any medication (including duplicate therapy) given at one time or over a period of time that is greater than the amount recommended by the manufacturer’s label, package insert, current standards of practice for a resident’s age and condition, or clinical studies or evidence-based review articles that are published in medical and/or pharmacy journals and that lacks evidence of:


- A review for the continued necessity of the dose;
           
- Attempts at, or consideration of the possibility of, tapering a medication;

- A documented clinical rationale for the benefit of, or necessity for, the dose, or for the use of multiple medications from the same pharmacological class.

Duplicate Therapy refers to multiple medications of the same pharmacological class/category, or any medication therapy that substantially duplicates a particular effect of another medication that the individual is taking.

Duration is the total length of time the medication is being received.

Excessive Duration means the medication is administered beyond the manufacturer’s recommended time frames or VMH-established stop order policies, beyond the length of time advised by current standards of practice, clinical practice guidelines, clinical studies, or evidenced-based review articles, and/or without either evidence of additional therapeutic benefit for the resident or clinical evidence that would warrant the continued use of the medication.

Extrapyramidal Symptoms (EPS) are neurological side effects that can occur at any time from the first few days of treatment to years later. EPS included various syndromes such as:
           

Gradual Dose Reduction (GDR) is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose, or if the dose or medication can be discontinued.

Indications for Use is the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident’s condition and therapeutic goals, and is consistent with the manufacturer’s recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review articles that are published in medical and/or pharmacy journals.

Insomnia is the inability to sleep characterized by difficulty falling asleep, difficulty staying asleep, early awakening, or non-restorative sleep, which may result in impaired physical, social or cognitive function.

Interdisciplinary Team (IDT) refers to a group of staff members, both professional and ancillary, representative of each service, coordinated by a Registered Nurse (RN), and responsible for the development of individual resident care and treatment plans, in accordance with the New Jersey Department of Health and Senior Services’ licensing standards. 

Medication Interaction is the impact of another substance (such as another medication, nutritional supplement including herbal products, food, or substances used in diagnostic studies) upon a medication. The interactions may alter absorption, distribution, metabolism, or elimination.  These interactions may decrease the effectiveness of the medication or increase the potential for adverse consequences.

Medication Regimen Review (MRR) is a thorough evaluation of the medication regimen by a pharmacist, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medications. The review includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities in collaboration with other members of the Interdisciplinary Team.

Monitoring is the ongoing collection and analysis of information (such as observations and diagnostic test results) and comparison to baseline data in order to:

Neuroleptic Malignant Syndrome (NMS) is a syndrome related to the use of medications, mainly antipsychotics, that typically presents with a sudden onset of diffuse muscle rigidity, high fever, labile blood pressure, tremors, and notable cognitive dysfunction. It is potentially fatal if not treated immediately, including stopping the offending medications.

Non-Pharmacological Interventions refers to approaches to care that do not involve medications, generally directed towards stabilizing or improving a resident’s mental, physical, or psychosocial well-being.

Psychopharmacological Medication is any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders.

Serotonin Syndrome is a potentially serious clinical condition resulting from over stimulation of serotonin receptors. It is commonly related to the use of multiple serotonin-stimulating medications (e.g. SSRIs, SNRIs, triptans, certain antibiotics). Symptoms may include restlessness, hallucinations, confusion, loss of coordination, fast heart beat, rapid changes in blood pressure, increased body temperature, overactive reflexes, nausea, vomiting, and diarrhea.

Tardive Dyskinesia refers to abnormal, recurrent, involuntary movements that may be irreversible, and typically present as lateral movements of the tongue or jaw, tongue thrusting, chewing, frequent blinking, brow arching, grimacing and lip smacking, although trunk or other parts of the body may also be affected.

PROCEDURE.

  1. New Jersey Veterans Memorial Homes

    1. Medications shall be accurately administered and documented by properly authorized individuals, as per prescribed orders and “stop-order” policies.

    2. Medications are stored to maintain their integrity and to support safe administration of the correct medication to the correct resident, by the correct route and in the correct dose.

    3. Medications and other pharmaceuticals are accessible only to authorized staff and are locked when not under the direct observation of the authorized staff.

    4. Controlled medications are stored in a manner to limit access and to facilitate reconciliation in accordance with Federal and State statutes, laws, rules and regulations, and in accordance with currently accepted standards of professional practice.

    1. Staff shall ensure that medications available for use are not expired, contaminated, or unusable.

    1. Staff shall ensure that medication labels are legible and intact, and contain the required information (see 29-02-004).

    1. Staff shall ensure that multi-does vials are labeled per VMH policy (time and date first opened) and manufacturers’ specifications, once use of the vial has been initiated.

    1. Staff shall ensure that temperature, light, and humidity controls meet specifications for the storage of the medication.

    1. Staff shall ensure that medication carts and medication rooms are kept clean and neat at all times.

    1. The VMH shall have a system in place to accurately identify recipients before any drug is administered, and staff shall confirm the resident’s identity prior to giving medications.

    1. Staff shall ensure that proper hand hygiene is practiced prior to administering medications.

    1. Staff shall immediately document the administration and/or refusal of the medication on the resident’s Medication Administration Record (MAR) after the administration or the attempt.

    1. Staff shall ensure that required information such as pulse, blood pressure, etc. is recorded on the Medication Administration Record (MAR) immediately after the medication has been administered.

  2. The Pharmacy and Therapeutics Committee

    1. The Pharmacy and Therapeutics Committee at each VMH shall establish and enforce procedures for documenting drug administration in accordance with law.

  3. Self-administration of medications

    1. Self-administration of medications shall be permitted by qualified residents only as specified by the policy of the Pharmacy and Therapeutics Committee and the assessment of the Interdisciplinary Team.

    2. Medication self-administration procedures shall include, at a minimum, the following:

      1. The written order of the prescriber;

      2. Storage of medications in the resident’s room, based on resident assessment;

      3. Specifications for labeling, including directions for use;

      4. Methods for documentation in the medical record, based on resident assessment;

      5. Training of residents in self-administration by the nursing staff or the consultant pharmacist; and

      6. Medications shall be accurately administered and documented.

  4. Unnecessary Medications and Gradual Dose Reductions

    1. Unnecessary Medications - Each resident’s medication regimen must be free from unnecessary medications. An unnecessary medication is any medication when used:

      1. In excessive dose (including duplicative therapy);

      2. For excessive duration;

      3. Without adequate monitoring;

      4. Without adequate indications for use;

      5. In the presence of adverse consequences which indicate the dose should be reduced or discontinued;

      6. Any combination of the above reasons.

    2. Unnecessary Medications - Each resident’s medication regimen shall be managed and monitored to achieve the following goals:

      1. The medication regimen helps promote or maintain the resident’s highest practicable mental, physical, and psychosocial well-being, as identified by the resident and/or the resident’s representative(s) in collaboration with the attending physician and the VMH staff.

      2. Each resident receives only those medications, in doses and for the duration clinically indicated, to treat the resident’s assessed conditions(s).

      3. Non-pharmacological interventions (such as behavioral interventions) are considered and used when indicated, instead of, or in addition to, medications.

      4. Clinically significant adverse consequences are minimized.

      5. The potential contribution of the medication regimen to an unanticipated decline or newly emerging or worsening symptom is recognized and evaluated, and the regimen is modified when appropriate.
    3. Gradual Dose Reduction (GDR) (also called tapering the dose) refers to the process of seeking an appropriate dose and duration for each medication and minimizing the risk of adverse consequences.

      1. The purpose of tapering a medication is to find an optimal dose or to determine whether continued use of the medication is benefiting the resident. 

      2. Tapering may indicate when the resident’s clinical condition has improved or stabilized, whether the underlying causes of the original target symptoms have resolved, and whether or not non-pharmacological interventions, including behavioral interventions, have been effective in reducing the symptoms.

      3. The time frames and duration of attempts to taper any medication depend on factors including the coexisting medication regimen, the underlying causes of symptoms, individual risk factors, and pharmacological characteristics of the medications.

      4. Some medications (e.g. antidepressants, sedative/hypnotics, opioids) require more gradual tapering so as to minimize or prevent withdrawal symptoms or other adverse consequences.

      5. Often the only way to know whether a medication is needed indefinitely and whether the dose remains appropriate is to try reducing the dose and to monitor the resident closely for improvement, stabilization, or decline.

      6. The pharmacist evaluates resident-related information during the monthly medication regimen review for dose, duration, continued need, and the emergence of adverse consequences for all medications.

      7. During the monthly review the physician evaluates the resident’s progress, the total plan of care, the orders, the resident’s response to medications, and determines whether to continue, modify, or stop a medication.

      8. During the quarterly MDS review the Interdisciplinary Team reviews the resident’s mood, function, behavior, and other domains that may be affected by medications.

    4. Antipsychotic Medications – State and Federal regulations require gradual dose reduction attempts for antipsychotic medications unless clinically contraindicated. Based on a comprehensive assessment of a resident, the VMH must ensure that:

      1. Residents who have not used antipsychotic medications are not given these medications unless antipsychotic medication therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record.

      2. Residents who use antipsychotic medications receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these medications.

      3. Within the first year in which a resident is admitted on an antipsychotic medication or after the VMH has initiated an antipsychotic medication, the VMH must attempt a gradual dose reduction in two separate quarters (with at least one month between the attempts), unless clinically contraindicated.

      1. After the first year, a gradual dose reduction must be attempted annually, unless clinically contraindicated.

    5. Antipsychotic Medications for Dementia

      1. Residents receiving antipsychotic medications to treat behavioral symptoms related to dementia may not require gradual dose reduction if it can be documented that the resident’s target symptoms returned or worsened after the most recent attempt at gradual dose reduction within the VMH; or

      2. The physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident’s function or increase distressed behaviors.

    6. Antipsychotic Medications for Psychiatric Disorders –

      1. Residents receiving antipsychotic medications to treat behavioral symptoms related to psychiatric disorders may not require gradual dose reduction if it can be documented that continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying psychiatric disorder; and

      2. The resident’s target symptoms returned or worsened after the most recent attempt at gradual dose reduction within the VMH, and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder.

    7. Sedative and Hypnotics – For as long as a resident remains on a sedative or hypnotic that is used routinely and beyond the manufacturer’s recommendations for duration of use, the VMH shall attempt to taper the medication quarterly unless clinically contraindicated. Clinically contraindicated means:

      1. The continued use of a sedative or hypnotic is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident’s function or cause psychiatric instability by exacerbating and underlying medical or psychiatric disorder; or

      2. The resident’s target symptoms returned or worsened after the most recent attempt at tapering the dose within the VMH, and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder

Revised:           July 2007
Revised:           March 2010

 

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