Handle with caution: difficulties persist with nursing home medication management

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No discussion of long-term care nursing is complete without broaching the topic of effective medication management. It is such a predominant part of the nursing routine that for some, a majority of each shift is spent on it.

Broad in scope, medication management can include everything from control of drug production to the last line of oversight at the facility level. At issue is whether skilled nursing facilities have developed a medication management system that maximizes resident health and safety, clinical efficacy, workflow efficiency, nursing time management and cost effectiveness.

Considering the complex nature of the task and the increasingly heavy demands placed on long-term care nurses, industry specialists say facilities are generally managing the process fairly well. But there are still areas in great need of improvement—namely, the inordinate amount of time nurses spend on medication-related tasks, says Diana Waugh, RN, president of Waterville, OH-based Waugh Consulting.

“The vital role of the nurse is medication management—and not merely the action of administering medications,” she says. “An informal study we conducted showed that 5.5 hours of the nurses' eight hours on the day shift was spent in administering medications, leaving 2.5 hours to manage the medications, along with the myriad other tasks required of nurses. This meant that medication management was sorely wanting.”

Cathleen Bergeron, president of The National Association Directors of Nursing Administration in Long Term Care (NADONA)/Massachusetts Chapter, concedes that medication errors still occur due to “systemic and human issues,” but she adds that safety has improved in recent years. Still, because skilled nursing facilities continue to rely on antiquated manual processes, she recommends administrators consider new methods to save time, money and effort.

As the director of nursing for Soldiers' Home in Holyoke, MA, Bergeron helped form a medication safety team three years ago to review protocols and evaluate their effectiveness. The team includes acting superintendent Mike Pasterczyk and pharmacist Joy Watt, R.Ph.

“Our primary mission is to look at why errors take place,” Bergeron says. “Even though the error rate is down, we need to talk about what a medication management system should look like. Should it be carts or a completely different way to administer meds?”

As a nurse with more than 30 years' perspective on medication practices, Bergeron says constant interruptions are among the biggest problems today. She wonders if nurses are required to do too much multitasking.

“When I started in nursing, we were alone in the med room to concentrate on dispensing medications without any distractions,” she says. “It may be worthwhile to return to the concept of having a nurse in a quiet area just passing meds. Instead of more nurses giving fewer meds, it could be fewer nurses giving more meds.”

Bergeron and Waugh support designating one nurse per shift as a medication specialist.

“I believe one nurse could pass meds on days to 100 residents if the administration times were arranged to make it possible,” Waugh says. “Dressed in camouflage, this nurse would be responsible for nothing other than med administration. The families would be referred to this nurse to help them with their questions.”

Another option—in states where it is possible—is the utilization of designated aides for medication administration, Waugh says.

“Too often, nurses argue that unless a nurse passes the meds, they can't be managed … and that is simply untrue,” she believes. “Physicians manage meds every day of the week and very rarely administer them. We need to look at our role in the same vein.”

Checks and balances

Any changes implemented at the facility level should be designed to address key operational and financial components of the medication management chain, advises Mark G. Keffeler, president and CEO of Omaha, NE-based Rx Care Assurance.

“These changes should include the relationship and interactions between the pharmacy provider and the facility,” he says. “It is of paramount importance that checks and balances be put in place at the facility to ensure proper handling and administration of the medications while also reducing med errors and costly waste. It is also important to streamline the med pass procedures to allow for the most efficient use of labor at the facility.”

To be sure, medication passes “are easier said than done,” says Kamala Kovacs, RN, director of nursing at the John L. Montgomery Care Center in Freehold, NJ. Nurses often forget to manage their time for medication preparation and administration by not inspecting their carts for stocked medication, not identifying new medication orders, not knowing medication interactions and not adhering to directions specifying “before” or “after” meals, she explains.

Charge nurses, physicians and pharmacy consultants all play key roles in medication management, but Carrie Price maintains that MDS coordinators are also valuable because they “typically assess residents' overall condition and will likely catch any medications that may be outdated or contraindicated.”

Pharmacy consultants can help eliminate unnecessary medications and establish policies to prevent them from occurring, the clinical product manager and implementation specialist for MDI Achieve says. This may occur “when a resident discharges to the hospital and re-admits—it is likely that the same medications just keep getting started and stopped without looking at the resident's current condition,” Price says.

The technology factor

While improving oversight, logistics and protocols are all important, the consensus among medication specialists is that facilities need to automate their systems. Manual processes that rely on handwritten notes have definite drawbacks, says Durga Kolli, director of nursing at Augsburg Lutheran Nursing Home in Baltimore.

“Handwritten orders are not always legible, which makes room for medication errors—especially dose and frequency,” she says. “At times, it can take almost 24 hours to deliver medication with the current system. If the system is computerized, we can order the medication here at our facility and it will show up at the pharmacy.”

Kolli adds that electronic medication administration records and treatment administration records can provide opportunities to avoid transcription errors and allow nurses “to spend more time with residents than with papers.”

Covington, KY-based Omnicare specializes in deploying electronic medication systems, including robotics and bar code technology for prescription fulfillment and dispensing. Its facility systems allow users to access a Web-based worksite to review and authorize various medication-related functions, including reorders, Medicare Part D rejections and receipts.

Manual operations—“peel, stick and fax”—are a very outdated concept, says Sonya Trezevant, Omnicare's vice president of marketing. Handheld scanners and other new technology can help nurses oversee, monitor and review the medication management process, she and other experts add.


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Inside medication management

As president of Waterville, OH-based Waugh Consulting, Diana Waugh, RN, has examined many different facets of medication management. Here are some of the most common issues she sees:

-Assessment of effectiveness: The medication regimen review completed by consultant pharmacists should be utilized by the resident's nurse to lead discussions with other nurses, physicians, the resident and the resident's family regarding medication utilization.

-Physician partnering: The nurse in charge of the resident's care should be interacting with physicians to increase medication effectiveness. A true partnership requires that both parties understand their component, the value of dovetailing knowledge, and discussing options toward the goal of optimum resident care.

-Beers List use: First released in 1991, the Beers list was initially created to help clinicians determine which medications should be avoided in nursing home patients since seniors in nursing homes are particularly at risk for suffering medication-related problems. This data needs to be known by the nurses managing medications and utilized during discussions with the physicians.

-Ordering and disposal of medications: From a cost perspective, it is the responsibility of the nurse to actively consider the quantity and number of duplicative meds that are often part of transfer orders—particularly narcotics. The issue of flushing meds has become a public health issue in some states. American Pharmacists Association guidelines state that medications should be mixed with cat litter, sealed in a plastic bag and placed in a proper garbage container.